eMedicine Specialties > Orthopedic Surgery > Foot & Ankle

Lisfranc Fracture Dislocation: Treatment

Author: Saul G Trevino, MD, Professor of Clinical Orthopedic Surgery, Department of Orthopedic Surgery, University of Missouri-Columbia School of Medicine
Coauthor(s): Allison M Wade, MD, Fellow, Penn State Bone and Joint Institute, Penn State University Milton S Hershey Medical Center, Hershey, PA; John S Early, MD, Foot/Ankle Specialist, Texas Orthopaedic Associates, LLP; Co-Director, North Texas Foot and Ankle Fellowship Baylor University Medical Center; Santaram Vallurupalli, MD, Research Resident, Department of Orthopedic Surgery, University of Missouri at Columbia
Contributor Information and Disclosures

Updated: Oct 6, 2009

Treatment

Medical Therapy

Medical treatment is reserved for injuries that are anatomically stable and nondisplaced. This type of injury is best labeled as a sprain, although associated fractures in the surrounding bone may be present (eg, MT fracture). An athlete with a stable Lisfranc injury usually cannot compete for the remainder of the season. Early return to high-level activity can lead to chronic pain and progressive arthropathy. Therefore, athletes should be given special consideration.

Initial treatment should consist of a well-molded, non – weight-bearing, short leg cast worn for a minimum of 6 weeks. Advancement of ambulation depends on resolution of symptoms. Because many of these injuries initially present with midfoot edema that may help to stabilize damaged tissues, all stable injuries should be re-examined approximately 2 weeks following injury. Obtain weight-bearing radiographs at 4-6 weeks to ensure continued anatomic alignment.

After 6 weeks, progressive weight bearing can be allowed in a well-molded cast, advancing as comfort allows. When full weight bearing in a cast is comfortable, the patient can be advanced to a supportive shoe and reconditioning. The patient can be advanced to an accommodative orthotic with a contoured carbon shank so as to minimize midfoot stress.

Combined closed reduction and casting has no role in the treatment of unstable injuries. Constantly maintaining reduction with casting alone has proven to be too difficult. In addition, interposing soft tissues can impede closed reduction. For example, the anterior tibial tendon can block reduction of a lateral Lisfranc dislocation; similarly, the peroneus brevis tendon can block a medial dislocation reduction.

Surgical Therapy

All injuries that are displaced and unstable require surgery. Complete assessment of the intercuneiform and cuboid integrity is important when determining stability. Clinical outcome is highly dependent on restoration of normal anatomic alignment. Present recommendations for treatment consist of open reduction of the unstable area, as well as rigid fixation, with an option in terms of the screws employed, such as 3.5-mm cortical screws or 4.0-4.5 cannulated screws (depending on the size of the bone). Multiple Kirschner wires (K-wires) also have been advocated, but maintaining reduction with them is more difficult (see Image 9).¹⁷ In fact, screw fixation has been shown to have significantly greater biomechanical stability than does K-wire fixation.¹⁸

Presentation variations

• Pure dislocation - Openly reduce all joints and follow with fixation of the medial joints with 3.5-mm cortical screws. Once anatomically aligned and fixed, the lateral 2 joints can be stabilized with 1.6-mm K-wires, if needed to maintain position. Wires are often not required, due to the ligamentous interconnections (see Images 10-13).
• Proximal instability - This includes tarsal instability and longitudinal impaction injuries that can disrupt the normal arcade of the TMT joints. Openly reduce and hold with fixation screws any instability between tarsal bones. If necessary, a mini-external fixator can be used to control proximal migration and comminution. Anatomically restore any shortening of the tarsals, and graft the defect with a structural graft from the iliac crest or proximal tibia. If more than 50% of the joint surface is destroyed, perform primary fusion among the involved bones to preserve long-term stability. Treatment then can proceed as it would for a pure dislocation (see Images 14-15).
• Distal fractures - MT fractures distal to the Lisfranc joint sometimes can interfere with stable fixation. In these instances, use intramedullary K-wires in conjunction with open reduction to anatomically realign the foot (see Images 16-17).
• Interarticular injury - This involves destruction of the articular surface through either bony fracture or through traumatic removal of cartilage from the subchondral bone. Anatomically restore large fragments. Remove interarticular debris, and assess the remaining joint. If greater than 50% of the joint surface of the medial 3 joints is destroyed, seriously consider acute fusion of these joints. Irrespective of the amount of damage to the articular surface of the lateral 2 joints, they should never undergo acute fusion.
• Patients with diabetes - If the dislocation is found acutely before onset of significant Charcot arthropathy, arthrodesis of the involved first, second, and third TMT joints can be beneficial. Take special care to document that blood flow is adequate for healing from the surgical procedure (transcutaneous pressure of oxygen [tcPO₂] or toe pressure >40 mm Hg). Fuse the medial 3 TMT joints, regardless of their articular integrity. Prolonged non – weight-bearing in a total contact cast is necessary to prevent reinjury due to neuropathy. Casting should be changed every 2 weeks. Weight-bearing status is assessed by evidence of solid fusion on follow-up radiographs. Fusions frequently take twice as long as nonneuropathic patients.

Preoperative Details

Often, surgery should be delayed until excessive swelling has resolved, because swelling places the soft tissues at risk. Supine position with a thigh or ankle tourniquet is recommended. Be aware of and ready to address all injuries present before beginning surgery.

Intraoperative Details

A 2-incision approach works best for complete visualization. The medial incision is in line with the first webspace. The branches of the superficial peroneal nerve are identified and protected. The muscle belly of the extensor hallucis brevis covers the neurovascular bundle. Identify and protect the deep peroneal nerve, dorsalis pedis artery, and extensor tendons. Once the area of the second TMT joint is reached, perform subperiosteal dissection across the Lisfranc joint to minimize damage to soft-tissue structures. If needed, a second incision is based over the lateral border of the third MT and is carried distally. The extensor digitorum brevis is divided bluntly, and the TMTs are entered subperiosteally. In this region, the third, fourth, and fifth TMT joints literally are one on top of the other and are easily visualized.

With the tarsus stabilized and the joints inspected, reduction usually is easy. The author finds it easiest to reduce the medial column first, by placing a provisional wire across the first TMT joint and, if necessary, a provisional wire between the first and second cuneiform. If acceptable, appropriate cannulated screws are then placed. The second part of the procedure is connecting the medial and middle columns. A cannulated screw is placed across the medial cuneiform to the base of the second MT so as to reduce the Lisfranc diastasis. Other authors suggest starting with the second MT to medial cuneiform fixation. A large, pointed bone-reduction clamp can be used to hold the reduction while screws are placed. The position of the fixation screws is depicted in Image 15.²

Because no real tissue layers are present at this level of the foot, wound closure can be accomplished with an absorbable suture to close joint capsules and a nonabsorbable suture in using a vertical or horizontal mattress technique to close the skin.

Postoperative Details

Immediately postoperatively, the authors recommend a well-padded posterior splint until swelling subsides in 1-2 weeks. At that time, the splint can be converted to a non – weight-bearing, short leg cast if swelling permits. Immobilization in a cast is up to 3 months. The period of time that screws should remain is controversial, as is the question of whether weight bearing should be permitted before screws are removed. Physicians agree that screws across viable joints should be left in no longer than 6 months from the time of surgery. Some advocate that no weight bearing be allowed until the screws are removed, at 3 months after surgery.

Follow-up

• Remove sutures during the 2-week postoperative visit.
• Patient should remain immobilized in a non – weight-bearing, short-leg cast until 6-8 weeks after surgery.  At that time, as symptoms permit, the cast can be switched to a removable boot or walking cast for another 6 weeks.
• During the 6-week postoperative visit, radiographically assess healing. If K-wires are used, they should be removed at the 6-week postsurgery follow-up visit.
• Follow up on a monthly basis until full weight bearing is achieved.
• During the 4-6 month postoperative visit, remove fixation screws across the TMT joints. Allow weight bearing as tolerated in a supportive shoe with accommodative insole and carbon shank.

Complications

The following factors can be considered complications of this injury:

• Foot compartment syndrome after a major trauma
• Nonanatomic reduction or alignment
• Posttraumatic midfoot arthritis (most common)¹
• Painful hardware, hardware failure, or breakage
• Flatfoot deformity with instability with weight bearing
• Complex regional pain syndrome (only 2 cases reported)
• Neuromas (usually the superficial peroneal nerve)
• Infections and wound complications

Along this joint line, continued chronic pain with weight bearing is best treated with fusion of the first, second, and third TMT joints in an anatomically correct position. With realignment and stabilization of the medial joints, laterally based pain usually subsides.

Treat persistent lateral pain following realignment of the medial joints with interposition arthroplasty rather than fusion. This is best performed using a segment of extensor digitorum brevis tendon rolled up and interposed into the debrided joint. This allows continued motion and prevents the compressive bony contact that generates the pain (see Images 19-22).

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