SLR - December 2019 - Garrett A. Melick
Reference: Robertson G, Ang K, Maffulli N, Keenan G, Wood A. Return to Sport Following Lisfranc Injuries: A Systematic Review and Meta-Analysis. Foot and Ankle Surgery: Official Journal of the European Society of Foot and Ankle Surgeons. 2018 Aug 8. Epub ahead of print.Scientific Literature Review
Reviewed By: Garrett A. Melick, DPM
Residency Program: Cambridge Health Alliance – Cambridge, MA
Podiatric Relevance: In the athletic population, research remains limited regarding prognostic indicators for return to sport following Lisfranc injuries. The purpose of this study is to determine the rate and time to return to sport following Lisfranc injury and associated therapeutic intervention, providing the surgeon with evidence to discuss the benefits of treatment methods and the likelihood of return to sport for this challenging injury. No clear hypothesis was drawn by the authors.
Methods: A systematic review of Level I to IV articles discussing Lisfranc injuries in athletic individuals was conducted without discrimination based on injury type, severity, or the level of athletic activity. Seventeen articles were included with a total of 380 Lisfranc injuries. Treatments included non-operative management in 71 feet, open reduction and internal fixation (ORIF) in 139 feet, percutaneous reduction internal fixation (PRIF) in 42 feet, primary partial arthrodesis (PPA) in 85 feet, and flexible Tight-rope/interosseous suture button in 7 feet. Indications for operative versus non-operative treatment and postoperative rehabilitation protocol varied across studies. Primary outcome measures included the rate of return to sport and time to return to sport. Additional secondary outcome measures included rate of return to pre-injury level of sport and complications.
Results: Regardless of treatment performed, the rate of return to sport was 87 percent (96 percent in non-operative treatment group and 84 percent in operative treatment group), and the average return time to sport was 16 weeks (8.7 weeks in non-operative and 21.2 weeks in operative group). Return to the pre-injury level of sport occurred in 80 percent of all injuries (90 percent non-operative and 77 percent operative). PRIF produced significantly better return rate to sport, return time to sport, and rate of return to pre-injury level of sport than ORIF and PPA. There were no significant differences when comparing PPA and ORIF with regard to these outcome measures.
Conclusions: When considering stable Lisfranc injury patterns with minimal or no displacement, non-operative treatment for athletic individuals is a suitable treatment. Conversely, given the dichotomy of injury patterns in the unstable Lisfranc injury, the treatment of choice is more controversial. When the injury pattern allows, PRIF provides the best prognosis for an athlete. However, some Lisfranc injuries require open treatment. Despite previous literature citing improved rate of return to sport with PPA, pooled results from this study suggest no significant difference regarding rate or time of return to sport when comparing PPA and ORIF. Unfortunately, the significant heterogeneity in injury type, severity, and indications for proposed treatment among the studies included makes it difficult to fully discern the prognosis of injury based on severity or type of injury (purely ligamentous, osseous, or combined). That being said, this article affirms my belief that in stable injury patterns conservative treatment with a verified rehabilitation protocol is warranted, and when possible, unstable injuries can be treated with PRIF techniques. I believe in cases of frank instability or severe fracture pattern PPA should be favored over ORIF, due to the relatively lower rate of complications and a lower rate of hardware removal.