1. Case for small group discussion
Lisfranc instability
Case for small group discussion
AOTrauma—Foot & Ankle
Module 13: Midfoot
Andrew Sands, US

2. Case description 55-year-old man Works for railroad as track worker
Must carry heavy things and step over third rail
Sustained twisting injury to foot
5’9” (1.80 m) and 165 lbs (75 kg): not an oversized person

3. Case description Seen in local emergency room
Subsequently seen in office with residual midfoot pain
Stress images taken

4. X-rays

5. Diagnosis Treatment options Nonoperative Internal fixation
External fixation
Fusion

6. Operation
This was done (below)
Comments?

7. 2 months postoperative
Continued pain after frame was removed

8. Longer term follow-up Presents 9 months later
Why does the patient have continued pain?
What would you do now?

9. Definitive operative plan
Instability after pure ligamentous injury with continuous pain
What is your plan?
Evaluate if equinus present?
Discuss management, calf release

10. Definitive surgery Tarsometatarsal (TMT) fusion to address instability
Calf release if equinus present

11. Take-home messages
If fracture or avulsion is present, it will heal bone to bone
ORIF in perfect position will usually lead to healing but anatomic positioning is mandatory
In case of a pure ligamentous injury, consider immediate fusion
If fusing, you can use plates or screws and bone graft
Evaluate for equinus and address if present
Ly, Thuan V, and Coetzee, J Chris. Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. J Bone Joint Surg Am. 2006; 88(3):