From the Guidelines
Treatment of a homolateral Lisfranc injury typically requires surgical intervention to restore anatomical alignment and stability of the midfoot. The initial management includes immobilization with a splint, elevation, ice application, and non-weight bearing status until definitive treatment.
Initial Assessment
When there is a fairly high clinical suspicion of an acute Lisfranc injury, the foot should be imaged, as recommended by the American College of Radiology 1. In addition to a typical three-view radiographic study of the foot, an AP view with 20 craniocaudal angulation can be added.
Diagnostic Approach
Obtaining weightbearing radiographs is recommended when possible because non-weightbearing radiographs are not reliable for detection of subtle injuries, as noted in the study by the Journal of the American College of Radiology 1. Weightbearing views have been shown to increase the abnormal alignment at the Lisfranc joint, thus making it easier to identify a Lisfranc injury.
Treatment Options
Surgical treatment is recommended for most displaced Lisfranc injuries and involves open reduction and internal fixation (ORIF) using screws, plates, or a combination of both to realign and stabilize the tarsometatarsal joints. The specific surgical approach depends on the injury pattern, with options including transarticular screws across the affected joints or bridge plating techniques.
Post-Operative Care
Post-operatively, patients remain non-weight bearing for 6-12 weeks in a cast or boot, followed by progressive weight bearing and physical therapy focusing on range of motion, strengthening, and proprioception exercises. Hardware removal may be considered after 4-6 months if it causes discomfort. For non-displaced stable injuries, conservative management with 6-8 weeks of non-weight bearing in a cast may be appropriate, but these cases require close monitoring to ensure the injury remains reduced.
Importance of Prompt Treatment
Surgical intervention is crucial because inadequate treatment of Lisfranc injuries can lead to chronic pain, post-traumatic arthritis, and significant functional limitations in the affected foot.
From the Research
Treatment of Homolateral Lisfranc Injury
- The treatment of Lisfranc injuries depends on the severity of the trauma and the stability of the injury 2, 3, 4, 5, 6.
- Stable lesions and those without dislocation can be treated conservatively with immobilization and no weight-bearing for a period of 6 weeks 2, 4, 6.
- Displaced injuries have worse outcomes and require surgical treatment with the main objectives of anatomical reduction and stability of the first three cuneiform-metatarsal joints 2, 3, 6.
- Different surgical procedures have been proposed, including:
- There is no superiority of one technique over the other, but anatomical reduction is the main determinant of post-operative outcomes 2.
- The severity of the injury and a quick diagnosis are the main determinants of the biomechanical and functional long-term outcomes 2, 4, 6.
Nonoperative Management
- Nonoperative management of Lisfranc injuries can be considered for stable injury patterns 5, 6.
- Outcomes of nonoperative management vary widely, with some studies reporting good functional outcomes and others reporting high rates of conversion to surgery 5.
- CT seems to be an important diagnostic tool in defining a stable injury 5, 6.
Surgical Intervention
- Surgical intervention is generally required for displaced or comminuted injuries 2, 3, 6.
- Open reduction and internal fixation (ORIF) is the most common approach, with a consensus towards bridge plating 6.
- Primary arthrodesis may offer benefits such as lower rates of post-traumatic arthritis and hardware removal, but is currently considered a niche treatment for acute injuries 6.