Lisfranc Fracture Dislocation Treatment & Management

Patients with nondisplaced injuries are treated conservatively. The complex must maintain its reduction under physiologic stress; this is is important to note because Lisfranc injuries can spontaneously reduce but still be unstable. In stable injury patterns, conservative treatment entails nonweightbearing with immobilization in a controlled ankle motion (CAM) boot or short leg cast for a period of 6 weeks, followed by progressive weightbearing. It is quite rare for a true Lisfranc injury to be stable for conservative therapy. 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.

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. ^[5]  Successful closed reduction of displaced Lisfranc dislocations is quite rare. 

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; however, studies have been inconsistent with regard to assessing open reduction with internal fixation (ORIF) versus primary arthrodesis (PA) for optimal acute treatment. ^{[24, 25, 26]}

In a study evaluating PA of the medial two or three TMT joints (n = 21) against 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. ^{[27, 28]} 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. ^[29] 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. ^[29] 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.

A meta-analysis of three randomized controlled trials by Smith et al demonstrated higher rates of removal of hardware with ORIF as compared with PA; there were otherwise no differences in risk for revision surgery, reported patient outcomes, or risk for nonanatomic reduction. ^[25]

A trial by Buda et al focused on the higher rate of removal of hardware seen in ORIF. ^[26] In this trial, removal of hardware was planned as part of the ORIF procedure. No difference in reoperation rates between ORIF and PA was noted.

Albright et al performed a cost-effectiveness analysis of PA versus ORIF and found that PA was significantly more cost-effective; the group cost for PA was $1429 per quality-adjusted life year (QALY), whereas that for ORIF was $3958/QALY. ^[30]  In view of the relatively limited resources available to the field, this difference in cost-effectiveness may play a larger role in future surgical considerations.

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. ^[31]

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 ^[32] 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, ^[33] which showed equivalence. Brin et al ^[34] reported satisfactory results in five recreational and professional athletes. Lundeen and Sara, ^[35] Baravarian and Geffen, ^[36] and Watson et al ^[37] also described their anecdotal use of this technique.

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.

For all injuries that are displaced and unstable, surgical treatment is required. ^[37] 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 options 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) and the use of plate fixation. ^[38] Multiple K-wires also have been advocated, but maintaining reduction with them is more difficult. ^[39] In fact, screw fixation (see the image below) has been shown to provide significantly greater biomechanical stability than K-wire fixation does. ^[40]

In the past few years, there has been a focus on transarticular screw fixation as a source of posttraumatic arthritis. Dorsal plate fixation has been suggested as an alternative that would not violate the articular surface. A small case series demonstrated that dorsal plating can appropriately maintain reduction of the Lisfranc joint. ^[41]  Studies have shown equivalent or improved outcomes with bridge plating as compared with transarticular screws. Kirzner et al demonstrated better functional and radiologic outcomes with bridge plating, ^[42] whereas Lau et al saw equivalent outcomes that were dependent on the quality of anatomic reduction, irrespective of the type of fixation. ^[12]

Primary fusion is typically reserved for use as a salvage operation, though some surgeons advocate PA. A study of factors affecting the success of TMT fusion found that isolated plate fixation (without transarticular screw fixation), smoking in the perioperative period, and nonanatomic alignment were all associated with decreased rates of fusion. ^[43] Bone grafting was significantly associated with improved union rates.

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

At present, however, the evidence supporting the use of these techniques is modest. ^[44]

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 this is necessary to maintain position. Because of the ligamentous interconnections, wires often are not required. (See the images below.)

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 miniature 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.)

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 achieve anatomic realignment of the foot. (See the image below.)

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 and fourth TMT joints literally are one on top of the other and are easily visualized.

With the tarsus stabilized and the joints inspected, reduction can be carried out with gentle pressure and manipulation. 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 cuneiforms. If acceptable reduction is achieved, appropriate MT-to-cuneiform screws are then placed.

The second part of the procedure is connecting the medial and middle columns. A 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. ^[45] (See the images below.)

An additional screw may be placed from the medial cuneiform to the middle cuneiform to complete the "box" with screws from the first and second MTs to their respective cuneiforms and the Lisfranc screw.

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.

Plate fixation

The approach and initial fracture reduction for plate fixation are similar to those for screw fixation. Once the reduction has been achieved, the dorsal plate can be applied. Typically, this procedure is used for comminuted fractures to bridge across the TMT joints (first, second, third, or some combination thereof). The fourth and fifth TMT joints are fixed with K-wires, which are removed at 6 weeks to prevent stiffness at these flexible joints.

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.

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) ^[46]
• 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 ^{[46, 47]}

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.)

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.

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.