SLR - December 2016 - Eric So
Reference: Deol RS, Roche A, Calder JD. Return to Training and Playing After Acute Lisfranc Injuries in Elite Professional Soccer and Rugby Players. Am J Sports Med. 2016 Jan;44(1):166–70.Scientific Literature Review
Reviewed By: Eric So, DPM
Residency Program: Grant Medical Center
Podiatric Relevance: There is little information in the literature pertaining to outcomes of Lisfranc injuries in the athlete. There are no evidence-based guidelines to help determine whether a patient is ready to return to training and competition. This article tackles this dilemma in elite rugby and soccer players. The authors’ main question was focused on the time to return to training and competition after Lisfranc joint injuries. The results of this study may be applicable for the clinician treating any high-level, high-impact athlete.
Methods: The authors conducted a retrospective review of 17 consecutive patients competing as a professional soccer or rugby player to address the time to return to training and competition. Diagnosis of Lisfranc injury was made clinically and radiographically. CT imaging was used to further assess any fracture seen on plain radiographs, and MRI imaging was used if no fracture was seen on plain radiographs. Primarily ligamentous injuries were assessed using the Nunley classification and bony injuries using the Hardcastle classification. Operative technique involved a 4.0 mm “Lisfranc Screw” between the medial cuneiform and base of the second metatarsal. Patients with instability of the TMTJ underwent ORIF with a 2.7 mm screw or extra-articular dorsal plate. Primary arthrodesis was performed in the presence of comminuted intra-articular fractures of the TMTJ. A standardized postoperative regimen was used, which entailed non-weightbearing for eight weeks and then transitioned to partial weightbearing. Physical therapy was initiated at eight weeks. At 16 weeks, patients were readmitted for hardware removal. All patients were reviewed at six months, 12 months and 24 months. Minimum follow-up time was two years. Time of return to training and competition and complications were recorded.
Results: All patients were male with mean age of 26.7 years (21 to 35). There were 11 professional soccer players and six professional rugby players. There were seven patients with Lisfranc ligamentous soft-tissue disruption classified as Nunley type 2. Ten injuries had osseous involvement. The time from injury to surgical fixation ranged from eight to 31 days (mean, 15.6). Two players underwent primary arthrodesis due to extensive comminution and intra-articular involvement. Sixteen patients returned to training and full competition with a mean time to return to training of 20.1 weeks (range, 18 to 24) and to full competition was 25.3 weeks (range, 21 to 31). There was a significant difference between the mean time to return to competition for rugby (27.8 weeks) and soccer players (24.1 weeks; P = 0.02). There was a statistically significant difference between ligamentous (22.5 weeks) compared with bony injuries (26.9 weeks; P = .003). One patient retired after ligamentous injury. There were three cases of neuropraxia of the deep peroneal nerve, two of them transient.
Conclusions: The use of a combined classification approach allowed for an anatomically descriptive illustration of each injury. Although no single method of fixation was implemented for all patients, the same surgical goal to achieve and maintain anatomic reduction remained central to each case. Primary arthrodesis was reserved for the comminuted intra-articular fractures. Both players returned to full activity, suggesting that primary arthrodesis, if deemed necessary to maintain anatomic reduction, can be suitable even for elite athletes. Although often regarded as a career-ending injury, all but one elite player had returned to competition. The only player to retire had a ligamentous injury due to persistent pain over the midfoot. The authors found the time to return to training to be 18 to 24 weeks and to competition 21 to 31 weeks. Patients in the ligamentous group returned to competition significantly quicker than the patients with bony injuries. However, the authors acknowledge that ligamentous injuries are more problematic to diagnose than bony injuries and may present a greater treatment and rehabilitation challenge. This study forms a basis of a guideline to aid the surgeon, treating medical teams and players to realistically plan the time to return to sport. Limitations of this study were a small number of patients, relatively short-term follow-up and heterogenous data. Strengths of this paper include the fact that data was collected prospectively and there were no patients lost to follow-up. The authors conclude that return to competitive sport may be enabled within 31 weeks, with bony injuries taking almost one month longer than ligamentous injuries. This paper affords the clinician a better understanding during consultation of athletes when return to training and competition is realistic.