Review Question - QID 5842

For primarily ligamentous Lisfranc dislocations, primary arthrodesis has been shown to have the best clinical outcomes when compared to ORIF.

The Lisfranc joint is inherently stable, as the articulation of the 2nd metatarsal (MT) base forms the keystone of the transverse tarsal arch. The medial and middle columns three tarsometatarsal (TMT) articulations of the Lisfranc joint have little motion and allow a rigid lever arm for propulsion during gait. Meanwhile, the lateral column, comprised of the 4th and 5th TMTs, have considerably more mobility and function to accommodate the foot on uneven terrain. Therefore, rigid fixation of the 1-3 TMTs is an essential component of fixing traumatic Lisfranc instability, and what little motion is lost is not morbid to the patient. Furthermore, since healing of the ligaments is less reliable than bony healing in the setting of rigid fixation, primary arthrodesis has been shown to have better outcomes than ORIF for purely ligamentous variants.

Ly and Coetzee report a randomized series of 43 patient with purely ligamentous Lisfranc dislocations, half treated with ORIF and half treated with primary arthrodesis of the 1-3 rays. The primary arthrodesis group had significantly higher AOFAS functional scores at two years post-op. Furthermore, 25% of the ORIF group went on to early arthritis and elected for revising their midfoot fixation to arthrodesis.

Henning et al. performed a similar randomization of primary arthrodesis versus ORIF in 40 patients; however, they included fractures and fracture dislocations rather than the purely ligamentous Lisfranc injury patterns. They found higher rates of subsequent procedures in the ORIF group, but no clinical outcome differences between the two groups at two years.

Figure A shows a homolateral lisfranc fracture dislocation. Homolateral refers to the displacement of all 5 TMT articulations being lateral.

Incorrect Answers:
1. Midfoot instability is poorly tolerated regardless of the setting and circumstances of injury
2. While arthrodesis is a salvage procedure for patients that develop late instability and arthritis after ORIF, it should also be considered as a primary treatment option. Outcomes following arthrodesis after failed ORIF are worse than those after primary arthrodesis
3. Rigid fixation of the lateral column should be avoided as these joints are essential to allow the foot to accommodate to uneven surfaces.
5. While suture fixation derived constructs may have a role in treating isolated Lisfranc ligament injuries, complete dislocations require rigid fixation for ORIF or primary arthrodesis