Lisfranc arthrodesis

Lisfranc injuries, also known as tarsometatarsal joint injuries, consist of injuries to the bases of the five metatarsals, their joints with the four peripheral bones of the tarsus and the rupture of the Lisfranc ligament, which is the main stabilising ligament of the midfoot.This is a relatively uncommon injury with an incidence of about 0.2% of all fractures. Often, Lisfranc injuries are diffuse in a multi-injury or low energy sports injuries leading to poor functional outcome.

First tarsometatarsal joint injuries are often associated with long-term disability and painful post-traumatic arthritis. Treatment strategies have evolved over the years. Traditional treatment often consisted of closed reduction and immobilization, or closed reduction and percutaneous osteosynthesis. These methods often did not result in anatomical reduction and the results were often unsatisfactory, leading to residual instability of the foot and limited functionality. Over time, the proposed treatment of first tarsometatarsal joint injuries has moved from closed reduction to open reduction and internal fixation.

Although open reduction and internal fixation remains the mainstay of treatment, the results are often suboptimal. Even with anatomic reduction, patient outcomes often deteriorate over time. Typical fixation methods used by surgeons include screw fixation and, more recently, dorsal plate placement.

When interarticular fixation is used, removal of the screws creates large osteochondral deficits on both sides of the joint. These osteochondral deficits may contribute to the high incidence of post-traumatic arthritis that often occurs with these injuries after osteosynthesis and screw removal. Dorsal plates preserve cartilaginous surfaces and offer similar functional results and patient satisfaction. However, the use of a dorsal plate often requires an additional surgical approach. These plates are designed to be temporary and if the material remains after osteosynthesis, there is essentially pseudoarthrosis and this can cause prolonged discomfort.

Recently, there has been a trend towards primary arthrodesis for purely ligamentous injuries. Comparative studies have reported better short- and medium-term outcomes with primary arthrodesis compared to internal fixation. After osseointegration of severe intra-articular fractures and subsequent material removal, incomplete closure and degeneration of the joints may occur, leading to pain, which may require salvage arthrodesis. In this case, one may consider primary arthrodesis as an alternative to osteosynthesis. Arthrodesis also eliminates the potential for post-traumatic arthritis and the need for material removal.

Primary arthrodesis may be a viable option in these high-energy Lisfranc injuries with good radiographic results, 100% closure, and low reintervention rates. The likelihood of malunion can be improved by including the medial column in the arthrodesis.