Lisfranc Injuries

 

Introduction

  • Injuries to the midfoot at the level of the tarso-metatarsal joints – specifically involving disruption of the articulation between the medial cuneiform and 2nd metatarsal
  • Lisfranc injuries represent a spectrum of injury including:
    • ligamentous sprain
    • unstable ligamentous disruption
    • undisplaced fracture
    • grossly displaced fracture-dislocation
  • Mechanism of injury:
    • combination of axial load with dorsiflexion / plantarflexion or abduction / adduction
    • frequently high energy trauma (e.g. RTA, fall from height)
    • increasingly common with much lower energy (simple trip etc)

 

​Presentation

  • Mechanism
    • high index of suspicion in high energy and athletic midfoot injuries
    • classical combination of axial loading through a plantarflexed foot
  • Symptoms
    • pain across midfoot
    • inability to weight bear
  • Signs
    • diffuse swelling across the midfoot
    • plantar ecchymosis (almost pathognomonic)
    • tenderness at the TMTJ

 

​Imaging

  • Plain radiographs
    • request AP, oblique and lateral views
    • look for:
      • disruption of the line from medial aspect of 2nd MT to medial aspect of middle cuneiform
      • widening between 1st and 2nd MTs
      • bony fleck between the base of the first and 2nd MT
      • dorsal displacement of the base of the 1st and / or 2nd MT (lateral view)
      • medial side of the 4th MT not lining up with medial aspect of cuboid
    • comparative weight-bearing x-rays of both feet performed 10-14 days post injury may help identify subtle instability
    • stress x-ray under anaesthetic less commonly used
  • CT Scan                 
    • very useful
    • helps to identify subtle injuries
    • preoperative planning
  • MRI
    • can help to identify a purely ligamentous injury

​

Classification

Hardcastle & Myerson classification is based on the direction of dislocation and involvement of number of TMT joints:

  • Type A – total incongruity – medial or lateral dislocation (homolateral)
  • Type B – partial incongruity
    • B1: isolated medial column dislocation of the 1st MT
    • B2: isolated lateral column dislocation of the 2nd-5th MTs
  • Type C – divergent
    • C1: ​divergent injury of some of the TMT joints (partial)
    • C2: divergent injury of all of the TMTJs (complete)

 

Management

Non-operative

  • Appropriate for stable, undisplaced injuries
  • Low demand or high-risk patients
    • NWB cast for 6 weeks
      • weight-bearing radiographs should be repeated 2 to 3 weeks after the injury to exclude subtle instability
    • walker boot is worn for another 4-6 weeks, weight-bearing as tolerated
    • evidence suggests most patients return to their pre-injury sporting activities

Operative

  • Unstable injuries are mostly treated surgically
  • With severe injuries or disruption, urgent closed reduction +/- temporary stabilisation may be needed to allow the soft tissues to settle:
    • cast / k-wires / ex-fix
  • Definitive options include ORIF or primary arthrodesis
  • Outcomes are strongly associated with accuracy of reduction

 

​Percutaneous fixation

  • Subtle, unstable injuries may be stabilised with percutaneous screw fixation
  • However, anatomic reduction is essential for optimum outcomes

 

Open reduction and internal fixation

  • Primary objective is anatomical reduction
  • Fixation options
    • Trans-articular screws
      • cause iatrogenic articular damage
      • potential for symptomatic hardware failure that can be difficult to remove
    • Bridge plating
      • use low profile locking plates
      • hardware removal optional
    • Alternative options
      • staples
      • flexible implants (internal brace / tightrope)
  • Surgical technique:
    • multiple approach options, depending on fracture pattern and soft tissues
      • medial / dorsomedial approach
        • useful for 1st TMTJ and medial NCJ
        • does not allow direct visualisation of 2nd TMTJ
      • dorsal (along line of 2nd MT)
        • allows access to 1st, 2nd and 3rd TMTJs
        • neurovascular bundle at risk as it emerges under the FHB musculotendinous junction
      • dorsolateral incision
        • allows visualisation of the 3rd TMTJ and laterally
        • care with skin bridge if used in combination with dorsomedial
    • principles
      • stable, anatomical fixation of 1/2/3 rays
      • temporary K-wire stabilisation of 4th and 5th TMTJ
      • consider stabilisation of medial intercuneiform / NCJ and cuboid if injured

 

Primary arthrodesis

  • Valid alternative to stabilisation, especially with:
    • extensive intra-articular damage
    • lower demand
  • Associated with lower hardware removal rates compared to ORIF
  • Potential advantages:
    • reliable stability
    • reduced hardware removal
    • equivalent outcome to ORIF
    • no need for future conversion to arthrodesis
  • Considerations:
    • long term incidence of adjacent joint OA unknown

 

Outcomes

  • Strongly related to quality of reduction
  • Early identification of injury severity/stability is essential
  • Delayed reconstruction is associated with poor outcome
    • primary arthrodesis is more reliable in delayed presentation

​

Complications

  • Post-traumatic arthritis
    • up to 80% if reduction non-anatomical
    • up to 54% at 10 years post ORIF
  • Mal-union
  • Non-union
  • Hardware removal
    • unclear indication
    • higher risk in ORIF vs fusion
  • Deep infection
    • 3-4%
  • Planovalgus deformity
  • associated with non-operative management and non-anatomical reducti
  • Neurovascular injury

 

 

MCQ

 

A 35-year-old man injures his right foot while playing football. He sustained fracture-dislocations of the 1st and 2nd TMTJs.

Which of the following techniques would lead to the best outcome?

  1. K-wire fixation of the medial column
  2. Spanning external fixator
  3. Percutaneous screws
  4. Below knee POP
  5. Anatomical ORIF of medial column

 

A 44-year-old man sustains an injury to his right foot. Stress radiographs show a Lisfranc injury.

Which is the main ligamentous injury?

  1. Interosseous 1st cuneiform-2nd MT ligament and plantar ligament between 1st cuneiform and 2nd and 3rd MT
  2. Spring and bifurcate ligaments
  3. Bifurcate and interosseous 1st cuneiform-2nd MT ligaments
  4. Long plantar ligament and plantar ligament between 1st cuneiform and 2nd and 3rd MT
  5. Interosseous 1st cuneiform-2nd MT ligament

 

 

References

  • Ly TV, Coetzee JC. Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. A prospective, randomized study. J Bone Joint Surg Am. 2006;88:514–20.
  • Henning JA, Jones CB, Sietsema DL, Bohay DR, Anderson JG. Open reduction internal fixation versus primary arthrodesis for Lisfranc injuries: a prospective randomized study. Foot Ankle Int. 2009;30:913–22.
  • Ponkilainen V, Mäenpää H, Laine HJ, Partio N, Väistö O, Jousmäki J, Mattila VM, Haapasalo H. Open Reduction Internal Fixation vs Primary Arthrodesis for Displaced Lisfranc Injuries: A Multicenter Randomized Controlled Trial. Foot Ankle Int. 2024 Mar 14:10711007241232667.
  • Guerreiro F, Abdelaziz A, Ponugoti N, Marsland D. Nonoperative management of lisfranc injuries - A systematic review of outcomes. Foot (Edinb). 2023 Mar;54:101977.
  • Rhodes AML, McMenemy L, Connell R, Elliot R, Marsland D. A Systematic Review of Outcomes Following Lisfranc Injury Fixation: Removal vs Retention of Metalwork. Foot Ankle Orthop. 2022 Oct 10;7(4):24730114221125447.
  • Swords M, Manoli A 2nd, Manoli A 3rd. Salvage of Failed Lisfranc/Midfoot Injuries. Foot Ankle Clin. 2022 Jun;27(2):287-301.