Lisfranc Fixation Techniques and Postoperative Functional Outcomes: A Systematic Review

Mid-term Radiologic and Clinical Results of Pediatric-adolescent Lisfranc Injuries

INTRODUCTION

The incidence of Lisfranc injury in pediatric-adolescent children is lower compared with adults. There is limited research on adolescent patients in this age group, with only a few case reports of pediatric patients. Furthermore, studies with adequate follow-up are lacking in the literature. This study aims to provide insights into the causes and types of fractures and evaluate mid-term clinical and radiologic outcomes.

METHODS

A retrospective analysis was conducted on pediatric-adolescent patients diagnosed with a Lisfranc injury who underwent surgical treatment between June 2015 and January 2022. Patients underwent open reduction and internal fixation using Kirschner wires and/or screws, had satisfactory imaging, and were followed up for at least 2 years. Radiologic measurements included intermetatarsal distance, meary angle, and calcaneal height angle, done while the patient was standing. Assessments were made using the AOFAS midfoot score, the Oxford Ankle Foot Questionnaire for Children (OxAFQ-C), Visual Analog Scale (VAS) scores, and physical activities.

RESULTS

The study included 14 surgically treated patients with a minimum 2-year follow-up. The average patient age was 12.6 years, with a mean follow-up of 52.4 months. In pediatric cases, crush injury was the predominant trauma type ( P = 0.009). There were no significant differences in calcaneal pitch angle or meary angle between healthy and injured feet ( P = 0.2 and 0.1), but a greater intermetatarsal distance was observed on the injured side ( P = 0.02). The mean Visual Analog Scale (VAS) score was 1.5, the AOFAS midfoot score averaged 91.5, and the OxAFQ-C score averaged 86.3%.

CONCLUSIONS

The mid-term outcomes for this age group were promising compared with adults. The use of Kirschner wires for fixation is more common in younger patients. Crush injuries and complications like compartment syndrome are more prevalent in the pediatric age group.

Results of Lisfranc Injuries Treated With Interosseous Suture Button Fixation With a Minimum 5-Year Follow-Up

BACKGROUND

Open reduction and internal fixation or primary arthrodesis are considered gold standards for treating Lisfranc injuries. However, several drawbacks are associated with these procedures, such as joint motion loss and potential cartilage damage. More recently, the suture button emerged as an alternative treatment for ligamentous Lisfranc injuries, which can be used either alone or in combination with traditional techniques, with the potential to mitigate some of these potential disadvantages. The primary outcome of the present study was to evaluate the functional outcomes of 20 patients treated with the suture button technique for Lisfranc injuries over a medium- to long-term follow-up period. The secondary outcome was to assess and describe the complications associated with this procedure.

METHODS

A retrospective review was conducted on 20 patients who underwent operation for acute Lisfranc injuries using the interosseous suture button technique between 2013 and 2019. The mean follow-up was 83 months (range 60-126). Clinical evaluation involved the assessment of complications, reoperations, visual analog scale (VAS) scores, American Orthopaedic Foot & Ankle Society (AOFAS) midfoot scores, patient satisfaction, and ability to return to previous activities. Radiographic analysis was performed aiming to evaluate reduction maintenance and osteoarthritis development.

RESULTS

Patients demonstrated excellent outcomes with an average VAS of 0.50 and a mean AOFAS midfoot score of 95.5. Incomplete reduction was the only factor we identified influencing lower VAS and AOFAS scores. Most complications were minor and solved with conservative treatment. More serious complications, such as loss of reduction and posttraumatic arthritis were observed in 2 patients each.

CONCLUSION

In this small series with a relatively long follow-up, we found that the use of an interosseous suture button technique was a reliable method to treat acute Lisfranc injuries, resulting in satisfactory clinical and functional outcomes. However, outcomes including posttraumatic arthritis and loss of reduction raise remain of concern.

Acute Lisfranc injury management

Lisfranc injuries were previously described as fracture-dislocations of the tarsometatarsal joints. With advancements in modern imaging, subtle Lisfranc injuries are now more frequently recognized, revealing that their true incidence is much higher than previously thought. Injury patterns can vary widely in severity and anatomy. Early diagnosis and treatment are essential to achieve good outcomes. The original classification systems were anatomy-based, and limited as tools for guiding treatment. The current review, using the best available evidence, instead introduces a stability-based classification system, with weightbearing radiographs and CT serving as key diagnostic tools. Stable injuries generally have good outcomes with nonoperative management, most reliably treated with immobilization and non-weightbearing for six weeks. Displaced or comminuted injuries require surgical intervention, with open reduction and internal fixation (ORIF) being the most common approach, with a consensus towards bridge plating. While ORIF generally achieves satisfactory results, its effectiveness can vary, particularly in high-energy injuries. Primary arthrodesis remains niche for the treatment of acute injuries, but may offer benefits such as lower rates of post-traumatic arthritis and hardware removal. Novel fixation techniques, including suture button fixation, aim to provide flexible stabilization, which theoretically could improve midfoot biomechanics and reduce complications. Early findings suggest promising functional outcomes, but further studies are required to validate this method compared with established techniques. Future research should focus on refining stability-based classification systems, validation of weightbearing CT, improving rehabilitation protocols, and optimizing surgical techniques for various injury patterns to ultimately enhance patient outcomes.

[Lisfranc injuries]

Lisfranc injuries are rare but severe injuries of the foot. They range from ligament sprain to complex fracture dislocations. Etiologically, a distinction is made between indirect and direct force and between high-energy and low-energy trauma. Inadequate diagnostics (injuries overlooked or misinterpreted) can lead to painful posttraumatic osteoarthritis, chronic instability and deformity of the foot. A fracture, malalignment and unclear findings in conventional radiological diagnostics necessitate computed tomography imaging including 3D reconstruction. Lisfranc injuries are often associated with accompanying pathologies of the foot that also need to be addressed. Only stable non-displaced fractures can be treated conservatively. Depending on the injury pattern, surgical treatment is performed percutaneously, minimally invasive or open. The prognosis following Lisfranc injury is determined by the severity of damage and the quality of reconstruction.

Nonunion Rate Following Primary Arthrodesis for Acute Lisfranc Injuries

Injury to the tarsometatarsal joint (TMT) results in instability throughout the midfoot that does not often improve with conservative management. If instability is identified, surgical intervention is frequently recommended, either open reduction and internal fixation (ORIF) or primary arthrodesis (PA). These 2 treatment options have been compared in the literature multiple times, often reporting similar outcomes. Due to this, as well as the need for subsequent hardware removal after ORIF has led many surgeons towards PA at the index surgery. Concern for nonunion is a leading concern with surgeons who advocate instead for ORIF. The purpose of this study is to review patients who underwent PA and observe nonunion rates. Nonunion at the TMT has been previously studied, but only in the chronic setting. We performed a retrospective study of 34 patients who had PA in the management of an acute Lisfranc injury. The average age in our study was 43.9 years old (range 19-72, SD 17.4) with an average follow-up of 9.4 months (range 4-33, SD 6.2). Radiographs were evaluated for signs of nonunion at regular postoperative intervals. Within the patients included in the study, a total of 71 TMT joints were fused. Overall successful fusion rate was 95.8% at an average of 7.9 weeks (range 6-12, SD 1.4) postoperatively. Individual nonunion rates at the first, second, and third TMT were 0%, 1.4% and 2.8% respectively. Our study demonstrates that primary arthrodesis provides a predictable outcome with low nonunion rates in the management of acute Lisfranc injury.

Statistical Fragility Analysis of Open Reduction Internal Fixation vs Primary Arthrodesis to Treat Lisfranc Injuries: A Systematic Review

BACKGROUND

There is a lack of consensus in the use of open reduction internal fixation (ORIF) vs primary arthrodesis (PA) in the management of Lisfranc injuries. Statistical fragility represents the number of events needed to flip statistical significance and provides context to interpret P values of outcomes from conflicting studies. The current study evaluates the statistical fragility of existing research with an outcome-specific approach to provide statistical clarity to the ORIF vs PA discussion. We hypothesized that statistical fragility analysis would offer clinically relevant insight when interpreting conflicting outcomes regarding ORIF vs PA management of Lisfranc injuries.

METHODS

All comparative studies, RCTs, and case-series investigating ORIF vs PA management of Lisfranc injuries published through October 5, 2023, were identified. Descriptive characteristics, dichotomous outcomes, and continuous outcomes were extracted. Fragility index and continuous fragility index were calculated by the number of event reversals needed to alter significance. Outcomes were categorized by clinical relevance, and median FI and CFI were reported.

RESULTS

A total of 244 studies were screened. Ten studies and 67 outcomes (44 dichotomous, 23 continuous) were included in the fragility analysis. Of the 10 studies, 4 studies claimed PA to correlate with superior outcomes compared to ORIF with regard to functional scores and return to function outcomes. Of these 4 studies, 3 were statistically robust. Six studies claimed PA and ORIF to have no differences in outcomes, in which only 2 studies were statistically robust.

CONCLUSION

The overall research regarding ORIF vs PA is relatively robust compared with other orthopaedic areas of controversy. Although the full statistical context of each article must be considered, studies supporting PA superiority with regard to functional scores and return to function metrics were found to be statistically robust. Outcome-specific analysis revealed moderate fragility in several clinically relevant outcomes such as functional score, return to function, and wound complications.

The Use of Dorsal Bridge Plate Fixation in the Operative Management of Lisfranc Injuries - A Retrospective Cohort Study at Medium Term Follow-Up

INTRODUCTION

Traditionally, early surgical management of Lisfranc injuries with transarticular screws (TAS) was deemed to be the optimal treatment. However, concerns of potential iatrogenic articular cartilage disruption has led to discrepancies in opinion amongst surgeons, with many surgeons now utilizing dorsal bridge plates (DBP) for ORIF of Lisfranc injuries.

OBJECTIVES

This study sought to investigate the clinical outcomes at medium-term follow-up of consecutive patients in our institution who underwent ORIF with DBP for Lisfranc injuries.

METHODS

All consecutive patients who underwent ORIF with DBPs for Lisfranc injuries were identified. Outcomes of interest included; visual analogue scale (VAS), functional foot index (FFI), American Orthopaedic Foot & Ankle Surgeons (AOFAS) hindfoot scores, and complications.

RESULTS

Overall, 37 consecutive patients (24 males) with a mean age of 34.8 ± 13.0 years underwent ORIF with DBPs for lisfranc injuries. After a mean 48.3 ± 28.7 months, the mean reported AOFAS and FFI scores were 77.4 ± 23.8 and 31.9 ± 32.7 respectively, with satisfactory reported pain scores as measured by VAS post-operatively at rest and whilst walking (2.2 ± 2.5 and 3.1 ± 2.6 respectively). The reported satisfaction rate was 86.5% (32/37). Overall, 25 patients (67.6%) had subsequent removal of metal or were listed for same, 88% (22/25) of whom did so electively in the absence of broken screws or infection.

CONCLUSION

This study found that the use of Dorsal Bridge Plates for Open Reduction and Internal Fixation of Lisfranc Injuries resulted in satisfactory functional outcomes, high rates of patient-reported satisfaction and a low complication rate at medium-term follow-up.

LEVEL OF EVIDENCE

Level IV; Retrospective Series of Consecutive Patients.

Open Reduction And Internal Fixation of Tarsometatarsal (Lisfranc) Fracture Dislocations-Is Arthrodesis Necessary?

INTRODUCTION

Controversy remains regarding the optimal management of tarsometatarsal (Lisfranc) fracture dislocations. Open reduction and internal fixation (ORIF) and ORIF with primary arthrodesis (PA) have been described in the treatment of these injuries, although adverse sequelae remain problematic. Previous work has yielded small cohorts with heterogenous results. We aimed to describe the outcomes of Lisfranc fracture dislocations managed with ORIF and/or PA to identify risk factors for complications, such as nonunion and revision surgery.

METHODS

A retrospective review of 206 consecutive tarsometatarsal fracture dislocations that underwent surgical repair between 2015 and 2021 was performed. Time to radiographic union was noted. Complications were recorded, including revision surgery, infection, symptomatic implant removal, posttraumatic arthritis, secondary arthrodesis, and nonunion. A comparative subgroup analysis of outcomes by treatment modality (ie, PA versus ORIF) and by injury severity (isolated injury versus concomitant lower extremity fracture) were performed. Logistic regression analysis was performed to assess factors associated with revision surgery.

RESULTS

104 patients met the inclusion criteria with a mean 13-month follow-up. Ninety-three (n = 93) patients underwent ORIF, and 11 patients underwent PA. Radiographic union was achieved in 94.2% of cases (98/104) at an average 106 days. Complications included superficial infection (3.8%), deep infection (7.7%), symptomatic implant removal (19.2%), posttraumatic arthritis (12.5%), secondary arthrodesis (4.8%), and nonunion (2.9%). No difference existed in the complication rates between those who underwent ORIF and those who underwent PA ( P = 0.50). Revision surgery rates were similar between patients who sustained isolated injuries and those with concomitant lower extremity fractures ( P = 0.31). Risk factors for revision surgery included open fractures (OR 4.01, P = 0.042) and previous psychiatric illness (OR 5.77, P = 0.016).

DISCUSSION

The vast spectrum of injury in Lisfranc fracture dislocations makes uniform treatment challenging. In this large consecutive series, few failed to achieve union or required secondary arthrodesis. Open fractures and previous psychiatric illness portended worse clinical outcomes. ORIF without PA remains a viable treatment in these injuries.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Management of Lisfranc Injuries: A Critical Analysis Review

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There is a spectrum of midtarsal injuries, ranging from mild midfoot sprains to complex Lisfranc fracture-dislocations.

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Use of appropriate imaging can reduce patient morbidity, by reducing the number of missed diagnoses and, conversely, avoiding overtreatment. Weight-bearing radiographs are of great value when investigating the so-called subtle Lisfranc injury.

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Regardless of the operative strategy, anatomical reduction and stable fixation is a prerequisite for a satisfactory outcome in the management of displaced injuries.

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Fixation device removal is less frequently reported after primary arthrodesis compared with open reduction and internal fixation based on 6 published meta-analyses. However, the indications for further surgery are often unclear, and the evidence of the included studies is of typically low quality. Further high-quality prospective randomized trials with robust cost-effectiveness analyses are required in this area.

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We have proposed an investigation and treatment algorithm based on the current literature and clinical experience of our trauma center.

Functional Outcomes of Dorsal Bridge Plating for Lisfranc Injuries With Routine Implant Retention: A Major Trauma Center Experience

OBJECTIVES

To assess medium-term functional outcomes and the complication profile for unstable Lisfranc injuries treated with dorsal bridge plate (DBP) fixation when implants are not routinely removed.

DESIGN

Large single-center retrospective case series.

SETTING

Level-1 Trauma Center, London, United Kingdom.

PATIENTS

Consecutive cases of skeletally mature individuals with unstable Lisfranc injuries treated operatively between 2014 and 2019.

INTERVENTION

Open reduction and DBP fixation with implants not routinely removed.

MAIN OUTCOME MEASUREMENTS

Patient-reported outcome measures at final follow-up. The Manchester-Oxford Foot Questionnaire summary index was the primary outcome measure. The American Orthopaedic Foot and Ankle Society (AOFAS) midfoot scale, complications, and all-cause reoperation rates were secondary outcome measures. Logistic regression models were used to identify risk factors that influenced outcomes.

RESULTS

Eighty-five patients were included. Mean follow-up was 40.8 months (24-72). The mean Manchester-Oxford Foot Questionnaire Summary Index was 27.0 (SD 7.1) and mean AOFAS score 72.6 (SD 11.6). The presence of an intra-articular fracture was associated with poorer outcomes, with worse MOXFQ and AOFAS scores (both P < 0.001). Eighteen patients (21%) required implants removal, with this more likely in female patients (OR 3.89, 95% confidence interval, 1.27 to 12.0, P = 0.02). Eight patients (9%) required secondary arthrodesis.

CONCLUSIONS

This is the largest series of Lisfranc injuries treated with DBP fixation reported to-date and the only to routinely retain implants. Medium-term outcomes are comparable to existing literature in which implants are routinely removed. The presence of an intra-articular fracture is a poor prognostic indicator. Implant removal is more likely to be needed in female patients.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for authors for a complete description of levels of evidence.

Comparison of flexible fixation and screw fixation for isolated Lisfranc ligament injuries: A protocol for a meta-analysis of comparative studies

BACKGROUND

The frequency of isolated Lisfranc ligament (ILL) injuries has been increasing recently with the increase in low-energy trauma resulting from sports injuries. For ILL injuries, the optimal method of fixation still remains controversial. The traditional fixation method is achieved by trans-articular screws, but recently, dorsal bridge plates and suture button (SB) fixation have become alternatives. Some biomechanical studies have showed that SB fixation can provide adequate strength compared to trans-articular screws. Therefore, a meta-analysis is imperative to provide evidence on whether flexible fixation is comparable to screw fixation for treatment of ILL injuries.

METHODS

We will conduct a comprehensive literature search in PubMed, Cochrane Library, EMBASE and Web of Science databases and for comparative studies. We will apply the risk-of-bias tool of the Cochrane Collaboration for Randomized Controlled Trials to assess the methodological quality. Risk-of-Bias Assessment Tool for Non-randomized Studies was used to evaluate the quality of comparative studies. Statistical analysis will be conducted using RevMan 5.4 software (Cochrane Collaboration, London, England).

RESULTS

This systematic review will evaluate the functional outcomes and radiographic results of flexible fixation for treatment of ILL injuries.

CONCLUSION

The conclusion of this study will provide evidence for judging whether flexible fixation is superior to screw fixation for treatment of ILL injuries.

A Systematic Review of Outcomes Following Lisfranc Injury Fixation: Removal vs Retention of Metalwork

Background

Following Lisfranc injury fixation, no consensus exists on whether to routinely remove metalwork. The aim of this study was to evaluate functional outcomes and complications in patients following routine removal of metalwork and in those with retained metalwork.

Methods

A systematic review of literature (1999-2020) reporting results of metalwork removal vs retention following Lisfranc injury fixation, was undertaken. The primary outcome was functional outcomes at 1 year following index surgery. Secondary outcomes were rates of complications including unplanned removal of metalwork.

Results

No studies directly comparing routine metalwork removal vs retention were found. A total of 28 studies reporting on 1069 patients were included. Of these, 10 studies (317 patients) reported on retention and 18 (752 patients) on routine removal of metalwork. The difference in the American Orthopaedic Foot & Ankle Society (AOFAS) score between removal and retention groups was 3.38 (95% CI 6.3-0.48), P = .02 (removal 79.97 [±16.09; 71-96]; retention 76.59 [±20.36; 65.4-94]). No difference in reported rates of infection was found between the 2 groups (0%-12% for both groups). Of the 317 patients in the retention group, metalwork was removed in 198 cases, resulting in a 62.5% unplanned removal rate.

Conclusion

In conclusion, this systematic review found limited evidence comparing different strategies of metalwork management after Lisfranc injury fixation. A randomized controlled trial is necessary to elucidate if routine removal of metalwork confers any true benefit.

Level of Evidence

Level IV, systematic review including case series.

Primary fusion versus open reduction internal fixation for purely ligamentous lisfranc injuries: A Prospective comparative study and analysis of factors affecting the outcomes

BACKGROUND

The studies evaluating the outcomes of treatment of purely ligamentous unstable Lisfranc injuries are scarce. This study aimed at comparing outcomes of primary tarso-metatarsal joints fusion versus open reduction and internal fixation in treatment of such condition and determining the possible factors that may alter the outcomes.

METHODS

This study comprised 30 patients; 16 in fusion group and 14 in ORIF group. One column was operated on in 2 patients, two columns in 21, and three columns in 7. The mean follow-up period was 36 months.

RESULTS

There was no statistically significant difference between both groups regarding patients or injury characteristics. The mean AOFAS and FFI-Rs scores were 88.9 and 22.7 in the fusion group, compared to 61.7 and 34.5 in the ORIF group (P = .03,.04 respectively). At final follow-up all patients in the primary arthrodesis group were maintaining an anatomical reduction versus 71.5% in the ORIF group. Sixteen patients (53%) reported prominent hardware troubles that required removal. Five patients in ORIF group developed osteoarthritis, and four of them underwent secondary fusion. There was significantly higher incidence of posttraumatic osteoarthritis in patients with non-anatomical reduction and complete injuries. Better mean AOFAS and FFI-Rs scores occurred with non-smokers and with anatomical reduction.

CONCLUSION

Based on this limited case series, purely ligamentous Lisfranc injuries were found to have better outcomes when managed with a primary fusion as compared to ORIF. Achieving and maintaining anatomical reduction was the most important factor that is significantly attributed to improved outcomes. Possible arthritic changes and additional surgeries apart from implant removal could be avoided by primary fusion.

LEVEL OF EVIDENCE

level I- prospective comparative case study.

Dislocation of the first metatarsophalangeal joint concomitant with Lisfranc joint dislocation in a 45-year-old man

A 45-year-old man presented with severe pinch-point crush injury to his left foot. Plain radiographs revealed dislocation of the first metatarsophalangeal joint and dorsolateral dislocation of the basal phalanx and sesamoids. The first tarsometatarsal joint was subluxed in the plantar direction and the second to fourth tarsometatarsal joints were subluxed dorsally. The sesamoids were displaced dorsolateral to the metatarsal head. There was a longitudinal tear of the joint capsule at the medial margin of the medial sesamoid, which was sutured together with the abductor hallucis tendon and collateral ligament. The Lisfranc and dorsal ligaments in the tarsometatarsal joint were torn and repaired after reduction and fixed with a plate. One year after surgery, there was contracture of the first metatarsophalangeal joint, but the patient had no pain and was able to run.