Introduction

 Damage or injury to the midfoot's long bones, particularly to the Lisfranc joint complex, is known as a Lisfranc injury. Dislocations, midfoot bone fractures, and sprains damage the ligaments that support and link these bones are some of the ways that this kind of injury can appear.¹ Lisfranc injuries essentially include either damage to the ligaments that give the joint structural support or a break in one or more of the midfoot bones. The French physician Jacques Lisfranc de St. Martin, who initially reported similar injuries in cavalry soldiers during the Napoleonic era, is credited with giving the ailment its historical name.² Because of their complexity, Lisfranc injuries have continued to be a major medical problem ever since and the functional importance of the midfoot in weight-bearing and mobility.

Lisfranc injuries are frequently observed in high-impact sports and activities nowadays, such as football and soccer. These injuries, which can result in ligamentous tears, bone fractures, or joint dislocations, frequently happen when a player falls on the back of another player's foot while it is pulled downward in a plantarflexed position.² Lisfranc injury is consequently a clinically serious and possibly incapacitating condition, ranging from minor ligament sprains to severe fractures and dislocations. Localised pain, soreness, and swelling are common symptoms of Lisfranc injuries, especially over the midfoot area. Post-traumatic arthritis (PTA) is one of the main long-term issues seen after Lisfranc injury, which is considered one of the most concerning sequelae of these injuries. PTA can lead to chronic stiffness, reduced joint function, and persistent pain, significantly affecting mobility and quality of life. Even when the initial injury is appropriately managed, some individuals may develop arthritis in the affected joints over time, highlighting the importance of accurate diagnosis and careful management to minimise long-term functional impairment.

Causes

Damage to the cartilage, the smooth, protective layer that lines the surfaces of bones within a joint, is the first step in the development of post-traumatic arthritis (PTA) after Lisfranc injury.^3,4 The midfoot's ligaments or bones may be ripped, shattered, or both in a Lisfranc injury. The cartilage may be directly compromised by the initial trauma at the site of the lesion, making the joint surfaces susceptible to deterioration. Furthermore, aberrant tension and mechanical strain are experienced by the joint during weight-bearing and movement if the midfoot's bones do not heal in perfect alignment. Over time, these repeated stresses exacerbate cartilage deterioration, progressively damaging the joint surfaces and ultimately leading to the development of arthritis. This process explains why even appropriately treated Lisfranc injuries can result in long-term joint degeneration and functional impairment.^3,4

Unfortunately, it is fairly usual for post-traumatic arthritis to develop following a Lisfranc injury. A study of published research indicates that 8% of patients eventually need joint fusion surgery as a result of chronic pain, deformity, or functional difficulties.³ Furthermore, follow-up X-rays show radiographic evidence of arthritis in up to 50% of patients, suggesting that structural joint changes are rather common even in cases with moderate symptoms.³ More than half of participants in a different long-term trial that tracked patients for almost eleven years had clinical symptoms that affected their everyday activities and general quality of life, and 72% of participants had imaging evidence of arthritis.⁵ These findings highlight the high prevalence of post-traumatic arthritis as a sequela of Lisfranc injuries and underscore the importance of careful diagnosis, treatment, and long-term monitoring to mitigate functional decline and optimise patient outcomes.⁵

Risk factors

• Missed or delayed diagnosis: Long-term joint damage may result from the bones healing out of alignment if the injury is not identified and treated promptly³
• Poor alignment following treatment: The unequal pressure might harm the cartilage if surgery is unable to entirely return the joint to its natural position⁴
• High-energy trauma: Car accidents, high falls, and other extreme trauma frequently result in increased cartilage injury right away⁵

Treatments

The severity of the injury, whether displacement is present, and the patient's symptoms all play a significant role in how Lisfranc injuries are treated. Surgery is usually necessary when conservative treatments like rest, immobilisation, or physical therapy are unable to significantly reduce discomfort or functional restrictions. For moderate to severe injuries, surgery is usually the best course of action, especially if the patient's ability to walk or carry out everyday tasks is being hampered by joint instability, misalignment, or chronic discomfort.

Joint Fusion (Primary Arthrodesis) and Internal Fixation with Open Reduction (ORIF) are the two main surgical procedures for treating Lisfranc injuries.

Internal Fixation and Open Reduction (ORIF) is a technique used to restore the anatomical alignment of the Lisfranc joint complex by meticulously realigning the midfoot's fractured or dislocated bones. Once the bones are properly aligned, they are fixed in place with screws, plates, or other fixation devices so that they can heal in the proper position.⁵ When done immediately after the injury, ORIF is especially efficient at stabilising the joint, easing discomfort, and regaining function. However, because cartilage injury or minor misalignments may still exist, ORIF does not completely remove the risk of post-traumatic arthritis, even with its overall success. Furthermore, some patients may need the hardware removed later on because of mechanical issues with screws or plates, inflammation, or discomfort.⁵

Another surgical option is Joint Fusion (Primary Arthrodesis), which permanently fuses the afflicted joints to remove mobility and alleviate pain. Particularly for patients with severe ligamentous damage or persistent instability who might not react well to ORIF, this treatment is becoming more and more popular. Arthrodesis stabilises the midfoot, lessens aberrant mobility, and directly treats pain by fusing the joints.⁶ According to research, including trials by Ly and Coetzee, primary arthrodesis can result in functional outcomes that are on par with ORIF, or even better in certain situations, while posing fewer long-term risks, including hardware-related issues or joint instability.⁶ While joint fusion inevitably limits movement at the fused joint, it often results in improved overall stability and pain control, particularly when performed early in high-risk patients who are more likely to develop chronic post-traumatic arthritis.

Apart from these surgical methods, there are a number of conservative or non-surgical treatments that may be taken into consideration, especially in cases of small injuries or when surgery is not recommended. Immobilisation with a cast or walking boot, limited weight-bearing to lessen midfoot strain, anti-inflammatory drugs to manage pain and swelling, and physical therapy to regain strength and mobility after the acute healing phase is over are some examples of these interventions. Some individuals may benefit from conservative treatment, but careful observation is necessary to guarantee that joint alignment is maintained and that symptoms do not worsen and may eventually call for surgery.

Overall, the choice of treatment for Lisfranc injuries must be individualised, taking into account the patient’s age, activity level, comorbidities, severity of the injury, and risk factors for post-traumatic arthritis. Prompt and appropriate management, whether surgical or conservative, plays a critical role in minimizing long-term complications, preserving foot function, and improving quality of life for affected individuals.^5,6

Summary

 Lisfranc injuries, which affect the long bones and ligamentous structures of the midfoot, are a complicated and clinically significant ailment that, if not treated quickly and appropriately, may have long-term effects. Weight-bearing, gait, and general foot stability depend on the Lisfranc joint complex, whose structural integrity and function are compromised by these injuries, which can take the form of fractures, dislocations, or ligamentous sprains.^1,2 The illness, which frequently causes localised discomfort, swelling, and sensitivity over the midfoot, can be brought on by trauma or high-impact activities like football or soccer.

One of the most significant long-term complications following Lisfranc injury is post-traumatic arthritis (PTA), which can develop even after appropriate treatment. PTA results from direct cartilage damage during the initial injury or from altered biomechanical stress when the midfoot bones do not heal in proper alignment. Over time, this leads to progressive joint degeneration, stiffness, functional limitation, and chronic pain, ultimately affecting mobility and quality of life.^3,4,5

A delayed or missing diagnosis, inadequate alignment after therapy, and high-energy trauma all increase the chance of developing PTA and other functional deficits. Therefore, it is essential to identify and treat Lisfranc injuries as soon as possible to prevent long-term joint degradation and maintain ideal foot function.^3,4,5 Developing a successful treatment plan requires a precise diagnosis, a thorough evaluation of displacement, and the detection of ligamentous or bone damage. In order to monitor joint integrity and the progression of arthritis and make sure that problems are detected early and treated effectively, imaging modalities like X-rays and long-term follow-up are crucial.^3,5

Post-traumatic arthritis risk factors, age, activity level, patient comorbidities, and the extent of the damage must all be taken into consideration when developing treatment plans. For small injuries or in situations when surgery is not appropriate, conservative measures such as immobilisation, limited weight-bearing, anti-inflammatory drugs, and physical therapy may be beneficial. However, in order to restore joint stability and avoid permanent disability, moderate to severe injuries usually necessitate surgical intervention. Internal Fixation with Open Reduction (ORIF) and Joint Fusion (Primary Arthrodesis), the two main surgical techniques, each have unique benefits and drawbacks. Although ORIF effectively relieves pain and facilitates functional recovery by stabilising the midfoot with screws or plates and restoring anatomical alignment, it does not completely remove the risk of PTA, and hardware problems may occur.⁵

Ultimately, successful management of Lisfranc injuries relies on early diagnosis, accurate assessment, and an individualised treatment plan that balances surgical and conservative approaches. Careful monitoring, attention to joint alignment, and timely intervention are essential to prevent post-traumatic arthritis, maintain midfoot stability, and optimise functional outcomes. By recognising the high prevalence of long-term complications, understanding the pathophysiology of post-traumatic arthritis, and employing appropriate treatment strategies, clinicians can significantly enhance patient recovery, mobility, and quality of life after Lisfranc injury.^5,6