AO Standard Technique | The Most Detailed Lisfranc Injury Surgical Illustration

I. Introduction

Compartment Syndrome

More than 25% of Lisfranc injury cases may be complicated by or trigger compartment syndrome. If compartment syndrome is suspected, fasciotomy and decompression should be performed.

Swelling is difficult to resolve before successful reduction. However, soft tissue coverage still needs to be assessed before surgical intervention.

Preoperative Planning

It is strongly recommended to develop a detailed preoperative plan for such complex injuries, with steps including:

1. Determine which joints are unstable.

2. Determine whether the instability arises from bony injury or ligamentous injury.

3. Develop the optimal reconstruction plan for each injury.

4. Determine the key points for restoring the length of the medial and lateral columns.

5. Assess the stability requirements of ligamentous injuries and plan accordingly (including instability of the intercolumn ligaments).

Overall Reconstruction Strategy

Surgical Sequence

Lisfranc injuries are highly heterogeneous, and treatment must be individualized.

A general stepwise reconstruction strategy may refer to:

1. Restore the anatomic relationship between the cuneiform and the navicular.

2. Reconstruct the normal anatomic relationship between the second metatarsal and the intermediate cuneiform (laying the foundation for subsequent reduction).

3. Reconstruct the normal anatomic relationship between the second metatarsal and the medial cuneiform.

4. Address the tarsometatarsal joint injuries in the order of the 1st → 3rd → 4th → 5th tarsometatarsal joints.

Fixation Principles

For bony injuries of the 1st-3rd tarsometatarsal joints, reconstruction is preferred; when reconstruction is not possible, arthrodesis is performed.

For unstable joints without bony injury, there is still no clear guideline on whether to choose fusion or temporary fixation, and it depends on the surgeon's preference and the overall injury condition.

Usually, fusion of the 1st-3rd tarsometatarsal joints has little effect on foot function.

The 4th-5th tarsometatarsal joints should retain mobility, and K-wire temporary fixation is preferred.

Some surgeons prefer to first use K-wires for temporary fixation of all injuries, verify foot stability and function, and then proceed with definitive plate and screw fixation.

Timing of Surgery

The degree of soft tissue injury and the patient's physiologic status jointly determine the timing of surgery.

II. Intraoperative Determination of Joint Instability

Stress radiographs under image intensification can assist preoperative assessment.

Alternatively, preoperative weight-bearing X-rays may be taken (if the patient can tolerate them).

These images help determine ligamentous instability between the cuneiform and metatarsal.

Anteroposterior View with Valgus Stress

Applying valgus stress can reveal:

1. Lateral displacement of the second metatarsal relative to the intermediate cuneiform.

2. Disruption of the first tarsometatarsal joint.

3. Widening of the gap between the medial cuneiform and the second metatarsal (suggesting Lisfranc ligament injury).

1. Lateral displacement of all metatarsals.

2. Lateral displacement of the middle and lateral columns.

3. Isolated lateral displacement of the middle column.

Medial View with Plantar Compression of the First Tarsometatarsal Joint

Applying plantar pressure at the first tarsometatarsal joint can identify dorsal capsular instability of the joint.

Normally, the dorsal cortex of the metatarsal should be collinear with the dorsal cortex of the cuneiform. Dorsal displacement of the metatarsal base beyond the cuneiform plane suggests instability of the first tarsometatarsal joint.

III. Reduction

Closed Reduction

Under anesthesia, apply axial traction and reduce by reversing the injury mechanism.

Open Reduction

If closed reduction cannot achieve anatomic joint reduction, it may be due to bony block or soft tissue interposition, and direct open reduction is required.

IV. Approach Preparation

The patient is placed supine with the knee flexed 90°.

Selection of Surgical Approach

The approach is selected according to the fracture pattern. Commonly used approaches include:

• Dorsolateral approach 30. Dorsolateral approach to the midfoot (AO official website version)

• Dorsomedial approach

• Medial universal incision

• Percutaneous navicular approach

• Safe zone for K-wire/steel pin placement

All Lisfranc injuries involve the second tarsometatarsal joint. By slightly extending the medial incision, the first and third tarsometatarsal joints can be addressed simultaneously.

Additional stab incisions may be used for lag screw/fiber tape placement (e.g., lag screw from the medial to the intermediate cuneiform).

V. Step 1: Instability Between the Medial and Intermediate Cuneiforms

If the injury involves instability between the medial and intermediate cuneiforms, temporary/definitive fixation or fusion may be selected:

• Place a positioning screw from the medial cuneiform to the intermediate cuneiform (as illustrated).

• Elastic dynamic fixation.

• Perform interosseous cuneiform arthrodesis (lag screws must not enter the interosseous space between the medial and lateral cuneiforms).

VI. Step 2: Instability of the Second Tarsometatarsal Joint (If Present)

Reconstruct the anatomic relationship between the second metatarsal and the intermediate cuneiform. This serves as the reference for reduction of the other tarsometatarsal joints, and precise alignment is crucial.

Ligamentous Instability

Reduction

●Insert a K-wire intramedullary from distal to proximal as a joystick to achieve axial alignment.

●Verify anteroposterior axial alignment and lateral dorsoplantar alignment under image intensification.

●Pass the K-wire across the joint and fix it to the intermediate cuneiform to maintain alignment.

Fixation

Place positioning screws across the joint to maintain reduction.

When bone quality permits, a mini T-plate may be selected.

If arthrodesis is required, after joint preparation, place articular lag screws and bone graft.

Note that lag screws may interfere with other implants (such as Lisfranc ligament stabilization devices) or be contraindicated due to comminution of the proximal second metatarsal; in such cases, a Lisfranc plate (or contoured 2.7 mm locking plate) may be selected.

Instability Caused by Proximal Second Metatarsal Fracture

Select according to fracture type:

• Lag screw (partial articular fracture)

• Plate ± lag screw (complete articular fracture with reconstructable articular surface)

• Locking plate ± lag screw (complete articular fracture with osteoporosis or inability to place lag screws)

• Primary fusion for length-stable/unstable fractures (articular surface not reconstructable)

If the tarsometatarsal joint remains unstable after reduction and fixation, a bridging plate may be temporarily applied until bone healing. Alternatively, primary fusion may be performed with跨articular lag screws.

VII. Step 3: Lisfranc Ligament Rupture

Goal: Reduce and compress the base of the second metatarsal to the medial cuneiform to provide stability.

Lisfranc Instability

Reduction

●Predrill on the lateral side of the second metatarsal base and the medial side of the medial cuneiform to facilitate placement of reduction forceps.

●Use pointed reduction forceps to reduce the second metatarsal base to the medial cuneiform, taking care to avoid the planned screw tract.

●Percutaneous application of reduction forceps may be used to compress along the direction of the Lisfranc ligament.

●Verify reduction by direct visualization and imaging.

Stabilization

Fixation options include:

• Positioning screw from the second metatarsal base to the medial cuneiform (or reversed)

• Elastic dynamic fixation

If the second metatarsal base is comminuted, a positioning screw may instead be placed between the first and second metatarsals.

VIII. Step 4: Instability of the First Tarsometatarsal Joint (If Present)

Ligamentous Instability

Reduction

For pure ligamentous injury, use pointed reduction forceps to reduce the joint.

Fixation

Place positioning screws to achieve stability, and two screws may be used to enhance stability.

The screw holes need to be countersunk to prevent prominence of the screw heads.

Instability Caused by Proximal First Metatarsal Fracture

The treatment plan is the same as for proximal second metatarsal fracture.

IX. Step 5: Instability of the Third Tarsometatarsal Joint (If Present)

Ligamentous Instability

Reduction

Use pointed reduction forceps to reduce the joint.

Fixation/Fusion

Place at least one intramedullary screw from distal to proximal to achieve fixation or primary fusion.

Alternatively, a contoured 2.7 mm bridging plate may be applied for temporary stabilization until healing; the plate should contour to the bone surface and be fixed with locking screws or screws in neutralization mode.

Proximal third metatarsal fractures are treated as above.

X. Step 6: Instability of the Fourth and Fifth Tarsometatarsal Joints (If Present)

Lateral column fractures are treated first according to the metatarsal fracture treatment plan, and then the fourth and fifth metatarsals are fixed to the cuboid with K-wires.

Ligamentous instability or residual instability after medial column fixation is treated as follows.

Reduction

Laterally displaced metatarsals should be anatomically reduced to the cuboid using reduction forceps.

Verify reduction by direct visualization and imaging.

Fixation

Insert K-wires from the bases of the fourth and fifth metatarsals to the cuboid for fixation. Once healed, remove the K-wires.

XI. Postoperative Care

Dressing

A non-adherent antimicrobial dressing is applied as the first layer, and sterile padding is wrapped from the toes to the knee, with reinforced padding medially, laterally, and posteriorly.

Immobilization

●In the first two weeks, use a three-sided plaster splint with the anterior side left open to accommodate swelling. Ensure that the vertical medial and lateral portions of the plaster do not overlap, and avoid pressure on the popliteal fossa and calf.

●Patients with pure ligamentous injury treated with elastic fixation may bear weight early and use a walking boot.

Follow-up

●Instruct the patient to elevate the affected limb (when seated, place the foot midway between the waist and the heart); for severe swelling, elevate in the supine position.

●Avoid direct pressure on the heel to prevent pressure sores.

●Operating room dressings are usually left in place until the first follow-up visit at 2 weeks postoperatively, when the dressing is changed and X-rays are taken; if infection or compartment syndrome is suspected, open and inspect earlier.

●Strict non-weight-bearing until radiographic healing and removal of K-wires (6-12 weeks)/bridging devices (≥12 weeks).

●Encourage daily toe movement and avoid formal physical therapy early on.

●If gastrocnemius contracture occurs, release surgery is required (more common in midfoot and hindfoot injuries).