Surgical Outcomes in Chronic Lisfranc Injuries without Secondary Degenerative Arthritis: A Systematic Literature Review

CATEGORY: Midfoot/Forefoot; Trauma INTRODUCTION/PURPOSE: Chronic Lisfranc (tarsometatarsal, TMT) joint injuries often present with various clinical symptoms and radiographic findings. If severe post-traumatic arthritis is present, a salvage arthrodesis is an appropriate intervention that provides the favorable outcomes. However, this procedure severely decreases TMT range of motion, a necessary attribute in the complete resolution of functionality, which is desired by many high-demand patients. Conversely, patients with chronic Lisfranc injuries occurred greater than six weeks prior to their diagnosis can present with no radiographic signs of degeneration. For this patient cohort, there is no consensus on a specific operative intervention. Therefore, this article will provide a systematic review of the current surgical options and associated outcomes to guide future clinical decisions in caring for these patients with no degenerative sequelae. METHODS: PubMed, ScienceDirect, Scopus, and Embase medical databases were searched from inception through March 5, 2019. Original studies that assessed the outcome of patients treated surgically for chronic Lisfranc injuries without secondary osteoarthritic changes were considered for inclusion. Only studies written in English and German were included. The following data were recorded from each study: number of patients, number of feet, patient age, mechanism of injury, type of injury (purely ligamentous or ligamentous with concomitant bony fractures), time between initial injury and operation, indications for surgery, pre-operative assessment, operative techniques, postoperative follow-up time, time to return to activity or sport, clinical outcome, and study design (prospective vs. retrospective, single vs. multicenter, level of evidence). The modified Coleman Score was used to assess the methodologic quality of included studies. RESULTS: Of the 6,845 screened, ten studies met the above criteria and were analyzed. All inclusions, with the exception of one study, were performed at a single center and were retrospective or prospective case series. The surgical techniques used to treat chronic Lisfranc injuries without arthritis include 1) open reduction and internal fixation with various types of hardware, 2) Lisfranc ligament reconstruction (utilizing the gracilis tendon or half of the extensor hallucis longus tendon), and 3) arthrodesis using screws. Overall, the studies generally reported low complication rates and acceptable functional outcomes. These postoperative outcomes were most frequently measured with the American Orthopaedic Foot & Ankle Society (AOFAS) score. Of the applicable studies, the mean preoperative AOFAS score of 55.7 significantly improved to 88.1 at final follow-up. CONCLUSION: No definitive consensus remains on how Lisfranc instability without concurrent degenerative arthritis should be surgically managed. Despite the delay in diagnosis, this patient cohort still experiences improved patient outcomes and few post- surgical complications with the operative techniques currently available. While the quality of these studies was satisfactory, a larger patient cohort and prospective analysis could further strengthen arguments for or against certain surgeries.