Lisfranc surgery: fixation, fusion and what to expect

When surgery is considered

For background on the injury, see Lisfranc injuries. The decision rests on whether the joint is stable. Stability is judged with weight-bearing X-rays and CT, and some injuries are checked under anesthesia.^[3,4,5] Surgery is generally advised when:

• the bones are displaced or the joint is unstable
• the injury is a fracture-dislocation
• imaging shows a gap between the bones, though surgeons use different measurements. In a review of 58 studies, the most common cutoff was 2 mm or more, with others using 1 mm or 3 mm^[6]
• a stable-looking injury later moves out of position in a cast^[7]

Some injuries need surgery urgently, particularly when severe swelling raises the risk of compartment syndrome.^[5]

The main types of operation

• Open reduction and internal fixation (ORIF). The surgeon realigns the bones through incisions on the top of the foot and holds them in place with screws or plates. There is a consensus toward bridge plating, in which a plate spans the joints.^[3] The hardware is sometimes removed later.^[3]
• Primary arthrodesis (fusion). The damaged joints are prepared and joined so they heal together. It gives up a small amount of movement in the midfoot, which normally moves little, in return for stability. It is often considered for purely ligament injuries.^[4,3]
• Flexible fixation. A suture button, a strong suture anchored across the joint, is another option for ligament injuries that holds the bones while allowing some natural motion.^[3]

Late problems after a Lisfranc injury, such as arthritis or a collapsed arch, may be treated with fusion. See foot and ankle joint fusion and replacement. For fractures elsewhere in the foot and ankle, see fracture surgery.

What do the results show?

• Fixation versus fusion. A meta-analysis of 18 studies found better pain and function scores after primary arthrodesis than after ORIF (average function score about 84 versus 76 out of 100, and pain about 1.4 versus 2.0 out of 10), a higher rate of return to pre-injury activity (79% versus 66%), and less post-traumatic midfoot arthritis (about 3% versus 17%). A few studies using other scoring tools favored ORIF.^[1]
• Reoperations. An earlier meta-analysis of two randomized trials and three observational studies (187 patients) found that ORIF was associated with a significantly higher need for revision surgery and more persistent pain, but with no significant difference in the pooled pain and function scores or infection rates.^[2]
• Which injuries. A review of the literature suggests that for unstable, purely ligamentous injuries, primary arthrodesis has better functional outcomes, fewer returns to the operating room and better cost-effectiveness, while for unstable injuries that involve bone fractures more research is needed before one operation can be recommended over the other.^[4]

Recovery

Recovery is slow, because the midfoot bears weight with every step. A typical plan is a splint or cast with no weight on the foot, a boot, then a gradual return to weight-bearing over weeks to months, followed by physical therapy. Hardware may need to be removed later, and it can take many months to return to sport or heavy work. The details depend on the injury and on the operation, and your surgeon will give you a timetable. See recovery after foot and ankle surgery and preparing for foot and ankle surgery.

Risks

Risks include infection, wound-healing problems, nerve irritation, stiffness, persistent pain, hardware that is prominent or breaks, joints that don’t fuse, loss of reduction, arthritis in the midfoot (more often after fixation than after fusion in the pooled data), a flattened arch, and the general risks of surgery, including blood clots.^[1,3] Swelling after a serious midfoot injury can also cause compartment syndrome, which needs urgent treatment.^[5] Delay in diagnosis and treatment is linked to poorer results.^[4]

Questions to ask before deciding

• Is my joint stable or unstable, and how was that decided?
• Would you recommend fixation or fusion for my injury, and why?
• Will I need the hardware removed?
• How long will I be off my foot, and when can I drive, work and return to sport?

When to seek care