What is the recommended treatment for a patient with marked attenuation of interosseous and plantar bands of the Lisfranc ligamentous complex, suggestive of at least a grade 2 sprain and possible rupture?

Treatment of Grade 2-3 Lisfranc Ligament Injury with Possible Rupture

For a Lisfranc injury with marked attenuation of the interosseous and plantar bands suggesting at least grade 2 sprain with possible rupture, surgical treatment with open reduction and internal fixation (ORIF) is strongly recommended, as displaced or unstable Lisfranc injuries have worse outcomes with conservative management and require anatomical reduction and internal fixation for optimal results. 1

Immediate Diagnostic Workup

• Obtain weight-bearing radiographs of both feet (AP, oblique, lateral, plus AP with 20° craniocaudal angulation) to assess for diastasis and compare with the uninjured side 2
• CT scan is indicated for preoperative planning to evaluate the full extent of osseous injury and associated metatarsal/cuneiform fractures that commonly accompany ligamentous Lisfranc injuries 2
• Your MRI findings showing marked attenuation with possible rupture already demonstrate an unstable injury requiring surgical intervention, as MRI has high correlation with intraoperative findings for unstable Lisfranc injuries 2

Treatment Algorithm Based on Injury Stability

For Unstable/Displaced Injuries (Your Case)

Surgical intervention is mandatory because:

• Displaced Lisfranc injuries have significantly worse outcomes without surgery 1
• Anatomical reduction is the single most important factor influencing results 3
• Missed or inadequately treated injuries result in severe post-traumatic osteoarthritis, foot deformities, and long-term disability 1, 3

Surgical Options

Primary ORIF with transarticular screws or dorsal plates:

• ORIF remains the current gold standard for ligamentous Lisfranc injuries 4
• Transarticular screws provide reliable fixation for purely ligamentous injuries 5, 3
• Dorsal plates should be considered if there is comminution of metatarsals or cuneiform bones 3
• Fiber tape constructs are emerging as an alternative that provides comparable biomechanical stability to screws without requiring later removal 5

Primary arthrodesis:

• Increasingly popular for complex injuries 4
• Recent evidence supports limited arthrodesis in more complex injuries 1
• Consider for high-energy injuries with significant articular damage 3

Surgical Timing

• Early surgical reconstruction is critical - the risk of additional cartilage and meniscal injury increases within 3 months of delay 6
• Schedule surgery as soon as medically appropriate after completing preoperative imaging 3

Postoperative Management

Immobilization and weight-bearing protocol:

• Non-weight-bearing cast and crutches for 2 weeks 2
• Progress to weight-bearing as tolerated at 3-6 weeks 2
• Replace cast with brace at 6+ weeks 2
• Return to physically demanding activities at 12-16 weeks 2

Rehabilitation:

• Start functional rehabilitation early focusing on motion restoration and strengthening exercises once appropriate healing has occurred 2
• Manual joint mobilization combined with exercise therapy provides superior outcomes compared to exercise alone 2
• Supervised exercise programs yield better results than unsupervised training 2

Return to Work Timeline

• Sedentary work: Resume at 3-6 weeks with mostly sitting, no lifting >10 kg, limited standing/walking on uneven surfaces 2
• Full work activities: 6-8 weeks depending on task requirements and physiotherapy progress 2
• Physically demanding jobs and sports: 12-16 weeks post-surgery 2

Critical Pitfalls to Avoid

• Never treat displaced Lisfranc injuries conservatively - this leads to chronic pain, instability, and post-traumatic arthritis 1, 3
• Do not delay surgery beyond 3 months - this increases risk of additional cartilage and meniscal damage 6
• Avoid prolonged immobilization beyond indicated timeframes - this causes muscle deconditioning and worse outcomes 7
• Do not rely solely on time from surgery to determine return to activity - use functional evaluation including hop tests 6

Pain Management

• NSAIDs can be used to reduce pain and swelling in the acute phase 7
• Apply ice-water mixture in plastic bag with damp cloth for 20-30 minutes, 3-4 times daily 7

Expected Outcomes

• Most patients can return to near pre-injury activity levels if properly diagnosed and appropriately treated 4
• Anatomical reduction achieved through surgery directly influences long-term outcomes 3
• Undisplaced injuries have excellent outcomes with non-operative treatment, but your case with marked attenuation and possible rupture does not fall into this category 1