Lisfranc surgery is an operation to realign and stabilize the bones and ligaments in the middle of your foot after a Lisfranc joint 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, and even a small disruption there can make it painful or impossible to bear weight. Surgery typically becomes necessary when the bones shift 2 millimeters or more out of alignment, a threshold most surgeons use to distinguish injuries that won’t heal properly on their own.
The Joint That’s Being Repaired
The Lisfranc joint isn’t a single joint. It’s a complex of small joints running across the midfoot, connecting five metatarsal bones to a row of smaller tarsal bones (three wedge-shaped cuneiforms and the cuboid). A web of ligaments holds these bones together on the top, bottom, and between them. The interosseous ligaments, buried deep between the bones, are the strongest of the group.
The second metatarsal sits in a recessed notch between the cuneiforms, acting like a keystone in an arch. This design gives the midfoot its rigidity, which is essential for pushing off the ground when you walk or run. When the ligaments holding this keystone in place tear, or when the surrounding bones fracture, the arch collapses and the foot loses its structural integrity. That’s a Lisfranc injury, and it ranges from a subtle ligament sprain to a complete dislocation of multiple joints.
When Surgery Is Needed
Not every Lisfranc injury requires an operation. Stable sprains where the bones remain aligned can heal in a cast or boot. Surgery enters the picture when imaging shows the bones have shifted apart. A systematic review of 58 studies found that the most commonly used threshold was 2 millimeters or more of widening between the bones, though some surgeons operate at just 1 millimeter of displacement. Other red flags that point toward surgery include a small chip of bone visible on X-ray (called a fleck sign), loss of arch height, or a ligament tear confirmed on MRI.
If the displacement isn’t corrected, the misaligned bones grind against each other with every step, almost guaranteeing painful arthritis down the road.
Two Main Surgical Approaches
Surgeons choose between two primary procedures depending on the severity and type of injury: open reduction with internal fixation (ORIF) and primary arthrodesis (fusion).
Open Reduction With Internal Fixation
ORIF is the more traditional approach. The surgeon makes one or two incisions along the top of the foot, manually pushes the displaced bones back into their correct positions, and locks them in place with metal screws, plates, or a combination of both. The goal is to restore the joint’s original anatomy while preserving its natural motion. Small T-shaped plates or specially designed Lisfranc plates are common choices, and temporary wires sometimes hold everything steady while the surgeon fine-tunes the alignment before placing permanent hardware.
The procedure follows a specific sequence. The relationship between the second metatarsal and the middle cuneiform is restored first because it serves as the reference point for everything else. From there, the surgeon works outward, addressing the first, third, fourth, and fifth joints in order. If the bones between the cuneiforms themselves are unstable, those get stabilized with screws or flexible fixation as well.
Primary Arthrodesis (Fusion)
Fusion permanently joins the damaged bones together, eliminating the joint surfaces entirely. The surgeon removes the cartilage from the affected joints, realigns the bones, and secures them with screws so they grow together into a single solid piece. This sounds drastic, but the inner Lisfranc joints don’t contribute much to foot flexibility in the first place. A large meta-analysis found that fusion produced better functional scores, lower pain levels, and a higher rate of return to activity compared to ORIF. Patients who had fusion were also less likely to need a second surgery for hardware removal.
Fusion is often favored when the joint surfaces are badly damaged or when the injury pattern suggests ORIF alone won’t hold up over time.
Flexible Fixation With Suture Buttons
A newer alternative uses a strong suture threaded through small metal buttons on either side of the joint. This provides a more flexible hold than rigid screws. In studies comparing the two, suture button fixation showed better pain and function scores at six months. By one year, though, outcomes were equivalent. The main appeal is that suture buttons don’t need to be removed later, which eliminates a second surgery. The tradeoff is a slightly higher chance of the joint widening again over time.
What Happens After Surgery
Recovery from Lisfranc surgery is slow and structured, largely because the midfoot bears your full body weight with every step. Rushing the process risks undoing the repair.
For the first two weeks, your foot stays in a surgical splint. Around day 14, you transition to a protective walking boot, but you still cannot put any weight on the foot. This strict non-weight-bearing phase lasts a full six weeks. During this time, you’ll get around on crutches, a knee scooter, or a hands-free crutch device.
At week six, partial weight-bearing begins. You’ll start putting gradual pressure on the foot while still using crutches and the boot. The transition from partial to full weight-bearing happens over the following weeks as healing is confirmed on X-rays. Most non-athletes reach full weight-bearing by about 8 to 12 weeks after surgery.
For elite athletes, the timeline is well studied. Over 90% successfully return to their sport, with most reaching competition level between 4 and 6 months after surgery. The average return-to-sport time for ligament injuries is closer to 9 months, since soft tissue heals more slowly than bone.
Hardware Removal
If you have ORIF with traditional screws, there’s a reasonable chance you’ll need a second, smaller surgery to take them out. Metal screws that cross a joint can break or cause stiffness if left in place permanently. A national survey of surgeons found that about 38% routinely remove hardware, typically around six months after the original surgery. The remaining 62% leave hardware in place unless it causes symptoms. One consideration: elective hardware removal carries roughly a 15% risk of minor nerve irritation near the incision.
Fusion patients generally don’t face this issue, since the hardware is meant to stay. The same goes for suture button fixation, which is designed to remain permanently.
Long-Term Outlook and Arthritis Risk
Even with a technically perfect surgery, the Lisfranc joint complex takes a significant hit from the initial injury. A multicenter study of 141 patients found that 45% developed midfoot arthritis within at least one year of their injury. This is the most common long-term complication, and it can cause chronic stiffness, aching with activity, or difficulty walking on uneven ground.
When post-traumatic arthritis becomes severe enough to limit daily life, a salvage fusion surgery can address it. This is one reason some surgeons prefer primary fusion from the start for more severe injuries: it eliminates the arthritic joint surfaces upfront rather than waiting for arthritis to develop and require a second operation later. For many patients, though, the arthritis remains mild or manageable with supportive footwear, orthotics, and activity modification.