The clinical question
A 34-year-old recreational runner landed awkwardly off a curb and reported immediate midfoot pain. Plain films on presentation looked unremarkable. Weight-bearing films showed a 3 mm diastasis between the first and second tarsometatarsal joints. MRI confirmed complete disruption of the Lisfranc ligament without an intact interosseous limb.
The question, as in every purely ligamentous Lisfranc, was not whether to intervene but how. ORIF with transarticular screws or a dorsal bridge plate is the historical default. Primary arthrodesis has moved from salvage into a reasonable index procedure for the purely ligamentous pattern in adults.
Key decision points
Three things pushed us toward primary fusion:
- Pure ligamentous injury — the published fusion literature shows its largest effect in exactly this subgroup.
- The patient's activity demands were specific and recreational, not professional. She wanted to run again, but a second surgery to remove hardware was not appealing to her.
- The second tarsometatarsal joint showed a small cartilage lesion on MRI consistent with chronic overload, which made us wary of preserving motion through a joint already beginning to wear.
If the interosseous ligament is truly gone, the joint is going to be unhappy. The question is whether you pay for that unhappiness now, in one operation, or later in two.
What the literature shows
The most recent meta-analysis (Magill et al., FAI 2021) aggregated eleven studies and more than three hundred patients. Reoperation rates were meaningfully lower in the primary fusion arm (roughly 17% vs. 30%), driven largely by hardware removal after ORIF. Patient-reported outcomes at two years were comparable on AOFAS and FFI.
The fusion literature does not, on balance, show better pain scores or faster return to work than ORIF. Where it changes the conversation is reoperation: a patient who accepts primary fusion is statistically less likely to come back for a second procedure.
What Anish took away
Three things I'm still thinking about: the value of the weight-bearing film at presentation — we almost missed this on the non-weight-bearing view; the cartilage lesion on MRI as a quiet vote against preserving motion; and the post-op conversation, which mattered more than the hardware choice. She is running at six months, four days a week, at a pace she describes as slower but comfortable. The foot is not, and will not be, what it was before the injury. That expectation was worth setting in the clinic, not in the recovery room.