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ORIF Lisfranc Injury (Tarsometatarsal Fracture-Dislocation)

Surgical technique guide for ORIF Lisfranc Injury (Tarsometatarsal Fracture-Dislocation) - FRCS exam preparation

Core Procedure
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High-yield overview

TWO DORSAL LONGITUDINAL INCISIONS: (1) Medial incision between 1st and 2nd metatarsals (8-10cm) exposing medial and middle columns (1st, 2nd, 3rd TMT joints), (2) Lateral incision over 4th metatarsal (6-8cm) exposing lateral column (4th and 5th TMT joints). Preserve skin bridge minimum 5-7cm to prevent necrosis. | advanced

Mnemonic

MEDIAL

Lisfranc Reduction Sequence

Mnemonic

LIS-FRANC

Critical Anatomy & Technical Points

Critical Danger Structures

Dorsalis Pedis Artery (HIGHEST RISK)

Location: Runs between 1st and 2nd metatarsals, only 0-5mm deep to skin in medial incision. Protection: Identify EARLY beneath EHB muscle; vessel loop; gentle retraction; injury causes foot ischemia requiring immediate vascular repair

Deep Peroneal Nerve

Location: Accompanies dorsalis pedis artery between MT1-MT2. Protection: Identify with artery; gentle retraction; injury causes 1st web space numbness (usually temporary neuropraxia if retraction-related)

Superficial Peroneal Nerve Branches

Location: Cross dorsum of foot superficially; intermediate and medial dorsal cutaneous branches at risk in both incisions. Protection: Careful subcutaneous dissection; loupe magnification; retract gently; avoid transection

Skin Bridge

Location: Between medial incision (MT1-MT2) and lateral incision (MT4). Protection: MINIMUM 5-7cm bridge; monitor for ischemia intraoperatively and postoperatively; necrosis may require flap coverage

Medial Plantar Nerve

Location: Deep to abductor hallucis on plantar-medial midfoot. Protection: Avoid plantar dissection; if plantar approach needed, identify and protect; injury causes medial plantar numbness and intrinsic weakness

Positioning and Preparation

Patient Position: Supine with bump under ipsilateral hip (15-20 degrees rotation) to neutralise external rotation of the limb, radiolucent table, thigh tourniquet (typically 250-300mmHg, or systolic plus 100mmHg), foot at end of table or on a radiolucent triangle for fluoroscopy access. A calf/thigh tourniquet is preferred over an ankle tourniquet because the deep dissection is dorsal and proximal. Confirm distal pulses (dorsalis pedis, posterior tibial) and document neurovascular status before inflation

Surgical Approach: TWO DORSAL LONGITUDINAL INCISIONS: (1) Medial incision between 1st and 2nd metatarsals (8-10cm) exposing medial and middle columns (1st, 2nd, 3rd TMT joints), (2) Lateral incision over 4th metatarsal (6-8cm) exposing lateral column (4th and 5th TMT joints). Preserve skin bridge minimum 5-7cm to prevent necrosis.

Incision: Dual dorsal longitudinal incisions: (1) 8-10cm between MT1-MT2 for medial/middle columns, (2) 6-8cm over MT4 for lateral column, preserve 5-7cm skin bridge

Myerson Classification

TypeDescriptionPatternTreatment Implications
Type ATotal incongruityAll 5 TMT joints displaced in same directionUsually lateral or dorsolateral; severe injury; full exposure needed
Type B1Partial incongruity - MedialMedial column displaced, lateral column stableMedial incision only may suffice
Type B2Partial incongruity - LateralLateral column displaced, medial column stableLess common; may need single lateral incision
Type CDivergentMedial and lateral columns displaced in opposite directionsMost severe; 1st MT medial, 2nd-5th lateral; dual incisions required

Clinical Pearl: Type C (divergent) is associated with highest energy, most severe soft tissue injury, and worst outcomes.

Operative Technique

Step 1: Exposure and assessment - medial column (1st-2nd-3rd TMT)

Exposure and assessment - medial column (1st-2nd-3rd TMT): Longitudinal incision between 1st and 2nd metatarsals (8-10cm), centered over TMT joint level. Incise skin and subcutaneous tissue carefully - DORSALIS PEDIS ARTERY AND DEEP PERONEAL NERVE run immediately beneath in this space. Identify and elevate extensor hallucis brevis muscle belly (covers neurovascular structures). Identify dorsalis pedis artery and deep peroneal nerve, place vessel loops for protection, gentle retraction. Expose 1st, 2nd, and 3rd TMT joints subperiosteally. Assess fracture pattern, joint displacement, cartilage damage, soft tissue interposition.

Clinical Pearl

Technical Tip: EXAM KEY: DORSALIS PEDIS ARTERY between MT1-MT2 is HIGHEST RISK structure - injury causes foot ischemia requiring immediate vascular surgery. Artery typically 0-5mm deep to skin, covered only by thin EHB muscle. CRITICAL to identify early, use vessel loops, protect throughout. Deep peroneal nerve runs with artery, injury causes 1st web space numbness. Examine joint surfaces for cartilage damage - extensive damage may favor primary fusion over ORIF. Remove soft tissue interposition (capsule, tendons) to allow reduction.

Dangers at this step

  • Skin necrosis from excessive tension
  • Damage to underlying structures

Step 2: Reduction sequence - 1st TMT joint (medial column first)

Reduction sequence - 1st TMT joint (medial column first): Begin with 1st TMT joint (medial cuneiform to 1st metatarsal base). Remove debris and hematoma from joint. Use bone clamps or K-wires to reduce joint anatomically. Confirm reduction fluoroscopically - lateral border of MT1 should align with lateral border of medial cuneiform on oblique view. Provisionally stabilize with K-wires. Assess stability - if unstable (purely ligamentous), consider primary fusion vs ORIF based on evidence and patient factors.

Clinical Pearl

Technical Tip: EXAM KEY: MEDIAL COLUMN FIRST is fundamental principle. 1st TMT joint is foundation - must be anatomically reduced and stabilized before proceeding distally. 1st TMT is mobile joint (10-15 degrees sagittal motion normally) - preservation of motion is goal with ORIF. However, if joint unstable or severe cartilage damage, may consider fusion. Reduction maneuver: longitudinal traction on MT1, direct pressure on base, confirm alignment on fluoroscopy before fixation.

Dangers at this step

  • Inadequate reduction
  • Iatrogenic fracture

Step 3: Reduction and fixation - 2nd TMT joint (keystone)

Reduction and fixation - 2nd TMT joint (keystone): Reduce 2nd TMT joint (intermediate cuneiform to 2nd metatarsal base) - this is the KEYSTONE of Lisfranc joint, recessed proximally. 2nd MT is most commonly injured. Remove debris. Use reduction clamps to restore medial border alignment of MT2 with medial border of C2 (AP view critical). Confirm no diastasis between MT1 and MT2 (<2mm normal). Provisionally stabilize. DECISION POINT: purely ligamentous injury may benefit from primary 2nd TMT fusion based on emerging evidence. Fracture-dislocation proceed with ORIF.

Clinical Pearl

Technical Tip: EXAM KEY: 2nd TMT is KEYSTONE - recessed proximally forming 'mortise', most rigid, least mobile normally, most commonly injured in Lisfranc. Anatomic reduction critical - medial border MT2 aligns with medial border C2 on AP, no 1st-2nd intermetatarsal diastasis (>2mm abnormal). Lisfranc ligament (C1 to MT2 base plantar) is torn in most injuries - ligament does NOT heal reliably, explains primary fusion debate. Fluoroscopy essential to confirm anatomic reduction before fixation.

Dangers at this step

  • Inadequate reduction
  • Iatrogenic fracture

Step 4: Fixation options medial and middle columns

Fixation options medial and middle columns: FIXATION OPTIONS: (1) TRANSARTICULAR SCREWS: traditional, 3.5mm or 4.0mm cortical screws from MT base to cuneiform, crosses joint, requires removal at 4-6 months to restore motion, risk of articular damage. (2) DORSAL PLATES: extra-articular, spans joint dorsally, avoid cartilage, can remain permanently, growing popularity. (3) PRIMARY FUSION: for purely ligamentous injuries (especially 2nd/3rd TMT), emerging evidence of superior outcomes, avoids hardware removal. Place screws/plates to achieve stable fixation. Confirm no articular penetration fluoroscopically.

Clinical Pearl

Technical Tip: EXAM KEY: Fixation controversy is high-yield exam topic. TRANSARTICULAR SCREWS: traditional gold standard, 3.5-4.0mm from MT2 to C2, MT3 to C3, ±MT1 to C1 depending on stability. MUST remove at 4-6 months to restore motion (permanent screws cause arthritis). DORSAL PLATES: increasingly used, extra-articular fixation avoiding cartilage, biomechanically stable, no removal needed. PRIMARY FUSION: emerging evidence for LIGAMENTOUS Lisfranc shows equal/better outcomes vs ORIF, fusion of 2nd and 3rd TMT only, preserves 1st and 4th/5th motion. Know evidence and be able to discuss pros/cons of each approach.

Dangers at this step

  • Malposition of hardware
  • Damage to adjacent structures

Step 5: Lateral column exposure and assessment (4th-5th TMT)

Lateral column exposure and assessment (4th-5th TMT): Lateral longitudinal incision over 4th metatarsal (6-8cm), preserving 5-7cm skin bridge from medial incision. Protect superficial peroneal nerve branches. Expose 4th and 5th TMT joints (cuboid to MT4 and MT5). Assess stability - lateral column often stabilizes with medial and middle column reduction due to ligamentous connections. If unstable or displaced, reduce anatomically. Assess fluoroscopically - medial border MT4 aligns with medial border cuboid on AP view.

Clinical Pearl

Technical Tip: EXAM KEY: Lateral column (4th and 5th TMT) is usually MORE STABLE than medial/middle columns - often reduces indirectly with medial column fixation due to intact intermetatarsal ligaments. May only need K-wire fixation or no fixation if stable after medial/middle column reduction. Over-fixation of lateral column can restrict motion and cause pain. 4th and 5th TMT joints are mobile (important for gait) - preserve motion if possible. Assess stability with gentle stress under fluoroscopy before deciding on fixation.

Dangers at this step

  • Skin necrosis from excessive tension
  • Damage to underlying structures

Step 6: Final reduction assessment and fixation completion

Final reduction assessment and fixation completion: After provisional fixation, perform comprehensive fluoroscopic assessment in AP, oblique, and lateral views. RADIOGRAPHIC CRITERIA: AP view - medial MT2 aligns with medial C2, no 1st-2nd diastasis, medial MT4 aligns with medial cuboid. Oblique view - medial MT3 aligns with medial C3, lateral MT1 aligns with lateral C1. Lateral view - no dorsal displacement, Meary's line straight. GOAL: <2mm residual displacement all joints. If inadequate, remove fixation and re-reduce. Once confirmed, place definitive fixation (screws, plates, or fusion technique). Remove provisional K-wires.

Clinical Pearl

Technical Tip: EXAM KEY: Anatomic reduction <2mm is CRITICAL for outcomes. Even 2-3mm residual displacement associated with poor outcomes and arthritis. Must confirm on all three views - AP, oblique, lateral. If any view shows >2mm displacement, MUST re-reduce - accept only anatomic reduction. This step separates good from poor outcomes. Examiner wants to see understanding that <2mm is the goal, not 'close enough'. Final stability testing with gentle intraoperative stress confirms secure fixation.

Dangers at this step

  • Inadequate reduction
  • Iatrogenic fracture

Step 7: Closure and immobilization

Closure and immobilization: Irrigate wounds thoroughly. Close in layers - periosteum/capsule if possible (absorbable), deep fascia, subcutaneous to eliminate dead space (minimize over prominent hardware), skin with nylon or staples. Apply sterile dressings. CRITICAL: assess skin bridge between incisions for ischemia. Place well-padded below-knee splint with foot in neutral position (slight plantarflexion acceptable to reduce tension on dorsal soft tissues). Elevate leg strictly for 48-72 hours. Monitor for compartment syndrome signs.

Clinical Pearl

Technical Tip: EXAM KEY: Wound closure critical - skin over midfoot is tenuous, especially over prominent hardware. May need to modify hardware placement if skin tension excessive. Skin bridge between incisions must be minimum 5-7cm and viable - monitor for ischemia. Strict elevation for 48-72 hours reduces swelling and wound complications. Compartment syndrome risk persists postoperatively - must monitor clinically (pain out of proportion, tense compartments, pain with passive stretch). Low threshold for fasciotomy if suspected - delay causes catastrophic outcomes.

Dangers at this step

  • Skin necrosis from excessive tension
  • Damage to underlying structures

Step 8: Post-operative protocol and hardware management

Post-operative protocol and hardware management: PROTOCOL: Strict non-weight-bearing in below-knee cast or boot for 6-8 weeks. Radiographs at 2, 6, and 12 weeks to monitor alignment and healing. If maintained and fractures healed, progressive weight-bearing in boot weeks 8-12 (25%, 50%, 75%, full). Transition to supportive shoes with arch support orthoses at 12 weeks. HARDWARE REMOVAL: if transarticular screws used, must remove at 4-6 months to restore TMT motion (permanent screws cause arthritis). Plates can remain permanently if asymptomatic. Return to full activities 4-6 months for ADLs, 6-12 months for athletics.

Clinical Pearl

Technical Tip: EXAM KEY: Non-weight-bearing for 6-8 weeks is essential - early weight-bearing risks loss of reduction and hardware failure. Transarticular screws MUST be removed at 4-6 months - permanent screws across TMT joints cause iatrogenic arthritis (joints need motion). This is major disadvantage of screws vs plates or primary fusion. Patient counseling critical - hardware removal is second surgery. Return to high-level athletics often 6-12 months, and many patients have permanent functional limitation despite anatomic reduction - realistic expectations important.

Dangers at this step

  • Malposition of hardware
  • Damage to adjacent structures

Step 9: Long-term follow-up and management of arthritis

Long-term follow-up and management of arthritis: Long-term follow-up at 6 months, 1 year, then annually. Monitor for development of post-traumatic arthritis (20-50% incidence over 5-10 years). Symptoms: midfoot pain with activity, stiffness, difficulty with uneven ground. Radiographs show joint space narrowing, osteophytes, subchondral sclerosis. Conservative management: orthoses, activity modification, NSAIDs, intra-articular steroid injections. If conservative fails: salvage TMT FUSION of symptomatic joints (2nd and 3rd most common, can preserve 1st and 4th/5th if asymptomatic). Fusion provides pain relief with minimal functional impact (TMT joints have limited motion normally).

Clinical Pearl

Technical Tip: EXAM KEY: Post-traumatic arthritis is most common long-term complication (20-50%) despite anatomic ORIF. Patient counseling at time of initial surgery should include this risk - Lisfranc is serious injury with high secondary surgery rate. Salvage fusion of symptomatic TMT joints is effective for pain relief - typically fuse 2nd and 3rd TMT (already minimal motion), preserve 1st TMT if possible (10-15 degrees motion important for gait), 4th/5th rarely symptomatic. Fusion outcomes generally good - 80-90% pain relief, minimal functional impact since joints have limited normal motion. This is why primary fusion debate exists - if high fusion rate anyway, why not fuse primarily for ligamentous injuries?

Dangers at this step

  • Iatrogenic injury to adjacent structures

Step 10: Assess for compartment syndrome and document neurovascular status

Assess for compartment syndrome and document neurovascular status: Before and after tourniquet release, palpate all foot compartments for tension. Lisfranc injuries, especially high-energy mechanisms, carry significant compartment syndrome risk (5-10%). Classic signs: pain out of proportion, pain with passive stretch of toes, tense compartments, pulselessness (late sign). If suspected, proceed immediately to foot fasciotomy - delay causes permanent damage. Document neurovascular status including dorsalis pedis pulse, posterior tibial pulse, sensation in all nerve distributions. Compare to preoperative status.

Clinical Pearl

Technical Tip: EXAM KEY: Compartment syndrome is devastating complication if missed. High index of suspicion required, especially with crush mechanism, delayed surgery, or extensive soft tissue injury. Don't be falsely reassured by palpable pulses - they are preserved until very late. Pain out of proportion and pain with passive stretch are early signs. Low threshold for fasciotomy if any concern - better to do an unnecessary fasciotomy than miss compartment syndrome. Nine compartments in foot - medial, lateral, superficial, adductor, four interossei, calcaneal.

Dangers at this step

  • Missed compartment syndrome causing permanent disability
  • Delayed diagnosis requiring amputation in severe cases

Complications

Complications: Recognition, Prevention & Management

Post-operative Care

Strict non-weight-bearing cast/boot 6-8 weeks. Progressive weight-bearing weeks 8-12. Custom orthoses (arch support) at 12 weeks. Hardware removal 4-6 months if transarticular screws. Return to ADLs 4-6 months, athletics 6-12 months. Annual follow-up to monitor for post-traumatic arthritis. Salvage TMT fusion if symptomatic arthritis develops.

Clinical Decision Scenarios

Use these scenarios to practise clinical reasoning and management decisions

CLINICAL SCENARIOStandard

CLINICAL PROMPT

"The examiner shows you radiographs of a 35-year-old who fell off a ladder. There is widening between MT1 and MT2 with subtle dorsolateral subluxation of MT2 base on the lateral view. How would you classify and manage this injury?"

PRACTICAL APPROACH
This is a Myerson Type B1 Lisfranc injury (partial incongruity, medial column involvement). Key findings are: (1) 1st-2nd intermetatarsal diastasis indicating Lisfranc ligament disruption, (2) MT2 base subluxation as the 2nd MT is the 'keystone' of Lisfranc complex. I would obtain CT to define bony injury, assess articular surfaces, and plan fixation. If >2mm displacement or instability on stress views, this requires operative management. My approach: dual dorsal incisions (medial between MT1-MT2 for medial/middle columns, lateral over MT4 for lateral column). Reduction sequence: MEDIAL COLUMN FIRST - reduce 1st TMT, then 2nd TMT (keystone), then assess lateral column stability. Fixation options include transarticular screws (need removal at 4-6 months) or dorsal plates (no removal needed). If purely ligamentous with no fracture fragments, I would discuss primary fusion of 2nd and 3rd TMT with the patient given emerging evidence of superior outcomes.
CLINICAL SCENARIOStandard

CLINICAL PROMPT

"Describe the primary fusion versus ORIF debate for Lisfranc injuries. When would you recommend each approach?"

PRACTICAL APPROACH
The primary fusion versus ORIF debate centers on purely LIGAMENTOUS Lisfranc injuries where no fracture fragments exist, only soft tissue disruption. The rationale for primary fusion: (1) Lisfranc ligament doesn't heal reliably when ruptured - high rates of chronic instability and secondary arthritis, (2) primary fusion eliminates risk of these complications, (3) avoids mandatory second surgery for screw removal, (4) potentially faster return to full weight-bearing. Evidence: Henning et al. (2009) and Ly & Coetzee (2006) showed primary fusion had equivalent or better AOFAS scores compared to ORIF, with lower secondary surgery rates. I recommend ORIF with transarticular screws or plates for FRACTURE-DISLOCATIONS where bony alignment can be restored - these have potential for healing. I recommend primary fusion of 2nd and 3rd TMT for LIGAMENTOUS injuries (preserving 1st and 4th/5th TMT if stable) because: (1) 2nd and 3rd TMT have minimal normal motion anyway (<5 degrees), (2) fusion doesn't significantly affect function, (3) eliminates secondary arthritis and hardware removal. Patient factors also influence - young high-demand athletes may prefer attempt at motion preservation.
CLINICAL SCENARIOStandard

CLINICAL PROMPT

"During surgery for a Lisfranc injury, you note brisk bleeding from the medial incision between MT1 and MT2. What structure is injured and how do you manage it?"

PRACTICAL APPROACH
This is almost certainly dorsalis pedis artery injury - the HIGHEST RISK vascular structure in Lisfranc surgery. The dorsalis pedis artery runs between 1st and 2nd metatarsals, only 0-5mm deep to skin, and is at greatest risk during the medial incision and deep dissection. Immediate management: (1) Apply direct pressure to control bleeding, (2) Do NOT blindly clamp - will cause additional injury, (3) Extend incision if needed for adequate visualization, (4) Identify both proximal and distal ends of the injured vessel, (5) If artery is lacerated/transected, it requires primary repair or vein graft by a vascular surgeon or microsurgical-trained surgeon. If injury is small, direct repair with 6-0 or 7-0 prolene may suffice. If segment is damaged, need vein graft (typically saphenous vein). Document dorsalis pedis pulse after repair. If repair fails or is not possible, monitor for ischemia - may need amputation in worst case. Prevention is critical: identify the artery EARLY beneath EHB muscle belly, use vessel loops, gentle retraction only. This is why loupe magnification and meticulous technique in the 1st-2nd intermetatarsal space is essential.

ORIF Lisfranc Injury - Exam Summary

Clinical summary

Evidence Base

Fracture-dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment

Level IV
Myerson MS, Fisher RT, Burgess AR, Kenzora JE • Foot & Ankle
Clinical Implication: Source of the Myerson classification used worldwide and the evidence basis for the under-2mm anatomic-reduction target. Establishes reduction quality as the single most important modifiable outcome variable.
Verify on PubMed (PMID 3710321)

Outcome after open reduction and internal fixation of Lisfranc joint injuries

Level IV
Kuo RS, Tejwani NC, DiGiovanni CW, et al • J Bone Joint Surg Am
Clinical Implication: Confirms anatomic reduction drives outcome and flags purely ligamentous injuries as a poor-prognosis subgroup, motivating the primary-arthrodesis debate.
Verify on PubMed (PMID 11097452)

Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. A prospective, randomized study

Level I
Ly TV, Coetzee JC • J Bone Joint Surg Am
Clinical Implication: Landmark RCT supporting primary arthrodesis of the medial two or three rays for PURELY LIGAMENTOUS Lisfranc injuries; does not apply to bony fracture-dislocations.
Verify on PubMed (PMID 16510816)

Open reduction internal fixation versus primary arthrodesis for Lisfranc injuries: a prospective randomized study

Level I
Henning JA, Jones CB, Sietsema DL, Bohay DR, Anderson JG • Foot & Ankle International
Clinical Implication: Primary arthrodesis substantially reduces the reoperation burden with equivalent functional scores; the ORIF reoperation rate is dominated by planned hardware removal.
Verify on PubMed (PMID 19796583)

Does open reduction and internal fixation versus primary arthrodesis improve patient outcomes for Lisfranc trauma? A systematic review and meta-analysis

Level I
Smith N, Stone C, Furey A • Clin Orthop Relat Res
Clinical Implication: Highest-level synthesis: functional outcomes are comparable, but ORIF carries a markedly higher hardware-removal burden - this must be discussed during preoperative counselling and shared decision-making.
Verify on PubMed (PMID 26022112)

Guidelines, Registries & Global Practice

ThemeGlobal evidence and society guidance
EpidemiologyLisfranc injuries are uncommon (roughly 0.2 percent of all fractures; about 1 per 55,000 person-years) and up to 20-40 percent are missed or misdiagnosed at first presentation, especially low-energy/subtle athletic sprains
Diagnosis of subtle injuryWeight-bearing AP/oblique/lateral radiographs of BOTH feet (comparison views) are the global standard; if normal but clinically suspected, proceed to CT (best for bony detail/occult fractures) or MRI (best for the Lisfranc ligament and purely ligamentous injury)
Reduction targetAn anatomic, near-anatomic reduction (under 2mm at any tarsometatarsal joint) is the universally accepted goal across AO Foundation, AOFAS and BOA practice - this drives long-term outcome
ORIF vs primary arthrodesisInternational debate, not country-specific: primary arthrodesis of the medial/middle columns is supported for PURELY LIGAMENTOUS injuries (Ly and Coetzee; Henning); ORIF remains standard for bony fracture-dislocations with reconstructable articular surfaces
Implant trendGlobal shift from transarticular screws (mandatory removal, iatrogenic cartilage injury) toward dorsal bridge plating and, for ligamentous injury, primary fusion; suture-button/flexible fixation is used selectively for isolated low-grade ligamentous (C1-MT2) instability in athletes, though long-term data remain limited
Return to sportAthletes with stabilised Lisfranc injuries typically return at 4-6 months minimum; counsel that many never regain full pre-injury performance

No billing or reimbursement codes are included by design - management decisions are evidence- and anatomy-driven, not coding-driven.

References

  1. Myerson MS, Fisher RT, Burgess AR, Kenzora JE. Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment. Foot Ankle. 1986;6(5):225-242. PMID: 3710321.

  2. Ly TV, Coetzee JC. Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. A prospective, randomized study. J Bone Joint Surg Am. 2006;88(3):514-520. PMID: 16510816.

  3. Henning JA, Jones CB, Sietsema DL, Bohay DR, Anderson JG. Open reduction internal fixation versus primary arthrodesis for Lisfranc injuries: a prospective randomized study. Foot Ankle Int. 2009;30(10):913-922. PMID: 19796583.

  4. Kuo RS, Tejwani NC, DiGiovanni CW, et al. Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am. 2000;82(11):1609-1618. PMID: 11097452.

4a. Smith N, Stone C, Furey A. Does open reduction and internal fixation versus primary arthrodesis improve patient outcomes for Lisfranc trauma? A systematic review and meta-analysis. Clin Orthop Relat Res. 2016;474(6):1445-1452. PMID: 26022112.

4b. Alcelik I, Fenton C, Hannant G, et al. A systematic review and meta-analysis of the treatment of acute Lisfranc injuries: open reduction and internal fixation versus primary arthrodesis. Foot Ankle Surg. 2019;26(3):299-307. PMID: 31103276.

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  2. Philbin T, Rosenberg G, Sferra JJ. Complications of missed or untreated Lisfranc injuries. Foot Ankle Clin. 2003;8(1):61-71.

  3. Mulier T, Reynders P, Dereymaeker G, Broos P. Severe Lisfranc injuries: primary arthrodesis or ORIF? Foot Ankle Int. 2002;23(10):902-905.

  4. Arntz CT, Veith RG, Hansen ST Jr. Fractures and fracture-dislocations of the tarsometatarsal joint. J Bone Joint Surg Am. 1988;70(2):173-181.

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  6. Nunley JA, Vertullo CJ. Classification, investigation, and management of midfoot sprains: Lisfranc injuries in the athlete. Am J Sports Med. 2002;30(6):871-878.