Lisfranc Midfoot

Lisfranc (midfoot) injuries result if bones in the midfoot are broken or ligaments that support the midfoot are torn. The severity of the injury can vary from simple to complex, involving many joints and bones in the midfoot.

A Lisfranc injury is often mistaken for a simple sprain, especially if the injury is a result of a straightforward twist and fall. However, injury to the Lisfranc joint is not a simple sprain that should be simply “walked off.” It is a severe injury that may take many months to heal and may require surgery to treat.

The midfoot will be affected if the bones are broken (fractured) or the ligaments are torn (ruptured). Injuries can vary, from a simple injury that affects only a single joint to a complex injury that disrupts multiple different joints and includes multiple fractures.

Lisfranc injuries tend to damage the cartilage of the midfoot joints. Cartilage covers the ends of bones in the joints, allowing the joints to move smoothly. If severe midfoot injuries are not treated with surgery, then damage to the cartilage and increased stress at the midfoot joints will result in both flatfoot and arthritis, which require complex surgery to correct. Even with successful surgery for the Lisfranc injury, arthritis can still develop in later life.

During your first visit, your doctor will talk to you about your symptoms and medical history. During the physical examination, your doctor will check all the structures of your injury, and compare them to your non-injured anatomy.  Most injuries can be diagnosed with a thorough physical examination.

Imaging Tests Other tests which may help your doctor confirm your diagnosis include:

X-rays. Although they will not show any injury, x-rays can show whether the injury is associated with a broken bone.

Magnetic resonance imaging (MRI) scan. If your injury requires an MRI, this study is utilized to create a better image of soft tissues injuries. However, an MRI may not be required for your particular injury circumstance and will be ordered based on a thorough examination by your Peninsula Bone & Joint Clinic Orthopedic physician.

If there are no fractures or dislocations in the joint and the ligaments are not completely torn, nonsurgical treatment may be all that is necessary for healing. A nonsurgical treatment plan includes wearing a non-weightbearing cast for 6 weeks. You must be very strict about not putting weight on your injured foot during this period. This then progresses to weightbearing in a removable cast boot or an orthotic.

Your doctor will want to follow up with you regularly and take additional x-rays to make sure your foot is healing well. In the course of follow up, if there is any evidence that the bones in the injured joint have moved, then surgery will be needed to put the bones back in place.

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.