The question of whether a Lisfranc injury requires surgery depends entirely on the severity of the damage to the midfoot structures. A Lisfranc injury is a disruption of the tarsometatarsal joint complex, which connects the midfoot to the forefoot, and can involve fractures, dislocations, or purely ligamentous tears. This spectrum of injury severity means that treatment can range from simple immobilization to complex surgical reconstruction. The decision for operative versus non-operative management is one that orthopedic surgeons make based on precise imaging and the degree of joint stability.
Understanding the Lisfranc Complex
The Lisfranc joint complex is a group of joints and strong ligaments that stabilize the midfoot and form the arch of the foot. The stability of this complex is maintained by a unique “keystone” configuration where the base of the second metatarsal bone is recessed between the three cuneiform bones.
The most important ligament is the Lisfranc ligament, which connects the medial cuneiform bone to the base of the second metatarsal bone on the plantar (sole) side of the foot. An injury here can range from a mild sprain to a complete rupture of the ligaments, often accompanied by fractures or a dislocation of the metatarsal bones. Injuries typically result from indirect forces, like twisting a foot that is pointed downward, or from high-impact trauma such as a motor vehicle accident or a fall from a height.
Determining the Need for Surgical Intervention
The decision to operate is primarily driven by the stability of the joint complex, which is assessed through imaging. An unstable injury means the bones have shifted or are likely to shift, which will prevent normal healing and lead to long-term complications.
Weight-bearing X-rays are a core diagnostic tool, as they reveal the alignment of the bones under normal load. If there is a widening, or diastasis, of more than two millimeters between the base of the first and second metatarsals, the injury is generally considered unstable and requires surgery. A CT scan may also be used to detect subtle, non-displaced fractures, while an MRI provides the best detail for assessing the extent of ligament damage.
Any fracture or dislocation that disrupts the anatomical alignment of the joints, or any sign of joint incongruity, is an indication for surgical intervention. Failure to restore the precise anatomical alignment of the midfoot can lead to chronic pain, arch collapse, and severe post-traumatic arthritis.
Non-Surgical Management Protocols
Non-surgical management is reserved strictly for stable injuries that show no significant displacement or complete ligamentous rupture. These stable injuries, often referred to as Lisfranc sprains, involve partial ligament tears without joint subluxation or widening beyond two millimeters.
The protocol requires strict non-weight-bearing in a cast or protective boot for a typical period of six to eight weeks. After the initial immobilization period, weight-bearing is gradually introduced, often with the use of a supportive insole.
Follow-up imaging is necessary to ensure the stable injury does not become unstable during recovery. If subsequent X-rays show any sign of displacement, the treatment plan must be immediately re-evaluated for surgical intervention. The entire recovery process, including physical therapy to restore strength and balance, can take three to four months before a return to full activity is possible.
Surgical Procedures and Recovery Outlook
When surgery is necessary, the primary objective is to achieve an accurate anatomical reduction of the joint and maintain that position while the structures heal. The two main surgical strategies employed are Open Reduction and Internal Fixation (ORIF) and Primary Arthrodesis (fusion).
Open Reduction and Internal Fixation (ORIF)
Open Reduction and Internal Fixation is typically used for acute injuries where the surgeon realigns the bones and uses metal hardware to hold the joint in place. This hardware is often temporary, and a second procedure is frequently required six to twelve months later to remove the implants. The advantage of ORIF is the preservation of joint movement, but it carries a higher risk of post-traumatic arthritis in the long term.
Primary Arthrodesis (Fusion)
Primary Arthrodesis, or joint fusion, involves removing the joint cartilage and permanently fusing the involved bones together. This procedure is often favored for chronic injuries, highly unstable injuries, or cases with severe joint fragmentation. Although fusion eliminates movement in the affected joints, it provides superior long-term stability, a lower rate of post-traumatic arthritis, and often better functional scores compared to ORIF.
Post-operative recovery for both procedures involves a non-weight-bearing period of six to eight weeks, followed by a gradual transition to weight-bearing in a boot. Full recovery can take six to twelve months. A significant long-term complication remains the development of post-traumatic arthritis, which may necessitate further surgical intervention later in life.