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 login to view 3 more bullets pathoanatomy unifying factor is disruption of the TMT joint complex login to view 1 more bullet may take form of purely ligamentous injuries or fracture-dislocations login to view 1 more bullet 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 login to view 1 more bullet middle column login to view 1 more bullet lateral column login to view 1 more bullet 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 login to view 1 more bullet ligamentous restraints login to view 1 more bullet 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 login to view 4 more bullets provocative tests may reproduce pain with pronation and abduction of forefoot Imaging Radiographs recommended views AP lateral oblique weight-bearing with comparison view login to view 1 more bullet findings five critical radiographic signs that indicate presence of midfoot instability login to view 14 more bullets 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 login to view 5 more bullets outcomes login to view 1 more bullet Operative temporary percutaneous pinning and delayed ORIF or arthrodesis indications login to view 1 more bullet outcomes login to view 1 more bullet open reduction and rigid internal fixation indications login to view 2 more bullets outcomes login to view 2 more bullets primary arthrodesis of the first, second and third tarsometatarsal joints indications (controversial) login to view 4 more bullets outcomes login to view 6 more bullets midfoot arthrodesis indications login to view 2 more bullets 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 login to view 2 more bullets 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 login to view 2 more bullets 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) login to view 2 more bullets malunion correction with primary arthrodesis login to view 2 more bullets Nonunion risk factors smoking treatment revision arthrodesis with bone grafting login to view 1 more bullet Hardware removal incidence ~75% of patients who undergo ORIF login to view 1 more bullet ~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 login to view 1 more bullet