The clinical question
A young, otherwise healthy collegiate athlete presents three weeks after an indirect midfoot injury. He was diagnosed at an outside ED as a midfoot sprain on non-weightbearing radiographs and placed in a boot. He is not improving. He has persistent pain over the Lisfranc complex with full weightbearing, plantar ecchymosis is no longer visible but he recalls it clearly, and he cannot tolerate a heel rise on the affected side.
The question is not whether he is injured. The question is whether this is the variant of Lisfranc injury where we should still be operating, and if so, how.
Imaging
Weightbearing radiographs told the story the outside films missed. Three millimeters of diastasis between the first and second metatarsal bases on the symptomatic side, with a normal contralateral comparison. The lateral showed loss of the normal dorsal alignment at the first TMT joint.
MRI confirmed a complete rupture of the Lisfranc ligament with associated bone edema at the second metatarsal base. There was no articular cartilage lesion at the first or second TMT joint that would have pushed us toward primary fusion on that basis alone.
The decision
We had a long conversation with the patient and his family about ORIF versus primary fusion. The literature does not give us a clean answer in the purely ligamentous variant, and reasonable surgeons disagree. Our position: in a first-time, purely ligamentous injury in a 20-year-old without articular damage, anatomic reduction and rigid fixation with modern implants gives us a reasonable shot at native joint preservation. If he fails, we fuse later — and we fuse a joint that has already been reduced and held for months, which is a much easier operation than fusing acutely.
The counterargument — that primary fusion avoids the second operation — is real. It is the right call in the patient who wants one operation and a predictable ceiling, or who has articular damage that will not recover. It was not the right call here.
Operative approach
Dorsal approach between the first and second TMT joints. The Lisfranc ligament was confirmed ruptured intraoperatively. Anatomic reduction of the second TMT was achieved with a pointed reduction clamp referencing the medial cuneiform. Fixation: bridge plate across the first TMT, dorsal plate across the second TMT, intercuneiform screw. Fluoroscopic confirmation of anatomic reduction in two planes.
Outcomes
Non-weightbearing for six weeks in a splint, then boot with graduated weightbearing. At twelve weeks he was out of the boot. At six months he had returned to sport-specific conditioning. Hardware removal is planned at nine to twelve months given his sport and the bridge-plating construct across the first TMT.
References
The cited papers on the related episode page are the primary references for this decision-making. The meta-analysis from Magill and the return-to-sport series from Chen and Osborn are the two most relevant in the purely ligamentous variant.