Stability at this joint level of the foot is the primary concern, and instability appears to be the primary pain generator. Because of the unpredictability of adequate ligamentous healing to support the foot, primary fusion of the medial three TMT joints has been advocated; however, studies have been inconsistent with regard to assessing open reduction with internal fixation (ORIF) versus primary arthrodesis (PA) for optimal acute treatment. [23, 24, 25]
In a study evaluating PA of the medial two or three TMT joints (n = 21) against ORIF (n = 20) in primarily ligamentous Lisfranc injuries, Ly et al reported that the PA group reached a postoperative activity level that was an estimated 92% of the preinjury level, whereas the ORIF group achieved an activity level that was only 65% of the preinjury level. [26, 27] They concluded that a stable PA seemed to have better short- and medium-term outcomes. It was unclear whether long-term results were improved.
Henning et al prospectively studied 40 patients who were randomly assigned to receive either primary ORIF (PORIF) or PA of the first, second, and third TMT joint combined with Kirschner-wire (K-wire) fixation of the fourth and fifth TMT joints. [28] At an average of 53 months postoperatively, 32 patients were interviewed by telephone. Using Short Form (SF)-36 and Short Musculoskeletal Function Assessment (SMFA) scores, the authors found no significant differences in patient satisfaction between the two groups.
Because of planned hardware removal in the PORIF group, the reoperation rate in this group was significantly higher than that in the PA group. [28] The PA group did have different complications from the PORIF group, including a nonunion and a delayed union, both of which were treated nonoperatively. Although this was a level 1 study, it was limited by sample size, a low rate of participation among eligible patients, and a 20% loss of patients to follow-up.
A meta-analysis of three randomized controlled trials by Smith et al demonstrated higher rates of removal of hardware with ORIF as compared with PA; there were otherwise no differences in risk for revision surgery, reported patient outcomes, or risk for nonanatomic reduction. [24]
A trial by Buda et al focused on the higher rate of removal of hardware seen in ORIF. [25] In this trial, removal of hardware was planned as part of the ORIF procedure. No difference in reoperation rates between ORIF and PA was noted.
Albright et al performed a cost-effectiveness analysis of PA versus ORIF and found that PA was significantly more cost-effective; the group cost for PA was $1429 per quality-adjusted life year (QALY), whereas that for ORIF was $3958/QALY. [29] In view of the relatively limited resources available to the field, this difference in cost-effectiveness may play a larger role in future surgical considerations.
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Radiograph illustrating diabetic patient with first ray instability of the right foot. The articular surfaces of the second and first metatarsal are level in the transverse plane, indicating proximal migration of the first ray. The left foot shows the advanced stage of an untreated Lisfranc injury with similar first ray instability.
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Clinical identification of typical plantar ecchymosis pattern observed in Lisfranc injuries.
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In this anteroposterior radiograph of a Lisfranc dislocation, note the disruption of the normal second tarsometatarsal alignment.
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In this lateral radiograph of a typical Lisfranc injury, note the malalignment of the metatarsal bases with the midfoot.
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In this medial oblique radiograph of a normal foot, note the medial borders of the cuboid and fourth metatarsal base. They should be even, as depicted by the black lines.
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In this medial oblique radiograph of a Lisfranc injury, note the loss of alignment between the cuboid and fourth metatarsal base (black lines). This is diagnostic of a Lisfranc injury and is as important as recognition of the second tarsometatarsal instability.
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Stress view. This patient, with a suspected Lisfranc injury, presents with a normal appearing anteroposterior radiograph of the foot. Plantar ecchymosis and clinical presentation of pain warrant further investigation. In this radiograph, alignment of the medial border of the second metatarsal and the medial cuneiform is near normal. Patient is unable to bear weight due to a femur fracture sustained in the same accident.
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In this stressed view, with adequate anesthesia to the patient, the foot is stressed in a medial/lateral plane. The forefoot is forced laterally with the hindfoot brought medially. Note that the second tarsometatarsal joint opens up, and the normal alignment between the medial border of the second metatarsal base and the middle cuneiform is distorted. This injury requires surgical stabilization.
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Standard anteroposterior radiograph demonstrates a Lisfranc fracture dislocation. Determining the extent of fracture involving the joint is difficult with plain radiographs.
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CT scan in the coronal plane can demonstrate the extent of injury at the joint. Compare with the plain radiograph of this injury in the related image. Note the plantar avulsion, suggesting severe disruption of the plantar ligamentous structures.
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This diagram depicts the suggested fixation order of placement and alignment of screws for surgical fixation of unstable Lisfranc injuries.
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Preoperative anteroposterior radiograph demonstrates a Lisfranc dislocation.
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Preoperative lateral radiograph demonstrates a Lisfranc dislocation.
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Postoperative anteroposterior radiograph demonstrates reduction and fixation of Lisfranc dislocation.
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Postoperative lateral radiograph illustrates placement of fixation screws for stabilization of Lisfranc joint.
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Preoperative anteroposterior radiograph demonstrates a Lisfranc injury with proximal tarsal instability. The medial cuneiform is displaced medially, bringing the joint line level with the second. The proximal anatomy must be restored and stabilized before addressing the tarsometatarsal joint.
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Postoperative anteroposterior radiograph demonstrates restoration of normal midfoot alignment. Screw fixation was used to stabilize the cuneiform prior to realigning the Lisfranc joint. Due to comminution of the second and third metatarsal shafts, Kirschner wires were used to hold their position. In this case, due to continued instability, a wire through the fourth tarsometatarsal joint was also used.
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Preoperative anteroposterior radiograph demonstrates a Lisfranc injury with associated distal fracture. Note the displacement of the base of the first metatarsal.
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Postoperative anteroposterior radiograph demonstrates fixation of the metatarsal, as well as stabilization of the Lisfranc joint.
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Preoperative anteroposterior radiograph demonstrates a missed old Lisfranc injury with subsequent valgus foot deformity and painful weight bearing throughout the midfoot.
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Preoperative lateral radiograph demonstrates loss of plantar integrity through Lisfranc joint area. The normal linear alignment of the bones from the metatarsal to the talus is lost, with a sag at the tarsometatarsal joint.
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In this postoperative anteroposterior radiograph demonstrating reduction of Lisfranc alignment and screw configuration for tarsometatarsal fusion, note that only the medial 3 joints are fused. The lateral 2 joints remain mobile and actually open up when compared with the previous pictures.
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Postoperative lateral radiograph demonstrates restoration of alignment with tarsometatarsal fusion.
