The patient has a Lisfranc injury. These are typically high energy injuries involving the Lisfranc ligament which connects the base of the 2nd metatarsal to the medial cuneiform. Dorsal dislocation is most common form. Anatomic reduction is necessary and can only reliably be achieved through open reduction and internal fixation. The ligament or a bony avulsion can become incarcerated in the joint preventing anatomic reduction. Following surgery patients should be treated with protected weight-bearing for 3-5 months and therapy emphasizing passive midfoot ROM. Midfoot post traumatic arthritis and pain are the long term outcomes of a non-anatomically reduced joint. Regardless when considering fusion or ORIF, operative reduction must be done.
Kuo et al showed less arthritis and better AOFAS scores with anatomic ORIF. The subgroup of patients with purely ligamentous injury showed a trend toward poorer outcomes even with anatomical reduction and screw fixation.
Ly and Coetzee performed a Level 1 investigation of 41 patients with an isolated acute or subacute Lisfranc dislocation treated with ORIF or primary arthrodesis of the medial column of midfoot. Two years postoperatively, the mean AOFAS Midfoot score was 68.6 points in the open-reduction group and 88 points in the arthrodesis group (p < 0.005). 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.
Henning et al conducted a Level 1 investigation of 40 patients with a Lisfranc fracture/dislocation treated with either ORIF or primary arthrodesis. They found that nearly 80% of the ORIF group needed subsequent hardware removal compared to 15% of the arthrodesis group. They found no statistical difference in functional outcomes at nearly 4 year follow-up. They concluded that there is no significant difference in SF-36 and Short Musculoskeletal Function Assessment outcome scores when compared to ORIF
Kuo RS, Tejwani NC, DiGiovanni CW: Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am 2000;82:1609-1618.
PMID:11097452 (Link to Abstract)
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 Mar;88(3):514-20.
PMID:16510816 (Link to Abstract)
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 Oct;30(10):913-22.
PMID:19796583 (Link to Abstract)
Thordarson DB: Fractures of the midfoot and forefoot, in Myerson MS (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2002, pp 1265-1296.