Lisfranc surgery is a procedure to realign and stabilize the bones and ligaments in the middle of your foot after a serious midfoot injury. The Lisfranc joint complex is where the long bones of your foot (metatarsals) connect to the small, cube-shaped bones closer to your ankle. When fractures displace these bones or torn ligaments allow them to shift out of position, surgery is the standard treatment to restore the foot’s structure and prevent long-term damage.
Why Surgery Is Needed
Not every Lisfranc injury requires an operation. If the bones haven’t shifted and the ligaments aren’t completely torn, a period of immobilization in a cast or boot can be enough. Surgery becomes necessary when imaging shows displaced fractures, dislocated joints, or instability in the midfoot. Even patients who initially qualify for nonsurgical treatment may end up needing surgery if follow-up X-rays reveal that the bones have moved during healing.
The key factor is alignment. Your midfoot acts as a rigid lever that transfers force from your heel to your toes when you walk, run, or push off the ground. If the bones heal even slightly out of place, the arch collapses and the foot loses its ability to function as that lever. That’s why surgeons treat any measurable instability aggressively.
Two Main Surgical Approaches
There are two primary operations for Lisfranc injuries, and the choice between them depends on the type of damage.
Open Reduction and Internal Fixation (ORIF)
ORIF is the traditional approach. The surgeon makes one or two incisions along the top of the foot, manually repositions the displaced bones into their correct alignment, and locks them in place with metal hardware. That hardware can include screws that compress the bones together, metal plates that bridge across the joint, or temporary pins for the outer part of the foot, which needs to stay mobile. The goal is to hold everything still long enough for the bones and ligaments to heal, after which some of the hardware may be removed.
Primary Fusion (Arthrodesis)
Instead of simply holding the bones in place temporarily, fusion permanently joins certain midfoot bones together. The surgeon removes the cartilage surfaces between the affected joints, compresses the bones together with screws or plates, and lets them grow into a single unit. This is typically performed on the inner two or three joints of the midfoot, which don’t need much motion for normal walking. The outer joints are left mobile whenever possible.
Fusion was originally considered a backup plan, reserved for cases where ORIF failed or when the injury was diagnosed late. That thinking has shifted. A randomized trial published in the Journal of Bone and Joint Surgery compared the two approaches in patients with primarily ligamentous injuries (meaning the damage was mainly to the soft tissue rather than the bone). At two years, patients who had primary fusion scored significantly higher on a standard midfoot function scale (88 points versus 68.6 for ORIF). They also estimated their activity level had returned to 92% of what it was before the injury, compared to just 65% in the ORIF group. Five of the twenty ORIF patients eventually developed persistent pain and deformity that required fusion anyway.
For injuries that are mostly bony fractures with intact ligaments, ORIF remains common because the joints may recover well once the fractures heal. For ligament-dominant injuries, many surgeons now favor primary fusion because the damaged ligaments often fail to restore enough stability on their own.
What Happens During the Procedure
Lisfranc surgery is performed under general anesthesia, sometimes with a nerve block to manage pain afterward. The surgeon typically works through one or two incisions on the top of the foot, using a dorsomedial (inner) or dorsolateral (outer) approach depending on which joints are involved. In some cases, small stab incisions are added to insert screws at the correct angle.
The damaged joints are exposed, any debris or cartilage fragments are cleared, and the bones are carefully pushed back into anatomic position under X-ray guidance. Once alignment is confirmed, screws or plates are placed to lock it in. For fusion cases, the joint surfaces are prepared by removing the remaining cartilage so raw bone sits against raw bone, encouraging the two surfaces to grow together. The outer two joints of the midfoot are usually stabilized with temporary pins rather than permanent hardware, since preserving motion there is important for adapting to uneven ground.
Recovery Timeline
Recovery from Lisfranc surgery is slow and demands patience. The midfoot bears enormous force with every step, so the healing tissue needs extended protection.
For the first six weeks, you will not be allowed to put any weight on the operated foot. You’ll use crutches or a knee scooter to get around. During the first two weeks, the focus is purely on protecting the surgical site and managing swelling. From weeks two through six, you may begin gentle range-of-motion exercises for your ankle and toes, but the midfoot itself stays completely unloaded.
Around week six, you’ll transition into a walking boot and begin putting partial weight on the foot. This phase typically lasts from week six through week ten, with weight gradually increasing as your surgeon monitors healing on X-rays. Full weight bearing in the boot usually follows, and most patients transition into a supportive shoe somewhere around the three-month mark.
Returning to sports or high-impact activities generally takes six months to a year, depending on the severity of the original injury and the type of surgery performed. Physical therapy plays a major role throughout, progressing from gentle mobility work to strengthening the small muscles of the foot, rebuilding balance, and eventually retraining your gait for running or jumping.
Hardware Removal
If you had ORIF with screws or plates, your surgeon may recommend removing the hardware. This is traditionally done around four months after the original surgery, with the goal of restoring joint motion once the bones and ligaments have healed. Hardware removal requires a second, smaller operation.
Whether removal is truly necessary is debated. Some research suggests that routine removal may not be needed in all patients, particularly if the hardware isn’t causing symptoms. Fusion patients generally don’t need hardware removal because their joints are intentionally locked in place permanently. Your surgeon will base the decision on your imaging, symptoms, and activity goals.
Outcomes and Complications
A systematic review of 462 patients across 17 studies found that the average functional outcome score after Lisfranc fixation was 76.3 out of 100 on a widely used midfoot scale. Patients who had fusion tended to score higher (around 89) than those who had ORIF (around 62), though this varied by injury type and study. Screws and bridge plates produced similar results statistically, with no significant difference between the two hardware types.
Complications are common enough to be worth understanding before surgery. In a large multicenter study of patients treated with ORIF, 70% experienced at least one postoperative complication. The most frequent was post-traumatic arthritis, affecting about 30% of patients. This is the gradual wearing down of cartilage in the injured joints, which can cause stiffness and aching that worsens with activity, sometimes years after the original surgery. Malunion, where the bones heal in a slightly imperfect position, occurred in about 22% of patients. Nerve irritation causing numbness or tingling on the top of the foot affected roughly 13%.
Post-traumatic arthritis is the main reason some patients eventually need a secondary fusion even after a technically successful ORIF. This is also why many surgeons have moved toward primary fusion for ligamentous injuries: fusing the joint from the start eliminates the risk of arthritis developing in that joint later.
Life After Lisfranc Surgery
Most people return to daily activities, work, and even recreational sports after Lisfranc surgery, but the foot rarely feels exactly the way it did before the injury. Some residual stiffness or mild aching with prolonged standing is common. Supportive footwear and custom orthotics can make a meaningful difference in long-term comfort. Many patients notice that their foot tolerates hard, flat surfaces less well than it used to, and may prefer cushioned or supportive shoes for years afterward.
For athletes, the timeline to full return varies widely. Professional athletes with access to daily rehabilitation sometimes return in six to nine months, while recreational athletes often find it takes closer to a year before they feel confident pushing off, cutting, or sprinting at full effort. The severity of the original injury matters more than the specific surgical technique in predicting how complete the recovery will be.