A neglected and/or a poorly treated Lisfranc injury can lead to midfoot instability and significant secondary malalignment. A lack of midfoot stability during mid stance phase of gait will have an impact on the patient’s lower extremity structurally and functionally. Based on the extent of the primary injury and the time of the revision surgery, the extent of involvement can vary significantly. The lack of stability in the midfoot often results in excessive motion at the Lisfranc joint leading to degenerative joints to varying degrees. The forefoot is often affected by the changes with forefoot overload and secondary contractors at the metatarsal phalangeal joints. If severe enough, the lack of stability can lead to severe disabling soft tissue changes secondary to the bony malalignment. In addition arthritic conditions of the diseased joints may develop. Osteophytes can progress and create increased pressure on the tendons and soft tissues that are worsened with shoes and/or weight bearing. The loss of the midfoot stability eventually will have a consequence of secondary functional changes which may lead to the inability to position the foot effectively during mid stance or for push-off in the gait cycle. The loss of midfoot stability is indicative in patient’s complaints and symptoms during stance, ambulation, and activities. Also, as the midfoot loses stability, the foot develops an abnormal foot posture. These changes are consistent with the collapsing of the arch and increased stress to the plantar soft tissue and osseous structures as the foot is loaded, resulting in foot and ankle pain (Fig. 16.2) [6]. These architectural changes of the foot typically lead to greater demands on muscular and ligamentous structures, resulting in fatigue and pain in the foot and ankle. It has been the author’s experience that degenerative arthritis along with abnormal foot postures and/or gait patterns makes the foot more susceptible to foot and ankle pain due to mechanical overloading. The changes in alignment lead to abnormal mechanical forces which in turn have a direct effect causing an increase of stress on the soft tissues. As a consequence of the injury, patients with a compromised sensory system may experience a breakdown in their soft tissues with the focused abnormal pressures (Fig. 16.3).

Following complex trauma in the foot, oftentimes there is a loss of mechanical integrity that leads to structural breakdown and secondary soft tissue changes. Injuries that may cause the pain and breakdown of the Lisfranc joint consist of unsuccessful ligamentous repair, severe articular fractures, failed open reductions and internal fixation, chronic neglected/misdiagnosed Lisfranc injury, deformity at the tarsal metatarsal joint, posttraumatic osteoarthritis, and Charcot arthropathy/neuropathic midfoot. These injuries may cause pain, malalignment, atrophy, impairment of the soft tissue envelope, contractures, soft tissue loss, joint adhesions, malunion, nonunion, dystrophic changes, and neurologic and/or vascular injury. When the index procedure has been misdiagnosed, mistreated, or ineffective, the proposed revision procedure must take into consideration the length of time since the original disability and the quality of the soft tissue envelop. Expectations on functional activities following a revision procedure are directly related to the individual patient’s given condition. In patients with residual deformity, the extent of the arthrodesis depended on the number of affected joints and the severity of deformity. Selecting the appropriate procedures is key to providing realignment and stability to the foot.

Patients that present with a failed or mistreated Lisfranc injury and are in need of a revision Lisfranc arthrodesis without significant malalignment can proceed with an in situ arthrodesis. An in situ arthrodesis is indicated for those patients with a condition that is limited to the medial or middle column and/or both and without malalignment. The surgeon needs to evaluate the entire lower extremity with a focus at the Lisfranc joint. The patient should be evaluated weight bearing and nonweight bearing. A Silfverskiold test should be performed to assess if there is a contracture of the posterior muscle group [7]. It has been the experience of the authors with revision surgery at the Lisfranc joint that the adaptive changes in this patient population typically exhibit a tight posterior muscle group and are in most instances in need of lengthening the posterior muscle group. The results of the Silfverskiold test will dictate the indication of an Achilles tendon lengthening or a gastrocnemius recession. When indicated, it has been the author’s choice to perform the Achilles tendon lengthening percutaneous or the gastrocnemius release through endoscopic technique [8, 9].

A single curvilinear incision is made over between the first and second tarsal metatarsal joint. The incision is made with care to identify and protect the superficial and deep peroneal nerves, dorsalis pedis artery, and vein. A full-thickness flap is created exposing the deformity. All soft tissue retraction is performed with either double-pronged skin hooks or mini Hohmann retractors in best efforts to protect the soft tissue envelop. If previous hardware is present, it is removed. If the hardware is fractured and can be easily obtainable, it is removed. Attention is directed to the involved joints and is exposed and checked under fluoroscopy. Typically there is a great deal of fibrous and capsular tissue in the involved joints. An extended period of time should be spent resecting this tissue and mobilizing the joints. This will expose the involved joints very well, will allow for mobilization, and also by removing this fibrous tissue and debris will prevent an unsatisfactory reduction in attempt to prevent a failed bony union. Next, manipulation of the forefoot from the midfoot is done with an osteotome and mallet and insertion of a laminar spreader (Fig. 16.4). The adjacent joints are checked for instability or malalignment. If the adjacent joints are involved, then attention is directed to the necessary joints, and debridement with joint preparation is performed. The cartilage and subchondral bone are removed with an osteotome and mallet to the intended joints. It is important to resect the plantar aspect of the joint in order to prevent dorsal angulation and malunion. A significant amount of time should be spent debriding and preparing the necessary joints. The authors typically utilize an osteotome, mallet, 2.0 drill bits, pics, and curettage technique to be sure extensive subchondral bone is debrided while maintaining the osseous integrity. Once all the required joints are adequately prepared for arthrodesis, a laminar spreader is inserted to each joint to inspect for loose fragments, and to be certain, the joint is prepared adequately.

The Lisfranc joint is deep and has a large surface area, and special attention is focused plantarly. In reducing the deformity, the aim is to restore alignment of the medial aspect of the base of the first metatarsal with the medial edge of the first cuneiform. Next, restoring alignment of the medial aspect of the base of the second metatarsal with the medial edge of the second cuneiform in the transverse plane is necessary. Alignment of the long axis of the talus with the long axis of the first metatarsal in both the sagittal and transverse planes is required to restore anatomical alignment (Fig. 16.5).

This is facilitated by initially correcting the position of the first metatarsal. This is performed by grasping the great toe, dorsiflexing the great toe joint, and rotating the first metatarsal into a neutral position (varus direction-out of valgus), while the base of the first metatarsal is pushed firmly against a stable well-aligned midfoot [10]. If there is noted instability of the proximal tarsal bones, medial, and/or lateral cuneiforms of the midfoot, these joints are debrided, aligned, and temporary stabilized prior to reducing the first tarsal metatarsal joint. Stabilization should occur from proximal to distal. Following reduction of the first metatarsal to a stable proximal midfoot, it is temporarily secured with a 2.0 Kirschner wire and is inserted from the first metatarsal proximally into the medial cuneiform while maintaining alignment. Next, the base of the second metatarsal is positioned appropriately followed by the third tarsal metatarsal. A large bone-reduction Weber clamp and/or Kirschner wire is placed obliquely to close the gap between the base of the second metatarsal and the medial cuneiform. A Kirschner wire is inserted from the proximal medial cuneiform aiming distally toward the base of the second metatarsal. If the third tarsal metatarsal joint is involved, this is reduced, and a 2.0 Kirschner wire is inserted from the proximal shaft of the third metatarsal into the respected cuneiform. If the fourth and fifth metatarsal tarsal joints are involved, it has been the author’s experience that once the first three tarsal metatarsal joints are positioned, the fourth and fifth metatarsal tarsal joints will be reduced anatomically [11]. The second and the third metatarsal are secured with additional Kirschner wires used in multiple planes stabilizing the metatarsals into the respective cuneiforms. Anteroposterior, medial oblique, and lateral fluoroscopic images are made to confirm the corrected alignment (Figs. 16.6 and 16.7).

Fixation is achieved using a lag technique involving solid 3.5 or 4.0 solid cortical screws and/or plating techniques. If there is noted proximal joint involvement, the proximal joints need to be fixated first to provide a stable midfoot in order to successfully align and fixate the Lisfranc joint [11]. A screw hole technique as described by Manoli and Hansen [12] allows for a difficult angulation, and the first screw is inserted from the first metatarsal to the medial cuneiform creating inter-fragmentary compression. The next screw is inserted from the stable superior proximal medial cuneiform obliquely oriented into the second metatarsal base. It is important that the surgeon understands the anatomy as the base of the second metatarsal is elevated or is at the peak of the “Roman Arch.” When inserting this screw, the surgeon should be aiming slightly superior so that the base of the second metatarsal is fixated adequately. This screw also employs inter-fragmentary compression. Additional screws can be inserted from the proximal metatarsal base into the cuneiform and from the base of the first metatarsal into the base of the second and/or third metatarsal. A high-speed burr is then used to debride the edges of the involved joints, and bone voids are then packed with autogenous or allogenic cancellous bone graft for a shear strain relief graft as described by Perren [13]. The gaps are filled with local bone graft which can be harvested from the calcaneus, and if additional bone graft is needed, allogenic bone or a bone graft substitute can be utilized [14]. Typical soft tissue and skin closure is performed.

Postoperatively, the patient is placed in a dorsally slotted non-weight-bearing plaster cast for 2 weeks [15]. Provided there are no wound problems and the reduction and construct is stable, a fiberglass below the knee cast is applied for an additional 4–6 weeks and until radiographic consolidation is evident. Full weight bearing in a fracture boot with physical therapy is then prescribed for 4 weeks.

Patients who present with malalignment and deformity of the forefoot require a realignment arthrodesis of the Lisfranc joint. Oftentimes, a severe or progressed failed Lisfranc joint will require additional procedures in order to reduce the foot into an anatomical position. There are varying degrees of deformity based on the initial injury, the original treatment, the type of treatment, and the secondary bony and soft tissue pathological changes to the adjacent joints. The medial and middle column arthrodesis requires fixation of the first, second, and sometimes the third tarsal metatarsal joints along with their intercuneiform joints. The naviculocuneiform and other adjacent joints may need to be included in this fusion if found to be unstable. In addition, the summation of time from the index injury and original treatment will have a secondary effect on the pathological bone and soft tissue changes. Patients needing a realignment arthrodesis typically present with an abduction of the forefoot and lateral translation and dorsiflexion of the metatarsals (Fig. 16.8).

A valgus deformity may present with medial soft tissues that may be stressed and the lateral soft tissues maybe contracted. In most cases, these patients present with a differing degree a flatfoot deformity along with a collapsing arch in association with abduction of the forefoot, lateral translation and dorsiflexion of the metatarsals, and a potentially progressed hindfoot valgus. The surgeon needs to evaluate the entire lower extremity. The patient should be evaluated weight bearing and nonweight bearing. A Silfverskiold test needs to be performed to assess if there is a contracture of the posterior muscle group [7]. It has been the experience of the authors that this patient population exhibits a tight posterior muscle group and is in need of lengthening the Achilles tendon or gastrocnemius. It is the author’s choice to most commonly perform the indicated Achilles tendon lengthening percutaneous or the gastrocnemius release through endoscopic technique [8, 9].

Incision planning is based on the quality of the soft tissue, the extent and the degree of deformity, and the previous history of the injury and treatment (Fig. 16.9).

The soft tissue envelope needs to be taken in to consideration. In some instances, there may have been previous incisions, there may be soft tissue changes as a result of the initial trauma, and/or the attenuation of the soft tissues changes from malalignment. The incisions are planned according to the deformity. For a severe deformity, two longer incisions are made: one dorsal medial over the first metatarsal and one over the third metatarsal. In some instances, the authors have been able to utilize one large curvilinear incision over the second tarsal metatarsal joint. If planned appropriately, the first, second, and third tarsal metatarsal joints as well as adjacent joints can be exposed appropriately. Regardless of the incision, the incision needs to be full thickness, and care must be taken to avoid the neuromuscular bundles of the dorsal aspect of the Lisfranc joint (Figs. 16.10, 16.11, and 16.12).