Comparative analysis of the clinical efficacy of primary fusion and open reduction and internal fixation in the treatment of ligamentous three-column Lisfranc injury
This retrospective study of 128 patients with ligamentous three-column Lisfranc injuries concludes that primary fusion yields superior long-term clinical outcomes, including better functional scores, lower reoperation rates, and fewer complications, compared to open reduction and internal fixation.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
The human foot is a marvel of engineering, a complex arch designed to bear the full weight of the body while absorbing the shock of every step. At the heart of this structure lies a critical junction where the long bones of the toes meet the shorter bones of the midfoot. This area, known as the Lisfranc complex, acts as the keystone of the arch, holding everything together. When this joint is severely injured, often by a high-energy accident like a fall from a height or a car crash, the ligaments that bind these bones can tear completely. Without these ligaments, the arch collapses, the foot becomes unstable, and walking turns into a source of constant, grinding pain. For decades, surgeons have debated the best way to fix this specific type of severe injury. The central question has been whether to simply realign the bones and hold them with screws and plates, hoping the torn ligaments heal on their own, or to remove the damaged joint surfaces entirely and fuse the bones together into one solid piece.
A team of researchers from three hospitals in China set out to settle this debate by looking at the real-world outcomes of 128 patients who suffered this exact injury. They focused specifically on cases where the injury involved all three columns of the midfoot and was caused purely by ligament damage, with no major bone fractures complicating the picture. The researchers divided these patients into two groups based on the surgery they received. One group underwent open reduction and internal fixation, a procedure where surgeons realign the bones and secure them with metal hardware, which is later removed once the bones have healed. The other group received primary fusion, where the surgeons cleaned out the damaged joint surfaces and permanently fused the bones together using metal plates and bone grafts, creating a single, rigid unit. The goal was to see which approach led to better long-term results, less pain, and a faster return to normal life.
The study followed these patients for more than two years, tracking their recovery with careful attention to how they felt, how well they could walk, and whether they needed further surgery. The results painted a clear picture. In the short term, just three months after the operation, both groups of patients reported similar levels of pain and similar scores on tests of foot function. At this early stage, the metal hardware in the fixation group was still holding the bones in place, providing temporary stability that masked the underlying weakness of the healing ligaments. However, the story changed significantly by the time the final follow-up arrived. The patients who had received the permanent fusion showed substantially better outcomes. They reported less pain, higher scores on physical function tests, and a greater ability to return to work.
The difference became stark when looking at complications and the need for additional operations. In the group where surgeons tried to save the joint with screws and plates, a significant number of patients faced serious problems later on. Thirteen percent of these patients required a second surgery. Some suffered from the metal hardware breaking, while others developed a collapse of the foot's arch or a deformity where the front of the foot splayed outward. These issues often arose after the metal was removed, revealing that the scarred ligaments could not provide enough strength to hold the foot together on their own. In contrast, the group that received the permanent fusion had a zero percent reoperation rate. While they did experience a different kind of side effect—stiffness in the midfoot that made fine movements harder—their foot remained stable and pain-free. The fusion procedure took slightly longer to perform because it involved preparing the bone surfaces and harvesting bone grafts, but it eliminated the risk of the joint failing later.
The researchers concluded that for this specific, severe type of ligament injury, fusing the joint is the superior choice. By creating a solid, unmovable connection between the bones, the surgery provides a level of stability that the body's own healing process cannot achieve on its own. This stability allows patients to return to their daily activities and work sooner, without the looming threat of the foot collapsing or the need for a second, corrective operation. While the trade-off is a loss of some natural flexibility in the midfoot, the study suggests that for active individuals and those with high demands on their feet, the certainty of a stable, pain-free foot is far more valuable than the hope of preserving a joint that is likely to fail. The findings offer a clear path forward for surgeons, suggesting that when the ligaments are completely torn and the joint is unstable, building a solid bridge is better than trying to repair a broken hinge.
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