Abstract
The Lisfranc ligamentous complex is the principal stabilizer of the tarsometatarsal joint and functions as the midfoot keystone. Injuries often follow an axial or rotational load applied to a plantarflexed foot, producing ligamentous disruption or, in severe cases, fracture-dislocation of the tarsometatarsal complex. Up to one-third of Lisfranc injuries are initially missed, particularly in low-energy mechanisms or polytrauma settings. Weight-bearing radiographs are essential for detecting subtle injuries and uncovering diastasis between the medial cuneiform and the second metatarsal. The Myerson classification categorizes injuries based on joint congruity, the direction of displacement, and extent of involvement. The decision to pursue conservative or surgical treatment depends on the Lisfranc ligament stability and displacement. Nonoperative management is appropriate only in nondisplaced injuries; delayed treatment can result in persistent midfoot pain, arch collapse, post-traumatic arthritis, and diminished function. Surgical techniques include open reduction and internal fixation, primary arthrodesis, bridge plating, suture button fixation, and percutaneous approaches. Lateral column injuries involving the fourth and fifth tarsometatarsal joints are advised to be treated with K-wire fixation. Anatomic alignment is the strongest predictor of successful recovery and return to activity. Residual displacement > 2 mm is associated with inferior outcomes and significantly reduced return-to-play rates, particularly in athletes who can have lasting effects even with successful fixation and may not reach preinjury performance levels. Optimal management is yet to be determined, and inadequate fixation increases poor outcomes, underscoring the importance of early recognition, precise reduction, and appropriate fixation strategy. This study is novel and integrates recent evidence including diagnostic and prognostic utility of weight-bearing, the clinical outcomes and biomechanics of treatment approaches including flexible fixation constructs such as suture button systems, and postoperative outcomes including gait analysis, return-to-play, and athletic performance outcomes.