Lisfranc Injury
Lisfranc injuries represent a spectrum of injury, ranging from a partial ligamentous sprain or undisplaced fracture to a grossly displaced, unstable ligamentous or osteoligamentous injury.
They generally result from a high-energy injury (fall from a height, a motorbike or motor vehicle accident) but may also result from a relatively lower-energy injury (competitive sports or a slip and ground-level fall).
The mechanism is usually a combination of axial load and dorsiflexion, plantarflexion, abduction, or adduction of the midfoot. It may consist of a pure ligamentous injury, a pure bony injury or a combination.
Partial injuries/sprains occur are typically low-energy injuries and are more common with axial load and plantarflexion. In these cases, the plantar tarsometatarsal ligaments remain intact, making the injury, by definition, a relatively stable injury.
Clinical Presentation
Patients typically present with diffuse pain and swelling in the midfoot and an inability to bear weight. Careful attention should be paid to soft tissue envelope, deformity, plantar ecchymosis, and neurovascular status. Tenderness over the midfoot and reproduction of pain with passive motion of the forefoot are suggestive of a Lisfranc injury.
A high index of suspicion should be kept based on the mechanism of injury and the presentation as above as approximately 20% Lisfranc injuries can be missed despite appropriate assessment and plain radiographs.
Imaging
In addition to standard plain radiographs, for subtle cases, weightbearing views (if achievable) or stress views (under anaesthesia) can be useful for further assessment of anatomical alignment. CT scan may also be beneficial with a subtle Lisfranc injury, particularly in a polytrauma patient or a patient with multiple extremity injuries. It also provides useful preoperative planning information in cases where the injury is obvious and identifies associated injuries. MRI is helpful in cases of suspected pure ligamentous injuries.
Classification
Hardcastle classification (1982) is based on the direction of dislocation and involvement of no of TMT joints:
Type A – Total incongruity – medial or lateral
Type B – Partial incongruity – medial or lateral
Type C – Divergent – total or partial
Myerson (1986) modified this classification accounting for the complexity of the injuries. The previous type B and type C injuries were subdivided into B1, B2, C1 and C2. In B1 injuries there is isolated medial dislocation of the first metatarsal. In B2 there is isolated lateral dislocation of the second to fifth metatarsals. Type C1 injury is a divergent injury of some of the TMT joints. C2 is a divergent injury of all of the TMTJs.
Management
Stable injuries
Stable, undisplaced injuries can be managed non-surgically with a NWB cast for 6 weeks. Depending on the pain status at 6 weeks, the patients can either undergo rehabilitation with a gradual return to their activities, or if pain is still present then a WB walker boot is worn for another 4-6 weeks. Nunley et al. reported very promising outcomes of this treatment regime with the majority of patients returning to their pre-injury sporting activities. Weight-bearing radiographs should be repeated 2 to 3 weeks after the injury to exclude a late displacement.
Unstable Injuries
Unstable injuries (pure ligamentous, displaced fractures, and dislocations) are treated surgically. Initial reduction and temporary stabilisation may be needed to allow the soft tissues to settle (usually 10-14 days) before definitive surgery. Definitive options include ORIF or primary arthrodesis.
Open Reduction and Internal Fixation
ORIF with transarticular screw fixation has long been considered the gold standard. Bridge plate fixation may provide an alternative in comminuted fractures. There remains a considerable controversy to the choice of implant (screws, plates, staples or combinations) and whether or not to remove definitive implants, and the optimal timing of their removal. However, studies have shown that the outcomes depend on the quality of anatomical reduction rather than the type of implants used for fixation.
A dorsomedial incision made over the second TMT joint gives access to the first and second TMT joints. A dorsolateral incision made between the third and fourth TMT joints gives access to the third TMT joint. If both incisions are required, care should be taken with the skin bridge.
There are several techniques to fixing Lisfranc injuries. In general, they are reduced from proximal to distal and from medial to lateral, after which they are temporarily held with K-wires and then fixed with the desired metalwork.
Metalwork Problems and Removal
There are a number of issues associated with using screws in Lisfranc injuries. It is still unclear when the screws should be removed. Some authors have suggested that screws should be removed after 8 weeks, although there are concerns that this could lead to late displacement. Some authors have suggested removal after 3–6 months.
However, screw breakage is common and the removal of broken screws can be challenging. It has also been suggested that the use of screws across joints leads to further articular damage and increases the risk of arthritis; hence the use of plates has been preferred by some authors.
Primary Arthrodesis
Primary arthrodesis of the affected TMTJs has become increasingly popular in the past 10 years, particularly in cases of pure ligamentous injuries. This relates to the fact that there is very little movement/isolated function of the 1st and 2nd TMT joints and there is prolonged healing time required for these injuries.
Long-term effect of loss of movements in these joints is unknown and adjacent joint arthritis may develop over time. There are no reports in literature to account for the incidence of adjacent joint disease.
Primary arthrodesis has been associated with lower hardware removal rates as compared to ORIF.
Some initial studies have reported good results with over 90% of patients able to return to pre-injury level of activity, with a significantly reduced the rate of subsequent surgeries.
Smith et al., in a meta-analysis comparing ORIF with primary arthrodesis, reported primary arthrodesis was associated with a lower reoperation rate for hardware removal relative to ORIF alone, but there was no difference in revision surgery rates, patient-reported outcomes, or risk of non-anatomic alignment between the two groups.
However, on the contrary, others have compared ORIF with complete and partial arthrodesis. Patients with complete arthrodesis experienced more pain, more stiffness and loss of the midfoot arch. No difference in pain levels was found in the ORIF and partial arthrodesis groups.
Return to sports
Deol et al. reported on the time to return to training and competition in a series of 17 consecutive professional rugby and football players with unstable Lisfranc injuries requiring surgical treatment. All players except one, were able to return to training and full competition at an average of 20 and 25 weeks respectively. Those with ligamentous injuries returned significantly faster than those with bony injuries.
McHale et al. performed an analysis on a consecutive series of 28 professional football players with Lisfranc injuries over a 10-year period, specifically assessing the return to competition and athletic performance following treatment. 93% were able to return to play at an average of 11 months. Although the athletic performance declined relative to pre-injury, the level of decline was not statistically significant relative to control groups.
Dubois-Ferriere et al. retrospectively reviewed 61 patients with Lisfranc injuries treated surgically over a 21-year with an average follow-up of 10.9 years and found that most patients were able to return to their previous level of function and employment. 72% had radiographic evidence of post-traumatic arthritis; 54% were symptomatic.
Complications
Short-term complications include foot compartment syndrome, venous thromboembolism, infection, and wound-related complications.
Long-term complications include painful hardware or hardware failure, midfoot arthritis, flatfoot deformity, and instability.
If a non-anatomic reduction is achieved, the prevalence of post-traumatic arthritis is significantly greater at up to 60%. Secondary osteoarthritis can be managed by complete or partial arthrodesis.
Missed Lisfranc Injuries
Studies have shown a worse outcome after delayed treatment of missed injuries. The type of injury also plays an important role. Type B results in a worse functional outcome than type C or A. This is probably because this partial dislocation can easily be missed on radiologic examination and treated after a delay.
A delay in treatment of more than 6 months provides a poorer functional outcome and leads to inability to return to preinjury level of activity.
Secondary corrective arthrodesis for malunited fracture-dislocations has a significantly worse result than primary open reduction and internal fixation of an acute injury.
References
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Clare M.P; Lisfranc Injuries; Curr Rev Musculoskelet Med (2017) 10:81–85.
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M.J. Welck, R. Zinchenko, B. Rudge; Lisfranc injuries; Injury, Int. J. Care Injured 46 (2015) 536–541.
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J. Rijn, M.J. Dorleijn, B. Boetes, S. Wiersma-Tuinstra, S. Moonen; Missing the Lisfranc Fracture: A Case Report and Review of the Literature; The Journal of Foot and Ankle Surgery Volume 51, Issue 2, March–April 2012, Pages 270-274.
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Hardcastle PH, Reschauer R, Kutscha-Lissberg E, Schoffmann W. Injuries to the tarsometatarsal joint. Incidence, classification and treatment. J Bone Joint Surg Br 1982;64(3):349–56.
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Myerson MS, Fisher RT, Burgess AR, Kenzora JE. Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment. Foot Ankle 1986;6(5):225–42.
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Nunley JA, Vertullo CJ. Classification, investigation, and management of midfoot sprains: Lisfranc injuries in the athlete. Am J Sports Med 2002;30(6):871–8.
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Ly TV, Coetzee JC. Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. A prospective, randomized study. J Bone Joint Surg Am. 2006;88:514–20.
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Henning JA, Jones CB, Sietsema DL, Bohay DR, Anderson JG. Open reduction internal fixation versus primary arthrodesis for Lisfranc injuries: a prospective randomized study. Foot Ankle Int. 2009;30:913–22.
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Reinhardt KR, Oh LS, Schottel P, Roberts MM, Levine D. Treatment of Lisfranc fracture-dislocations with primary partial arthrodesis, Foot Ankle Int. 2012;33:50–6.
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Smith N, Stone C, Furey A. Does open reduction and internal fixation versus primary arthrodesis improve patient outcomes for Lisfranc trauma? A systemic review and meta-analysis. Clin Orthop Relat Res. 2016;474:1445–52.
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Deol RS, Roche A, Calder JD. Return to training and playing after acute Lisfranc injuries in elite professional soccer and rugby players. Am J Sports Med. 2016;44:166–70.
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McHale KJ, Rozell JC, Milby AH, Carey JL, Sennett BJ. Outcomes of Lisfranc injuries in the National Football League. Am J Sports Med. 2016;44:1810–7.
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Dubois-Ferriere V, Lübbeke A, Chowdhary A, Stern R, Dominguez D, Assal M. Clinical outcomes and development of symptomatic osteoarthritis 2 to 24 years after surgical treatment of tarsometatarsal joint complex injuries. J Bone Joint Surg Am. 2016;98:713–20.
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Lau S1, Guest C, Hall M, Tacey M, Joseph S, Oppy A.; Functional Outcomes Post Lisfranc Injury-Transarticular Screws, Dorsal Bridge Plating or Combination Treatment? J Orthop Trauma. 2017 Aug;31(8):447-452.