What is the treatment for a Lisfranc (Lisfranc joint injury) dislocation?

Treatment of Lisfranc Dislocation

The optimal treatment for Lisfranc dislocation requires surgical management to achieve anatomic reduction and ensure stability of the tarsometatarsal joints, which directly impacts outcomes and prevents complications such as post-traumatic arthritis and foot deformities. 1

Diagnostic Approach

• Initial evaluation should include weightbearing radiographs of the foot when possible, as non-weightbearing radiographs are not reliable for detecting subtle injuries 2, 1
• Add an AP view with 20° craniocaudal angulation to the standard three-view radiographic study (AP, oblique, and lateral) 2
• Include both feet on AP radiographs to help detect subtle malalignment when compared with the uninjured side 2
• When radiographs are normal or equivocal but clinical suspicion remains high, advanced imaging is indicated:
  • CT is particularly valuable in acute hyperflexion injuries and high-energy polytrauma, providing detailed imaging of fracture patterns 2
  • MRI shows high correlation with intraoperative findings for unstable Lisfranc injuries and is superior for ligamentous injury assessment 2, 1

Treatment Algorithm

Conservative Management

• Only indicated for stable lesions without displacement 3
• Treatment includes immobilization and initial avoidance of weight-bearing 3

Surgical Management

• Indicated for all unstable or displaced Lisfranc injuries 1, 3
• Surgery should be performed within 10-14 days of injury; delayed treatment may require open debridement due to scar tissue formation 4

Surgical Options:

1. Open Reduction and Internal Fixation (ORIF)

   • Preferred for bony Lisfranc injuries with good bone quality 3, 5
   • Fixation methods:
     • Transarticular screws - provide rigid fixation 3
     • Dorsal plates - preferred in cases with comminution of metatarsals or cuneiform bones 3

2. Closed Reduction and Percutaneous Fixation (CRPF)

   • Typically reserved for low-energy, purely ligamentous Lisfranc injuries 4
   • Minimizes soft-tissue trauma and reduces risk of postoperative complications 4
   • Options include:
     • Percutaneous screw fixation 4, 5
     • Suspensory fixation (suture button) - allows for increased range of motion of the medial column 4

3. Primary Arthrodesis

   • Growing evidence supports primary arthrodesis for unstable purely ligamentous Lisfranc injuries 6
   • Benefits include better functional outcomes, increased cost-effectiveness, and reduced rates of return to theater 6

Post-Operative Management

• Non-weight-bearing for 6 weeks 4
• Immobilization in a splint for the first 2 weeks, then transition to a boot 4
• Between weeks 6-12, introduce partial progressive weight-bearing with arch support 4
• Full weight-bearing and return to full activity at 12-16 weeks postoperatively 4

Pitfalls and Caveats

• Up to 20% of Lisfranc fracture-dislocations go unnoticed or are diagnosed late, especially low-energy or purely ligamentous injuries 3
• Non-anatomical reduction (occurring in approximately 1/3 of cases) leads to poorer outcomes 5
• Reduction is more difficult to achieve with an associated fracture of the base of the second metatarsal, which is present in almost 50% of cases 5
• Post-traumatic osteoarthritis develops in approximately 45% of patients within one year despite treatment 5
• Screw fixation appears to provide superior functional outcomes compared to pin fixation as measured by FAAM scores 5