SLR - November 2021 - Jessica A. Hethcoat
Return to Play After Low-Energy Lisfranc Injuries in High-Demand Individuals: A Systematic Review and Meta-Analysis of Athletes and Active Military Personnel
Reference: Attia, Ahmed Khalil et al. “Return to Play After Low-Energy Lisfranc Injuries in High-Demand Individuals: A Systematic Review and Meta-Analysis of Athletes and Active Military Personnel.” Orthopaedic Journal of Sports Medicine vol. 9,3 2325967120988158. 8 Mar. 2021, doi:10.1177/2325967120988158.
Level of Evidence: IV
Scientific Literature Review
Reviewed By: Jessica A. Hethcoat, DPM
Residency Program: Scripps Mercy Hospital – San Diego, CA
Podiatric Relevance: Low-energy Lisfranc injuries are more likely to occur in athletic individuals, with the incidence in college football players being 20 percent, as compared to 0.2 percent of fractures in the general population. Recent research suggests this specific condition is underdiagnosed and can result in >2 millimeters displacement, affecting football athletes for seasons to come. This meta-analysis is the first of its kind, specifically looking at low-energy Lisfranc injuries in the athlete/military personnel population.
Methods: A level IV systematic review was performed, including 15 studies and 441 patients, which were identified after searching MEDLINE (PubMed), EMBASE, Google Scholar, and Cochrane databases through June 2019. The primary outcomes were return-to-play (RTP) and return-to-duty (RTD) rates and time to RTP/RTD. Secondary outcomes included time missed from practice, games missed, time to full recovery, midfoot arthritis rate, and reoperation rate. Of the 15 studies included in the meta-analysis, six studies were level III evidence, eight studies were level IV, and one study had level V evidence.
Results: Of the 15 studies and 441 patients that were included in this study, 380 patients (86.17 percent) were able to RTP and RTD. There was no significant difference to RTP/RTD between athletes versus military personnel, between ligamentous versus bony injury, in operative versus non-operative treatment. Even within primary arthrodesis versus ORIF there was no significant difference in RTP/RTD. There was a difference in the amount of time missed from practice/duty when it came to operative (58.02 days) vs. nonoperative treatment (116.4 days), as well as bony injury (98.9 days) versus ligamentous injury (76.5 days) but this difference was also found not to be significant.
Conclusions: Ultimately, this study is useful for a very specific population and did not find statistical significant differences in patient outcomes when it came to the type of injury, whether surgery was performed, and the type of treatment performed. This study does have clinical significance in that a low-energy Lisfranc injury, especially in active populations, needs to be on the radar of podiatric physicians. When these types of injuries go undiagnosed, it can result in years of pain and loss of function. Especially in professional sports, Lisfranc injuries were the worst performing against all NFL variables in a sample of more than 100,000 collegiate football players. These studies highlight the need for a high index suspicion and initiation of appropriate treatment for patients exhibiting signs and symptoms of this injury. Ultimately more research is needed on this topic.