Routine Retention of Metalwork After Extra-articular Dorsal Plate Fixation of Ligamentous Lisfranc Injuries in Elite Athletes Enables Early Return to Sports

Abstract

Background:

Operative intervention to achieve accurate anatomic reduction for unstable ligamentous Lisfranc joint injuries in athletes is recommended for good outcomes, although open reduction and internal fixation (ORIF) compared with primary arthrodesis is still debated. In addition, there is also no consensus on whether metalwork should be routinely removed or retained after Lisfranc joint ORIF.

Purpose:

To evaluate outcomes of retaining metalwork after ORIF for acute isolated ligamentous Lisfranc injuries in a cohort of professional elite athletes, focusing on complications such as metalwork breakage, reoperation, and expected return to sports (RTS) time.

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 32 elite athletes (mean follow-up, 40.6 months [range, 26-58 months]) with acute isolated ligamentous Lisfranc injuries treated with ORIF using the extra-articular dorsal bridge-plating technique were evaluated. Removal of metalwork was not planned routinely unless symptomatic. Descriptive data, time to RTS, player status at the last visit, and complications specific to metalwork retention were analyzed and reported.

Results:

All 32 athletes had a diastasis of >2 mm, categorized as Nunley and Vertullo type 2 injuries. The mean time of return to their preinjury level of sports was 18.7 weeks (range, 14-25 weeks). Soccer players returned to their sport significantly earlier (17.3 weeks vs 19.9 weeks; P = .09) when compared with rugby players. Four athletes (12.5%) required removal of metalwork at a mean of 8.5 months postoperatively. Three cases were due to screws backing out and 1 case had a broken screw with pain across the plate region. There were 3 additional patients with broken screws that were left in situ, as the patients were asymptomatic and still playing competitively. Two other athletes required conversion to arthrodesis because of painful midfoot arthritis at 16 months and 35 months after fixation, respectively. Despite that, all these athletes returned to their professional career at their last review.

Conclusion:

Retention of metalwork after extra-articular dorsal bridge-plating ORIF for acute isolated ligamentous Lisfranc injury in elite athletes enables return to preinjury sporting level without significant mechanical complications, and selective removal of metal may be considered if symptoms arise.

Keywords

complications elite athletes ligamentous Lisfranc injury low-energy open reduction and internal fixation retention of metalwork return to sport

Low-energy isolated ligamentous Lisfranc injury has been increasingly described in athletes.^{7,9,11,14,21,23,24,26,30,31} This variant of Lisfranc injury can be very subtle and hard to diagnose, unlike the high-energy Lisfranc injuries, which occur after major traumatic events typically involving fracture dislocations.^{7,9,11,14,21,23,24,26,30,31} Up to 20% of Lisfranc injuries are missed at initial presentation, and this is especially the case in ligamentous injuries due to the subtlety of imaging findings.^{4,5,11,14,24,30} As a result, morbidities such as chronic pain, midfoot collapse, and posttraumatic arthritis can negatively affect elite athletes and are potentially career-limiting.^6,9,10,20,30 In an epidemiology study⁶ of severe foot injuries in American collegiate athletes involving a total of 3607 foot injuries, Lisfranc injuries were found to have the highest operative rate (54.17%) and were associated with the highest season-ending injury rate (70.83%).

Operative treatment has been shown to have better outcomes than nonoperative treatment in unstable subtle Lisfranc joint injuries.^{5,14,16,20,21,30} Accurate anatomic reduction of the Lisfranc joint is vital to achieving good outcomes, although operative treatment for ligamentous Lisfranc injury with open reduction and internal fixation (ORIF) compared with primary arthrodesis is still debated.^{4,7,13,16,17,30,32} Those supporting primary fusion cite the higher rates of reoperation associated with ORIF and the need for metalwork removal.^{4,17,27,30,32,33} It has been argued that this should not be regarded as a complication. Buda et al⁴ compared patients with Lisfranc injuries treated with ORIF with those who underwent primary arthrodesis and reported similar reoperation rates when staged metalwork removal was excluded.⁴

Removal of metalwork after ORIF of Lisfranc joint injuries is generally performed to restore midfoot joint motion, prevent stiffness and altered biomechanics of the midfoot, and reduce the risk of metalwork prominence causing impingement.^4,27,30,33 However, there is a lack of evidence to suggest if metalwork should be routinely removed after ORIF of Lisfranc joint injuries.^27,33 Routine removal of metalwork has been implicated with morbidities such as deep peroneal nerve injury, surgical site infection, risks of additional anaesthesia, and increased health care costs.^{3,19,25,27,29} In fact, a recent systematic review of outcomes after removal versus retention of metalwork after Lisfranc injury fixation reported a lack of published data to allow meaningful comparison, although the available functional outcome scores and complication rates were found to be similar between both groups.²⁷

Therefore, this study aimed to evaluate the outcomes of ORIF for acute isolated ligamentous Lisfranc injury with retention of metalwork in a cohort of professional elite athletes. The purpose was to report on complications such as metalwork breakage, reoperation rate, and the expected time to return to sports (RTS).

Methods

Institutional approval was provided in line with the United Kingdom Health Research Authority guidance, as this study does not require ethical approval because it is considered to be an audit of clinical data. The prospectively kept data of all elite athletes with acute isolated ligamentous Lisfranc injuries who underwent a primary ORIF from January 2017 to January 2022 by the senior author (J.C.) were retrospectively reviewed.

Elite athletes with acute isolated ligamentous Lisfranc injuries presenting within the first 3 weeks of injury were included. Elite athletes were defined by their participation at national or international level competitions or those who were paid to perform their sporting activities as a professional career. Only those athletes who underwent ORIF with the dorsal bridge-plating technique without transarticular fixation and with a minimum of a 2-year follow-up were included. Athletes with high-energy Lisfranc injuries affecting several tarsometatarsal joints, cases with associated fractures to the foot and ankle, those who had articular cartilage damage, primary arthrodesis and other form of fixation during ORIF, previous midfoot surgeries, or revision cases (fixation failure, infection, re-diastasis) were excluded from this study.

A combination of clinical examinations and radiographic assessments were used to diagnose acute ligamentous Lisfranc injuries. All patients had midfoot pain, swelling, and tenderness with radiographic evidence of acute ligamentous Lisfranc injuries. Full weightbearing anteroposterior and lateral radiographs with nonweightbearing oblique view of the foot and magnetic resonance imaging scan of the foot were performed. If there was no displacement on the initial radiographs, the patient was asked to repeat full weightbearing single leg stance anteroposterior and lateral radiographs (Stork view) at 5 to 10 days after the injury. The Nunley and Vertullo classification²¹ was used, and if the ligamentous injury was unstable with displacement of >2 mm, then ORIF was indicated. Patients with a fleck sign indicating an avulsion injury of the Lisfranc ligament were also included in this cohort, as they were considered as primarily a ligamentous injury. Weightbearing computed tomography scan was not routinely performed preoperatively.

Patient characteristics (age and sex), types of sports, clinical examinations, radiographic findings, types of injuries, complications, reinjury, revision surgery, duration of follow-up, time to RTS competitively, and player status at the last visit were retrieved and analyzed. In particular, complications related to the retention of metalwork were reviewed.

Operative Treatment

All the patients had surgery performed by a single high-volume sports foot and ankle surgeon (J.C.). A longitudinal incision was made over the second tarsometatarsal joint with careful dissection in layers. The dorsal neurovascular bundle (deep peroneal nerve and dorsalis pedis artery) was identified and protected deep to the extensor hallucis brevis musculotendinous junction.²² Subperiosteal dissection was then performed to expose the Lisfranc joint and progressive elevation of the neurovascular bundle medially to reach the first tarsometatarsal joint. Minimal dissection of the Lisfranc joint was required, as these were all acute ligamentous injuries without bony fractures. The Lisfranc joint was reduced and held in anatomic position with a pointed bone reduction forceps. A dorsal, diamond-shaped Lisfranc plate (Arthrex) was used to bridge the joints. This was a low-profile locking plate that was contoured to allow fixation into the first and second metatarsal bases as well as the medial and intermediate cuneiforms. There was no routine utilization of Lisfranc screws from the medial cuneiform to the base of second metatarsal in this series of patients.

Postoperative Rehabilitation

All patients were placed into a Plaster-of-Paris backslab (posterior splint) for 2 weeks with strict elevation of the foot to reduce swelling. Suture removal was performed at the 2-week wound review. Patients were mobilized nonweightbearing until 3 weeks postoperatively, followed by partial weightbearing in the walking boot (Aircast XP Walker; DJO, LLC) for 3 weeks and then full weightbearing in the boot for another 3 weeks. Active ankle range of motion exercises were commenced once they were out of the backslab. Proprioceptive training was initiated after 6 weeks when they started full weightbearing in the walking boot. After 9 weeks, the patients were allowed to ambulate in trainers with the gradual introduction of running and full training. Fitness to RTS competitively was determined by the athletes’ club medical team.

Routine removal of metalwork was not planned to reduce the time to RTS participation and avoid risks of reoperation. Removal of metalwork was only indicated if there was painful or prominent metalwork. Asymptomatic broken metalwork such as screws was not considered to be an indication for removal of metalwork.

Statistical Analysis

Frequency tables and descriptive statistics (mean, median, range, and standard deviation where appropriate) were used for descriptive statistics. Continuous variables were presented as means or medians and categorical variables as proportions. The Student t test was used for continuous variables while the chi-square test and the Fisher exact test were used to compare categorical variables. Data were analyzed using SPSS Version 16 (IBM). Complications related to metalwork retention were tabulated and detailed.

Results

Within the study period, there were 32 elite athletes with acute isolated ligamentous Lisfranc injuries treated with ORIF. All these athletes had a minimum 2-year follow-up (mean, 40.6 months; range, 26-58 months), and they were still playing competitively at their last review. The mean age was 23.9 years (SD, 4.04; range, 18-32 years), and 29 of the athletes were men (90.6%). More than half of the athletes were professional rugby players in the English Premiership (n = 17; 53.1%), and the rest (n = 15; 46.9%) were professional soccer players in the English Premier League or Championship clubs (top 2 tiers of English football).

In terms of the types of injuries, 3 athletes (9.4%) had a fleck sign (avulsion-type injury), while the rest had isolated ligamentous injuries. (Figures 1 and 2). All athletes had a diastasis of >2 mm categorized as Nunley and Vertullo type 2 injuries with no arch height loss. After surgery, all the patients returned to their preinjury level of sports, and their mean time to RTS was 18.7 weeks (SD, 2.94; range, 14-25 weeks). No significant differences were found between the time to RTS and sex, age, and the type of injury, although the time to RTS significantly differed depending on the sport. Soccer players returned to their sport competitively significantly earlier (17.3 weeks vs 19.9 weeks; P = .09) when compared with their rugby counterparts.

Figure 1.

(A) Radiographs show the right foot isolated ligamentous Lisfranc injury (fleck sign), with a diastasis of >2 mm. (B) Postoperative radiographs at the last review (29 months) with intact metalwork. WB, weightbearing; WT bearing, weightbearing.

Figure 2.

(A and B) Radiographs illustrate a left foot isolated ligamentous Lisfranc injury, with a diastasis of >2 mm upon weightbearing. (C and D) Postoperative radiographs at the last review (40 months) with intact metalwork.

Two patients had altered sensation in the distribution of the deep peroneal nerve, where 1 resolved and 1 persisted at their last follow-up review. There were no cases of extensor hallucis longus tendon irritation or disruption in this series. Regarding retention of metalwork, 4 athletes (12.5%) required removal of metalwork. Three cases were due to loose screws backing out causing impingement (only the loose screw was removed), and 1 case had a broken screw with pain across the plate region (all screws and the plate were removed). One of the 3 patients with a single loosened screw removed had another single screw breakage that was asymptomatic and thus left in situ. Removal of metalwork for these 4 patients was performed at a mean of 8.5 months postoperatively (range, 7-12 months). All patients returned to their preinjury level of sports after removal of metalwork. There were 3 additional patients with broken screws (2 patients with single broken screw and 1 patient with 2 broken screws), which were left in situ, as the patients were asymptomatic and still actively participating in their field of sports (Figure 3). There were no significant differences in terms of sex, age, type of injury or type of sports when comparing those with or without broken or loose screws.

Figure 3.

(A) Preoperative weightbearing radiographs demonstrating isolated ligamentous Lisfranc injury with diastasis of the left foot followed by ORIF. (B) Radiographs show 1 broken screw in the cuneiform at 4 months with a well reduced Lisfranc joint. (C) Radiographs show 2 broken screws in the cuneiforms at 24 months without symptoms, with the patient still playing professionally at his last review (46 months). ORIF, open reduction and internal fixation.

Two patients developed painful arthritis, requiring conversion to arthrodesis of the first and second tarsometatarsal joints. One of the patients was a 27-year-old male rugby player who had the arthrodesis at 35 months after the initial injury and returned to elite rugby thereafter, while the other patient was a 32-year-old female rugby player who had the arthrodesis performed at 16 months after the initial injury and returned to international rugby.

Discussion

The most important finding of this study is that ORIF of acute isolated low-energy ligamentous Lisfranc injuries via dorsal extra-articular bridge-plating in elite athletes enabled RTS at the professional level without serious complications. This finding is significant because it contributes to the literature that ORIF for low-energy ligamentous Lisfranc injuries allowed elite athletes to RTS at a mean time of 18.7 weeks and provided good outcomes at a mean of 40.6 months follow-up. Several earlier publications reported poorer functional outcomes for ligamentous Lisfranc injuries treated with ORIF when compared with primary arthrodesis.^16,17 Notably, Kuo et al¹⁶ reported outcomes after ORIF for 48 patients with Lisfranc injuries (15 cases of purely ligamentous injuries and 33 cases of mixed ligamentous and osseous injuries) and reported inferior functional outcomes and a higher rate of posttraumatic arthritis for patients with purely ligamentous injuries compared with those with mixed injuries although acknowledging that differences were not significant. In a landmark prospective randomized study published by Ly and Coetzee¹⁷ involving 41 patients, primary arthrodesis of the medial 2 or 3 rays (n = 21 patients) were compared with ORIF (n = 20 patients) in patients with purely ligamentous injuries at a mean follow-up of 43 months. They reported that the ORIF group had poorer American Orthopedic Foot and Ankle Society scores and visual analog scale for pain scores, as well as higher rates of reoperation and conversion to arthrodesis. However, although the Lisfranc injuries included in the 2 studies were ligamentous, they included high-energy injuries where the tarsometatarsal joints of the midfoot were disrupted, unlike the subtle low-energy type seen in athletes with isolated diastasis of the Lisfranc joint.³⁰ This study included only elite athletes with subtle ligamentous Lisfranc injuries (Nunley and Vertullo type 2) with no associated bony fractures, unlike earlier studies.

The two studies above^16,17 used transarticular screws for ORIF without routine removal, which may result in iatrogenic articular cartilage damage especially when allowed to weight bear resulting in persistent pain and progression of arthritis. This was corroborated by Alberta et al¹ in their biomechanical study comparing transarticular screw fixation with dorsal plating in displaced ligamentous Lisfranc injuries. In their study, both techniques demonstrated similar biomechanical ability to resist tarsometatarsal joint displacement with weightbearing but the transarticular screws caused significant disruption of articular surfaces. Hence, the authors suggested that dorsal bridge-plating might be a viable alternative to transarticular screw fixation given the similar biomechanical characteristics devoid of the collateral articular cartilage damage. Several subsequent studies have also demonstrated that transarticular screw fixation of Lisfranc injuries can cause significant damage to the articular cartilage.^1,8,10,12 In particular, Denove et al⁸ recently performed a biomechanical study of 10 cadaveric specimens with ligamentous Lisfranc injury and found further articular cartilage damage after simulated weightbearing with transarticular screw fixation, whereas earlier studies measured only the articular cartilage damage from screw placement in a static model. As a result, extra-articular bridge-plating has become a widely accepted alternative method for ORIF of Lisfranc injuries.^15,30 On the other hand, in terms of time taken to RTS, Deol et al⁹ reported a series of 17 elite professional soccer and rugby players with acute Lisfranc injuries (7 with ligamentous injuries and 10 with osseous injuries). In their study, all except 1 athlete were able to return to their preinjury level of competitive sports after ORIF followed by routine metalwork removal at 16 weeks. These elite athletes took a mean of 25.3 weeks to return to competitive play, with elite rugby players taking a significantly longer mean time at 27.8 weeks in contrast to elite soccer players at 24.1 weeks. Interestingly, although the cohort of elite athletes in this study had a shorter mean time of 18.7 weeks to return to their sports competitively due to the avoidance of routine metalwork removal, the soccer players still returned to play significantly earlier at 17.3 weeks when compared with the rugby players at 19.9 weeks.

Another important finding of this study is that the retention of metalwork did not lead to increased rates of reoperation. Out of 32 elite athletes, only 4 required removal of metalwork—3 athletes had a single loose screw removed because it was backing out and causing impingement pain, and 1 athlete had the entire metalwork removed because of a painful broken screw. Two other athletes required conversion to arthrodesis due to painful midfoot arthritis at 16 months and 35 months after initial fixation, respectively. Despite that, both of them returned to their professional career as of the last review. There is no consensus as to whether metalwork should be removed or retained after Lisfranc injury fixation, resulting in the decision usually being based on the surgeon’s preference and personal experience.^27,33 Concerns about leaving metalwork in situ included altered biomechanics of the midfoot and resultant metalwork breakage once the patient starts to participate in heavy impact activities.^4,27,33 Theoretically, adjacent joint disease could also develop due to the additional load transfer from the immobilized joints when metalwork is left in situ. Hence, the general principle for planned metalwork removal after Lisfranc injury fixation is to prevent abnormal biomechanics of the midfoot by restoring anatomic motion of the midfoot joints, reduce pain from metalwork prominence, and potentially enable easier interval surgeries if necessary for symptomatic midfoot arthritis.^4,27,33 However, routine removal of metalwork has been shown to lead to additional risks of surgical site infection, additional anaesthesia, and increased health care costs. ^{3,25,27,29,33} Specific to Lisfranc joint injury, the rate of deep peroneal nerve damage was 23% when routine removal of metalwork was planned after ORIF.¹⁹ In the present study, a single diamond shaped dorsal Lisfranc locking plate was used with only a single screw in each bone to confer stability after Lisfranc joint reduction without transarticular or Lisfranc screws. Therefore, we postulate that the advantage of this construct is that it is stable enough to hold joint reduction for the initial healing but may not be rigid enough to withstand impact during running or sporting activities, thus allowing some micromotion (toggling) that may resemble physiological movements. However, screw breakage can occur at the head-neck junction of the locking screw under excessive loading from sporting activities, which will then allow motion at the midfoot joints as necessary. This is similar to the ankle syndesmosis joint movement seen after loosening or breakage of screw fixation in ankle syndesmosis injuries.^2,18,28 In their randomized controlled trial for routine versus on-demand removal of syndesmotic screw, Boyle et al² suggested that perhaps the fixation of the syndesmosis with a single screw is strong enough to permit ligamentous healing but weak enough to allow eventual implant fatigue followed by screw loosening or breakage to allow satisfactory return of the distal tibiofibular articular function without the need for routine removal of screw in most patients. Likewise in our study, despite potential screw breakage, the construct used has low density and does not add much bulk to the midfoot to cause scarring. The clinical significance that follows this finding is that retention of semi-rigid dorsal plating metalwork after Lisfranc joint fixation can be considered without significant negative effects to patients.

Limitations

There were several limitations in this study, such as results from a single surgeon, absence of a control group for comparison, and lack of patient-reported outcome measures. Although the results may not be relevant to other extra-articular fixation implants, all the patients had undergone a standardized surgical procedure with a single implant and followed a standard postoperative rehabilitation protocol. It was also not feasible to have a control group for comparison, as this cohort of patients had unstable ligamentous Lisfranc injury (Nunley and Vertullo type 2) in which operative intervention was indicated. The lack of patient-reported outcomes was compensated by the data on the ability to return to preinjury sporting level and the time to RTS, which are considered as the most important metrics from an elite athlete and club/team’s perspective. In addition, this cohort of patients had access to high-level resources such as dedicated physical therapists and cutting-edge rehabilitation facilities, which may confound the ability to return to preinjury sporting level, but again, this is the nature of professional elite athletes who are intrinsically motivated and constantly pushing themselves to RTS. Despite these limitations, to the best of our knowledge, this is the first study to report on the largest cohort of professional elite athletes with acute isolated ligamentous Lisfranc injuries treated with ORIF and retention of metalwork.

Conclusion

Footnotes

Final revision submitted October 12, 2024; accepted November 20, 2024.

One or more of the authors has declared the following potential conflict of interest or source of funding: C.C.H. has received remuneration from speaking in an educational program by Arthrex. J.C. has received remuneration from speaking in an educational program by Arthrex. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Ethical approval for this study was waived by the National Health Service Health Research Authority.

ORCID iD

Choon Chiet Hong

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