Lisfranc Injury: Surgery vs Nonsurgical Treatment — Who Actually Needs Surgery?
Updated: Aug 27
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Lisfranc Injury: Surgery vs Nonsurgical Treatment — Who Actually Needs Surgery?
By Sarang Desai, DO — Fellowship-Trained Orthopedic Foot and Ankle Surgeon
Sports Medicine | McKinney and Flower Mound, Texas
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You hurt your midfoot. Maybe you stepped off a curb wrong, landed awkwardly on a teammate's foot, or twisted your foot during a cut on the field. Now someone has mentioned the word "Lisfranc" and you're trying to figure out one thing:
Do I actually need surgery?
It's the right question to ask — and the answer depends entirely on whether your injury is stable or unstable. That single distinction drives everything: the treatment plan, the recovery timeline, and the long-term outcome.
As a fellowship-trained foot and ankle surgeon who treats Lisfranc injuries in athletes and everyday patients across McKinney, Flower Mound, and the greater Dallas-Fort Worth area, I walk patients through this decision regularly. Here's exactly how I think through it.
For the full overview of Lisfranc injuries: Lisfranc Injury Surgery: The Complete Guide · Why Lisfranc Injuries Are Such a Big Deal in Athletes · How Lisfranc Injuries Are Diagnosed: X-ray vs CT vs MRI
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THE SINGLE MOST IMPORTANT QUESTION: IS IT STABLE OR UNSTABLE?
Older classification systems for Lisfranc injuries were based on anatomy — which bones were broken, which direction things moved. These systems describe the injury but don't actually help make treatment decisions very well.
The modern approach is stability-based. A 2024 review in the Bone & Joint Journal advocates exactly this: classify the injury by stability, using weight-bearing radiographs and CT as the key diagnostic tools. This approach directly guides treatment.
Here's how to think about it:
STABLE = The bones stay aligned when you put weight on the foot. The Lisfranc ligament is intact or only partially sprained. No displacement on weight-bearing X-rays. No significant findings on CT or MRI.
→ These can be treated without surgery.
UNSTABLE = The bones shift when loaded. The Lisfranc ligament is torn. There is displacement ≥2 mm on weight-bearing radiographs, widening between the first and second metatarsal bases, or frank dislocation.
→ These need surgery.
It sounds simple, but the challenge is that many Lisfranc injuries fall into a gray zone — they look borderline on initial non-weight-bearing X-rays, and the instability only reveals itself on weight-bearing views or advanced imaging. This is exactly why an estimated 20% of Lisfranc injuries are initially missed.
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WHO DOES NOT NEED SURGERY
Not every Lisfranc injury requires an operation. The 2024 International Foot and Ankle Sports Consensus (IFASC) — a modified Delphi process involving 32 international orthopedic foot and ankle surgeons — reached unanimous agreement that:
Stable, nondisplaced injuries with intact ligaments on MRI may be managed nonoperatively with close monitoring.
Specifically, nonsurgical treatment is appropriate when:
- Weight-bearing X-rays show no displacement (no widening of the Lisfranc interval, no shift of the metatarsals)
- MRI shows an intact Lisfranc ligament — or at most a low-grade sprain without complete disruption
- CT shows no fracture displacement or comminution
- The patient can bear weight (even if painful) without the foot collapsing into a flatfoot position
What does nonsurgical treatment look like?
The most reliable protocol, based on current evidence:
1. Non-weight-bearing in a boot or short leg cast for 6 weeks — this is critical. The injury needs time to heal without stress.
2. Progressive weight-bearing in a boot for an additional 2–4 weeks
3. Transition to supportive shoes with arch support — custom orthotics can help
4. Physical therapy focusing on intrinsic foot strengthening, proprioception, and gait retraining
5. Serial weight-bearing X-rays to confirm the alignment stays maintained as weight-bearing progresses
What are the outcomes?
A study of 55 CT-confirmed nondisplaced Lisfranc injuries treated nonoperatively found that 64% scored over 90 points (out of 100) on the VAS-FA (a validated foot and ankle questionnaire) at 2–6 year follow-up. Only 7% scored below 60 — meaning the vast majority did well. Only one patient required secondary surgery.
For athletes, the data is even more encouraging: stable ligament injuries treated nonoperatively allowed 96.8% of athletes to return to sport, with a mean return time of just 2.8 months.
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The key point: nonsurgical treatment works very well — but ONLY for truly stable injuries. The entire system falls apart if an unstable injury is mistakenly treated without surgery.
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The biggest mistake I see: A patient is seen in the ER, gets non-weight-bearing X-rays that look "fine" or show only subtle findings, is told it's "just a midfoot sprain," and is sent home in a boot. No weight-bearing X-rays are ever obtained. No CT or MRI is ordered. The patient walks on a torn Lisfranc ligament for weeks, the midfoot collapses, and by the time they see a specialist, what was a fixable injury is now a much bigger problem.
If there is any clinical suspicion of a Lisfranc injury — midfoot tenderness, pain with the squeeze test, inability to bear weight, ecchymosis on the plantar surface of the midfoot — weight-bearing X-rays are mandatory. If weight-bearing views are equivocal, CT or MRI is the next step.
For details on imaging: How Lisfranc Injuries Are Diagnosed: X-ray vs CT vs MRI
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WHO NEEDS SURGERY
The short answer: anyone with an unstable or displaced Lisfranc injury.
From the Swedish Fracture Register — the largest epidemiologic study to date, with 2,084 Lisfranc injuries — approximately 39% of patients underwent surgical treatment. That means the majority were treated conservatively, but a substantial proportion required surgery.
Surgical indications include:
- Displacement ≥2 mm on weight-bearing radiographs at the Lisfranc interval (the space between the medial cuneiform and the base of the 2nd metatarsal)
- Any diastasis (widening) between the 1st and 2nd metatarsal bases that increases on weight-bearing views
- Fracture-dislocation patterns — displaced fractures through the tarsometatarsal joints
- Comminuted fractures through the joint surfaces
- Failed conservative treatment — injuries that appeared stable initially but displace during follow-up weight-bearing X-rays
- Complete Lisfranc ligament tears on MRI with clinical instability
Why is surgery so important for unstable injuries?
Because the Lisfranc joint is the keystone of the midfoot arch. If it's unstable and you try to walk on it, the arch collapses. The metatarsals shift. The foot widens and flattens. Cartilage that's no longer properly aligned wears out. The result: post-traumatic arthritis, chronic pain, and a foot that doesn't work right.
A landmark study found that the single most important determinant of a good long-term outcome was anatomical reduction — meaning getting the bones back exactly where they belong (P=0.05). Among patients followed for an average of nearly 11 years after surgery, 72% had radiographic evidence of osteoarthritis and 54% had symptomatic arthritis. The biggest risk factors? Non-anatomic reduction, high-energy injury pattern, and smoking.
The message is clear: if surgery is needed, it needs to be done well. Anatomic alignment is everything.
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THE THREE MAIN SURGICAL OPTIONS
Once surgery is indicated, the next question is: what kind of surgery? There are three main approaches, and choosing the right one depends on the injury pattern, the patient's age, activity level, and the condition of the joint surfaces.
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1. OPEN REDUCTION AND INTERNAL FIXATION (ORIF)
This is the most common surgical approach worldwide. In the Swedish registry, 51% of operatively treated Lisfranc injuries were fixed with plates, with screws as the next most common.
What it means: The surgeon makes an incision (or incisions) over the top of the midfoot, directly visualizes the displaced joints, reduces (repositions) the bones into anatomic alignment, and holds them there with screws, plates, or a combination.
The goal: Restore perfect alignment while preserving the joint — no joint surfaces are removed. The hardware holds things in place while the ligaments and bone heal.
Advantages:
- Preserves the native joint — the cartilage surfaces are kept intact
- Appropriate for most injury patterns, including purely ligamentous and fracture-dislocation types
- Well-studied with decades of follow-up data
- 94% of athletes return to some level of sport after ORIF
Disadvantages:
- Hardware removal is very common — a 2024 meta-analysis found 64.1% of ORIF patients underwent reoperation, with the overwhelming majority being hardware removal. In athletes, 93.5% of secondary procedures after ORIF were hardware removal.
- Post-traumatic arthritis remains a concern: approximately 17.3% after ORIF in a meta-analysis, and up to 25–37% in longer-term studies of higher-energy injuries
- Return to preinjury activity: 65.7% in a meta-analysis — meaning about a third of patients don't fully return to their previous level
- Purely ligamentous injuries may have a trend toward poorer outcomes even with anatomic reduction and screw fixation
Hardware used:
- Bridge plates — span across the tarsometatarsal joints, holding alignment. Current consensus favors bridge plating as the primary ORIF technique.
- Transarticular screws — placed directly across the joint. Effective but risk damaging articular cartilage as they cross the joint surface.
- Combined plate and screw constructs — a multicenter study of 172 patients found that combined screw and plate fixation was associated with lower complication risk (AOR 0.23, P=0.019) compared to other constructs.
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2. SUTURE BUTTON FIXATION (FLEXIBLE FIXATION)
This is the newest approach and is gaining significant traction, especially for purely ligamentous Lisfranc injuries in athletes.
What it means: Instead of rigid screws or plates across the joint, a high-strength suture with a small button on each side of the bone is used to hold the alignment. Think of it like a strong internal stitch that allows a small amount of physiologic motion — similar to how the suture button is used for syndesmotic injuries in ankle fractures.
The data is compelling:
The 2024 IFASC consensus and systematic review of 406 athletes found that for unstable ligament injuries, suture button fixation compared to ORIF showed:
- Higher AOFAS scores: 95.5 vs. 89.4
- Lower complications: 10.9% vs. 18.2%
- Zero failures: 0% vs. 4.9%
- Zero secondary procedures: 0% vs. 30.5%
At minimum 5-year follow-up, a study of 20 patients treated with suture button fixation showed a mean AOFAS score of 95.5 and mean VAS pain of 0.50 — excellent results maintained over time.
A direct comparison of suture button vs. conventional screw fixation for isolated Lisfranc ligament injuries (63 patients) found that suture button had better early functional scores (P<0.001) though scores equalized after screw removal. Suture button avoids the need for a second surgery to remove hardware — a major advantage.
Newer flexible fixation techniques, including the InternalBrace system, show comparable results to suture button with excellent AOFAS scores (92.4 vs. 91.5) and stable radiographic reduction at minimum 2-year follow-up.
The consensus recommendation from 32 international experts:
Elite athletes with unstable ligament Lisfranc injuries should undergo fixation (not fusion). Suture button fixation is emerging as the preferred method for this specific injury pattern because it preserves joint motion, avoids cartilage damage from transarticular screws, and eliminates the need for hardware removal.
Important caveat: Suture button fixation works best for purely ligamentous injuries in good bone. For fracture-dislocations with comminution, rigid fixation (plates, screws) or arthrodesis may be more appropriate.
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3. PRIMARY ARTHRODESIS (FUSION)
What it means: Rather than just holding the bones together and hoping the joint heals, the surgeon removes the damaged cartilage from the affected tarsometatarsal joints and fuses them permanently with plates and screws. The joints are deliberately eliminated.
Why would anyone fuse joints on purpose?
Because the medial tarsometatarsal joints (1st, 2nd, and 3rd) have very little motion to begin with — they're essentially rigid stability joints. Fusing them sacrifices minimal motion and eliminates the possibility of post-traumatic arthritis at those joints, since there's no joint surface left to wear out.
The evidence is surprisingly strong:
A 2024 systematic review and meta-analysis of 18 studies found that primary arthrodesis compared to ORIF had:
- Better AOFAS scores: 84.4 vs. 75.7 (P=0.004)
- Lower VAS pain: 1.4 vs. 2.0 (P=0.006)
- Higher return to preinjury activity: 79.2% vs. 65.7%
- Much lower post-traumatic arthritis: 2.8% vs. 17.3%
- Dramatically fewer unplanned reoperations: 14.7% vs. 38.3% (P<0.001)
A randomized controlled trial of Lisfranc injuries with first TMT joint dislocation (78 patients) confirmed: primary arthrodesis produced significantly better AOFAS midfoot scores, FAAM sports scores, SF-36 physical function, and VAS pain scores than ORIF (all P<0.05). The ORIF group had 10 cases of re-dislocation and 13 patients with persistent midfoot pain. The arthrodesis group had zero re-dislocations and zero hardware failures.
An earlier meta-analysis (2019) of RCTs alone found ORIF was associated with 17.5× higher odds of needing revision surgery (OR 17.56, P<0.00001) and significantly higher pain scores compared to primary arthrodesis.
When I consider primary arthrodesis:
- Comminuted fracture-dislocations where the joint surfaces are destroyed and cannot be reconstructed
- High-energy crush injuries with significant cartilage damage
- Purely ligamentous injuries in non-athletes — particularly when the medial column (1st and 2nd TMT joints) is involved and the patient prioritizes pain relief over theoretical joint preservation
- Failed prior ORIF with post-traumatic arthritis requiring revision
When I avoid primary arthrodesis:
- Young competitive athletes with ligamentous injuries — the consensus recommends fixation (not fusion) for these patients
- Lateral column injuries (4th and 5th TMT joints) — these joints have important motion for gait adaptation on uneven surfaces. Fusing them can cause problems.
- Low-energy, minimally displaced injuries that can be adequately reduced and held with fixation
The unknown: Long-term data beyond 5–10 years after primary arthrodesis is limited. There is a theoretical concern about adjacent joint arthritis — the joints next to the fused segments could be overloaded over time. This has not been well studied, and it's one reason I'm cautious about fusing joints in a 22-year-old athlete who has 50+ years of activity ahead of them.
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HOW I THINK THROUGH THE DECISION
Here's my actual thought process when a Lisfranc injury patient is sitting in front of me:
Step 1: Is it stable or unstable?
Weight-bearing X-rays and advanced imaging (CT/MRI) answer this. If it's stable → nonsurgical treatment. If it's unstable → surgery.
Step 2: What's the injury pattern?
- Purely ligamentous → fixation preferred over fusion (especially in athletes). Suture button or flexible fixation is an excellent option.
- Fracture-dislocation with salvageable joint surfaces → ORIF with plates ± screws, anatomic reduction is paramount.
- Fracture-dislocation with destroyed joint surfaces → primary arthrodesis of the affected joints (usually medial column).
Step 3: Who is the patient?
- Young competitive athlete → I strongly favor joint-preserving fixation. The 2024 international consensus unanimously agrees: fixation, not fusion, for unstable ligament injuries in athletes.
- Middle-aged recreational athlete → more nuanced. If the joint surfaces are intact, fixation. If there's significant comminution, arthrodesis may give a more predictable long-term result.
- Older, lower-demand patient → primary arthrodesis of the medial column may be the most reliable path to a pain-free foot with fewer reoperations.
Step 4: Can I get an anatomic reduction?
The single most important factor in long-term outcome. If the answer is no — because the fracture is too comminuted, the cartilage is too damaged — then fusion may be better than leaving a malreduced joint in place.
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COMPARING THE THREE OPTIONS — AT A GLANCE
ORIF | Suture Button | Primary Arthrodesis |
Fracture-dislocations with intact cartilage | Purely ligamentous injuries, especially athletes | Comminuted injuries with destroyed cartilage |
Yes | Yes | No — joint is fused |
75–89 | 92–96 | 84–92 |
94% (any level), 65–86% (preinjury level) | 93–100% | 94% (any level), 74% (preinjury level) |
17–37% | ~10% (limited data) | 2.8% |
33–64% (mostly hardware removal) | 0–8% | 14–18% |
Very common (~60%) | Rarely | Less common (~18%) |
Hardware issues, arthritis, need for later fusion | Loss of reduction (rare) | Adjacent joint issues (theoretical) |
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RETURN TO SPORT — WHAT ATHLETES NEED TO KNOW
The 2024 IFASC consensus reached unanimous agreement that athletes can expect to return to sport 4–6 months after surgery and to full weight-bearing 8–12 weeks postoperatively.
The data across treatment methods:
- Conservative treatment (stable injuries): 93% return to sport, 88% to preinjury level. Ligament injuries returned at 2.8 months; bony injuries at 4.5 months.
- Surgical fixation (ORIF/suture button): 94% return to any level, 86% to preinjury level. Mean return to competitive sport in elite soccer and rugby players: 25.3 weeks (range 21–31 weeks).
- Primary arthrodesis: 94% return to any level, 74% to preinjury level — the lowest preinjury return rate, which makes sense because fusing joints inherently limits some motion and adaptation.
Key finding from elite athletes: Ligamentous injuries returned to competition faster than bony injuries (22.5 weeks vs. 26.9 weeks, P=0.003). Bony injuries took longer across all treatment methods.
Sport-specific considerations:
- Soccer, basketball, football — cutting, pivoting sports that demand a stable, mobile midfoot. Joint-preserving fixation is generally preferred.
- Running — the midfoot is critical for push-off. Runners generally do well with either fixation or fusion of the medial column, though fusion may reduce push-off efficiency slightly.
- Pickleball, tennis — lateral movement sports. Most patients return by 4–6 months.
- Golf — the lead foot (left foot for right-handed golfers) takes enormous rotational stress through the midfoot. Patients typically return by 4–5 months, sometimes with a modified swing initially.
- CrossFit — heavy loading (cleans, snatches, box jumps) places high demands on the midfoot. Return is typically 5–6 months with gradual reintroduction of impact activities.
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COMPLICATIONS — WHAT CAN GO WRONG
Lisfranc injuries are high-stakes, and complications are not rare, particularly after high-energy injuries.
Post-traumatic arthritis — the most common long-term complication regardless of treatment method. In a study with up to 24-year follow-up, 72% had radiographic arthritis and 54% had symptomatic arthritis after ORIF. Risk factors: nonanatomic reduction, high-energy injury, smoking.
Post-traumatic arthritis after ORIF ranged from 12.5% to 37% depending on the study and injury severity. After primary arthrodesis, rates were dramatically lower (2.8%) because there's no joint left to develop arthritis.
Reoperation — in a Level 1 trauma center study of 118 patients, 33% required unplanned secondary procedures, most often for painful hardware removal (26%) or infection debridement (9%).
Open injuries and high-energy mechanism were independent risk factors for complications in a multicenter study of 172 patients (AOR 2.79 for open fractures, AOR 2.13 for high-energy injuries).
Infection — deep infection rates range from 3.8% to 8% depending on injury severity and patient factors (diabetes, smoking, open injuries).
Loss of reduction — the hardware fails to maintain alignment, the bones shift, and the outcome deteriorates. This is more common with isolated screw fixation than with plate constructs or suture button.
Nonunion — low overall (approximately 3–6%) but can require revision surgery.
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THE ROLE OF TIMING
Early surgery matters. The 2024 Bone & Joint Journal review emphasizes that early diagnosis and treatment are essential to achieve good outcomes.
In elite athletes, time from injury to fixation ranged from 8 to 31 days in a study of 17 premier league soccer and rugby players. Hardware was removed at 16 weeks, and the remaining 16 of 17 players returned to full competition.
Delayed treatment of a displaced Lisfranc injury — whether because of missed diagnosis or prolonged conservative management of an unstable injury — makes everything harder:
- The bones scar in malposition
- Cartilage degrades from abnormal loading
- The surgical options narrow
- Outcomes worsen
If you're reading this and you've had midfoot pain for weeks after an injury that was called "just a sprain," and you're not getting better, get weight-bearing X-rays and see a foot and ankle specialist. Time matters.
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COMMON MISCONCEPTIONS
"My X-ray was normal, so I don't have a Lisfranc injury."
Non-weight-bearing X-rays can look completely normal in an unstable Lisfranc injury. The instability only shows up under load. This is the #1 reason Lisfranc injuries are missed — an estimated 20% of the time.
"I can walk on it, so it can't be that bad."
Many patients with Lisfranc injuries can walk, especially early on when adrenaline and swelling mask the instability. The ability to walk does not determine stability. Weight-bearing X-rays do.
"I was told I just need a boot for 6 weeks."
That's correct — IF the injury is truly stable. But a boot won't fix an unstable injury. It will just give you 6 weeks of false security while the midfoot potentially collapses.
"Fusion sounds terrible — I don't want my joints fused."
Understandable reaction. But the 1st, 2nd, and 3rd tarsometatarsal joints have very little motion normally. Fusing them sacrifices minimal function while eliminating the risk of post-traumatic arthritis at those joints. Many patients with medial column fusions return to full sport. The data actually shows better outcomes after fusion than ORIF in several studies.
"ORIF is always better because it preserves the joint."
Preserving a damaged joint that develops painful arthritis within 2 years isn't a win. If the joint surfaces are destroyed, fusion gives a more reliable, less painful outcome with fewer reoperations. Joint preservation only works if the joint is worth preserving.
"I'll just get the hardware out later and I'll be fine."
Hardware removal addresses hardware-related pain, but it doesn't reverse post-traumatic arthritis that's already developed. Many patients who undergo hardware removal after ORIF still have ongoing midfoot pain from cartilage damage. This is why getting the original treatment right matters more than any second procedure.
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FREQUENTLY ASKED QUESTIONS
1. What percentage of Lisfranc injuries need surgery?
Approximately 39% based on the largest epidemiologic study (2,084 injuries from the Swedish Fracture Register). The majority are treated nonoperatively, but all unstable or displaced injuries require surgery.
2. How do I know if my injury is stable or unstable?
Weight-bearing X-rays are the key test. If you can't bear weight, stress views under anesthesia or advanced imaging (CT/MRI) can answer the question. A displacement of ≥2 mm on weight-bearing views indicates instability.
3. Can a Lisfranc injury heal without surgery?
Yes — stable, nondisplaced injuries with an intact Lisfranc ligament heal well with immobilization and non-weight-bearing for 6 weeks. 64% scored over 90/100 on functional outcomes at 2–6 year follow-up.
4. What happens if a Lisfranc injury is missed?
The midfoot can collapse under weight-bearing, cartilage wears out, and chronic pain develops. A delayed diagnosis narrows treatment options and worsens outcomes. This is why proper imaging and specialist evaluation are critical.
5. What's the difference between ORIF and fusion?
ORIF repositions the bones and holds them with hardware while preserving the joint. Fusion removes the damaged cartilage and permanently joins the bones. ORIF preserves motion; fusion eliminates the joint (and its potential for arthritis).
6. Is fusion better than ORIF?
Meta-analyses consistently show fusion has better functional scores, less pain, lower arthritis rates, and fewer reoperations than ORIF with rigid fixation. However, long-term data beyond 10 years is limited, and fusion may not be ideal for young athletes with ligamentous injuries.
7. What is suture button fixation?
A flexible fixation technique using high-strength suture and buttons to hold the Lisfranc interval. Compared to screws, it allows physiologic motion, avoids cartilage damage, and eliminates the need for hardware removal. Best for purely ligamentous injuries.
8. Which surgery is best for athletes?
For unstable ligament injuries: fixation (suture button or ORIF), not fusion. For fracture-dislocations with salvageable joints: ORIF. For fracture-dislocations with destroyed joints: arthrodesis. The 2024 international consensus unanimously recommends fixation over fusion for ligament injuries in elite athletes.
9. How long until I can bear weight after surgery?
Most protocols begin partial weight-bearing at 4–6 weeks and progress to full weight-bearing by 8–12 weeks. The exact timeline depends on the injury pattern and fixation type. With suture button fixation, some surgeons allow earlier weight-bearing.
10. How long until I can return to sport?
The international consensus: 4–6 months postoperatively for most athletes. Systematic review data shows a mean of 8.9 months for ligament injuries treated surgically and about 25 weeks for elite soccer/rugby players to return to full competition.
11. Will I need hardware removal?
After ORIF with screws: very likely — 60–65% require hardware removal. After suture button fixation: rarely (0–8%). After primary arthrodesis: ~18%.
12. What is the risk of arthritis after Lisfranc surgery?
After ORIF: 17–37% depending on follow-up length and injury severity. After primary arthrodesis: ~3%. After suture button: ~10% (limited data). Nonanatomic reduction is the biggest risk factor.
13. Can I avoid surgery if the injury is only to the ligament (no fracture)?
If the ligament injury is stable (no displacement on weight-bearing X-rays, intact ligament on MRI), yes — nonsurgical treatment works well. If the ligament is completely torn and the joint is unstable, surgery is needed regardless of whether bone is broken.
14. Does smoking affect my outcome?
Yes. Smoking is a risk factor for post-traumatic arthritis and complications after Lisfranc surgery. Quit before surgery if possible.
15. I had a Lisfranc injury treated with a boot and now my foot hurts more. What should I do?
See a foot and ankle specialist immediately. You may have an unstable injury that was missed or one that progressed. Weight-bearing X-rays and possibly CT/MRI will clarify whether you need surgery.
16. My surgeon recommended ORIF but I've read fusion is better. Should I push for fusion?
Not necessarily. The "right" surgery depends on your specific injury pattern, age, activity level, and the condition of your joint surfaces. The studies showing fusion is "better" often include mixed injury patterns. For purely ligamentous injuries in young active patients, joint-preserving fixation is generally preferred. Discuss both options with your surgeon.
17. Can Lisfranc injuries be fixed with minimally invasive surgery?
Some injuries can be fixed with percutaneous (through-the-skin) screw placement or arthroscopic-assisted techniques. However, anatomic reduction is critical, and many injuries require open visualization to achieve it. Minimally invasive doesn't help if the reduction isn't perfect.
18. Is it possible to need fusion after ORIF fails?
Yes — this is called secondary or salvage arthrodesis, and it's one of the most common reasons for reoperation after ORIF. Rates range from about 5–10% in the literature. The outcomes of secondary arthrodesis are generally worse than primary arthrodesis, which is why getting the initial treatment decision right matters.
19. What if only one joint is involved?
Isolated injuries (usually the 1st or 2nd TMT joint) can be treated with focused fixation of just that joint. Not every Lisfranc injury involves all five tarsometatarsal joints.
20. I hurt my foot playing pickleball/soccer/basketball. How do I know if it's a Lisfranc injury vs. a regular sprain?
Lisfranc injuries cause midfoot pain (the middle of the top of your foot), not ankle pain. Key signs: pain with the squeeze test (squeezing the midfoot), inability to bear weight, plantar ecchymosis (bruising on the bottom of the foot). If you can't push off your toes or stand on one leg without severe midfoot pain, this is a Lisfranc injury until proven otherwise.
21. Do all three TMT joints need to be fused if I need arthrodesis?
No. Only the involved joints are fused. Most commonly, the medial column (1st and 2nd TMT joints) is fused. The lateral column (4th and 5th TMT joints) is almost never fused in the acute setting because those joints have important motion.
22. What happens to the joints next to a fusion over time?
This is the theoretical concern of adjacent joint arthritis — and honestly, the long-term data is lacking. It's a reasonable concern, especially in young patients, and it's one reason I individualize treatment rather than fusing everyone.
23. How do I know if my surgeon has enough experience with Lisfranc injuries?
Ask how many they treat per year. Fellowship-trained foot and ankle surgeons see these injuries regularly. Orthopedic trauma surgeons also manage them frequently. A surgeon who sees one or two a year may not have the same pattern recognition.
24. Will my foot ever be 100% normal?
Honest answer: probably not. Lisfranc injuries are serious, and even with perfect treatment, most patients have some residual stiffness, swelling, or mild discomfort — especially with prolonged standing or high-impact activity. But over 90% of patients return to sport, and the majority are satisfied with their outcome. "Normal" may be a new normal, but it's usually a very functional one.
25. What shoes should I wear after recovery?
Supportive shoes with a stiff sole and good arch support. Custom orthotics can help redistribute pressure across the midfoot. Avoid flat, flexible shoes (flip-flops, ballet flats) for at least 6–12 months. Many patients with Lisfranc injuries benefit from orthotics permanently.
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ABOUT THE AUTHOR
Dr. Sarang Desai is a fellowship-trained orthopedic foot and ankle surgeon with particular expertise in sports medicine. With over 15 years of experience, Dr. Desai serves as a professional sports team physician and treats the full spectrum of foot and ankle conditions — including Lisfranc injuries, ankle fractures, Achilles tendon injuries, chronic ankle instability, cartilage injuries, peroneal tendon disorders, bunions, foot and ankle arthritis, total ankle replacement, and complex revision surgery.
He is a published researcher, an orthopedic implant inventor, a national lecturer, and a former University of Texas All-American athlete.
Offices in McKinney and Flower Mound, Texas, serving patients throughout Plano, Frisco, Denton, Lewisville, Southlake, Dallas, Fort Worth, Arlington, and the greater Dallas–Fort Worth metroplex and beyond.
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If you've been told you have a Lisfranc injury and aren't sure whether you need surgery — or if you've had midfoot pain after an injury that hasn't gotten better with rest and a boot — bring your imaging and come in for a thorough evaluation. Getting this decision right the first time makes all the difference.
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This article is for educational purposes only and does not constitute personal medical advice. Always consult a qualified physician about your individual situation.
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