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Injuries to the tarsometatarsal (TMT) joints, commonly known as Lisfranc injuries, encompass a wide spectrum, ranging from purely ligamentous injuries to simple and complex fractures often associated with varying degrees of significant soft tissue trauma ^, . Due to their relative rarity, these injuries are frequently overlooked in initial evaluations. Even when promptly treated by specialists, Lisfranc injuries are reported to result in significant morbidity, including deformities and loss of function in the affected foot ^,, .

Achieving anatomical reduction and surgical fixation is essential for unstable or dislocated injuries to reduce the risk of severe impairment of the foot in the midterm ^,, . Fixation methods include percutaneous K-wires, transarticular screws, dorsal bridge plating, and suture button fixation. Primary TMT arthrodesis has also been described ^, . However, no consensus exists on the best primary operative treatment strategy for Lisfranc injuries due to varied presentations, study conditions, populations, and inconsistent outcome measures or reduction assessments ^, .

In addition to radiological analyses, patient-reported outcome measures and clinical scores are well-established for evaluating treatment success. However, data on biomechanical function after surgical treatment of Lisfranc injuries also remain limited ^,,,,,, . We therefore aimed to evaluate midterm outcomes of surgically treated Lisfranc injuries by integrating objective clinical scores, subjective patient-reported outcome measures, and comprehensive biomechanical analysis, including EMG, gait analysis, joint alignment assessment, and dynamic pedobarometry. We hypothesized that operative treatment of Lisfranc injuries sufficiently restores biomechanical function and gait.

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The inclusion criteria were as follows: patients with unilateral bony injuries to the tarsometatarsal joint, surgically treated at our clinic with an observation interval of at least 18 months post-injury. Exclusion criteria included patients with significant additional fractures outside the TMT injury on either foot, lower extremity arthroplasty, or other gait-altering disorders affecting the lower extremities. Patients who met these criteria and consented to participate were invited to undergo gait analysis, electromyography (EMG), pedobarography, and clinical examination. A control group consisting of healthy volunteers, chosen to be closely matched in BMI, gender and age, was also recruited.

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A 3D biomechanical gait analysis, electromyography (EMG), and pedobarography were conducted on a 5-meter walkway at a self-selected pace. Participants walked back and forth continuously, completing the track 8–10 times. Gait and EMG analyses were performed using the 3D MyoMotion and MyoMuscle systems (myoRESEARCH 3.18, Noraxon U.S.A.). EMG electrodes were placed on the lateral head of the gastrocnemius as well as the soleus and tibialis anterior muscles, with EMG amplitudes normalized to submaximal isometric contraction (sMVC). Inertial measurement unit sensors, calibrated and positioned on the pelvis, thighs, shanks, and feet, measured anatomical angles and range of motion (ROM) at 100 Hz ( Fig. 1 ). Sensor positions were used to calculate the ROM of the hip, knee, and ankle joints.

Inertial measurement unit sensors, calibrated and positioned on the pelvis, thighs, shanks, and feet.

Pedobarography was performed using a pressure distribution platform (Zebris 1.5 FDM, Zebris Medical, Germany) equipped with 11,264 sensors (resolution: 1.4 sensors/cm²). To ensure natural gait, the pressure platform was embedded within a wooden walkway ( Fig. 2 ). Force data were normalized to body weight and analyzed across seven foot zones: medial heel, lateral heel, midfoot, medial forefoot, inner forefoot, lateral forefoot, and toes ( Fig. 2 ). Data from at least five trials were averaged for each participant. All participants walked without assistive devices, and measurements were taken barefoot.

Wooden walkway with the embedded pressure platform for the measurement of pedobarometry. Seven foot zones for the measurement of force data normalized to the bodeweight: medial heel (HM), lateral heel (HL), midfoot (MF), medial forefoot (FM), inner forefoot (FI), lateral forefoot (FL), and toes (T).

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Two validated questionnaires (AOFAS Score and FAAM Score) were used to assess subjective and functional outcomes.

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Data analysis was conducted using SPSS version 29.0.2.0. Mean values and standard deviations (SD) were calculated. A one-way ANOVA was used to compare the control group, injured side, and healthy side, with a significance level of α = 0.05. The Bonferroni post hoc test was applied for homogeneous variances, while the Welch test was used for non-homogeneous variances. Comparisons between the control and patient groups were performed using the Kolmogorov-Smirnov test, followed by an unpaired t -test. Statistical significance was defined as p ≤ 0.05. The Eta coefficient was employed to assess correlations between nominal and metric variables, with significance determined using univariate analysis of variance. A Pearson correlation was carried out to examine possible correlations between clinical scores and selected gait parameters.

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The study group comprised 12 individuals (12 feet), including 8 males and 4 females, with a mean age of 44.3 years (range: 25–64). The mean follow-up period after surgical treatment was 55.3 months (SD 20.2, range: 32–88). The control group consisted of 12 healthy volunteers without lower extremity injuries (8 males and 4 females), chosen to be comparable in gender, age and BMI, with a mean age of 38.2 years (range: 21–64). Average follow-up in the study group was 55 months (SD: 20.2, 22–88)

Six of the Lisfranc injuries were caused by low-energy mechanisms. The remaining six were high-energy injuries, including four crush injuries, one high-velocity impact from a motorcycle accident, and one crush/translation injury caused by a forklift wheel. These were classified as high-energy mechanisms.

According to the Hardcastle-Myerson classification, four injuries were classified as type A, seven were type B2, and one was type C1. All patients underwent surgical treatment with osteosynthesis of the TMT joint using a combination of Kirschner wires (K-wires), screws, and plates. In four cases, dorsal fasciotomy was additionally performed due to impending compartment syndrome.

Conventional gait analysis revealed no significant differences between the study and the control group, or between sides in the study group ( Table 1 ). Gait analysis using 3D biomechanical gait and electromyography revealed significantly greater hip abduction and adduction as well as knee adduction of the injured side compared to the control group, while the uninjured side showed no significant differences from the control group ( Table 2 ). The remaining measurements showed no differences in motions of the knee and ankle joints during gait analysis. Compared to the healthy side, only the external rotation of the hip was significantly greater on the injured side.

Table 2

Range of motion (ROM, in degrees °) of investigated joints in three-dimensional gait analysis compared between the patients’ affected (IS) and healthy side (HS) compared to the control group (CG). Significant differences are marked with asterisk and were pairwise compared using Bonferroni correction (*). Movements of joints in the opposite direction are marked as negative values.

Parameter		Group (mean±SD)			p-value	Bonferroni comparisons
		CG	IS	HS		CG-IS	CG-HS			IS-HS
	Max	20.7 ± 3.8	23.9 ± 5.0	24.4 ± 5.2	0.133
Hip Flexion (°)	Min	-16.2 ± 4.4	-14.8 ± 3.1	-15.6 ± 4.0	0.686
	ROM	38.1 ± 4.2	39.4 ± 5.5	40.2 ± 4.2	0.540
	Max	3.6 ± 2.8	6.0 ± 3.4	3.9 ± 2.4	0.102
Hip Abduction (°)	Min	-6.1 ± 1.5	-8.2 ± 2.6	-7.4 ± 3.2	0.128
	ROM	10.3 ± 2.8	14.6 ± 1.4	12.0 ± 3.2	0.001*	0.001*	0.375			0.066
	Max	5.6 ± 6.1	11.0 ± 9.8	1.5 ± 6.8	0.017*	0.286	0.595			0.014*
Hip Rotation (°)	Min	-7.0 ± 5.6	-1.0 ± 7.4	-9.9 ± 6.1	0.006*	0.089	0–783			0.005*
	ROM	13.5 ± 5.4	13.6 ± 3.2	13.3 ± 3.4	0.977
	Max	59.0 ± 5.4	62.8 ± 7.9	59.4 ± 9.1	0.420
Knee Flexion (°)	Min	1.3 ± 3.4	3.5 ± 5.4	3.1 ± 6.9	0.582
	ROM	57.7 ± 4.2	60.5 ± 5.6	57.5 ± 5.0	0.269
	Max	6.6 ± 6.1	5.0 ± 2.9	3.6 ± 4.8	0.303
Knee Abduction (°)	Min	-2.2 ± 2.5	-3.0 ± 4.3	-6.5 ± 4.8	0.028*	1.0	0.036*			0.118
	ROM	10.3 ± 6.4	8.7 ± 2.3	10.7 ± 3.7	0.262
	Max	6.3 ± 4.9	10.7 ± 6.1	7.9 ± 4.7	0.584
Knee Rotation (°)	Min	-8.2 ± 4.5	-6.5 ± 3.7	-7.3 ± 3.7	0.135
	ROM	14.7 ± 4.9	17.6 ± 5.0	15.7 ± 5.0	0.362
	Max	15.01 ± 1.9	17.2 ± 3.0	15.5 ± 3.2	0.142
Ankle Dorsiflexion (°)	Min	-11.7 ± 5.6	-11.9 ± 6.8	-13.6 ± 6.0	0.723
	ROM	27.6 ± 4.6	29.8 ± 7.2	29.1 ± 6.2	0.665
	Max	2.0 ± 4.4	4.2 ± 3.8	3.5 ± 6.7	0.557
Ankle Abduction (°)	Min	-16.7 ± 6.1	-13.4 ± 5.7	-12.4 ± 8.6	0.285
	ROM	19.3 ± 7.6	17.9 ± 5.5	16.8 ± 5.7	0.639
	Max	13.2 ± 8.9	11.4 ± 6.5	12.8 ± 2.7	0.787
Ankle Inversion (°)	Min	-3.5 ± 1.3	-3.7 ± 2.6	-4.1 ± 3.3	0.794
	ROM	16.7 ± 8.6	15.5 ± 4.8	17.4 ± 3.5	0.758

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