Surgery is recommended for all injuries with a fracture in the joints of the midfoot or with abnormal positioning (subluxation) of the joints. The goal of surgical treatment is to realign the joints and return the broken (fractured) bone fragments to a normal position.

Internal fixation. In this procedure, the bones are positioned correctly (reduced) and held in place with plates or screws. Because the plates or screws will be placed across joints that normally have some motion, some or all of this hardware may be removed at a later date. This can vary from 3 to 5 months after surgery, and is at the surgeon’s discretion.

Occasionally, the hardware may break before it is removed. This is not unusual when screws or plates span bones that have some movement. Metal can fatigue and fail under these conditions, just as a paperclip will fail if bent repeatedly. Most often surgery is successful even if some of the hardware fails.

Fusion. If the injury is severe and has damage that cannot be repaired, fusion may be recommended as the initial surgical procedure. A fusion is essentially a “welding” process. The basic idea is to fuse together the damaged bones so that they heal into a single, solid piece.

Lisfranc injuries that may require fusion include joints that cannot be repaired with screws or plates or when the ligaments are severely ruptured. The hardware will not need to be removed because the joints are fused and will not move after they heal.

External Fixation. Chronic malunion and malalignment of fractures are often best addressed using techniques developed in Russia in the 1960s by Gavril Ilizarov. He pioneered the early science on distraction osteogenesis, which allows us to grow and lengthen bone by very gradual distraction. Small pins and wires are fixed through bone to external circular rings to allow for gradual deformity correction. These techniques allow us to lengthen shortened bones, correct severe bony malalignment, and fill in areas of traumatic bone loss.

Rehabilitation. After either surgery (reduction or fusion), a period of nonweightbearing for 6 to 8 weeks is recommended in a cast or cast boot.

Weightbearing is started while the patient is in the boot if the x-rays look appropriate after 6 to 8 weeks. The amount of weight a patient can put on their foot, as well as the distance the patient is allowed to walk, is at the surgeon’s discretion. Impact activities, such as running and jumping, should be avoided until the hardware has been removed.