Defining Operative Indications in Lisfranc Injuries

Category: Trauma; Midfoot/Forefoot Introduction/Purpose: Injuries to the midfoot, especially subtle, primarily ligamentous ones, have historically been under- recognized. The literature surrounding midfoot injuries has also evolved as understanding has improved. Earlier studies focused on non-subtle midfoot dislocations and fracture dislocations, injuries in which the need for operative intervention was perhaps obvious. However, in more subtle injuries, there is some lack of clarity amongst orthopaedic surgeons as to what constitutes an operative indication. The purpose of this study was to perform a literature review of Lisfranc injuries to answer the simple question of what the operative indication was in the given study. Methods: A literature search [MEDLINE (PubMed), EMBASE, Google Scholar, and Cochrane databases] was performed to identify studies on Lisfranc injuries. Given that the purpose was to assess surgical indications for Lisfranc injuries, all studies that included a surgical indication for Lisfranc injuries, including case reports and review articles, were included. Studies that were not relevant to that question (i.e. biomechanical studies, anatomic studies, etc.) were excluded. PRISMA guidelines were followed where applicable, although since this study did not involve the synthesis of outcome data, some aspects were not relevant. Studies were classified as having no operative indication, a vague operative indication, or an explicit operative indication. A vague operative indication is one that referenced displacement or instability without explicitly defining those terms, i.e. displacement between which bones (M1-M2, C1-M2, or otherwise) and to what degree (any displacement, >1mm, >2mm, or otherwise) with or without stress exam. Results: 737 studies were identified with the search term 'Lisfranc injury.' After review of the titles, 389 were felt to be potentially relevant to the question at hand. The papers were then reviewed to establish whether the indication for surgery was explicitly stated. We were unable to access 31 of these studies, and a further 51 were felt not to be relevant, leaving 307 studies that were assessed. 63.2% of these studies (194/307) did not give any specific indication for surgery. While 113 studies did give an indication for surgery, 59.3% of these studies (67/113) gave only a vague indication for surgery. Only 15.0% of studies assessed (46/307) had a clear, explicit operative indication. Conclusion: It is a basic tenet of any surgical discipline that one must understand what does and does not require surgery. The answering of this question perhaps becomes more difficult when the pathology is subtle and difficult to define. However, establishing clear guidelines is a necessity in this setting. There appears to be a relative lack of clear and explicit operative indications in the literature with respect to Lisfranc injuries. Surgeons and authors should be clear and consistent about which injuries require surgery; as we move forward, better outcome data will allow us to refine our indications.