Lisfranc Injuries

Casey M. O’Connor

Jillian Kazley

Positioning

The patient is positioned in the supine position.
A bump should be placed under the ipsilateral hip for correct position of the foot.
A tourniquet should be placed on the ipsilateral side of the injury.

Surgical Approach

Dorsomedial approach—the incision is centered between the first and second tarsometatarsal (TMT) joints (Figure 28-1).

Figure 28-1. Dorsomedial incision of the midfoot. From Schiff AP, Gross CE, Pellegrini MJ, Hamid KS, Easley ME. Open reduction and internal fixation of the Lisfranc fracture-dislocation. In: Easley ME, Wiesel SW, eds. Operative Techniques in Foot and Ankle Surgery. Philadelphia, PA: Wolters Kluwer; 2017:chap 132:Tech Figure 3A-C.

This approach will provide access to the first to third TMT joints.
Deep dissection is performed between the extensor hallucis longus and extensor hallucis brevis tendons.
The extensor hallucis brevis is retracted laterally, at which point the deep peroneal nerve and dorsalis pedis artery can be identified and protected.
The first TMT capsule can be incised and subperiosteal dissection carefully performed to avoid injury.

The dorsolateral approach may be used if access to the fourth, fifth, or the lateral aspect of the third TMT joint is needed. The incision is centered between the fourth and fifth TMT joints.
- There should be at least a 3-cm skin bridge when using a dual-incision approach.
- Deep dissection should be performed between the extensor digitorum brevis and the extensor digitorum communis tendons.
Medial approach—a medial incision can be used for hardware placement from the first to the base of the second metatarsal.

Reduction and Fixation Techniques

Current best evidence supports the use of open reduction internal fixation (ORIF) for fractures or avulsion Lisfranc injuries compared to purely ligamentous injuries treated with primary fusion.

Closed Reduction

May be done before ORIF to approximate the fracture
Axial traction applied to the great toe and other affected TMT joints either by hand or with the aid of finger traps

External Fixation

Unicolumnar frame—a 4.0 Schanz pin through the calcaneus and another at the base of the fourth and fifth metatarsal bases to maintain lateral column length
This can be used for temporary fixation because the soft tissues improve or can be used as definitive fixation for the lateral TMT joints.
Bicolumnar frame—a 5.0 Schanz pin is placed medial to lateral; a 4.0 Schanz pin is again placed at the base of the fourth and fifth metatarsal bases; and a 4.0 Schanz pin is placed in the medial aspect of the first metatarsal head.

Open Reduction Internal Fixation

Depending on the severity of the injury and the joints involved, injuries can be approached through either a dual or single incision.
Internal fixation of the TMT joint complex progresses from medial to lateral.
Provisional reduction and fixation should be placed across all the involved joints primary to implant use.
Use of 4.0-, 3.5-, or 2.7-mm screw fixation can be performed during ORIF and is dependent on surgeon preference and bone purchase.
It is surgeon preference to approach with the first or second TMT joint first. We discuss initial reduction of the second metatarsal.