What is the treatment for a Lisfranc dislocation?

Treatment of Lisfranc Dislocation

The optimal treatment for Lisfranc dislocation requires anatomic reduction and stable fixation, with surgical intervention being necessary for all unstable or displaced injuries to prevent long-term disability. 1

Diagnosis

• Initial evaluation should include weightbearing radiographs of the foot when possible, as non-weightbearing radiographs are not reliable for detecting subtle injuries 2
• If radiographs are negative but clinical suspicion remains high, advanced imaging is recommended:
  • MRI has high correlation with intraoperative findings for unstable Lisfranc injuries 2
  • CT is particularly valuable in acute hyperflexion injuries and high-energy polytrauma 2

Treatment Algorithm

Conservative Management

• Reserved ONLY for stable injuries without displacement 1
• Treatment includes:
  • Immobilization in a below-knee cast
  • Non-weight bearing initially 1

Surgical Management

• Indicated for ALL unstable or displaced Lisfranc injuries 1
• Goals of surgery:
  1. Achieve optimal anatomic reduction (directly impacts outcomes)
  2. Ensure stability of the tarsometatarsal joints, particularly the first, second, and third 1

Surgical Options:

1. Open Reduction and Internal Fixation (ORIF):

   • Transarticular screws or dorsal bridging plates 3, 1
   • Dorsal bridging plates avoid damage to the tarsometatarsal joints 3
   • May include a "homerun" screw from the medial cuneiform to the base of the second metatarsal 3

2. Primary Arthrodesis:

   • Particularly beneficial for ligamentous injuries and cases with first tarsometatarsal joint dislocation 4
   • Recent evidence shows better medium-term outcomes with primary arthrodesis compared to ORIF for first TMT joint dislocations 4
   • Lower rates of redislocation and hardware failure compared to ORIF 4

3. Minimally Invasive Techniques:

   • May be considered in cases with massive soft tissue swelling 5
   • Can include K-wire fixation combined with mini-TightRope® 5

Post-Operative Protocol

• Non-weight bearing in a below-knee cast for 6 weeks 3
• Followed by 6 weeks of protected weight-bearing in a walker boot 3
• Temporary K-wires are typically removed at 6 weeks 3
• Dorsal bridging plates may be removed at 4-6 months postoperatively 3

Complications and Pitfalls

• Up to 20% of Lisfranc injuries are initially missed or diagnosed late, especially low-energy or purely ligamentous injuries 1
• Failure to achieve anatomic reduction can lead to:
  • Post-traumatic arthritis
  • Foot deformities
  • Significant disability 1
• Hardware failure and loss of reduction are potential complications that lead to worse outcomes 3
• Redislocation is more common with ORIF (25% in one study) compared to primary arthrodesis 4

Special Considerations

• In cases with comminution of metatarsals or cuneiform bones, dorsal plates may be preferred over transarticular screws 1
• Decompression with dorsal skin incisions should be considered in cases with severe soft tissue damage 6
• Dynamic examination under anesthesia may be necessary to fully appreciate the extent of the injury 5

Remember that anatomic reduction and stable fixation are directly correlated with better functional outcomes, making proper surgical management essential for these injuries 3, 1.