Return to Play after Low-Energy Lisfranc Injuries in High Demand Individuals: A Systematic Review and Meta-Analysis of Athletes and Active Military Personnel

Abstract

Category: Sports; Midfoot/Forefoot Introduction/Purpose: Low-energy Lisfranc injury is increasingly reported in the literature. While there is a relatively large body of studies discussing the high energy Lisfranc injuries, the evidence available on this low-energy injury in active individuals with high demand remains scarce and mostly retrospective. The injury can range from a non-displaced ligamentous sprain to fracture-dislocations, and management varies from non-operative management to primary arthrodesis with a multitude of variables potentially affecting the return to play (RTP) and return to duty (RTD). This study aims to report on return to play (RTP) rate and time with regard to the type of the injury, whether bony or ligamentous, management whether non-operative, open reduction and internal fixation (ORIF) or the increasingly debated primary arthrodesis (PA). Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, relevant studies in English literature were identified between database inceptions to June 2019. Electronic based search on MEDLINE (PubMed), EMBASE, Google Scholar, and Cochrane databases using the following keywords with their synonyms: ('Lisfranc' AND 'athlete' AND 'midfoot sprain'). In addition, the reference lists from previous review articles were searched manually to check for eligible studies. Two investigators (AA, KM) independently reviewed all titles, abstracts, and the full text of articles that were potentially eligible based on the abstract review. The eligible studies were selected according to the inclusion and exclusion criteria. Any disagreement was resolved by the senior author (DF). The primary outcomes were (1) return to play rate and (2) time to return to play, whereas the secondary outcomes were (1) games missed, (2) time out of practice, (3) midfoot arthritis, and reoperation. Results: 15 studies were eligible for meta-analysis with a total of 441 subjects. Out of 441 subjects, a total of 380 (86.16%) were able to return to play and duty. There were no statistically significant difference in RTP comparing op vs. non-op [OR=0.714, CI: 0.17-2.88,I2=0%] nor ORIF vs. PA [OR=0.780, CI: 0.310-1.963, I2=0%]. The overall RTP in bony and ligamentous injuries were 82.1% [CI:70.9-93.4%, I2=0%] and 95.8% [CI:92.6-99.1%, I2=0%], respectively with no statistically significant differences [OR=1.909, CI=0.64- 5.64, I2=37%]. The mean time out in non-op and op. groups were 58.01 [CI:13.6-102.4, I2=98.03%] and 116.4 [CI:62.4-170.4; I2=99.45%] days, respectively. The mean time out in bony and ligamentous injury groups were 98.8 [CI:6.1- 191.6, I2=99.82%] and 76.4 [CI:37.9-115.02; I2=99.83%] days, respectively with statistically significant differences [SMD:3.621, CI:- 5.7-13, I2=83.17%]. Conclusion: Our meta-analysis on low-energy Lisfranc injuries in high demand individuals found an overall excellent RTP/RTD rate. The time out was not affected by the management, bony or ligamentous nature of the injury nor players' position. However, the low level of evidence and significant heterogeneity of the included studies precludes making conclusions regarding the exact time out or optimal management. Superior quality studies on low energy Lisfranc are needed.