Lisfranc Fracture Dislocation Treatment & Management

Updated: Jul 10, 2017
  • Author: Saul G Trevino, MD; Chief Editor: Thomas M DeBerardino, MD  more...
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Treatment

Approach Considerations

Patients with undisplaced injuries are treated conservatively. Patients with displaced Lisfranc injuries should undergo closed or open reduction. All Lisfranc injuries that cannot be reduced and be made to remain stable by closed means should undergo internal fixation. An absolute indication for open reduction is vascular compromise that does not improve with closed reduction. [4]

Successful closed reduction of displaced Lisfranc dislocations is quite rare. Closed treatment of displaced Lisfranc injuries should probably be reserved for patients who have sustained catastrophic spinal cord injuries and are not expected to walk again.

Anatomic alignment is important for stable function, but the risk of infection and soft-tissue compromise may preclude surgery until the tissues stabilize. Patients with open injuries or vascular compromise should be approached carefully. A delayed fusion of the medial three tarsometatarsal (TMT) joints can be performed if pain persists with weightbearing.

Future and controversies

Role of acute fusion

Stability at this joint level of the foot is the primary concern, and instability appears to be the primary pain generator. Because of the unpredictability of adequate ligamentous healing to support the foot, primary fusion of the medial three TMT joints has been advocated.

In a study evaluating primary arthrodesis (PA) of the medial two or three TMT joints (n = 21) against open reduction with internal fixation (ORIF) (n = 20) in primarily ligamentous Lisfranc injuries, Ly et al reported that the PA group reached a postoperative activity level that was an estimated 92% of the preinjury level, whereas the ORIF group achieved an activity level that was only 65% of the preinjury level. [20, 21] They concluded that a stable PA seemed to have better short- and medium-term outcomes. It was unclear whether long-term results were improved.

Henning et al prospectively studied 40 patients who were randomly assigned to receive either primary ORIF (PORIF) or PA of the first, second, and third TMT joint combined with Kirschner-wire (K-wire) fixation of the fourth and fifth TMT joints. [22] At an average of 53 months postoperatively, 32 patients were interviewed by telephone. Using Short Form (SF)-36 and Short Musculoskeletal Function Assessment (SMFA) scores, the authors found no significant differences in patient satisfaction between the two groups.

Because of planned hardware removal in the PORIF group, the reoperation rate in this group was significantly higher than that in the PA group. [22] The PA group did have different complications from the PORIF group, including a nonunion and a delayed union, both of which were treated nonoperatively. Although this was a level 1 study, it was limited by sample size, a low rate of participation among eligible patients, and a 20% loss of patients to follow-up.

Timing of screw removal

Suggestions of length of time that screws should remain in place range from 6 weeks to 3 months after weightbearing begins (up to 6 months from the time of surgery). Results demonstrate that if fixation screws remain in place indefinitely, they have a high tendency to break with time, thereby causing pain. If the joint is not fused purposely during surgery, then some motion is expected; this constant motion causes hardware failure.

The timing of screw removal remains a question. Advocates of early removal stress the fear of early screw failure as the main reason for removal. Others believe that the screws should remain in place even during early weightbearing to slowly help condition the damaged ligaments to resume supporting the foot. Long-term follow-up is needed before this issue can be resolved.

Use of different bioabsorbable materials

The advantage of using different bioabsorbable materials to provide short-term stability following surgical reduction is that no screws need to be removed. Two key questions to be answered are as follows:

  • What effect do degradation products have on joint chemistry?
  • Is the sheer strength of bioabsorbable screws sufficient to maintain the reduction in this situation?

In 2002, Thordarson et al reported results from 14 patients at an average follow-up of 20 months. At this short-term follow-up, they determined that bioabsorbable screws are safe and that they eliminate the need for screw removal. Larger studies with long-term follow-up are needed to determine the true efficacy. [23]

Suture button fixation

Several papers have addressed the use of suture button fixation in Lisfranc injuries with the hope of allowing some physiologic motion and to avoid putting screws across the articular cartilage of the first cuneiform and the second MT.

Ahmed et al [24] did a cadaveric study that showed more displacement with suture button fixation of isolated Lisfranc ligament injuries in cadaver specimens, which was in contradistinction to the study by Panchbhavi et al, [25] which showed equivalence. Brin et al [26] reported satisfactory results in five recreational and professional athletes. Lundeen and Sara, [27] Baravarian and Geffen, [28] and Watson et al [29] also described their anecdotal use of this technique.

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Medical Therapy

Medical treatment is reserved for injuries that are anatomically stable and nondisplaced. This type of injury is best labeled as a sprain, though associated fractures in the surrounding bone may be present (eg, metatarsal [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 nonweightbearing 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 stabilize damaged tissues, all stable injuries should be reexamined approximately 2 weeks after injury. Weightbearing radiographs should be obtained at 4-6 weeks to ensure continued anatomic alignment.

After 6 weeks, progressive weightbearing can be allowed in a well-molded cast, advancing as comfort allows. When full weightbearing 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 proved 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.

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Surgical Therapy

For all injuries that are displaced and unstable, surgical treatment is required. [29] Complete assessment of the intercuneiform and cuboid integrity is important for 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 along with rigid fixation, with an option in terms of the screws employed (eg, 3.5-mm cortical screws or 4.0-4.5 cannulated screws, depending on the size of the bone). [30] Multiple K-wires also have been advocated, but maintaining reduction with them is more difficult. [31] In fact, screw fixation (see the image below) has been shown to provide significantly greater biomechanical stability than K-wire fixation does. [32]

This diagram depicts the suggested fixation order This diagram depicts the suggested fixation order of placement and alignment of screws for surgical fixation of unstable Lisfranc injuries.

Guide wires should be placed carefully under fluoroscopic control to avoid multiple passes through the involved joint. In addition, they should be placed plantar to the midline to avoid fractures.

Alternative surgical treatments include the following:

  • PA of the first, second, and third MT-cuneiform joints
  • Suture button fixation
  • Dorsal bridge plating

At present, however, the evidence supporting the use of these techniques is modest. [33]

Presentation variations

In cases of pure dislocation, openly reduce all joints, then perform fixation of the medial joints with 3.5-mm cortical screws. Once these are anatomically aligned and fixed, the lateral two joints can be stabilized with 1.6-mm K-wires, if necessary to maintain position. Because of the ligamentous interconnections, wires often are not required. (See the images below.)

Preoperative anteroposterior radiograph demonstrat Preoperative anteroposterior radiograph demonstrates a Lisfranc dislocation.
Preoperative lateral radiograph demonstrates a Lis Preoperative lateral radiograph demonstrates a Lisfranc dislocation.
Postoperative anteroposterior radiograph demonstra Postoperative anteroposterior radiograph demonstrates reduction and fixation of Lisfranc dislocation.
Postoperative lateral radiograph illustrates place Postoperative lateral radiograph illustrates placement of fixation screws for stabilization of Lisfranc joint.

In cases of proximal instability—including 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 the image below.)

Preoperative anteroposterior radiograph demonstrat Preoperative anteroposterior radiograph demonstrates a Lisfranc injury with proximal tarsal instability. The medial cuneiform is displaced medially, bringing the joint line level with the second. The proximal anatomy must be restored and stabilized before addressing the tarsometatarsal joint.

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 the image below.)

Postoperative anteroposterior radiograph demonstra Postoperative anteroposterior radiograph demonstrates restoration of normal midfoot alignment. Screw fixation was used to stabilize the cuneiform prior to realigning the Lisfranc joint. Due to comminution of the second and third metatarsal shafts, Kirschner wires were used to hold their position. In this case, due to continued instability, a wire through the fourth tarsometatarsal joint was also used.

Interarticular injury involves destruction of the articular surface either through 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 more than 50% of the joint surface of the medial three joints is destroyed, consider acute fusion of these joints. Irrespective of the amount of damage to the articular surface of the lateral two joints, they should never undergo acute fusion.

In patients with diabetes, if the dislocation is found acutely before the 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 three TMT joints, regardless of their articular integrity. Prolonged nonweightbearing in a total contact cast is necessary to prevent reinjury due to neuropathy. Casting should be changed every 2 weeks. Weightbearing status is assessed by evidence of solid fusion on follow-up radiographs. Fusions frequently take twice as long as they do in nonneuropathic patients.

Procedural details

Often, surgery should be delayed until excessive swelling has resolved. 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 the surgical procedure.

A two-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 reduction is achieved, 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. [34] (See the images below.)

Postoperative lateral radiograph illustrates place Postoperative lateral radiograph illustrates placement of fixation screws for stabilization of Lisfranc joint.
Postoperative anteroposterior radiograph demonstra Postoperative anteroposterior radiograph demonstrates fixation of the metatarsal, as well as stabilization of the Lisfranc joint.

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.

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Postoperative Care

The authors recommend a well-padded posterior splint be used from immediately after the procedure until swelling subsides in 1-2 weeks. At that time, the splint can be converted to a nonweightbearing short leg cast if swelling permits. During the 2-week postoperative visit, remove sutures.

The patient should remain immobilized in a nonweightbearing 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 were used, they should be removed during this visit.

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Complications

The following can be considered complications of Lisfranc injury:

  • Foot compartment syndrome after a major trauma
  • Nonanatomic reduction or alignment
  • Posttraumatic midfoot arthritis (most common) [35]
  • Painful hardware, hardware failure, or breakage
  • Flatfoot deformity with instability with weightbearing
  • Complex regional pain syndrome (only two cases reported)
  • Neuromas (usually the superficial peroneal nerve)
  • Infections and wound complications
  • Vascular injuries [35, 36]

Along this joint line, continued chronic pain with weightbearing 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. (See the images below.)

Preoperative anteroposterior radiograph demonstrat Preoperative anteroposterior radiograph demonstrates a missed old Lisfranc injury with subsequent valgus foot deformity and painful weight bearing throughout the midfoot.
Preoperative lateral radiograph demonstrates loss Preoperative lateral radiograph demonstrates loss of plantar integrity through Lisfranc joint area. The normal linear alignment of the bones from the metatarsal to the talus is lost, with a sag at the tarsometatarsal joint.
In this postoperative anteroposterior radiograph d In this postoperative anteroposterior radiograph demonstrating reduction of Lisfranc alignment and screw configuration for tarsometatarsal fusion, note that only the medial 3 joints are fused. The lateral 2 joints remain mobile and actually open up when compared with the previous pictures.

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.

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Long-Term Monitoring

Follow-up is continued on a monthly basis until full weightbearing is achieved.

After 3-6 months, remove fixation screws across the TMT joints. Allow weightbearing as tolerated in a supportive shoe with accommodative insole and carbon shank.

The issue of how long screws should remain is controversial, as is the question of whether weightbearing 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 weightbearing be allowed until the screws are removed, at 3 months after surgery.

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