What Is Lisfranc Surgery?
The Lisfranc ligament runs between two bones in the middle of the foot called the medial cuneiform and the second metatarsal. The place where these two bones meet is called the Lisfranc joint. The name comes from French surgeon Jacques Lisfranc de St. Martin (1790-1847), who was the first physician to describe injuries to this ligament.
Tearing of the Lisfranc ligament and other ligaments around the Lisfranc joint can lead to instability and disruption of the joints in the middle of the foot. The goal of surgery is to restore normal alignment to the foot. Whether the injury results in a subtle misalignment of the bones or a more obvious dislocation of joints, the surgery is intended to put the bones back into their original position.
Surgery for a Lisfranc injury should be done when the midfoot joints are not lined up anatomically. Most commonly this misalignment is identified on X-ray, however CT and MRI scans also can be helpful in diagnosis. Surgery is needed to realign and stabilize the misaligned joints. Some injuries with noticeable cartilage damage may require fusion of the joints.
You do not need surgery for a Lisfranc injury if you have a sprain of the ligaments of the foot that do not create instability. Such injuries typically require you to restrict activity and use a boot or cast for six or eight weeks. Surgery also should be avoided if you have significant soft tissue swelling, severe peripheral vascular disease or fracture due to nerve dysfunction, which can be seen with diabetic neuropathy. You should speak with your orthopaedic foot and ankle surgeon prior to Lisfranc surgery if you have these conditions.
This is usually an outpatient procedure, meaning the patient can go home the same day as surgery. General anesthesia, spinal anesthesia, an ankle block, or popliteal with sedation are anesthesia options. A nerve block may be used to help control pain after the surgery. A tourniquet usually is used to reduce bleeding. Most patients will require at least one incision on the top of the foot. A second incision may be needed depending on the severity of the injury.
The first incision is made on the top of the foot in a line between the big toe and second toe at the middle of the foot. The tissues are then carefully protected to minimize risk of injury to tendons or nerve structures. The joints are realigned and held in position temporarily with wires. The orthopaedic surgeon will start by realigning the medial cuneiform to the base of second metatarsal and then realign the other joints around this joint. An X-ray will verify that the joints are aligned. A second incision often is necessary for more severe injuries. This second incision is typically made on the top of the foot but more toward the little toe side.
A series of screws or plates will be used to help hold the bones in place. These screws and plates are placed beneath the skin. One of the screws often placed is known as a "home run" screw. It runs between two bones called the medial cuneiform and the second metatarsal. This screw mimics the path of the injured Lisfranc ligaments. Some injuries require wires to be left in place. These wires are left partly exposed outside of the skin.
A fusion surgery involves a similar overall technique. The main difference is that the cartilage is removed from the joint surfaces prior to inserting plates or screws. The goal is to make the bones grow together to eliminate the arthritis.
The patient is placed into a non-weightbearing splint immediately after surgery. This protects the bones and incisions. The patient should elevate the foot as much as possible to help reduce swelling and pain. Pain will typically be controlled with pain pills.
Sutures will be removed about two weeks after surgery and the patient will have a cast or CAM boot. No weightbearing is allowed for 6-8 weeks after surgery. A walking cast or boot is then used for another 4-6 weeks. If pins were used to hold the fourth and fifth metatarsals in place, they are removed 6-8 weeks after surgery.
Patients usually are able to wean out of the boot and into an athletic shoe in 10-12 weeks. They will benefit from a more rigid shoe with an arch support insert to help reduce stresses through the middle of the foot. Physical therapy may be prescribed for strengthening and improvement in function. It can take longer than one year for full recovery.
Risks and Complications
All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots.
With Lisfranc surgery there is a nerve that runs very close to the site of the incision. This nerve can be injured, which can result in numbness. If numbness occurs it typically is not painful and the foot recovers with time. Another common problem after a Lisfranc injury is the development of post-traumatic arthritis in the joints of the middle of the foot. This is due to degeneration of cartilage in the area of the injured joints. This can lead to pain and stiffness in the middle part of the foot.
Will the plates and/or screws stay in my foot forever?
The hardware that is placed during surgery is sometimes removed 4-6 months after surgery. Hardware placed for a fusion typically is not removed unless it becomes bothersome.
Should I have my recently injured foot realigned, or do I need it fused?
This is a debated topic. A patient typically will do well with realignment of the bones for simple Lisfranc injuries. More substantial injuries that result in obvious displacement of the joints or fracture involving the joint surfaces may be better treated with a fusion. Other factors to consider include a patient’s age and any existing foot arthritis. Your foot and ankle orthopaedic surgeon will discuss your treatment options to find the best solution for your problem.
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