Flexible fixation versus open reduction internal fixation and primary arthrodesis for ligamentous Lisfranc injuries: A systematic review and meta-analysis.

Introduction: Flexible fixation (FF) has allowed treatment of isolated ligamentous Lisfranc injuries while preserving joint motion. We hypothesize that patient-reported outcome measures (PROMs), complications, and return-to-activity rates will be similar between patients undergoing FF versus those undergoing open reduction internal fixation (ORIF) or primary arthrodesis (PA).

Methods: Databases included PubMed, OVID Medline, Embase, SCOPUS, Cochrane Central Register of Clinical Trials, and clinicaltrials.gov from their inception to 5/13/2024. Search terms focused on treatment of Lisfranc injuries with FF, ORIF, or PA. Only English studies were included. Studies were included if the Lisfranc injury was purely ligamentous and had PROM scores. Quality, validity, and comparability were assessed using MINORS and GRADE criteria. Meta-analysis was conducted using pooled statistics. Cohen's d and odds ratios (OR) determined effect sizes.

Results: Twenty-five studies were included. There were 184 patients undergoing FF, 236 patients undergoing ORIF, and 80 patients undergoing PA. Postoperatively, American Orthopaedic Foot and Ankle Society (AOFAS) scores were 89.7 ± 10.0, 78.7 ± 44.2, and 87.4 ± 31.8, VAS-pain scores were 1.5 ± 1.5, 1.6 ± 3.8, and 0.3 ± 2.6, and return to activity rates (RTA) were 100 %, 63.3 %, and 78.4 %, respectively. Rates of post-traumatic arthritis were 0 %, 13.0 %, and 0 %, hardware removal were 0 %, 86.0 %, and 22.5 %, and complications were 3.8 %, 17.7 %, and 23.5 %. Meta-analysis demonstrated that FF had superiority over ORIF regarding better AOFAS scores and RTA with lower rates of post-traumatic arthritis, hardware removal, and complications (p < 0.05). Also, FF had superiority over PA with higher RTA and lower rates of hardware removal and complications. PA demonstrated better VAS-pain scores (p < 0.05).

Conclusion: FF had satisfactory outcomes after Lisfranc injury treatment. Low-quality evidence suggested that FF had better outcomes, however, this conclusion was drawn from single-arm studies which have significant limitations. Further prospective, comparative studies should investigate this relationship.