So Doctor, How Bad Is My Lisfranc Injury?

Soooo I started doing research on these Lisfranc injuries right when I first had gotten hurt because well, let’s be honest I had nothing but time on my hands and I was curious. I also appreciate a good journal article. 😉

Overall, I think the best way to determine to what degree of injury your Lisfranc injury is, is to determine the grade of how far displaced the bones may be, any fractures, and the condition of the ligaments. All of which is determined with an Xray, CT and/or an MRI. Also, as a disclaimer, I am no doctor so take this with a grain of salt and go get checked out! My surgeon had mentioned this method when determining whether or not to have surgery. This information has helped me get a more tangible grasp on my Lisfranc injury.

I especially liked the article from 2022 Mascio, Greco, Maccauro, & Perisano. I recommend reading the whole article. Many articles do mention current controversies in the literature concerning the management and treatment due to the difficulty in diagnosing and categorizing. Comforing right?!

One way to classify Lisfranc injuries are by a grade system:

• Grade 1: Sprain to the Lisfranc ligaments with <2mm diastasis (distance between bones) and no arch height loss

• Grade 2: Sprains with diastasis of 2-5mm between the 1st and 2nd metatarsals with no arch height loss

• Grade 3: Sprains with diastasis >5mm between 1st and 2nd metatarsals with longitudinal arch height loss

Another way to classify Lisfranc injuries is if the Lisfranc is stable or unstable:

• Stable Injuries

  • Grade I Lisfranc injuries are considered to be stable (no bone displacement or diastasis) and can be treated non‐operatively. If it is a Grade I Lisfranc injury, then it is common to be treated with 6 weeks of nonweightbearing status and results are typically very promising. Either in a cast or boot followed by a period of graduated weight bearing and possibly the use of orthotics (Mascio, Greco, Maccauro, & Perisano, 2022).

• Not stable!

  • If Lisfranc injuries are not stable, this means that bones have most likely been displaced or there is diastasis. Unstable or dislocated injuries have worse outcomes and require surgical treatment. Most times when surgical intervention is needed, there are two main objectives of anatomical reduction and stability of the first three cuneiform-metatarsal joints. There have been many different surgical procedures proposed over the years but it is noted that there is no superiority of one technique over the other. What determines the post-operative outcomes is rather the anatomical reduction (Mascio, Greco, Maccauro, & Perisano, 2022). However, the severity of the injury and a quick diagnosis are the main determinant of the biomechanical and functional long-term outcomes (Mascio, Greco, Maccauro, & Perisano, 2022).

    
    

So what are the surgical interventions? An ORIF or PA:

There are numerous surgeries that can be contemplated but the two most common surgeries for a Lisfranc injury are an Open Reduction Internal Fixation (ORIF) or Primary Arthrodesis (PA).  Both physicians that I consulted with mentioned these two as suitable options. An ORIF was recommended due to my young age, active nature, and the benefits of flexibility and mobility in the foot post surgery. An ORIF allows the body to regrow the ligament in the Lisfranc joint. With a PA, the foot bones are fused together leaving the foot with much less mobility than it originally had. Surgeons mentioned that I may have to get a fusion later in life, but we cross that bridge if/when we get there.

I agree with these consultations and had my surgery; however, the researcher in me has looked into the studies as of late. Lately, I have found that the studies show the PA has better long-term outcomes. This makes sense as you would not have to go into surgery again or have as much arthritis due to less trauma to the site. The one caveat with this research is these researchers outright say that they have a hard time finding consistency with their sample (people) due to the misdiagnosis and difficult classifications with this injury. Also, studies can be difficult to get consistent results anyway as people typically do not follow up 20 years down the road.

So, The Bad News Of Getting An ORIF:

“Evidence is mounting that with regard to unstable purely ligamentous Lisfranc injuries primary arthrodesis (PA) has: better functional outcomes, increased cost effectiveness and reduced rates of return” (Grewal, Onubogu, & Southgate, 2020). 

“Based on this limited case series, purely ligamentous Lisfranc injuries were found to have better outcomes when managed with a primary fusion as compared to ORIF. Arthritic changes and additional surgeries apart from implant removal could be avoided by primary fusion” (Kandil, Abouzeid, Eltaher, & Eltregy, 2022).

There was one study from (Balazs, Hanley, Pavey, & Rue), that showed an ORIF was more advantageous in military patients.

It is believed that the inherent stability of the Lisfranc joints depends on the scar tissue which forms following open reduction and internal fixation. This scar tissue however, is not strong enough to support the injured joint and has been found that the associated ligaments do not heal after fixation. This results in instability of the joint on weight bearing leading to the development of arthritis with chronic pain and foot deformity. (Partap, Raghunanan, & Seepaul, 2022)

**It was this article that scared me. And then it continued…

“A good functional outcome has been found in patients treated with primary arthrodesis with some reporting as high as 90% of patients returning to their pre-operative level of function…However, it has been shown that patients were able to return to their previous physical activities despite undergoing a primary arthrodesis [10]. The level of sporting participation when compared to their pre-injury level was found to be the same or improved in 75%” (Partap, Raghunanan, & Seepaul, 2022).

One article mentioned patients treated for Lisfranc injury had a significantly lower walking speed than healthy subjects. This same article showed significantly lower flexion/extension in the midfoot than healthy subjects as well.

So now that I have officially scared you, I want to share why you will be okay:

· Regardless of chosen surgery, recovery seems the same according to Mascio, Greco, Maccauro, & Perisano (2022).

· There has not been much research in young patients.

· There has been more ORIF surgeries than PAs. There must be a reason why.

· I did find several articles that mentioned no difference between an ORIF and PA post complications after hardware removal. (Mascio, Greco, Maccauro, & Perisano, 2022)

· You will walk again.

· You are not an amputee.

· You very well may play again. It just may take some time.

Return To Sports:

In Lorenz and Beauchamp’s article, they followed the return to play sports in 15 athletes following either conservative or surgical treatment. Athletes with Grade I injuries had excellent outcomes with conservative treatment and returned to play between 11‐18 weeks. Athletes with Grade II injuries had good outcomes with ORIF and returned to play between 12‐20 weeks. However when managed conservatively, poorer outcomes were noted with a diastasis >2 mm in Grade II injuries. Results for athletes with Grade III or complex dislocations are not well described, but it is safe to say these injuries would be season ending and have a significantly longer return to play than both Grade I or II injuries. (Lorenz & Beauchamp, 2013). Mine was a diastasis of 5.3. If you think you have a messed up foot, all I can recommend is getting it checked out.

I will recommend: It was found that when fixation screws remain in place indefinitely, they have a high tendency to break over time and have a high likelihood to cause pain.

Through everything that I researched, it was noted that quick identification and management of these injuries is crucial to reduce risk of progressive midfoot instability, arch collapse, forefoot abduction, or post-traumatic osteoarthritis (OA) that could result in stiffness, chronic pain, and dysfunction of the foot and ankle complex [1]. (Mascio, Greco, Maccauro, & Perisano, 2022). I can tell you that I have been playing volleyball again and jumping and I can run without a limp. I hope this was both informative but also encouraging. Good luck out there and keep at it!

References

Mascio, A., Greco, T., Maccauro, G., & Perisano, C. (2022). Lisfranc complex injuries management and treatment: current knowledge. Internaltional Journal of Physiology, Pathophysiology and Pharmacology, 161-170.