SLR - December 2021 - Joseph F. Albers
Reference: Ponkilainen VT, Partio N, Salonen EE, Laine HJ, Mäenpää HM, Mattila VM, Haapasalo HH. Outcomes after Nonoperatively Treated Non-Displaced Lisfranc Injury: A Retrospective Case Series of 55 Patients. Arch Orthop Trauma Surg. 2021 Aug;141(8):1311-1317.Level of Evidence: IV
Scientific Literature Review
Reviewed By: Joseph F. Albers, DPM
Residency Program: Ascension Wisconsin – Milwaukee, WI
Podiatric Relevance: Lisfranc injuries comprise a broad spectrum of tarsometatarsal joint injuries that range from subtle injuries to complete dislocations. The incidence of subtle injuries has been found to be more common than previously thought. Previous studies have focused solely on the surgical treatment of Lisfranc injuries. Current knowledge of the role of the nonoperative treatment of Lisfranc injuries is based on a few retrospective case series. Hence, consensus on which patients can be treated nonoperatively does not exist. Furthermore, to date there have been no RCTs that compare the nonoperative and operative treatment for Lisfranc injuries giving us limited data on the subject. Evaluating the efficacy and outcomes of non-operative treatment for increasingly diagnosed subtle nondisplaced Lisfranc injuries is valuable for physician medical decision making and reasonable treatment outcome expectations.
Methods: In this study, patients were collected by recruiting all computer tomography-confirmed Lisfranc injuries treated during a five-year period at a major trauma hospital. Between two and six years after suffering the injury, patients completed the visual analogue scale foot and ankle questionnaire. In total, 233 patients with Lisfranc injuries were identified. Of these, 175 were treated nonoperatively and 58 operatively. Nonoperative treatment protocol was implemented for nondisplaced Lisfranc injuries in all patients with <2 millimeters of dislocation in the second and third TMT or between the second metatarsal and the medial cuneiform. All were measured utilizing a non weight bearing CT. Nonoperative treatment protocol was as follows, non-weightbearing immobilization in a cast for 4-6 weeks followed by progressive weightbearing towards full weightbearing during the next four weeks.
Results: In total, 55 patients returned adequately completed questionnaires and were included in the study. Of those, 22 patients had avulsion fractures and 33 had simple non-displaced intra-articular fractures. Of these patients, 30 (55 percent) scored over 90 points in both the pain and function subscales of the VAS-FA, and 35 (64 percent) scored over 90 points overall. In addition, three (5 percent) patients scored under 60 points in both the pain and function subscales of the VAS-FA, and four (7 percent) scored under 60 points overall. Only one patient with avulsion fractures underwent secondary surgery.
Conclusions: The incidence of subtle Lisfranc injuries may be higher than previously published. Therefore, treatment of these subtle Lisfranc injuries must be studied and the long term outcomes recorded. According to the findings of this study nonoperative treatment has a role in the treatment of Lisfranc injuries, and the results of the study support the view that avulsion and simple intra-articular fractures with < 2 millimeters of displacement may be treated nonoperatively. The results of nonoperative and operative treatment should be compared in a prospective randomized controlled study setting in future studies.