Summary A Lisfranc injury is a tarsometatarsal fracture dislocation characterized by traumatic disruption between the articulation of the medial cuneiform and base of the second metatarsal. Diagnosis is confirmed by radiographs which may show widening of the interval between the 1st and 2nd ray. Treatment is generally operative with either ORIF or arthrodesis. Epidemiology Incidence account for 0.2% of all fractures Demographics males > females more common in the third decade ETIOLOGY Pathophysiology mechanism of injury MVAs, falls from height, and athletic injuries injury cascade mechanism is usually caused by indirect rotational forces and axial load through hyper-plantarflexed forefoot hyperflexion/compression/abduction moment exerted on forefoot and transmitted to the TMT articulation metatarsals displaced in dorsal/lateral direction pathoanatomy unifying factor is disruption of the TMT joint complex injuries can range from mild sprains to severe dislocations may take form of purely ligamentous injuries or fracture-dislocations ligamentous vs. bony injury pattern has treatment implications Associated conditions tarsal fractures proximal metatarsal fractures Lisfranc equivalent injuries can present in the form of contiguous proximal metatarsal fractures or tarsal fractures can involve multiple TMT joints Anatomy Osteology Lisfranc joint complex consists of three articulations including tarsometatarsal articulation intermetatarsal articulation intertarsal or intercuneiform articulations columns of the midfoot medial column includes first tarsometatarsal joint middle column includes second and third tarsometatarsal joints lateral column includes fourth and fifth tarsometatarsal joints (most mobile) Ligaments Lisfranc ligament an interosseous ligament that goes from medial cuneiform to base of 2nd metatarsal on plantar surface critical to stabilizing the 1st and 2nd tarsometatarsal joints and maintenance of the midfoot arch Lisfranc ligament tightens with pronation and abduction of forefoot plantar tarsometatarsal ligaments injury of the plantar ligament between the medial cuneiform and the second and third metatarsals along with the Lisfranc ligament is necessary to give transverse instability. dorsal tarsometatarsal ligaments dorsal ligaments are weaker and therefore bony displacement with injury is often dorsal intermetatarsal ligaments between second-fifth metatarsal bases no direct ligamentous attachment between first and second metatarsal Biomechanics Lisfranc joint complex is inherently stable with little motion due to stable osseous architecture second metatarsal fits in mortise created by medial cuneiform and recessed middle cuneiform, "keystone configuration" ligamentous restraints see individual ligaments above Classification Hardcastle & Myerson Classification Type A Complete homolateral dislocation Type B1 Partial injury, medial column dislocation Type B2 Partial injury, lateral column dislocation Type C1 Partial injury, divergent dislocation Type C2 Complete injury, divergent dislocation Presentation History history of high energy trauma or sporting accident Symptoms severe midfoot pain inability to bear weight Physical exam inspection & palpation medial plantar ecchymosis swelling throughout midfoot tenderness over tarsometatarsal joint motion instability test grasp metatarsal heads and apply dorsal force to forefoot while other hand palpates the TMT joints dorsal subluxation suggests instability if first and second metatarsals can be displaced medially and laterally, global instability is present and surgery is required when plantar ligaments are intact, dorsal subluxation does not occur with stress exam and injury may be treated nonoperatively provocative tests may reproduce pain with pronation and abduction of forefoot Imaging Radiographs recommended views AP lateral oblique weight-bearing with comparison view may be necessary to confirm diagnosis findings five critical radiographic signs that indicate presence of midfoot instability discontinuity of a line drawn from the medial base of the 2nd metatarsal to the medial side of the middle cuneiform seen on AP view diagnostic of Lisfranc injury widening of the interval between the 1st and 2nd ray seen on AP view may see bony fragment (fleck sign) in 1st intermetatarsal space represents avulsion of Lisfranc ligament from base of 2nd metatarsal diagnostic of Lisfranc injury dorsal displacement of the proximal base of the 1st or 2nd metatarsal seen on lateral view medial side of the base of the 4th metatarsal does not line up with medial side of cuboid seen on oblique view disruption of the medial column line (line tangential to the medial aspect of the navicular and the medial cuneiform) seen on oblique view CT indications useful for preoperative planning in the setting of comminuted bony injuries can help identify subtle injuries MRI indications can be used to confirm presence of purely ligamentous injury Differential Key Differential metatarsal base fracture metatarsal stress fracture tarsal fracture Treatment Nonoperative cast immobilization for 8 weeks indications certain non-displaced injuries that are stable with weight bearing nonoperative candidates nonambulatory patients presence of serious vascular disease severe peripheral neuropathy outcomes significantly lower functional and radiographic outcomes noted with non-operative management of displaced or transverse unstable injuries Operative temporary percutaneous pinning and delayed ORIF or arthrodesis indications displaced Lisfranc fracture dislocation injury with significant soft tissue swelling outcomes temporizing reduction and pinning and delayed definitive management with ORIF/arthrodesis has been shown to have decreased risk of wound infection in some low level studies. open reduction and rigid internal fixation indications any evidence of instability (> 2mm shift) favored in bony fracture dislocations as opposed to purely ligamentous injuries outcomes anatomic reduction required for a good result excluding hardware removal, no difference in complications or functional outcomes between ORIF and arthrodesis primary arthrodesis of the first, second and third tarsometatarsal joints indications (controversial) purely ligamentous arch injuries delayed treatment chronic deformity complete Lisfranc fracture dislocations (Type A or C2) outcomes function outcomes level 1 evidence demonstrates equivalent functional outcomes compared to primary ORIF medial column tarsometatarsal fusion shown to be superior to combined medial and lateral column tarsometatarsal arthrodesis some studies have shown that primary arthrodesis for complete Lisfranc fracture dislocations (Type A or C2) results in improved functional outcomes and quality of reduction compared to ORIF complications excluding hardware removal, no difference in complications between ORIF and arthrodesis midfoot arthrodesis indications destabilization of the midfoot's architecture with progressive arch collapse and forefoot abduction chronic Lisfranc injuries that have led to advanced midfoot arthrosis and have failed conservative therapy Technique Cast immobilization close followup with repeat radiographs should be performed to ensure no displacement with weightbearing with non-operative management Temporary percutaneous pinning technique reduce medial and lateral columns and stabilize with k-wires K-wires left in place until soft tissue swelling subsides can proceed with K-wire removal and ORIF/arthrodesis when soft tissues allow timing to definitive surgery can delay up to 2-3 weeks for soft tissue swelling to improve Open reduction and rigid internal fixation timing within 24 hours or delay operative treatment until soft tissue swelling subsides (up to 2-3 weeks) approach single or dual longitudinal incisions can be used based on injury pattern and surgeon preference longitudinal incision made in the web space between first and second rays first TMT joint is exposed between the long and short hallux-extensor tendons reduction & fixation reduce intercuneiform instability first fix first through third TMT joints with transarticular screws screw fixation is more stable than K-wire fixation can also span TMT joints with plates if MT base comminution is present postoperative care early midfoot ROM, protected weight bearing, and hardware removal (k-wires in 6-8 weeks, screws in 3-6 months) gradually advance to full weight bearing at 8-10 weeks if patient is asymptomatic and screws transfix only first through third TMT joints, they may be left in place preclude return to vigorous athletic activities for 9 to 12 months Primary arthrodesis of the first, second and third tarsometatarsal joints arthrodesis & fixation expose TMT joints and denude all joint surfaces of cartilage use cortical screws or square plate to fuse joints in the presence of both medial and lateral column dislocation, temporary lateral column pinning is recommended over lateral column arthrodesis postoperative care apply cast or splint for 6 weeks progress weight bearing between 6 and 12 weeks in removable boot full weight bearing in standard shoes by 12 weeks post-op Midfoot arthrodesis arthrodesis & fixation expose TMT joints and midfoot and remove cartilage from first, second, and third TMT joints add bone graft reduce the deformity using windlass mechanism variety of definitive fixation constructs exist postoperative care apply cast or splint for 6 weeks progress weight bearing between 6 and 12 weeks in removable boot begin weight bearing as tolerated at 12 weeks if evidence of healing is noted on radiographs Complications Posttraumatic arthritis incidence most common complication risk factors delayed treatment ORIF up to 80% risk with non-anatomic ORIF 54% of patients have symptomatic OA at ~10 years followed ORIF treatment treat advanced midfoot arthrosis with midfoot arthrodesis Malunion risk factors non-anatomic ORIF of Lisfranc injury treatment shoe modifications (cushioned heel with rocker sole) indications nonsurgical candidate malunion correction with primary arthrodesis indications surgical candidate that has failed non-operative treatment Nonunion risk factors smoking treatment revision arthrodesis with bone grafting indicated unless patient is elderly and low demand Hardware removal incidence ~75% of patients who undergo ORIF often a planned secondary procedure, required to allow the TMT joints to return to motion ~20% of patients following arthrodesis Deep infection incidence 3-4% risk factors significant soft tissue swelling at time of definitive surgery treatment irrigation and debridement, possible hardware removal. Planovalgus foot deformity risk factors non-operative management non-anatomic reduction following ORIF Prognosis Overall Impact on Life Quality significant variability regarding return to full activity given heterogenous group of patients in nearly all studies in the military population, at ~3 year follow-up, ~70% patients undergoing ORIF or primary arthrodesis were able to resume occupationally required daily running. Poor prognostic variables missed diagnosis easily missed and diagnosis is critical missed injuries can result in progressive foot planovalgus deformity result in chronic pain and ambulatory dysfunction