Review Question - QID 9013

The patient has a chronic ligamentous Lisfranc injury of his right foot, which would be best treated with primary arthrodesis of the involved tarsometatarsal joints.

Early recognition of an injury to the Lisfranc ligamentous complex is critical to prevent deformity and significant morbidity. If there is suspicion for this injury, and initial radiographs are negative, weightbearing radiographs should be taken. Non-displaced injuries can be treated with a short leg walking cast with initial non-weightbearing. More than 2 mm of shift in joint position indicates instability, and anatomic reduction and stabilization is critical to a positive long-term outcome. Current studies indicate that primarily ligamentous and chronic injuries tend to have better outcomes with primary arthrodesis.

Ly et al. performed a Level 1 prospective, randomized controlled trial of 41 patients with an isolated primarily ligamentous Lisfranc injury treated with either open reduction and internal fixation (ORIF) or primary arthrodesis. Two years postoperatively, the mean AOFAS midfoot score was 68.6 points in the ORIF group and 88 points in the arthrodesis group. Postoperative level of activities was significantly higher in the arthrodesis group and 25% of the ORIF group required a subsequent revision to an arthrodesis. They concluded that primary arthrodesis of the medial two or three rays has a better short and medium-term outcome than ORIF.

Sangeorzan et al. reported on 16 patients that underwent revised to open reduction and medial column arthrodesis after failure of initial treatment. 69% of patients had good to excellent results. Age had no significant impact on outcomes and patients with chronic injuries had worse outcomes overall. The authors emphasize early treatment and the critical importance of anatomic reduction.

Figure A is a weight-bearing radiograph of the right foot demonstrating disruption of a line drawn from the medial base of the second metatarsal to the medial side of the middle cuneiform and widening of the interval between the first and second ray. Figure B is a lateral radiograph that does not demonstrate any significant dorsal subluxation. Figure C demonstrates subluxation of the 2nd metatarsal on the middle cuneiform with no involvement of the the fourth or fifth tarsometatarsal joints.

Incorrect answers:
Answer 2: The patient does not have any significant bony involvement on his radiographs. Open reduction and internal fixation should be considered for patients with significant bony involvement or acute presentation.