SLR - September 2021 - Kathryn T. Cecere

Return to Play After Low-Energy Lisfranc Injuries in High-Demand Individuals

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: Kathryn T. Cecere, DPM
Residency Program: University of Florida Health – Jacksonville, FL

Podiatric Relevance: High impact injuries to the Lisfranc joint most commonly occur in automobile accident victims, military personnel, athletes in contact sports, or a mechanism as simple as a ground level fall. There are however, lower impact Lisfranc injuries that are consistent with more ligamentous injuries. This is commonly seen in football, rugby and soccer players as the foot is plantarflexed and forcefully abducted upon contact. There are few studies on these lower impact injuries in athletes available in the current literature. The purpose of this study was to evaluate the rates of return to play and return to duty in athletes in military personnel. This study also reviewed injury type and injury management within the respective population.

Methods: In this systematic review, an electronic search was performed for articles that included “Lisfranc”, “athlete” and “midfoot sprain”. The reference lists from these articles were also used to manually check for eligible studies. Two researchers independently reviewed all eligible articles and selected those according to the inclusion and exclusion criteria. A senior author was available to resolve any disparities.  Primary outcomes were defined as return to play and return to duty. Secondary outcomes were games missed, time missed from practice, midfoot arthritis, and reoperation. Inclusion criteria were studies on Lisfranc or midfoot sprains in athletic high-demand individuals and the outcomes of interest. Exclusion criteria were those articles that did not report any of the outcomes of interest, text not in English, articles that reported high- energy Lisfranc injuries, or studies on a population other than athletes and military personnel.15 articles were included for review.

Results: Of the 15 studies included in the meta-analysis, 441 patients were included. 86.17 percent of patients were able to return to play/return to duty. The return to play in athletes was 91.24 percent and the return to duty in military personnel was 81.25 percent. The mean time missed from practice/duty for operative versus nonoperative treatment was 58.02 days/116.4 days. The mean time missed from practice/duty for bony versus ligamentous injury was 98.9 days/76.5 days. The reoperation rate was 70.7 percent in ORIF and 32.2 percent in primary arthrodesis. There was no statistically significant difference in return to play rates for operative versus nonoperative treatment, ORIF versus primary arthrodesis, bony versus ligamentous injuries, time missed from practice/duty, midfoot arthritis rate or reoperation rate. There was heterogeneity in time missed from practice/duty, reoperation, DJD within operative group and reoperation within ORIF versus primary arthrodesis group.

Conclusions: While Lisfranc injuries typically have detrimental impacts on high level athletes and military personnel, this study concluded that there is excellent return to practice/duty rates in individuals who suffered from low impact Lisfranc injuries. Interestingly, those individuals who underwent primary arthrodesis had shorter amounts of time missed from play and faster running speed (29 seconds faster per mile) at fitness testing as compared with the ORIF group. One limitation to this study was that all articles included were retrospective and with no control group. Further studies of higher quality are needed to further evaluate this topic.    

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