Summary

Flexible fixation use in the treatment of ligamentous Lisfranc injury has significant potential as a fixation option, as demonstrated by excellent clinical results.

Abstract

Background

Ligamentous Lisfranc injury has serious implications if treated inappropriately, but the optimal fixation strategy is unclear. Flexible ligamentous fixation has become more popular as it has the potential to avoid iatrogenic cartilage damage created by screw placement and decrease frequency of hardware removal, while allowing physiologic motion.

Purpose

To review the biomechanical, clinical, and radiographic results, and perform meta-analysis of postoperative outcomes for ligamentous Lisfranc injuries treated with flexible fixation.

Methods

PubMed, Medline, and Google Scholar were searched for articles relating to flexible fixation of ligamentous Lisfranc injury. Abstracts and articles were screened against predefined inclusion and exclusion criteria, and 14 were selected for final inclusion. Data on surgical techniques, patient demographics, postoperative outcomes, and clinical results was recorded from the 11 clinical studies. Where appropriate, meta-analysis was performed. Biomechanical data was recorded as well.

Results

One biomechanical study demonstrated significantly less diastasis under axial load in specimens undergoing screw fixation than suture button compared to intact counterparts (-0.1 vs +1.1 mm, p<0.05). Another found no difference in the decrease in diastasis under axial load from injured state to screw or suture button fixation (1.2 vs 1.0 mm, p=0.5). The third found no difference in displacement between intact models and either screw or suture button fixation under either axial or abduction load. Average postoperative AOFAS score was 90.1 (n=150, 6 studies), and VAS 1.5 (n=137, 5 studies). Rate of return to activity was 100% (n=35, 5 studies), and 100% of patients maintained radiographic alignment postoperatively (n=62, 6 studies). No complications or subsequent hardware removals were reported.

Conclusions

Flexible fixation use in the treatment of ligamentous Lisfranc injury has significant potential as a fixation option, as demonstrated by excellent clinical results. Biomechanical evidence is inconclusive but suggests a trend towards decreased diastasis in specimens fixed with screws compared to suture buttons.

Clinical Relevance
Systematic review of the literature reveals that the quality of research is limited by small sample sizes and lack of high-quality studies, which suggests the importance of a prospective randomized clinical trial comparing flexible fixation to screw fixation for ligamentous Lisfranc injuries.