ORIF Lisfranc Injury (Tarsometatarsal Fracture-Dislocation)

Indication. Operative fixation is indicated for any injury that leaves the tarsometatarsal (TMT) complex unstable or incongruous: a displaced fracture-dislocation (greater than 2mm at any TMT joint), subtle instability on weight-bearing stress radiographs, a purely ligamentous injury with instability, and open injuries once the soft tissues have been controlled. Stable, non-displaced sprains that line up on weight-bearing films are managed non-operatively in a cast or boot. Work the injury up before you cut. Confirm the pattern and plan fixation with:

• Weight-bearing AP, oblique and lateral radiographs of BOTH feet (comparison views) — the global standard. Look for 1st–2nd intermetatarsal diastasis, loss of the medial MT2 / medial cuneiform line, and the "fleck sign" (an avulsed Lisfranc ligament fragment).
• CT for bony detail, occult fractures and surgical planning.
• MRI when the radiographs are normal but a purely ligamentous injury is suspected — it shows the Lisfranc ligament directly. The one decision that matters. Once you have decided to operate, the core manoeuvre is the same — an anatomic reduction of the medial and middle columns. What varies is how you hold it:

Consent specifically for post-traumatic arthritis (the most common late problem, 20–50 percent over 5–10 years even after anatomic fixation), wound problems over the skin bridge or prominent hardware, dorsalis pedis injury and foot ischaemia, compartment syndrome, and a likely second operation to remove transarticular screws. Many patients never regain full pre-injury performance — set realistic expectations. Setup. Supine with a bump under the ipsilateral hip (15–20 degrees) to neutralise the limb's external rotation; radiolucent table; thigh tourniquet (250–300mmHg, or about systolic plus 100mmHg). A thigh (not ankle) tourniquet is preferred because the deep dissection is dorsal and proximal. Foot at the end of the table or on a radiolucent triangle for full fluoroscopic access. Confirm and document the dorsalis pedis and posterior tibial pulses and the neurology before inflation. Loupe magnification helps nerve and vessel identification in the 1st–2nd intermetatarsal space.

The goal: reduce every TMT joint anatomically through two dorsal incisions, protecting the dorsalis pedis artery and deep peroneal nerve, and hold the reduction with screws, plates or a selective fusion. The exposure — two dorsal longitudinal incisions with a generous skin bridge — is laid out in full below (and in depth on the dorsal approach to the midfoot page).

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Rehabilitation | Phase | Timing | Immobilisation | Milestones | |-------|--------|----------------|------------| | 1 | 0–8 weeks | Strict non-weight-bearing in a below-knee cast or boot | Radiographs at 2, 6 and 12 weeks to confirm maintained alignment | | 2 | 8–12 weeks | Progressive weight-bearing in a boot (25 percent to 50 percent to 75 percent to full) | Transition to a supportive shoe with an arch-support orthosis at about 12 weeks | | 3 | 4–6 months | Supportive shoe and orthosis | Hardware removal if transarticular screws were used; return to ADLs | | 4 | 6–12 months | Orthosis for heavy tasks | Graded return to athletics; counsel that many never regain full performance | Transarticular screws must be removed at 4–6 months to restore TMT motion — permanent screws across these joints cause iatrogenic arthritis, the major disadvantage of screws versus plates or primary fusion. Dorsal plates can stay permanently if asymptomatic, and a primary fusion needs no second operation. Follow up at 6 months, 1 year, then annually to watch for post-traumatic arthritis; if it develops and is refractory to orthoses, activity modification and injection, a salvage fusion of the symptomatic joints (typically the 2nd and 3rd TMT, preserving the 1st and lateral column) gives good pain relief.

Epidemiology. Lisfranc injuries are uncommon — roughly 0.2 percent of all fractures, about 1 per 55,000 person-years — and notoriously under-recognised: 20–40 percent are missed or misdiagnosed at first presentation, especially low-energy athletic sprains. High-energy mechanisms (motor-vehicle crashes, falls from height, crush) produce the fracture-dislocations; subtle ligamentous injuries dominate the athletic population. Pathoanatomy — why diastasis happens. The Lisfranc ligament runs from the PLANTAR surface of the medial cuneiform (C1) to the base of the 2nd metatarsal — the strongest interosseous ligament of the midfoot. There is NO direct ligament between MT1 and MT2: the 1st metatarsal is held to the 2nd only indirectly through the cuneiforms. When the Lisfranc ligament fails, the 1st–2nd intermetatarsal space widens (diastasis) — the hallmark radiographic sign. Three columns and the keystone.

• Medial column — the 1st TMT; the most mobile (10–15 degrees of sagittal motion), so preserving motion matters.
• Middle column — the 2nd and 3rd TMT; the keystone. The 2nd metatarsal base is recessed proximally between the cuneiforms, forming a mortise analogous to the ankle. It is the most rigid, the least mobile, and the most commonly injured — so the most important to reduce anatomically.
• Lateral column — the 4th and 5th TMT; mobile and important for gait.

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