A Closer Look At Surgical Options For The Ligamentous Lisfranc Injury

Injuries to the Lisfranc joint complex are not always obvious. Physicians miss many of these injuries when patients initially present at the emergency department, leading to less than adequate conservative treatment measures that eventually progress to lasting pain and post-traumatic arthritis. Some have argued the case for a primary arthrodesis of the Lisfranc joint for purely ligamentous injuries but some practitioners still believe that open reduction internal fixation (ORIF) is an adequate treatment for this subtle injury.¹

One should perform a thorough evaluation of patients with midfoot pain after a trauma such as a crush injury, motor vehicle accident or low energy incidents such as twisting of the foot. Noting a specific point of tenderness at the tarsometatarsal joint, midfoot pain with the piano key test (which consists of pressing down on the head of the second metatarsal like a piano key) and plantar ecchymosis can help guide the practitioner to further investigate the possibility of a Lisfranc complex injury.

As Nunley and Vertullo alluded to in their research, weightbearing radiographs are absolutely necessary to evaluate for any diastasis at the Lisfranc joint.² Non-weightbearing radiographs can allow the midfoot ligaments to compress the tarsometatarsal joint and mask a subtle diastasis at the second metatarsal-medial cuneiform joint. Other studies have shown the sensitivity of magnetic resonance imaging (MRI) at identifying joint injury when plain film radiographs do not show any acute process but the patient complains of persistent pain in the midfoot.³

A review of the literature for surgical treatment of these injuries leads us to the research performed by Coetzee and Ly.¹ The authors stated that a primary arthrodesis of the second metatarsal cuneiform joint coupled with fusion of the first and occasionally the third (as needed) leads to better postoperative outcomes than ORIF. Screw fixation is an adequate method for both arthrodesis and ORIF even as the options for repair of this injury have become more numerous in recent years.

Most hardware companies have developed plating systems specifically for the first and second tarsometatarsal joints to allow for an anatomic contour and more stable construct when one is performing both ORIF and arthrodesis. Most plates incorporate a compression into the plate to allow for additional compression if one does not perform screw fixation, or if screw fixation is not possible.

Arthrex has recently developed an InternalBrace system, which avoids large anatomic dissections and attempts to replace the ligamentous structures with a synthetic one.⁴ This system is relatively new and does not have enough long-term follow-up to determine if post-traumatic arthritis develops despite fixation with this system.

Given all of the surgical options for a ligamentous Lisfranc injuries and all the approaches I have seen thus far in residency, I favor the primary arthrodesis. I feel that this treatment is definitive and offers less reason for a possible secondary surgery. Although hardware removal is always on the list as a possible secondary surgery, having to progress to a fusion from an ORIF that remains symptomatic seems like a problem that surgeons could avoid by performing the fusions initially.

Although fusions are technically more involved, having the appropriate equipment in the operating room can help eliminate the frustrations and difficulties of joint preparation. If saw resection is the method of joint preparation, then it is imperative to choose a long enough saw blade to ensure that no plantar shelf is left behind, causing dorsiflexon of the metatarsal. If curettage is the method of joint preparation, then having a Weinraub retractor or other K-wire type distractor ensures great joint visualization for preparation, and also eliminates the slipping out of the joint that often happens when using a lamina spreader or similar device.

Fixation methods are numerous and effective if one employs them in the correct manner. Screws or plates, separate or combined, are all adequate methods of fixation for both ORIF and arthrodesis when one obtains adequate compression of the site and it is maintained through stress fluoroscopy. As always, don’t be afraid to use the C-arm intraoperatively. Stressing the midfoot to ensure no diastasis happens with fixation can help to decrease the chance of nonunion or malunion when the patient begins to bear weight.

The ligamentous Lisfranc injury can be a devastating injury without timely, accurate diagnosis and proper treatment. As companies begin to invest more time and effort into making foot and ankle specific hardware, the fixation options for this area of the foot are becoming vast and versatile. Regardless of fixation methods or technique, it is important to consider the postoperative outcome and long-term possibilities of post-traumatic arthritis that may require additional or more invasive treatments.

References

1. Coetzee JC, Ly TV. Treatment of primarily ligamentous Lisfranc joint   injuries: primary arthrodesis compared with open reduction and internal fixation. surgical technique. J Bone Joint Surg. 2007; 89(Suppl 2 Pt 1):122–127.
2. 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.
3. Raikin SM, Elias I, Dheer S, et al. Prediction of midfoot instability in the subtle Lisfranc injury. comparison of magnetic resonance imaging with intraoperative findings. J Bone Joint Surg. 2009; 9(1):892-9.
4. Giza E. Lisfranc Injury Repair with Lisfranc InternalBrace™ Ligament Augmentation. Available at https://www.arthrex.com/resources/videos-case-presentations/vyzNI2_QYUW9pgFZ1k5f5w/lisfranc-injury-repair-with-lisfranc-internalbrace-ligament-augmentation .