When the first Lisfranc fixation fails, revision surgery is undertaken to stabilise the midfoot adequately. To alleviate discomfort and restore correct alignment, revision may entail joint fusion (arthrodesis), realignment, or device removal, depending on the underlying problem. When the precise cause of failure is recognised and dealt with, the best results are achieved. Knowing the causes of failure and the available surgical choices is essential to going forward after a failed Lisfranc repair.

What is a Lisfranc Fixation?

The Lisfranc joint is the tarsometatarsal (TMT) articulation, which is where the cuboid and cuneiform metatarsals meet the midfoot. It is responsible for midfoot stability, arch support, and weighted transmission during gait.

Surgical stabilisation is frequently necessary to prevent long-term dysfunction because injuries to this location are infamously fragile and readily overlooked.¹

Why does Lisfranc Fixations fail?

Even with surgery, 15–30% of individuals have problems that would need to be revised. The causes include:

• Hardware compilations → break, loose, and migration
• Loss of reduction → bones shift out of place
• Nonunion or malunion → bones do not heal properly
• Degenerative arthritis → cartilage breakdown leads to chronic pain
• Infection and wound issues
• Improper diagnosis or missed injury components → at initial surgery^2,3

Clinical signs of failed Lisfranc Fixation

If you have any of the following, you may be suffering from failed fixation:

1. Persistent or worsening midfoot pain
2. Difficulty walking or bearing weight
3. Visible deformity or collapse of the arch
4. Swelling that doesn't resolve
5. Pain with push-off or foot rotation

To assess alignment and healing, your orthopedic surgeon will employ weight-bearing imaging, CT scans, or X-rays.⁴

When to consider revision surgery?

Revision surgery is usually considered when:

• Pain or dysfunction persists beyond 6–12 months
• Conservative therapy has failed
• Imaging shows nonunion, malalignment, or arthritis
• Hardware is damaged or misplaced
• The patient is motivated and healthy enough for reoperation⁵

Revision surgical techniques

The type of revision is determined by the joint's state and cause of failure:

• Hardware Removal → If screws or plates cause pain, they may be removed once fusion or healing is confirmed. It is often done under local or regional anesthesia
• Re-fixation and Realignment → If reduction is lost, bones are realigned and stabilised again using plates, screws, or bridge constructs. May involve bone grafting for bone loss
• Primary Arthrodesis (Fusion) → is frequently used when joints are arthritic or unstable. It removes cartilage and fuses the joint permanently using screws or plates. It's often preferred in chronic or revision cases 
• Bones grating (Crepitus)→ Autograft or allograft used to support fusion in case of bone loss or poor healing⁶

Outcomes and Prognosis

When joint fusion or stabilisation is accomplished through revision surgery, the underlying problem is addressed:

• Pain significantly improves
• Patients regain the ability to walk without assistive devices
• Return to low-impact activity is possible
• However, some stiffness or loss of foot flexibility is expected
• Return to high-level athletics is less predictable

Numerous studies demonstrate that following a successful revision fusion, patient satisfaction and pain levels improve.⁷

Summary

Failed Lisfranc fixation is difficult, but it's not a failure. You can regain pain-free mobility and midfoot stability with a thorough evaluation and expert revision surgery. Key takeaways:

• Fixation may fail due to hardware issues, malalignment, or arthritis
• Surgery options include hardware removal, re-fixation, or fusion
• Recovery takes time, but outcomes are generally positive with proper care

FAQs

How common is revision after Lisfranc Surgery?

It is rare to have revision surgery following Lisfranc surgery; according to one study, the rates for ORIF and primary arthrodesis were 14% and 17%, respectively.⁸

Will I be able to walk normally following revision surgery?

Yes, walking normally is a frequent long-term aim following revision surgery, but it is not immediate and requires a period of healing and therapy. Patients will use a walker or crutches immediately after surgery and will progressively transition to fewer supporting aids as they develop, frequently walking without a limp after many months.^9,10

Is fusion better than re-fixation in revision cases?

In revision instances, neither fusion nor re-fixation is necessarily "better"; the best option relies on the particular clinical circumstance, and each has possible advantages and disadvantages.¹¹