Lisfranc Fracture ORIF

Indication

The Lisfranc joint is located in the midfoot (Figure 1). The main indication for this procedure is a displaced or unstable Lisfranc fracture or dislocation. The purpose of the surgery is to reposition the bones and joints in the mid-part of the foot so that the associated torn ligaments (the strong tissues that hold these bones together and support the arch) can heal.

Figure 1: Lisfranc Joint

Lisfranc Joint

Procedure

The location of the incision is dictated by the location of the fracture and joints that are dirupted. If all five locations of the lisfranc joint are disrupted, then two incisions may need to be made on the top of the foot; one on the top inside and one on the top outside. If the first three tarsometatarsal joints are disrupted, then only one incision is made on the top inside aspect of the foot.

Once the disrupted tarsometatarsal joints are located, the dissection is carried down to the involved joints and the debris is cleaned out. The disrupted joints are then repositioned back to the position they were in prior to the injury. The joints are then fixed with strong screws. However, if the fragmentation is excessive, a plate may be required (Figure 2). One exception is a disruption of the 4th and 5th tarsometatarsal joints; in this case, the bone is provisionally fixed with wires. The wires are then removed after about six weeks so that some movement of these joints can be encouraged.

Figure 2

Lisfranc ORIF

Recovery

Recovery from surgery to fix a Lisfranc fracture, subluxation, or dislocation can vary depending on the severity fo the original injury and the stability of the fixation.However, a typical recovery might include:

0-6 (or 8) weeks Post-Surgery
The patient is non-weight bearing to allow for adequate healing. Not only do the bones need adequate healing, but the disrupted ligaments as well. The ligaments actually require a longer time to heal.

6 (or 8) – 10 (or 14) weeks Post-Surgery
The patient can being weight-bear as tolerated provided the foot is protected in a walking boot, such as a CAM walker. This boot (characterized by a rigid sole and a rocker-bottom contour) serves to disperse the force away from the middle of the foot and up the leg.

10 (or 14) + Post-Surgery
At the 10-14 week mark, the patient can then transition into a stiff soled shoe.

A displaced injury takes a number of months to recover. For most Lisfranc injuries about 70% of the recovery occurs in the first 6 months, but it is often a year or more before our patient has reached their point of maximal improvement following a significant Lisfranc injury.

Potential General Complications

Asymmetric Gait (leading to pain elsewhere)

Deep Vein Thrombosis (Blood Clot)

Failure to Resolve ALL Symptoms

Pulmonary Embolism (PE)

Wound Healing Problems

 

Potential Specific Complications

Nerve Injury

Injury to the nerves between the 1st and 2nd metatarsals (deep peroneal nerve) and on the top inside aspect of the 1st metatarsal (medial branch of the superficial peroneal nerve) can occur due to the placement of the incisions. Nerve injury can occur due to retraction, direct injury, or from scarring during the recovery process. If these nerves are injured or cut, the patient could end up with numbness or pain along the path of the nerve.

Broken Hardware

Although screws are inserted to help stabilize the joints, they are not fused together. Movement is encouraged through the healing process and the incorporated screws may have a potential to break. Although removal of the screws may be necessary, judgment is critical since removal of the screws will weaken the midfoot.

Midfoot Collapse

Related to the complication of broken hardware, if the screws are removed, the weakened midfoot has the potential to collapse through the tarsometatarsal joint.

Painful Hardware

Pain may be associated with the screws that are used to secure the joints. This occurrence is much higher in a lisfranc injury because the hardware has a higher tendency to be more prominent than other parts of the foot.

Edited August 2nd, 2009