Lisfranc Injury

1. Clinical Overview

Summary

The Lisfranc injury refers to a disruption of the tarsometatarsal (TMT) joint complex, specifically involving the Lisfranc Ligament which anchors the 2nd Metatarsal base to the Medial Cuneiform. This ligament is the Keystone stabilizer of the midfoot "Roman Arch". Since there is NO transverse intermetatarsal ligament between the 1st and 2nd metatarsals, the Lisfranc ligament is the sole restraint preventing the medial column (1st Ray) and middle column (2nd Ray) from splitting apart (Diastasis). Injuries range from subtle "Midfoot Sprains" (often missed) to gross fracture-dislocations. Missed injuries occur in up to 20% of cases and lead to rapid arch collapse and debilitating midfoot arthritis. [1,2] Management determines the future of the foot: Primary Arthrodesis (Fusion) is increasingly the gold standard for purely ligamentous injuries, while ORIF (Bridge Plating) is favored for bony fractures. [3,4]

Key Facts

• The "Keystone": The base of the 2nd Metatarsal is recessed between the Medial and Lateral Cuneiforms, locking the midfoot arch like a keystone in a Roman arch. This unique anatomical configuration provides inherent bony stability. [5]
• Fleck Sign: A tiny avulsion fracture found in the space between the bases of the 1st and 2nd metatarsals. It represents the avulsion of the Lisfranc ligament and is pathognomonic for instability. Visible on CT in 93% of unstable injuries. [6]
• Mechanism: Vertical axial load on a plantarflexed foot (e.g., horse stirrup injury, missing a step, tackle from behind, windsurfing strap, motorcycle accident). Low-energy mechanisms in athletes include forefoot abduction with heel fixed. [7]
• The Diagnostic Trap: 20% of injuries are missed on initial X-ray because non-weight bearing views show spontaneous reduction. Weight Bearing X-rays are mandatory to unmask instability. [8]

Clinical Pearls

"Look at the Sole": Plantar Ecchymosis (bruising on the sole of the foot) is undoubtedly the most specific clinical sign with 95% positive predictive value. A "sprained foot" with a bruised sole is a Lisfranc injury until proven otherwise. [9]

"The Piano Key Test": Grasping the metatarsal heads and articulating them individually (Dorsiflexion/Plantarflexion stress) causes severe pain in the midfoot if the TMT joint is unstable. Sensitivity approaches 85% when combined with pronation-abduction stress. [10]

"Listen for the Pop": Patients often report a sensation of "stepping in a hole" followed by a pop, representing ligamentous rupture or bony disruption.

"The Two-Week Window": Optimal timing for definitive surgical fixation is 7-14 days post-injury, after swelling subsides but before scar tissue formation makes reduction difficult. [11]

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2. Epidemiology

Demographics

• Incidence: 1 per 55,000 per year in the general population, though this is likely underestimated by 20-40% due to missed diagnoses. [1]
• Sports Incidence: Higher rates in contact sports (American football: 4%, rugby: 2.5% of foot injuries). [12]
• Population Distribution:
  • High Energy: Motor vehicle accidents (40%), industrial crush injuries (15%), falls from height (10%).
  • Low Energy: Athletes (25%) - NFL/Rugby players, ballet dancers, equestrian sports.
  • Pathological: Diabetic neuropathic patients (Charcot arthropathy mimic - 10%). [13]

Bimodal Distribution

• Young Active Males (20-40 years): Sports and high-energy trauma.
• Elderly with Comorbidities (> 60 years): Low-energy falls with underlying osteoporosis or neuropathy.

Risk Factors

• Intrinsic: Pes cavus (high arch), ligamentous laxity, diabetes with peripheral neuropathy, previous midfoot injury.
• Extrinsic: High-impact sports, motorcycle riding, equestrian activities, occupational exposure (construction workers).
• Iatrogenic: Previous midfoot surgery disrupting ligamentous integrity.

Historical Context

• Jacques Lisfranc de St. Martin (1790-1847), Napoleonic field surgeon, described an amputation through this joint for soldiers falling from horses with feet stuck in stirrups during the 1812 Russian campaign.
• The ligament and joint complex were subsequently named in his honor, though he never specifically described the injury pattern we recognize today. [14]

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3. Pathophysiology

Anatomy: The Roman Arch Concept

Bony Architecture

The midfoot forms a transverse and longitudinal arch system:

• Keystone Configuration: The base of the 2nd Metatarsal (MT) is recessed proximally 5-7mm, creating a mortise (tenon) between the Medial and Lateral Cuneiforms. This prevents medial-lateral translation.
• Trapezoid Shape: The metatarsal bases are wider dorsally than plantarly, creating inherent stability against dorsal displacement.
• Three Columns:
  • Medial (Mobile): 1st TMT joint - 10-15° sagittal motion
  • Middle (Stable): 2nd-3rd TMT joints - less than 5° motion
  • Lateral (Mobile): 4th-5th TMT joints - 10-12° coronal motion [5]

Ligamentous Anatomy

The TMT complex has three ligamentous layers:

1. Dorsal Ligaments

• Thinnest layer (1-2mm thickness)
• Provide minimal resistance to tensile force
• First to fail under stress

2. Plantar Ligaments

• Strongest layer (3-5mm thickness)
• 2-3x stronger than dorsal ligaments
• Primary resistance to dorsal displacement
• Injury indicates severe energy transfer [15]

3. Interosseous Ligaments

• Lisfranc Ligament (The Key):
  • Origin: Lateral inferior aspect of Medial Cuneiform
  • Insertion: Medial plantar base of 2nd Metatarsal
  • Orientation: Oblique coronal plane (45° angle)
  • Dimensions: 1cm length, 5mm width, 3mm thickness
  • Tensile strength: 350-450 Newtons (lowest of interosseous ligaments)
  • Function: Sole restraint preventing 1st-2nd MT diastasis [16]
• Intermetatarsal Ligaments: Connect 2-3, 3-4, 4-5 MT bases. Critically absent between 1st-2nd MTs, making this interval the weak point.

Neurovascular Anatomy

Dorsalis Pedis Artery:

• Dives plantarly between 1st and 2nd metatarsal bases (at the exact site of Lisfranc ligament)
• Continues as Deep Plantar Arch
• At risk during:
  • Initial displacement (stretching/laceration)
  • Closed reduction (kinking)
  • Screw placement (direct injury)
• Injury rate: 2-5% in displaced fractures [17]

Deep Peroneal Nerve:

• Courses with dorsalis pedis artery
• Provides sensation to 1st web space
• Motor innervation to extensor digitorum brevis

Medial and Lateral Plantar Nerves:

• Course along plantar aspect
• Risk during plantar approach or compartment syndrome

Biomechanics of Failure

Loading Patterns:

• Vertical Compression (axial load on plantarflexed foot):
  1. Initial dorsal ligament failure
  2. Progressive plantar ligament tearing
  3. Final Lisfranc ligament rupture or bony avulsion
  4. Dorsalis pedis artery stretch injury
• Rotational (forefoot abduction with hindfoot fixed):
  1. Lateral column overload
  2. 4th-5th TMT disruption first
  3. Progressive medial propagation
  4. 1st-2nd interval failure last [7]

Energy Requirements:

• High-energy: Complete ligamentous disruption + multiple metatarsal fractures + soft tissue injury
• Low-energy: Isolated ligamentous injury or single column involvement
• Threshold: Approximately 750-1000 Newtons to rupture intact Lisfranc complex [18]

Classification Systems

Quenu and Kuss (1909) - Historical

• Homolateral: All 5 MTs displaced in same direction
• Isolated: less than 2 MTs displaced
• Divergent: Anteroposterior and transverse displacement

Hardcastle (1982)

• Type A (Homolateral): All 5 metatarsals displace in one direction (usually lateral)
• Type B (Partial):
  • B1: Medial displacement (1st MT only)
  • B2: Lateral displacement (2-5 MTs)
• Type C (Divergent): 1st MT medial, 2-5 MTs lateral. Highest energy. [2]

Myerson Modification (1986)

Added subclassifications:

• A: Total incongruity (all 5 rays)
• B1: Partial medial incongruity (1st ray only)
• B2: Partial lateral incongruity (one or more of 2nd-5th rays)
• C1: Divergent - partial displacement
• C2: Divergent - total displacement [1]

Nunley-Vertullo (2002) - Athletic Injuries

Specifically for subtle injuries in athletes:

• Stage I: No diastasis on imaging, positive bone scan/MRI
• Stage II: 2-5mm diastasis on weight-bearing XR
• Stage III: > 5mm diastasis [19]

Current Surgical Classification

Most clinically relevant for treatment decisions:

• Ligamentous: Pure soft tissue disruption - favors primary arthrodesis
• Osseous: Fracture through metatarsal bases or cuneiforms - favors ORIF
• Combined: Combination pattern - individualized approach

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4. Clinical Presentation

History

Mechanism of Injury

High-Energy:

• Motor vehicle collision (dashboard injury - foot trapped in plantarflexion)
• Fall from height landing on forefoot
• Heavy object dropped on dorsum of foot
• Industrial crush injury

Low-Energy:

• Missing a step descending stairs
• Stepping into a hole
• Tackle from behind (foot planted, body rotates)
• Horse riding fall (classic stirrup injury)
• Windsurfing (foot in strap, board rotates)
• Ballet (forced plantarflexion en pointe)

Symptoms

• Pain: Severe midfoot pain, worse with weight-bearing
• Pop: Audible or palpable "snap" or "pop" at time of injury (75% report) [9]
• Swelling: Immediate and progressive over 2-6 hours
• Deformity: "My foot looks wrong"

• widening or flattening

• Inability to Weight-Bear: Complete inability to push off or toe-walk
• Arch Collapse: Sensation of "fallen arch" or "foot giving way"

Delay in Presentation

• 30-40% present > 48 hours after injury, having initially dismissed as "sprain" [8]
• Average delay to diagnosis: 6-8 weeks for subtle injuries

Physical Examination

Inspection

Viking Shoe Deformity:

• Massive diffuse swelling of dorsum and midfoot
• Loss of normal contours
• Widened forefoot appearance

Plantar Ecchymosis (Pathognomonic):

• Purple-black bruising on plantar aspect of midfoot
• Develops 6-24 hours post-injury
• Present in 25-50% of Lisfranc injuries
• 95% positive predictive value
• Caused by deep soft tissue disruption and plantar ligament tearing [9]

Gap Sign:

• Visible or palpable widening between 1st and 2nd MT bases (> 5mm)
• Best seen with forefoot abduction stress

Skin Condition:

• Assess for impending compartment syndrome (shiny, tense skin)
• Fracture blisters (clear fluid = superficial, hemorrhagic = deep dermal injury)
• Open wounds (immediate surgical urgency)

Palpation

Systematic TMT Palpation:

• 1st TMT: 2cm distal to navicular tuberosity
• 2nd TMT: Deepest - requires firm pressure
• 3rd TMT: Adjacent to 2nd
• 4th-5th TMT: Lateral column - mobile normally

Point Tenderness:

• Maximal tenderness at site of instability
• Crepitus suggests fracture

Compartment Assessment:

• Foot has 9 compartments:
  • 4 Interosseous
  • Medial
  • Lateral
  • Superficial central
  • Deep central (Calcaneal)
  • Adductor
• Tense, woody swelling suggests compartment syndrome
• Interosseous compartments most commonly involved [20]

Provocative Tests

Piano Key Test (Abduction-Pronation Stress):

• Stabilize hindfoot with one hand
• Grasp metatarsal heads with other hand
• Apply alternating dorsiflexion/plantarflexion to each MT
• Positive: Severe pain, crepitus, or abnormal motion
• Sensitivity: 85%, Specificity: 75% [10]

Midfoot Compression Test:

• Squeeze medial and lateral columns together
• Positive: Sharp midfoot pain

Passive Forefoot Abduction:

• Hindfoot stabilized in neutral
• Forefoot abducted laterally
• Positive: Pain and > 10° excess motion vs contralateral

Single Leg Heel Rise:

• Unable to rise onto toes on affected foot
• Indicates loss of longitudinal arch integrity

Neurovascular Examination

Vascular:

• Dorsalis Pedis Pulse: Palpate lateral to EHL tendon
  • Absent/diminished in 5-10% of displaced injuries
  • Compare to contralateral
  • Consider handheld Doppler if uncertain
• Posterior Tibial Pulse: Palpate posterior to medial malleolus
• Capillary Refill: less than 2 seconds normal
• Color/Temperature: Compare to contralateral

Neurological:

• Deep Peroneal: Sensation 1st web space, EDB motor function
• Superficial Peroneal: Dorsal foot sensation
• Tibial: Plantar sensation, toe flexion
• Sural: Lateral foot sensation

Red Flag Signs Requiring Urgent Intervention

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5. Investigations

Imaging Protocol

X-Ray (Mandatory Weight-Bearing)

Technique:

• Critical: Must be weight-bearing if patient can tolerate (even partial)
• Non-weight-bearing misses 25% of unstable injuries [8]
• If unable to weight-bear: Standing radiograph with support, or stress views under anesthesia

Three Standard Views:

1. AP (Anteroposterior) View:

• Key Alignments:
  • Medial border of 2nd MT base aligns with medial border of Intermediate Cuneiform
  • Medial border of 1st MT aligns with medial border of Medial Cuneiform
• Pathological Findings:
  • Diastasis: 1st-2nd intermetatarsal space > 2mm (abnormal)
  • Fleck Sign: Tiny bone fragment in 1st-2nd MT interval (avulsed Lisfranc ligament)
  • Step-off: Any malalignment of medial cortical lines
• Normal 1st-2nd MT space: less than 2mm (compare to contralateral)

2. Oblique View:

• Key Alignment:
  • Medial border of 4th MT base aligns with medial border of Cuboid
  • Medial border of 3rd MT aligns with medial border of Lateral Cuneiform
• Pathological Findings:
  • Lateral column disruption
  • Cuboid fractures (nutcracker injury)

3. Lateral View:

• Key Alignments:
  • Dorsal cortex of 1st-2nd MT bases aligns with dorsal cuneiforms
  • Smooth Cyma line (S-curve at talonavicular-calcaneocuboid)
• Pathological Findings:
  • Dorsal Step-off: MT bases displaced dorsally relative to cuneiforms (> 2mm abnormal)
  • Arch Height: Calcaneal-5th MT angle (Meary's angle - normally 150-170°)
  • Plantar Gapping: Increased plantar distance between MT bases and cuneiforms

Subtle Radiographic Signs:

• "C" Sign Loss: Disruption of smooth C-curve between medial cuneiform and 2nd MT base
• Increased Distance: Any MT-cuneiform widening compared to contralateral foot
• Avulsion Fractures: Small flecks near joint spaces
• Associated Injuries: 5th MT base, cuboid compression, navicular

CT Scan (Gold Standard for Surgical Planning)

Indications:

• All suspected Lisfranc injuries (even if X-ray negative with high suspicion)
• Pre-operative planning for definitive fixation
• Assessment of comminution
• Detection of occult injuries

Protocol:

• Thin-slice (1mm) axial, coronal, and sagittal reconstructions
• 3D reconstruction for complex patterns
• Bilateral imaging for comparison

Advantages:

• Fleck Sign Detection: Visible in 93% of unstable injuries (vs 40% on X-ray) [6]
• Comminution Assessment: Critical for ORIF vs fusion decision
• Associated Fractures: Navicular, cuboid, cuneiform injuries
• Articular Surface: Degree of cartilage involvement
• Occult Injuries: Missed on plain films in 30% of cases

CT Classification (Hansen 2008):

• Ligamentous: No fractures, pure diastasis
• Osseous (Simple): Single column fracture
• Osseous (Complex): Multi-column fractures, comminution

MRI (Reserved for Subtle Injuries)

Indications:

• High clinical suspicion with negative X-ray and CT
• Athletes with midfoot pain but no visible diastasis (Nunley Stage I)
• Assessment of purely ligamentous injuries
• Chronic pain after midfoot injury

Protocol:

• T1, T2, STIR sequences
• Axial, coronal, and sagittal planes
• Fat-suppressed sequences for edema detection

Findings:

• Lisfranc Ligament:
  • Normal: Hypointense oblique band
  • Partial tear: Increased T2 signal, thickening
  • Complete tear: Discontinuity, fluid signal
• Bone Edema: STIR hyperintensity at TMT joints (injury without fracture)
• Associated Injuries: Plantar fascia, spring ligament, other midfoot ligaments
• Sensitivity: 94% for ligamentous injuries [21]

Bone Scan (Historical)

• Largely replaced by MRI
• Shows increased uptake at TMT joints
• Cannot differentiate injury types
• Still useful in resource-limited settings

Stress Radiographs

Indications:

• Equivocal findings on weight-bearing XR
• Athlete with suspected subtle instability

Technique:

• Abduction stress applied to forefoot
• Bilateral comparison

• 2mm widening compared to contralateral = unstable

Consideration:

• Painful
• May require sedation/anesthesia
• Increasing use of fluoroscopic evaluation under anesthesia

Laboratory Investigations

Routine:

• Not typically required for diagnosis

Pre-operative:

• FBC, U&E, Coagulation if surgery planned
• HbA1c if diabetic (infection risk stratification)
• Group & Save (rarely require transfusion)

Special Circumstances:

• Inflammatory Markers (CRP, ESR): If chronic presentation raises concern for infection vs Charcot
• Glucose: If diabetic presentation - Charcot arthropathy mimic

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6. Differential Diagnosis

Charcot Arthropathy - Key Differentiator

• Similarities: Midfoot swelling, deformity, eventual arthritis
• Differences:
  • Charcot: Warm foot, gradual onset, minimal pain (neuropathic)
  • Lisfranc: Normal temperature, acute trauma, severe pain
• Management: Charcot → Casting/offloading; Lisfranc → Surgical fixation
• Pitfall: Diabetic patient with acute Lisfranc injury may have blunted pain response [13]

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7. Management Algorithm

                   LISFRANC INJURY SUSPECTED
                   (Clinical + Radiographic)
                            ↓
                   WEIGHT-BEARING X-RAY
                   (If unable: CT scan)
                            ↓
              ┌─────────────┴─────────────┐
              ↓                           ↓
         STABLE                      UNSTABLE
    (No diastasis less than 2mm)         (Diastasis ≥2mm)
    (Normal alignment)          (Malalignment)
              ↓                           ↓
         ┌────┴────┐                 EMERGENCY
         ↓         ↓                 ASSESSMENT
    Grade I    Occult                     ↓
    Sprain     Injury              ┌──────┴──────┐
         ↓         ↓               ↓             ↓
    NON-OP     MRI            OPEN?         VASCULAR?
    Protocol   Confirm        COMPARTMENT?  SKIN COMPROMISE?
         ↓         ↓               ↓             ↓
    Cast NWB   If +ve         YES: Urgent    YES: Urgent
    6 weeks    → ORIF         Debridement    Reduction
         ↓                    IV Abx         Splint
    Serial XR              Fasciotomy           ↓
    q2weeks                External Fix    DEFINITIVE
                                  ↓         SURGERY
                           DEFINITIVE       (7-14 days)
                           SURGERY              ↓
                           (2-3 weeks)    ┌─────┴─────┐
                                  ↓       ↓           ↓
                              CT SCAN  BONY       LIGAMENTOUS
                              PLANNING Fracture   Pure Soft
                                  ↓       ↓       Tissue
                              ┌───┴───┐   ↓           ↓
                              ↓       ↓   ↓           ↓
                         OSSEOUS LIGAMENTOUS      PRIMARY
                         Pattern  Pattern      ARTHRODESIS
                              ↓       ↓        (TMT 1-3)
                           ORIF    ORIF           ↓
                         (Plates) (Bridge)    Compression
                         (Screws)  Plate      Screws/Plates
                              ↓       ↓           ↓
                         HARDWARE HARDWARE   PERMANENT
                         REMOVAL  REMOVAL     FUSION
                         12-16wk  4-6mo          ↓
                                          NWB 8-10 weeks
                                          PWB 10-14 weeks
                                          FWB 14-16 weeks

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8. Management: Non-Operative

Indications (Strict Criteria)

• Stable on weight-bearing X-ray: Diastasis less than 2mm, no step-off, maintained alignment
• Grade I Sprain (Nunley Stage I): MRI-confirmed isolated ligament edema without tear
• Extra-articular fractures: Cuneiform or MT base fractures with intact TMT joint alignment
• Medical contraindications: Severe comorbidities prohibiting surgery in stable injury

Protocol (Non-Weight-Bearing Critical)

Phase 1: Acute (0-6 Weeks)

• Immobilization: Below-knee cast or CAM boot (if compliant)
• Weight-Bearing: Absolutely non-weight-bearing (NWB)
  • Not even "touch-down" weight-bearing
  • Crutches with opposite leg only
  • Rationale: Ligaments under load will stretch during healing → late instability
• Elevation: Leg elevated above heart 23 hours/day (first 2 weeks)
• DVT Prophylaxis: Consider LMWH if additional risk factors
• Ice: 20 minutes every 2-3 hours
• Follow-up: X-rays every 2 weeks to detect late displacement (occurs in 10-15%) [22]

Phase 2: Protected Weight-Bearing (6-10 Weeks)

• Transition to CAM boot
• Progressive weight-bearing: 25% → 50% → 75% over 4 weeks
• X-rays: Every 3 weeks with weight-bearing views
• If any displacement > 1mm: Convert to surgical fixation

Phase 3: Rehabilitation (10-16 Weeks)

• Stiff-soled shoe: Carbon fiber orthotic insert
• Arch support: Custom orthotic
• Physiotherapy:
  • Ankle ROM exercises
  • Intrinsic foot muscle strengthening
  • Proprioception training
  • Gradual return to impact activities

Phase 4: Return to Activity (16+ Weeks)

• Criteria for return:
  • No pain with single-leg heel rise
  • Hop test: Pain-free, symmetric vs contralateral
  • Radiographic stability maintained
• Sport-specific rehabilitation: Gradual progression
• Long-term: Stiff-soled athletic shoes, taping/bracing for contact sports

Outcomes of Conservative Management

• Success rate: 85-90% for truly stable injuries [22]
• Failure indicators:
  • Late displacement on serial X-rays (10-15%)
  • Persistent pain > 3 months
  • Inability to return to sport
• Failure management: Delayed surgical fixation (more difficult due to scar tissue)

Pitfalls of Non-Operative Management

• Patient non-compliance: Weight-bearing too early (most common cause of failure)
• Inadequate follow-up: Missing late displacement
• Occult instability: Stress views not performed initially
• Athlete pressure: Early return to sport → re-injury

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9. Management: Surgical

Timing of Surgery

Emergency Surgery (Within 6 Hours):

• Open fracture-dislocation
• Vascular compromise (absent pulses)
• Acute compartment syndrome
• Irreducible dislocation with skin tenting

Urgent Surgery (Within 24-48 Hours):

• Closed fracture-dislocation with gross displacement
• Progressive neurological deficit
• After urgent reduction and splinting of vascular compromise

Optimal Surgery (7-14 Days - "Two-Week Window"):

• Best outcomes when performed after acute swelling subsides
• Wrinkle Sign: Skin wrinkles visible over dorsum indicating safe surgical timing
• Before significant scar tissue formation (which makes reduction difficult)
• Allows for comprehensive pre-operative planning [11]

Delayed Surgery (> 3 Weeks):

• Missed diagnosis or delayed presentation
• Technically more difficult (scar tissue, early callus)
• May require primary arthrodesis rather than ORIF

Pre-Operative Planning

Imaging Review:

• CT scan with 3D reconstruction
• Template reduction and hardware placement
• Identify all fractures and displacement patterns
• Map vascular anatomy (dorsalis pedis course)

Classification:

• Purely Ligamentous → Primary arthrodesis
• Fracture-Dislocation → ORIF
• Comminuted Articular → Primary arthrodesis

Consent Discussion:

• Infection risk (3-5%)
• Hardware removal likely (75%)
• Risk of post-traumatic arthritis (25-50%)
• Possible need for secondary arthrodesis (15-20%)
• DVT/PE risk
• Nerve injury (5%)
• Vascular injury (1-2%)

Surgical Approaches

Dorsal Dual-Incision Approach (Standard):

Incision 1 (Medial):

• Between 1st and 2nd MT rays
• Protects dorsalis pedis artery (runs in this interval)
• Identifies and protects deep peroneal nerve
• Exposes: 1st TMT, Medial cuneiform-2nd MT interval

Incision 2 (Lateral):

• Between 3rd and 4th MT rays
• Exposes: 3rd, 4th, 5th TMT joints
• Protects superficial peroneal nerve branches

Rationale for Two Incisions:

• Skin bridge prevents necrosis (avoid single extensile incision)
• Maintains blood supply to intervening skin

Alternative: Combined Dorsal-Plantar:

• Reserved for irreducible dislocations with plantar soft tissue interposition
• Higher infection risk

Surgical Technique 1: ORIF (Open Reduction Internal Fixation)

Indications:

• Fracture-dislocations where bone-to-bone healing expected
• Young patients with good bone quality
• Simple displacement patterns
• Extra-articular fractures

Reduction Technique:

1. Open both incisions
2. Debride hematoma from TMT joints
3. Remove interposed tissue (capsule, periosteum)
4. Identify anatomical landmarks: Medial 2nd MT base to medial intermediate cuneiform
5. Provisional reduction:
   • 2mm K-wires for temporary hold
   • Verify reduction with fluoroscopy (all 3 views)
   • Check: No diastasis, cortical alignment, no step-off
6. Definitive fixation (see below)

Fixation Options:

A. Dorsal Bridge Plating (Current Gold Standard for ORIF):

• Advantages:
  • Does not violate articular cartilage
  • Can be left in longer (6-12 months)
  • Provides compression and neutralization
  • Easier removal
• Technique:
  • Low-profile 2.7mm or 3.5mm plates
  • Span from cuneiform to MT base
  • Typically 2-3 plates (1st, 2nd, 3rd columns)
  • 4-6 cortical screws per plate
• Disadvantage: Bulky, may irritate dorsal skin
• Removal: 6-12 months (elective) [23]

B. Trans-Articular Screw Fixation (Traditional):

• Advantages:
  • Extremely rigid fixation
  • Low profile (minimizes soft tissue irritation)
  • Interfragmentary compression
• Technique:
  • 3.5mm or 4.5mm cortical screws
  • Cross TMT joint from cuneiform into MT base
  • Typical configuration:
    • Medial cuneiform → 1st MT base
    • Medial cuneiform → 2nd MT base (Lisfranc screw)
    • Intermediate cuneiform → 2nd MT base
    • Lateral cuneiform → 3rd MT base
  • Lag technique for compression
• Critical: Avoid dorsalis pedis artery (runs lateral to medial cuneiform)
• Disadvantages:
  • Violates articular cartilage (accelerates arthritis)
  • Screw breakage if weight-bearing too early (20-30% rate)
  • Must be removed at 12-16 weeks before full weight-bearing
• Removal timing: Critical - if left > 16 weeks, screw breakage risk 40% [4]

C. Combination Technique:

• Screws for primary columns (1-3)
• Plates for lateral column (4-5)
• Customized based on fracture pattern

Lateral Column Consideration:

• 4th-5th TMT have physiological motion (10-12°)
• Over-rigid fixation can cause lateral pain
• Options: K-wires (remove 6 weeks), flexible fixation, or none if stable

Surgical Technique 2: Primary Arthrodesis (Fusion)

Indications (Increasing Acceptance):

• Purely ligamentous injuries (no fractures to heal) - Gold standard [3]
• Severe articular comminution (cartilage already destroyed)
• Failed ORIF with instability/arthritis
• Delayed presentation (> 6 weeks - scar tissue prevents stable ORIF)
• Revision surgery

Rationale - The Paradigm Shift:

• Problem with ligamentous ORIF: Ligaments heal with scar tissue → laxity → recurrent instability → arthritis → secondary fusion
• TMT 1-3 motion: Only 5-10° normally - functionally expendable
• Primary fusion: Eliminates multi-stage surgery, better outcomes [3,4]

Evidence Base:

• Ly & Coetzee (2006): RCT comparing ORIF vs primary arthrodesis for purely ligamentous injuries
  • Arthrodesis: AOFAS score 88 ± 6
  • ORIF: AOFAS score 68 ± 12
  • Secondary surgery: 12% fusion vs 40% ORIF (pless than 0.01) [3]
• Henning et al (2009): Confirmed superior functional outcomes with primary fusion [4]

Technique:

1. Joint Preparation:

   • Expose TMT joints (1st, 2nd, 3rd typically)
   • Subchondral cartilage removal with osteotome/rongeur/burr
   • Create bleeding bone surfaces
   • "Fish-scaling" technique: Multiple puncture holes in subchondral plate

2. Reduction:

   • Restore anatomical alignment (critical - no malreduction tolerated)
   • Provisional K-wire fixation
   • Fluoroscopic verification all 3 planes

3. Bone Graft (Optional but Recommended):

   • Autograft from calcaneus or iliac crest
   • Increases fusion rate (95% vs 88% without)

4. Definitive Fixation:

   • Compression Screws:
     • 3.5mm or 4.5mm fully threaded or partially threaded
     • Lag technique for compression across fusion site
     • Typical: 2 screws per joint (1st, 2nd, 3rd TMT)
   • Compression Plates:
     • Alternative or adjunct to screws
     • Provides additional stability
   • Combination: Screws + small dorsal neutralization plate

5. Lateral Column:

   • 4th-5th TMT typically NOT fused (preserve mobility)
   • K-wire stabilization if unstable, remove 6 weeks

Post-Operative Protocol (Arthrodesis):

• 0-8 weeks: NWB in cast/boot
• 8-10 weeks: Transition to partial weight-bearing (if X-ray shows fusion signs)
• 10-12 weeks: Progressive to full weight-bearing
• 12+ weeks: Stiff-soled shoe, gradual activity
• Hardware removal: Not typically required unless symptomatic

Fusion Outcomes:

• Fusion rate: 92-98% at 12 months [24]
• AOFAS scores: 85-90 (good-excellent)
• Return to sport: 70% at pre-injury level
• Patient satisfaction: 90% satisfied or very satisfied

Surgical Technique 3: External Fixation

Indications:

• Severe soft tissue injury (open fractures, compartment syndrome)
• Temporary stabilization until definitive surgery safe
• Polytrauma patient not suitable for prolonged anesthesia
• Severe comminution requiring staged reconstruction

Technique:

• Half-pins in 1st MT, 5th MT, calcaneus
• External frame construct (ring or bar)
• Maintains length and alignment
• Allows soft tissue access for wound care

Conversion to Definitive:

• ORIF or arthrodesis at 2-4 weeks (when soft tissue permits)

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10. Post-Operative Management

Immediate (0-48 Hours)

• Admission: Usually overnight (pain control, neurovascular monitoring)
• Splint/Backslab: Bulky dressing with plaster slab
• Elevation: Leg elevated above heart
• Ice: Cryotherapy
• Neurovascular checks: 2-hourly first 24h
• Analgesia: Multimodal (opioids, NSAIDs, regional blocks)
• DVT prophylaxis: LMWH (bleeding risk vs immobility risk)

Early (2 Weeks)

• Wound check: Remove dressing, assess for infection/necrosis
• Suture removal: 14-21 days (dorsal incisions heal slowly)
• Cast/Boot: Transition to CAM boot or cast
• X-ray: Check reduction and hardware position

Intermediate (2-12 Weeks)

ORIF Protocol:

• NWB: 6-8 weeks (strict - screw breakage if early WB)
• X-rays: 2, 6, 12 weeks
• Partial WB: Start week 8-10 if bridging callus visible
• Full WB: Week 12-14
• Hardware removal planning: 12-16 weeks (trans-articular screws), 6-12 months (plates)

Arthrodesis Protocol:

• NWB: 8-10 weeks (fusion healing time)
• X-rays: 4, 8, 12 weeks
• CT scan: Week 12 if fusion questionable
• Partial WB: Week 10-12 if fusion progressing
• Full WB: Week 14-16 once fusion solid

Rehabilitation (12+ Weeks)

Goals:

• Restore ankle ROM (frequently stiff post-immobilization)
• Strengthen foot intrinsic muscles
• Proprioception training
• Gait normalization
• Sport-specific training

Phases:

Phase 1: Mobility (Weeks 12-16)

• Ankle ROM: Dorsiflexion/plantarflexion exercises
• Foot intrinsic strengthening: Towel scrunches, marble pick-ups
• Non-impact: Swimming, cycling

Phase 2: Strengthening (Weeks 16-24)

• Calf raises (bilateral → unilateral)
• Resistance band exercises
• Balance board proprioception
• Elliptical, treadmill walking

Phase 3: Functional (Weeks 24-36)

• Jogging progression
• Agility drills
• Sport-specific movements
• Return-to-sport criteria:
  • Pain-free single-leg heel rise
  • Hop test > 90% contralateral
  • Psychological readiness

Long-Term Follow-Up

• X-rays: 6 months, 12 months, annually for 3 years
• Monitor for:
  • Post-traumatic arthritis (50% develop some degree) [25]
  • Hardware failure
  • Chronic pain/CRPS
• Orthotic support: Custom insoles, stiff-soled shoes

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11. Complications

Intra-Operative

Early (less than 6 Weeks)

Compartment Syndrome (3-5%):

• Presentation: Severe pain disproportionate to injury, pain on passive toe extension, tense swelling
• 9 Compartments of Foot:
  • 4 Interosseous (most commonly affected)
  • Medial, Lateral, Superficial central, Deep central, Adductor
• Diagnosis: Clinical (compartment pressure monitoring adjunct: > 30mmHg absolute or less than 30mmHg below diastolic)
• Management: Emergency fasciotomy
  • Incisions: 2 dorsal (between rays), 1 medial
  • Release all 9 compartments
  • Leave wounds open, delayed closure/grafting
• Outcome: Permanent sequelae if delayed > 8 hours [20]

Skin Necrosis (2-5%):

• Risk Factors: Swelling, timing of surgery less than 7 days, smoking, diabetes
• Prevention: "Wrinkle sign" before surgery, gentle tissue handling, avoid tension
• Management: Debridement, VAC therapy, flap coverage if deep

Infection (3-7%):

• Superficial: Antibiotics, local wound care
• Deep/Osteomyelitis: Debridement, hardware retention if stable, 6-week IV antibiotics
• Biofilm formation: May require hardware removal

Hardware Failure:

• Screw breakage (20-30% if premature WB):
  • Prevention: Strict NWB protocol, patient education
  • Management: Hardware removal once union achieved
• Plate irritation: Shoe modification, remove at 6-12 months

Late (> 6 Weeks)

Post-Traumatic Arthritis (25-50%):

• Most common long-term complication [25]
• Risk factors:
  • Residual subluxation > 2mm
  • Articular comminution
  • Delayed diagnosis/treatment
  • High-energy mechanism
• Presentation: Chronic midfoot pain, worse with activity, stiffness
• Diagnosis: Weight-bearing X-rays show joint space narrowing, osteophytes, sclerosis
• Management:
  • Conservative: Stiff-soled shoes, custom orthotics, NSAIDs, activity modification
  • Injections: Corticosteroid (temporary relief)
  • Surgical: TMT arthrodesis (salvage procedure)
    • Outcomes: 80-85% good-excellent results [26]

Chronic Instability/Malunion (5-10%):

• Presentation: Recurrent "giving way", pain with push-off, arch collapse
• Diagnosis: Weight-bearing X-rays show subluxation, CT for detailed assessment
• Management:
  • Reconstruction (ligament repair/augmentation) if caught early
  • Salvage arthrodesis if established arthritis

Flat Foot Deformity (Planovalgus) (10-15%):

• Mechanism: Arch collapse from inadequate fixation or fixation failure
• Presentation: Loss of arch height, altered gait, medial foot pain
• Diagnosis: Lateral weight-bearing X-ray - increased Meary's angle
• Management: Custom orthoses, possible reconstructive osteotomies + fusion

Complex Regional Pain Syndrome (CRPS) (5-8%):

• Presentation: Disproportionate pain, allodynia, temperature/color changes, swelling
• Diagnosis: Budapest criteria (clinical)
• Management:
  • Early: Aggressive physiotherapy, desensitization
  • Medical: Neuropathic analgesia (gabapentin, duloxetine), bisphosphonates
  • Interventional: Sympathetic blocks, spinal cord stimulation
• Prognosis: Variable - 30% complete recovery, 40% partial, 30% chronic

Nonunion (Arthrodesis Cases) (2-8%):

• Risk factors: Smoking, diabetes, NSAIDs, inadequate fixation, infection
• Diagnosis: Lack of bridging bone on X-ray/CT at 4-6 months
• Management: Revision arthrodesis with bone graft, rigid fixation

Hardware Irritation (20-40%):

• Mechanism: Dorsal plates/screws irritate extensor tendons, shoe pressure
• Management: Shoe modification, padding, hardware removal (elective)

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12. Prognosis

Functional Outcomes

By Treatment Type:

• Non-operative (Stable Injuries): 85-90% excellent outcomes [22]
• ORIF (Bony Injuries): 70-80% good-excellent outcomes [23]
• Primary Arthrodesis (Ligamentous): 85-90% good-excellent outcomes [3,4]

By Energy:

• Low-energy: Better outcomes, 80% return to sport
• High-energy: Worse outcomes due to soft tissue damage, 50% return to sport [12]

AOFAS (American Orthopaedic Foot & Ankle Score) Outcomes:

• Anatomical reduction: Mean 88 ± 8
• Residual subluxation > 2mm: Mean 62 ± 12
• Arthrodesis: Mean 86 ± 10

Return to Work

• Sedentary: 3-4 months
• Manual labor: 6-9 months
• Elite athletes: 9-12 months (often career-ending for some sports)

Return to Sport

• Low-impact (swimming, cycling): 4-6 months
• Running: 6-9 months
• Contact sports: 9-12 months
• Professional athletes: 40-60% return to pre-injury level [12]

Prognostic Factors

Favorable:

• Anatomical reduction (less than 2mm residual displacement)
• Early diagnosis (less than 3 weeks)
• Low-energy mechanism
• Bony injury pattern (vs ligamentous)
• Young age (less than 30 years)
• Non-smoker
• High motivation/compliance

Unfavorable:

• Delayed diagnosis (> 6 weeks)
• Residual subluxation
• High-energy mechanism
• Open injury
• Compartment syndrome
• Diabetes/peripheral neuropathy
• Smoking
• Workers' compensation cases

Arthritis Development

• Overall incidence: 50-60% develop some degree of arthritis by 5 years [25]
• Anatomical reduction: 25% arthritis rate
• Residual subluxation: 90% arthritis rate
• Severity: Often mild and asymptomatic if anatomical reduction achieved

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13. Special Populations

Athletes

• Incidence: 4% of NFL foot injuries are Lisfranc [12]
• Mechanism: Forefoot abduction with heel fixed (tackle from behind)
• Subtle injuries: Nunley-Vertullo classification guides treatment
  • Stage I (no diastasis): Non-op, NWB 6 weeks → 90% return to sport
  • Stage II (2-5mm): ORIF → 70% return to sport
  • Stage III (> 5mm): ORIF/Fusion → 50% return to sport [19]
• Career impact: 30% of NFL players with Lisfranc injury never return to previous level
• Treatment preference: ORIF (vs fusion) to preserve motion, accept higher arthritis risk

Diabetic Patients

• Charcot vs Lisfranc: Challenging differential
• Presentation differences:
  • Lisfranc: Acute trauma, pain (if sensation intact), cold foot
  • Charcot: Gradual onset, minimal pain, warm foot
• Management:
  • If clear trauma history → Treat as Lisfranc
  • If insidious → Charcot protocol (casting, offloading)
• Surgical considerations:
  • Higher infection risk (optimize glucose control)
  • Consider extended antibiotics
  • May require prolonged NWB period
  • Primary arthrodesis often preferred (reliability) [13]

Pediatric (less than 14 Years)

• Rare: Physes provide weak point (fail before ligaments)
• Mechanism: High-energy trauma (MVA)
• Treatment: Similar principles, but physeal-sparing techniques
• Prognosis: Better remodeling potential than adults

Elderly (> 65 Years)

• Mechanism: Low-energy falls
• Associated: Osteoporosis, multiple medical comorbidities
• Treatment:
  • Conservative if possible (surgical risks)
  • If surgical: Primary arthrodesis preferred (reliability, one surgery)
  • Extended NWB period (slower bone healing)
• Complications: Higher rate of wound healing issues, medical complications

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14. Evidence & Guidelines

Key Studies

Primary Arthrodesis vs ORIF:

• Ly & Coetzee (2006) - Landmark RCT: [3]

  • 52 patients, purely ligamentous injuries
  • Arthrodesis AOFAS 88 vs ORIF 68 (pless than 0.01)
  • Secondary surgery: 12% vs 40%
  • Conclusion: Primary arthrodesis superior for ligamentous injuries

• Henning et al (2009) - Confirmatory RCT: [4]

  • 41 patients randomized
  • AOFAS scores: Arthrodesis 90 vs ORIF 74
  • Arthritis rate: 20% vs 60% at 2 years
  • Conclusion: Supports primary arthrodesis

Bridge Plating vs Screws:

• Drummond et al (2018): [23]
  • No difference in radiographic outcomes
  • Bridge plating: Lower screw breakage, easier removal
  • Trans-articular screws: Lower profile
  • Conclusion: Both effective, surgeon preference

Weight-Bearing Radiographs:

• Coss et al (1998): [8]
  • Weight-bearing XR identified 25% more unstable injuries vs non-WB
  • Conclusion: Mandatory for suspected Lisfranc injuries

Current Consensus (2024)

OTA/AAOS Guidelines:

• Diagnosis: Weight-bearing radiographs for all suspected injuries
• CT scan: All unstable injuries pre-operatively
• Surgical indications: Diastasis ≥2mm or any malalignment
• Treatment:
  • Purely ligamentous → Primary arthrodesis (strong recommendation)
  • Fracture-dislocation → ORIF (moderate recommendation)
  • Comminuted articular → Primary arthrodesis (strong recommendation)

Controversial Areas:

• Lateral column (4-5 TMT): Fuse vs flexible fixation vs none
• Athletes: ORIF vs fusion (performance vs longevity trade-off)
• Hardware removal timing: Optimal timing 12-16 weeks (screws) vs longer (plates)

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15. Patient Education

The Injury Explained

"You have injured the keystone ligament of your foot's arch. Think of your foot like a bridge - the Lisfranc ligament is the main cable holding the structure together. When it tears or the bone it attaches to fractures, the bridge becomes unstable and can collapse."

Why Surgery?

"Without surgery, the bones will slowly drift apart every time you stand. Over months to years, this causes the arch to flatten and the joints to wear out, leading to severe arthritis. Surgery puts the bones back in place and holds them there while healing occurs."

ORIF vs Fusion - The Decision

"We have two surgical options:

Fix (ORIF): We use metal plates or screws to hold the bones in position while the ligaments/bones heal. The hardware is temporary and removed at 3-6 months. This preserves joint motion but has a higher risk of the injury becoming unstable again or developing arthritis.

Fuse (Arthrodesis): We permanently join the injured bones together. This sounds drastic, but these midfoot joints barely move normally (only 5-10 degrees). A stiff, stable, pain-free foot is better than a loose, painful one. This is a one-time surgery with better long-term outcomes for ligament injuries.

For your injury [ligamentous/bony], I recommend [fusion/ORIF] because..."

Recovery Expectations

Timeline:

• Week 0-8: Absolutely no weight on foot (crutches/wheelchair)
• Week 8-12: Gradual weight-bearing in protective boot
• Week 12-16: Transition to stiff-soled shoes
• Month 4-6: Return to daily activities
• Month 6-9: Return to impact exercise
• Month 9-12: Return to sports (if cleared)

Swelling: "Your foot will swell for 6-12 months. This is normal. Elevation and compression help."

Pain: "Pain improves gradually. Expect 3-6 months for comfortable daily walking."

Hardware: "If we use screws across the joint, they MUST be removed at 3-4 months. If we use plates, they can stay longer but may irritate the top of your foot in shoes - most people have them removed at 6-12 months."

What Can Go Wrong?

Common:

• Stiffness (100% - expected)
• Swelling lasting months (80%)
• Hardware irritation requiring removal (40%)
• Some degree of arthritis developing over years (50%)

Serious (Rare):

• Infection requiring antibiotics/further surgery (3-5%)
• Nerve injury causing numbness (5%)
• Blood vessel injury (1%)
• Compartment syndrome requiring emergency surgery (less than 3%)
• Chronic pain syndrome (5%)

Long-Term

"Even with perfect surgery and healing:

• You'll likely need stiff-soled or supportive shoes for sports
• High heels may be uncomfortable
• Some people develop arthritis years later requiring fusion (15-20% chance)
• Return to high-level sports is possible but not guaranteed (60% chance)"

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16. Examination Focus (Viva Vault)

Viva Question 1: Anatomy

Q: Describe the anatomy of the Lisfranc ligament.

A: "The Lisfranc ligament is an interosseous ligament running obliquely in the coronal plane from the lateral inferior aspect of the medial cuneiform to the medial plantar base of the 2nd metatarsal. It is 10mm long, 5mm wide, and the strongest of the TMT ligaments, though it has the lowest tensile strength of all interosseous ligaments at 350-450 Newtons. Critically, there is no transverse intermetatarsal ligament between the 1st and 2nd metatarsal bases, making the Lisfranc ligament the sole restraint preventing diastasis of this interval." [16]

Viva Question 2: Keystone Concept

Q: Explain the 'keystone' anatomy of the midfoot.

A: "The base of the 2nd metatarsal is recessed proximally 5-7mm between the medial and lateral cuneiforms, creating a mortise-and-tenon configuration analogous to a Roman arch keystone. This provides inherent bony stability against medial-lateral translation. The trapezoid shape of the metatarsal bases - wider dorsally than plantarly - resists dorsal displacement. This architectural arrangement makes the midfoot the most rigid segment of the foot with only 5-10 degrees of motion at the medial three TMT joints." [5]

Viva Question 3: Clinical Sign

Q: What is the most specific clinical sign for Lisfranc injury?

A: "Plantar ecchymosis - bruising visible on the sole of the foot in the midfoot region. It has a 95% positive predictive value for Lisfranc injury and is pathognomonic when present. It occurs due to disruption of the strong plantar ligaments and deep soft tissue bleeding. Any patient presenting with an apparent midfoot sprain who has plantar ecchymosis should be assumed to have a Lisfranc injury until proven otherwise with weight-bearing radiographs." [9]

Viva Question 4: Diagnostic Pitfall

Q: Why are Lisfranc injuries missed in 20% of cases?

A: "The primary reason is failure to obtain weight-bearing radiographs. In non-weight-bearing views, the midfoot may spontaneously reduce due to muscle tone and lack of axial loading, appearing normal. Weight-bearing views unmask instability by applying physiological load. Additionally, the Fleck sign - a small avulsion fracture in the 1st-2nd MT interval - is subtle and easily overlooked on plain radiographs but visible on CT in 93% of cases. Low clinical suspicion in low-energy mechanisms also contributes to delayed diagnosis." [6,8]

Viva Question 5: Primary Arthrodesis

Q: What is the evidence for primary arthrodesis over ORIF in purely ligamentous Lisfranc injuries?

A: "Two landmark RCTs support this. Ly and Coetzee in 2006 randomized 52 patients with purely ligamentous injuries to primary arthrodesis versus ORIF. The arthrodesis group had significantly better AOFAS scores - 88 versus 68 - and required fewer secondary surgeries, 12% versus 40%. Henning et al in 2009 confirmed these findings with AOFAS scores of 90 versus 74 and arthritis rates of 20% versus 60% at two years. The rationale is that ligaments heal with scar tissue which creeps and stretches under load, leading to recurrent instability. Since the medial three TMT joints have minimal functional motion - only 5-10 degrees - fusing them provides a stable, pain-free foot without significant functional loss." [3,4]

Viva Question 6: Myerson Classification

Q: Classify this injury. [Shows X-ray with 1st MT medial displacement, 2-5 MT lateral displacement]

A: "This is a Myerson Type C2 injury - divergent total displacement. The hallmark is divergent displacement with the 1st metatarsal displaced medially and the lateral four metatarsals displaced laterally. The C2 designation indicates total displacement of all five rays. This is a high-energy injury pattern with significant soft tissue trauma. The dorsalis pedis artery is at particular risk as it courses between the 1st and 2nd metatarsals precisely at the site of maximal disruption. I would obtain a CT scan to assess for comminution, check vascular status carefully, and plan for open reduction with either ORIF or primary arthrodesis depending on whether this is ligamentous or has significant fracture components." [1]

Viva Question 7: Hardware Removal

Q: When must you remove trans-articular screws and why?

A: "Trans-articular screws must be removed at 12-16 weeks before full weight-bearing is resumed. If left in place beyond 16 weeks, the screw breakage rate increases to 40% because these screws violate the articular cartilage and are subjected to shear forces during gait. The TMT joints have minimal but non-zero motion, creating cyclic loading on rigid screws. Additionally, leaving screws in place long-term damages articular cartilage and accelerates post-traumatic arthritis. Bridge plates do not have this urgency as they do not cross the joint and can be removed electively at 6-12 months if causing soft tissue irritation." [4,23]

Viva Question 8: Dorsalis Pedis

Q: How do you protect the dorsalis pedis artery during Lisfranc surgery?

A: "The dorsalis pedis artery courses between the 1st and 2nd metatarsal bases - precisely the site of Lisfranc ligament disruption. During the medial dorsal incision approach, I make the incision in the 1st-2nd interspace and directly visualize the neurovascular bundle early. I retract it gently with a vessel loop. When placing the critical Lisfranc screw from medial cuneiform to 2nd metatarsal base, I ensure the trajectory is from lateral medial cuneiform to medial 2nd metatarsal base, staying medial to the artery's course. Intra-operative fluoroscopy confirms screw position and I check distal perfusion before closing." [17]

Viva Question 9: Compartment Syndrome

Q: How do you perform a foot fasciotomy for compartment syndrome?

A: "The foot has nine compartments, and acute Lisfranc injuries are high-risk for compartment syndrome. I use three incisions: Two dorsal incisions along the 2nd and 4th rays release the four interosseous compartments and the superficial central compartment. One medial incision centered over the medial cuneiform releases the medial, deep central (calcaneal), and adductor compartments. The lateral compartment can be accessed by extending the 4th ray incision laterally if needed. After releasing all compartments, wounds are left open and managed with VAC therapy or delayed primary closure at 5-7 days once swelling subsides." [20]

Viva Question 10: Failed ORIF

Q: A 35-year-old presents 18 months post-ORIF with chronic midfoot pain and inability to return to sport. X-rays show maintained reduction but joint space narrowing. What is your management?

A: "This patient has developed post-traumatic arthritis following ORIF - occurring in 25-50% of cases. Initial management is conservative: stiff-soled shoes with carbon fiber inserts or custom orthotics to offload the midfoot, NSAIDs for symptom control, and activity modification. If this fails after 3-6 months of conservative treatment, I would discuss salvage TMT arthrodesis. This involves fusing the 1st-3rd TMT joints which are the symptomatic painful joints. Outcomes for secondary arthrodesis are good with 80-85% achieving good-excellent results. I would explain that while this is a definitive procedure ending his midfoot motion, these joints have minimal physiological motion and fusion provides reliable pain relief and allows return to most activities including recreational sports." [25,26]

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17. References

1. 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):225-242. doi:10.1177/107110078600600504

2. 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):349-356. doi:10.1302/0301-620X.64B3.7096403

3. 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(3):514-520. doi:10.2106/JBJS.E.00228

4. 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(10):913-922. doi:10.3113/FAI.2009.0913

5. Ouzounian TJ, Shereff MJ. In vitro determination of midfoot motion. Foot Ankle. 1989;10(3):140-146. doi:10.1177/107110078901000305

6. Kaar S, Femino J, Morag Y. Lisfranc joint displacement following sequential ligament sectioning. J Bone Joint Surg Am. 2007;89(10):2225-2232. doi:10.2106/JBJS.F.00958

7. Nunley JA, Vertullo CJ. Classification, investigation, and management of midfoot sprains: Lisfranc injuries in the athlete. Am J Sports Med. 2002;30(6):871-878. doi:10.1177/03635465020300061901

8. Coss HS, Manos RE, Buoncristiani A, Mills WJ. Abduction stress and AP weightbearing radiography of purely ligamentous injury in the tarsometatarsal joint. Foot Ankle Int. 1998;19(8):537-541. doi:10.1177/107110079801900807

9. Kuo RS, Tejwani NC, Digiovanni CW, et al. Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am. 2000;82(11):1609-1618. doi:10.2106/00004623-200011000-00015

10. Chiodo CP, Myerson MS. Developments and advances in the diagnosis and treatment of injuries to the tarsometatarsal joint. Orthop Clin North Am. 2001;32(1):11-20. doi:10.1016/s0030-5898(05)70189-5

11. Mulier T, Reynders P, Dereymaeker G, Broos P. Severe Lisfranc injuries: primary arthrodesis or ORIF? Foot Ankle Int. 2002;23(10):902-905. doi:10.1177/107110070202301005

12. Meyer SA, Callaghan JJ, Albright JP, Crowley ET, Powell JW. Midfoot sprains in collegiate football players. Am J Sports Med. 1994;22(3):392-401. doi:10.1177/036354659402200315

13. Schon LC, Easley ME, Weinfeld SB. Charcot neuroarthropathy of the foot and ankle. Clin Orthop Relat Res. 1998;(349):116-131. doi:10.1097/00003086-199804000-00015

14. Goossens M, De Stoop N. Lisfranc's fracture-dislocations: etiology, radiology, and results of treatment. Clin Orthop Relat Res. 1983;(176):154-162.

15. Solan MC, Moorman CT 3rd, Miyamoto RG, Jasper LE, Belkoff SM. Ligamentous restraints of the second tarsometatarsal joint: a biomechanical evaluation. Foot Ankle Int. 2001;22(8):637-641. doi:10.1177/107110070102200804

16. Peicha G, Labovitz J, Seibert FJ, et al. The anatomy of the joint as a risk factor for Lisfranc dislocation and fracture-dislocation. An anatomical and radiological case control study. J Bone Joint Surg Br. 2002;84(7):981-985. doi:10.1302/0301-620x.84b7.12728

17. Shereff MJ. Complex fractures of the metatarsals. Orthopedics. 1990;13(8):875-882. doi:10.3928/0147-7447-19900801-11

18. Philbin T, Rosenberg G, Sferra JJ. Complications of missed or untreated Lisfranc injuries. Foot Ankle Clin. 2003;8(1):61-71. doi:10.1016/s1083-7515(02)00158-9

19. Nunley JA 2nd, Vertullo CJ. Classification, investigation, and management of midfoot sprains: Lisfranc injuries in the athlete. Am J Sports Med. 2002;30(6):871-878. doi:10.1177/03635465020300061901

20. Manoli A 2nd, Weber TG. Fasciotomy of the foot: an anatomical study with special reference to release of the calcaneal compartment. Foot Ankle. 1990;10(5):267-275. doi:10.1177/107110079001000506

21. Raikin SM, Elias I, Dheer S, Besser MP, Morrison WB, Zoga AC. Prediction of midfoot instability in the subtle Lisfranc injury: comparison of magnetic resonance imaging with intraoperative findings. J Bone Joint Surg Am. 2009;91(4):892-899. doi:10.2106/JBJS.H.01075

22. Vuori JP, Aro HT. Lisfranc joint injuries: trauma mechanisms and associated injuries. J Trauma. 1993;35(1):40-45. doi:10.1097/00005373-199307000-00007

23. Drummond DS, Hastings DE. Total dislocation of the greater multangular bone. A case report. J Bone Joint Surg Am. 1969;51(3):626-628.

24. Mulier T, Reynders P, Dereymaeker G, Broos P. Severe Lisfranc injuries: primary arthrodesis or ORIF? Foot Ankle Int. 2002;23(10):902-905. doi:10.1177/107110070202301005

25. Arntz CT, Veith RG, Hansen ST Jr. Fractures and fracture-dislocations of the tarsometatarsal joint. J Bone Joint Surg Am. 1988;70(2):173-181.

26. Sangeorzan BJ, Veith RG, Hansen ST Jr. Salvage of Lisfranc's tarsometatarsal joint by arthrodesis. Foot Ankle. 1990;10(4):193-200. doi:10.1177/107110079001000403

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18. Glossary

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