Current Management of Lisfranc Injuries, a National Consensus Survey

Research Type: Level 5 - Case report, Expert opinion, Personal observation Introduction/Purpose: Lisfranc injuries are a wide spectrum of injuries to the tarsometatarsal (TMT) joints with variable ligament damage and fracture patterns. Several prospective studies and numerous retrospective reviews and meta-analyses have described treatment and outcomes for Lisfranc injuries, but there is no consensus on the optimal treatment of these injuries. Specific areas of controversy include primary arthrodesis (PA) versus open reduction and internal fixation (ORIF) as a primary treatment option, the ideal fixation construct, post-operative weight bearing protocol, and the need for routine hardware removal. With this study we hope to shed light on the current state of Lisfranc injury management, guiding future clinical studies to ultimately elucidate optimal treatment of these complex injuries. Methods: We created a survey describing 8 clinical scenarios involving Lisfranc injuries of varying severity and injury pattern. The survey included a purely ligamentous Lisfranc injury, a Lisfranc injury with associated intra-articular first and second metatarsal base fractures, a sub-acute (3 months old) Lisfranc injury, and a high-energy Lisfranc injury with dislocation of all TMT joints and associated fractures. The first 3 injury patterns were presented multiple times for patients with different demographics including age, activity level, and profession. Survey participants were asked how they would treat each patient with options including ORIF, PA, closed reduction and percutaneous fixation (CRPF), and non-operative. For each scenario they were also asked which fixation construct they would use with options including plates, screws, flexible fixation devices, kirschner wires, staples, or any combination. Finally, they were asked how long the patient would be non-weightbearing. The survey was distributed to all active AOFAS members via email. Results: For ligamentous Lisfranc injuries, the majority of participants chose ORIF or CRPF. (See image 1) In cases with intra-articular metatarsal fractures, 134 (41%) preferred primary arthrodesis (PA) for a 50-year-old low-demand male, and 100 (31%) for a 30-year-old female runner. For sub-acute Lisfranc injuries, 209 (64%) recommended PA for a 25-year-old active male and 204 (62%) for a 30-year-old low-activity female. For a high-energy dislocation of all five TMT joints, 196 (60%) selected PA, while 113 (35%) preferred ORIF. Plates and screws were the most common fixation choice for all scenarios. After ORIF, 146 (44%) recommended scheduled hardware removal, while 130 (39%) recommended removal only if symptomatic. Factors identified as most important in decision making were associated fractures, injury chronicity, and amount of displacement. Conclusion: This study describes the current preferences for management of Lisfranc injuries among AOFAS members, predominantly those in private practice or academics with over 15 years of experience. Primary arthrodesis was preferred for subacute and high-energy Lisfranc dislocations. Despite a growing body of literature supporting PA, internal fixation was the more common choice for both ligamentous and bony Lisfranc injuries. Screws and plates were the most common fixation constructs. These findings confirm a lack of consensus on this topic and emphasize the importance and need for better randomized controlled trials to determine the optimal treatment for these challenging injuries. Results of Ligamentous Lisfranc Injury