Abstract
Background
Lisfranc injuries are a heterogeneous group of injuries with significant incidence of missed diagnoses. Due to the mechanisms of these injuries, other injuries, such as ankle fractures, may occur concomitantly. However, there is a scarcity of literature characterizing the clinical outcomes of these combined injuries. Consequently, there is little consensus on treatment best practices and prognosis. Therefore, this study seeks to describe the injury patterns, treatment approaches and outcomes of these combined injuries.
Methods
A retrospective study was conducted on nine adult patients with concomitant Lisfranc and ankle injuries treated by board certified Foot and Ankle Surgeons at an academic setting from 2022–2025. Patient demographics, injury characteristics, treatment, complications, and clinical and patient reported outcomes were analyzed. Descriptive analyses were conducted.
Results
Most injuries (n = 8, 88%) were caused by low energy. The most common ankle fracture pattern was isolated lateral malleolar fractures (n = 4). Of the Lisfranc injuries 6 were bony, while the remaining 3 were ligamentous. Only 3 out of 9 Lisfranc injuries were diagnosed after initial X-ray and exam. Most injuries were treated operatively (6 out of 9 Lisfranc injuries; 8 out of 9 ankle injuries) with open reduction and internal fixation (ORIF); 5 patients received operative treatment for both ankle and Lisfranc injuries. Complications included hardware failure or symptoms, nonunion, and Complex Regional Pain Syndrome (CRPS). PROMIS Pain Interference and Physical Function improved at 3 months post-operatively in the seven patients with post-operative data.
Conclusion
Unexpectedly, most instances of dual ankle and Lisfranc fractures were precipitated by low energy mechanisms. ORIF was the primary treatment modality with subsequent removal of hardware (ROH) conducted in four out of the nine patients. Most patients had reduced pain levels following surgery. Further study is needed to characterize these injuries and their outcomes relative to isolated ankle and midfoot injuries.
Introduction
Lisfranc injuries often present as unstable ligamentous or bony injuries to the midfoot which have a relatively low incidence rate, making up about 0.2% of all fractures and occurring in 1 in 55,000 patients. Despite their associated morbidity, the rate of diagnosis may be underestimated as Lisfranc fractures are commonly missed or misdiagnosed. ,, These injuries are often a result of low energy mechanisms such as simple falls, crush, or high-energy mechanisms such as motor vehicle accidents or falls from height and have a relatively high prevalence in high-energy trauma when compared to other foot injuries. As a result of their presentation with other distracting injuries, including fractures, these may go untreated or treatment may be delayed, which can result in chronic pain, instability, and deformity.
In a retrospective study of 2084 Lisfranc injuries, Juto et al. found that ipsilateral ankle fractures made up 16% of the concomitant injuries that patients sustained, second only to other foot fractures. While prior studies have described the specific prevalence of metatarsal fractures, limited research has evaluated the association between Lisfranc and ankle fractures, and none, to our knowledge, discuss outcomes beyond individual case studies. As a result, there is little information regarding treatment and outcomes of these combined injuries.
Therefore, the objectives of this study are to elucidate the mechanisms of concomitant Lisfranc and ankle fractures, options for treatment, and patient outcomes following this injury combination with a larger sample size than previously reported. The findings therein should promote further diagnostic scrutiny and academic study in order to appropriately treat these associated traumatic injuries.
Methods
Following institutional review board approval, patients of three fellowship-trained orthopaedic foot and ankle surgeons diagnosed with concomitant Lisfranc and ankle injuries were retrospectively identified at a single academic institution. Inclusion criteria consisted of adult patients (≥18 years) who sustained a combined Lisfranc and ankle injury and underwent operative or nonoperative management between 2022 and 2025. In order to maintain homogeneity, patients were excluded if they suffered polytrauma or other musculoskeletal injuries such as other foot fractures, toe fractures, or metatarsophalangeal joint dislocations. Demographic data (age, sex, BMI, race), risk factors (smoking, vitamin D levels, diabetes), injury characteristics (mechanism of injury, fracture classification), and treatment details (timing and type of fixation, postoperative protocols) were collected. Injury classifications were based on radiologic imaging, which included radiographs and computed tomography (CT). Treatment was based on surgeon discretion and evidenced base treatment, such as ORIF for unstable Lisfranc or ankle injuries. Complications- including hardware failure, loss of reduction, infection, and need for revision surgery- were recorded. Clinical outcomes were evaluated using PROMIS Pain Interference and Physical Function scores. All data were extracted from the electronic medical records. Descriptive statistical analyses were performed.
Results
Patient demographics
Nine adult patients with concomitant Lisfranc and ankle injuries were identified, as summarized in Table 1 . The sex distribution was nearly even (55.6% male). Most patients were White (88.9%), and the majority were non-smokers (88.9%). No patients had diabetes. Most of the cohort qualified as overweight (25–29.9 kg/m 2) or obese (30+ kg/m 2) per CDC guidelines, while only 2 out of 9 patients were healthy weight (18.5–24.9kg/m 2). Injuries occurred across a broad range of ages (27–66) but were more common amongst adults over 40 years old, which comprised 7 out of 9 patients in this study, with an average age of 48.7 years at the time of injury.
Table 1
Patient demographics.
| n | % | |
|---|---|---|
| Sex | ||
| Male | 4 | 44.4 |
| Female | 5 | 55.6 |
| Race | ||
| White | 8 | 88.9 |
| Black | 1 | 11.1 |
| Smoker | ||
| Yes | 1 | 11.1 |
| No | 8 | 88.9 |
| Diabetic | ||
| Yes | 0 | 0 |
| No | 9 | 100 |
| BMI (kg/m 2) | ||
| Healthy (18.5–24.9) | 2 | 22.2 |
| Overweight (25–29.9) | 2 | 22.2 |
| Obese (30+) | 5 | 55.6 |
| Age at Injury (Years) | ||
| 20–29 | 1 | 11.1 |
| 30–39 | 1 | 11.1 |
| 40–49 | 3 | 33.3 |
| 50–59 | 1 | 11.1 |
| 60+ | 3 | 33.3 |
Injury descriptions
Eight out of nine patients sustained injuries via low energy mechanisms, such as ground level falls or twisting injuries, as seen in Table 2 . The one high energy injury resulted from a skydiving incident. Ankle fracture patterns varied, with the most common variants being isolated lateral malleolar fractures (n = 4; 44%) and bimalleolar fractures (n = 3; 33%). Two patients sustained trimalleolar fractures (22%). All isolated lateral malleolar fractures classified as type B when using the Danis-Weber method of classification. Lisfranc injuries were predominantly bony (associated fracture) (n = 6; 67%), while the remaining three were classified as purely ligamentous (33%).
Table 2
Injury descriptions.
| Mechanism | n |
|---|---|
| Low Energy | 8 |
| High Energy | 1 |
| Ankle Injury | n |
| Isolated Medial Malleolar | 0 |
| Isolated Lateral Malleolar | 4 |
| Bimalleolar | 3 |
| Trimalleolar | 2 |
| Lisfranc Injury | n |
| Bony | 6 |
| Ligamentous | 3 |
The imaging modalities used to diagnose these injuries were radiographs and CT. No other imaging modality was used. All nine ankle fractures were identified on initial X-ray. Identification of Lisfranc injuries varied by imaging modality. X-ray alone was sufficient to identify Lisfranc and ankle injuries in 3 out of 9 patients (33.3%), while CT was needed to confirm X-ray findings concerning for Lisfranc injuries in 4 patients (44.4%). In two cases (22.2%), the Lisfranc injury was not identified on initial radiographs and was subsequently detected on CT imaging obtained for preoperative planning of the concomitant ankle injury. Regardless of whether X-ray was sufficient to identify the Lisfranc injury, CT was obtained pre-operatively in all nine patients to aid with surgical planning. While neither of the Lisfranc injuries that were initially unidentified on X-ray were operated on at first, three out of the four Lisfranc injuries that were confirmed on CT underwent surgical fixation.
Injury management and outcomes
All patients underwent surgical management of at least one of their two concomitant injuries, namely via open reduction and internal fixation (ORIF). Other procedures included closed reductions and a deltoid ligament repair. Non-operative management was performed for 3 of the presenting Lisfranc injuries and for 1 ankle fracture. This included immobilization for 6 weeks from the time of surgery with weight-bearing restrictions being dictated by the operatively treated injury. Decision for surgical fixation was made based on pre-operative and/or intra-operative evaluation of stability of the injury. Five out of 9 patients (55.6%) received ORIF for both Lisfranc and ankle injuries, while three patients (33.3%) underwent only ankle ORIF and one patient only Lisfranc ORIF ( Table 3 a). The specifics of each procedure are outlined in Table 4 . Overall, 6 out of 9 Lisfranc injuries and 8 out of the 9 ankle fractures underwent initial operative treatment ( Table 3 b).
Table 3
Treatment overview and complication profile.
| Part A. Initial Surgery, Revision Surgery, and Complications | ||
|---|---|---|
| n | ||
| Initial Surgery (ORIF) | Both Ankle & Lisfranc | 5 |
| Lisfranc Only | 1 | |
| Ankle Only | 3 | |
| Revision Surgery | Yes | 4 |
| No | 5 | |
| Complications | Broken Hardware | 1 |
| Symptomatic (Intact) Hardware | 2 | |
| Complex Regional Pain Syndrome | 1 | |
| Failed Non-Operative Treatment | 1 | |
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