High rates of return to sport following suture button fixation for ligamentous Lisfranc injuries: A systematic review

Abstract

BACKGROUND

The purpose of this systematic review was to evaluate the clinical and radiological outcomes at short-term follow-up following suture button fixation for the management of ligamentous Lisfranc injuries.

AIM

To assess the effectiveness of suture button fixation in managing ligamentous Lisfranc injuries through a systematic evaluation of short-term clinical and radiological outcomes.

METHODS

During March 2024, the PubMed, EMBASE, and Cochrane library databases were systematically reviewed to identify clinical studies examining outcomes following suture button fixation for the management of ligamentous Lisfranc injuries. Data regarding patient demographics, pathological characteristics, subjective clinical outcomes, radiological outcomes, complications, and failure rates were extracted and analyzed.

RESULTS

Eight studies were included. In total, 94 patients (94 feet) underwent suture button fixation for the management of ligamentous Lisfranc injuries at a weighted mean follow-up of 27.2 ± 10.2 months. The American Orthopaedic Foot and Ankle Society score improved from a weighted mean pre-operative score of 39.2 ± 11.8 preoperatively to a post-operative score of 82.8 ± 5.4. The weighted mean visual analogue scale score improved from a weighted mean pre-operative score of 7.7 ± 0.6 preoperatively to a post-operative score of 2.0 ± 0.4. In total, 100% of patients returned to sport at a mean time of 16.8 weeks. The complication rate was 5%, the most common complication of which was residual midfoot stiffness (3.0%). No failures nor secondary surgical procedures were recorded.

CONCLUSION

This systematic review demonstrated that suture button fixation for ligamentous Lisfranc injuries produced improved clinical outcomes at short-term follow-up. In addition, there was an excellent return-to-sport rate (100%) at a weighted mean time of 16.8 weeks. This review highlights that suture button fixation is a potent surgical treatment strategy for ligamentous Lisfranc injuries; however, caution should be taken when evaluating this data in light of the lack of high quality, comparative studies, and short-term follow-up.

Key Words: Lisfranc joint; Suture button fixation; Systematic review; Tarsometatarsal joint; Midfoot; Ligamentous Lisfranc injuries

Core Tip: Suture button fixation for ligamentous Lisfranc injuries yields promising short-term clinical outcomes and facilitates a swift return to sporting activities. Despite its low complication and failure rates compared to traditional rigid fixation methods, caution is warranted due to the absence of high-quality comparative studies and limited long-term follow-up data. Further research with larger sample sizes and standardized outcome measures is necessary to validate these findings and assess the procedure's long-term efficacy.

INTRODUCTION

Lisfranc injuries encompass a spectrum of injuries involving the midfoot, ranging from isolated ligamentous sprains to complex fracture-dislocations. An injury to the Lisfranc joint is a rarely encountered pathology, constituting 0.2% of all fracture injuries[1,2]. Lisfranc fracture-dislocations are typically the product of high-energy trauma. Conversely, low-energy injuries that are commonly observed in sporting activities tend to cause partial disruption and sprains of the tarsometatarsal ligamentous joint complex[3-5]. Non-operative management is typically indicated for non-displaced isolated ligamentous Lisfranc injuries, involving immobilization in a cast or boot followed by restricted weight-bearing protocols[2].

Displaced ligamentous Lisfranc injuries have historically been treated via open reduction internal fixation (ORIF) or primary arthrodesis. A major drawback with these approaches is their tendency to impose rigid stabilization, thus limiting motion at the medial column of the foot, which is associated with increased pain and prolonged recovery periods with reduced rates of return to sports or regular activities[6]. Additionally, these rigid fixation techniques are classically associated with post-operative complications such as impaired wound healing, metal irritation, and midfoot osteoarthritis[7-9]. As a result, there has been a growing interest in the development of surgical techniques that can provide a more anatomic reduction, while circumventing the complications associated with rigid fixation. Suture button fixation has emerged as a more flexible form of fixation that may provide an alternative to previously used rigid fixation constructs[10]. This procedure utilizes interosseous sutures with endobuttons, and aims to provide a more physiological reduction, allowing some degree of motion across the midfoot, thereby restoring normal joint kinematics. This flexible fixation construct leads to appropriate tension across the Lisfranc joint, potentially decreasing post-operative stiffness and adjacent joint arthritis[10,11].

However, there is currently no consensus regarding the clinical outcomes following the use of suture button fixation for ligamentous Lisfranc injuries. Thus, the purpose of this systematic review is to examine the clinical outcomes following suture button fixation for the treatment of ligamentous Lisfranc injuries. In addition, the level and quality of evidence of the included studies was analyzed.

MATERIALS AND METHODS

Search strategy

During March 2024, a systematic review of the MEDLINE, EMBASE, and Cochrane Library databases was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The following search terms were used: (Lisfranc or tarsometatarsal) and (ligament or ligamentous). Clinical studies published in English in a peer review journal, evaluating the outcomes associated with suture button fixation following ligamentous Lisfranc injuries were included (Table 1). As multiple databases were utilized, duplicates of studies were removed. Non-clinical studies, clinical studies with less than 5 patients, and case reports were excluded (Table 1). The titles, abstracts, and full text articles of all of the searched studies were screened by two independent researchers by applying the inclusion and exclusion criteria. Any discrepancies were consulted with the senior author to reach an agreement. This study did not require any ethical or study approval and was not registered with an online database.

Table 1 Inclusion and exclusion criteria.

Inclusion criteria	Exclusion criteria
Clinical studies evaluating outcomes associated with suture button fixation following ligamentous Lisfranc injuries	Non-clinical studies
Published in a peer review journal	Case reports
Written in English	Less than 5 patients
	Cadaveric studies
	Animal studies

Assessment of level of evidence and methodological quality

The level of evidence (LOE) was assessed based on the guidelines published by The Journal of Bone and Joint Surgery[12]. Non-randomized studies were assessed for the methodological quality of clinical evidence and risk of bias using the Risk of Bias In Non-randomized Studies-of Interventions (ROBINS-I) tool[13]. The ROBINS-I tool assesses 7 domains to identify potential biases. The initial 2 domains pertain to potential confounding variables and the selection process of participants in the study. The third domain involves the classification of interventions. The remaining 4 domains evaluate biases that may arise from deviations in interventions, missing data, outcome measurement, and selection of reported results. The last domain provides an overall bias assessment of the study. Each domain's bias risk is categorized as 'low', 'moderate', 'serious', and 'critical', with an additional option for 'no information’. Two independent reviewers evaluated the ROBINS-I score for each included study. The senior author was consulted to examine the available evidence and resolve any inconsistencies in order to reach a consensus.

Data extraction and evaluation

Two separate reviewers independently extracted and assessed relevant data from each study. The relevant characteristics of each surgical procedure was collated. Patient demographics, procedure characteristics, clinical outcomes, subjective outcomes, injury etiology, pathological characteristics, return to sport, total complications, and failures were evaluated.

Statistical analysis

All statistical analysis was performed using R studio software (version 4.2.0). Descriptive statistics were calculated for all continuous and categorical variables. Continuous variables were reported as weighted average mean and estimated standard deviation. Categorical variables were reported as frequencies and percentages.

RESULTS

A total of 573 studies were generated. Of these, 8 met the inclusion and exclusion criteria (Figure 1).

Figure 1 PRISMA flow diagram.

Study characteristics and patient demographics

Study characteristics and patient demographics are listed in Table 2. Two studies were LOE III[14,15] and 6 were LOE IV[16-21]. Six studies were at moderate risk of bias and 2 studies were at severe risk of bias (Figure 2) Across the 8 studies, a total of 95 patients underwent suture button fixation for ligamentous Lisfranc injuries. The weighted mean post-operative follow-up time was 27.2 ± 10.2 months (range, 12-42). There were 53 males (63.1%) and 31 females (36.9%). Across 2 studies, there were 10 right ankles (43.5%) and 13 Left ankles (56.5%)[18,21].

Figure 2 Risk of bias in non-randomized studies-of interventions.

Table 2 Study characteristics and patient demographics.

Author	Level of evidence	Patients number	Ankles number	Follow-up (months)	Age (years)	Sex (Male/Female)	Traumatic Aetiology (sporting/non-sporting)	Time to surgery (weeks)
Charlton et al[17], 2015	4	7	7	25	24.6	1/6	7/0	5.3
Cho et al[14], 2021	3	31	31	16	40.9	18/13	15/16	Not recorded
Chun et al[18], 2021	4	12	12	13.2	31.6	7/5	Not recorded	2.8
Crates et al[19], 2015	4	11	11	33	Not recorded	Not recorded	Not recorded	Not recorded
Gee et al[15], 2019	3	6	6	12.3	29.7	5/1	Not recorded	Not recorded
Jain et al[20], 2017	4	5	5	24	22.1	5/0	5/0	Not recorded
Sullivan et al[16], 2022	4	12	12	42	21.1	9/3	12/0	5.3
Yongfei et al[21], 2021	4	11	11	20.5	35.4	8/3	3/8	0.6

Pathological characteristics

Pathological characteristics are listed in Table 2. Five studies reported the injury aetiology[15-17,20,21]. A traumatic aetiology was associated with 100% of patients in studies that reported injury aetiology, with sporting-related injuries occurring in 63.6% of patients, and non-sporting-related injuries occurring in 36.4% of patients. The nature of the ligamentous injuries were reported in 7 studies[14-19,21]. Full thickness ligamentous tears occurred in 100% of patients, with 78% reporting an acute full thickness tear and 25% reporting a chronic full thickness tear. Four studies reported the time to surgery following the initial injury[16-18,21]. The weighted mean time to surgery following the initial injury was 11.8 ± 26.6 weeks.

Clinical outcomes

Subjective clinical outcomes are listed in Table 3. Five studies reported post-operative subjective clinical outcome measurements[14,15,17,18,21]. The American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scoring tool was the most commonly utilized subjective clinical outcome scoring tool in 4 studies. The weighted mean AOFAS score was 39.2 ± 11.8 preoperatively (range, 45.1-66.2) which increased to 82.8 ± 5.4 post-operatively (range, 84.3-97). The visual analogue scale (VAS) was reported in 3 studies. The weighted mean VAS score decreased from 7.7 ± 0.6 preoperatively, to 2.0 ± 0.4 post-operatively.

Table 3 Clinical and functional outcomes.

Author	Patients number	Feet number	Patient reported outcome measurement				Number return to sport (%)	Number return to pre-injury level (100%)	Time to return to sport (weeks)	Time to return to training (weeks)
			AOFAS		VAS
			Preop	Postop	Preop	Postop
Charlton et al[17], 2015	7	7	65	97	n/r	n/r	7	7	26	13
Cho et al[14], 2021	31	31	45.1	84.3	7.9	2.3	n/r	n/r	n/r	14
Chun et al[18], 2021	12	12	66.17	93.5	n/r	n/r	12	12	n/r	n/r
Crates et al[19], 2015	11	11	n/r	n/r	n/r	n/r	11	11	21.7	15
Gee et al[15], 2019	6	6	n/r	n/r	n/r	1.6	6	6	2	25.9
Jain et al[20], 2017	5	5	n/r	n/r	n/r	n/r	5	5	20.4	16.1
Sullivan et al[16], 2022	12	12	n/r	n/r	n/r	n/r	12	12	13.8	10.8
Yongfei et al[21], 2021	11	11	n/r	92.4	7.1	1.8	11	11	n/r	n/r

AOFAS: American orthopedic foot and ankle society; VAS: Visual analogue; n/r: Not recorded.

Time to full weightbearing post-operatively was reported in 5 studies (Table 3)[15-17,19,20]. The weighted mean time to full weightbearing was 7.5 ± 3.5 weeks following the index procedure. Return to sporting activity was reported in 7 studies, with 100% of patients reporting return-to-sport at a weighted mean time of 16.8 weeks (Table 3). Of these patients, 100% returned to their preinjury level of activity.

Complications, failures, and secondary surgical procedures

In total, 5 complications (5.3%) were observed across the 8 studies (Table 4). The most common complication was bony erosions (2%). In total, there were 0 failures and 0 secondary surgical procedures.

Table 4 Complications, failures, and secondary surgical procedures.

Author	Patients number	Feet number	Complications	Failures	Secondary surgical procedures
Charlton et al[17], 2015	7	7	None	0	0
Cho et al[14], 2021	31	31	Bony erosions = 2	0	0
Chun et al[18], 2021	12	12	None	0	0
Crates et al[19], 2015	11	11	Not recorded	Not recorded	Not recorded
Gee et al[15], 2019	6	6	None	0	0
Jain et al[20], 2017	5	5	Transient deep peroneal nerve sensation = 1	0	0
Sullivan et al[16], 2022	12	12	Mid irritation from medial button = 1, Paraesthesia on dorsum of foot = 1	0	0
Yongfei et al[21], 2021	11	11	None	0	0

DISCUSSION

The most important finding of this systematic review was that suture button fixation for the treatment of ligamentous Lisfranc injuries produced improved clinical outcomes at short-term follow-up. In addition, there was an excellent return-to-sport rate (100%) at a weighted mean time of 16.8 weeks following the index procedure. This review highlights that suture button fixation is a potent surgical treatment strategy for ligamentous Lisfranc injuries; however, caution should be taken when evaluating this data in light of the lack of high quality, comparative studies, and short-term follow-up.

Ligamentous Lisfranc injuries pose significant diagnostic challenges due to its vague clinical presentation and poor sensitivity on radiographic imaging[22]. With almost 20% of injuries misdiagnosed or underestimated on initial clinical or radiographic examination, patients often experience adverse clinical outcomes due to delayed treatment, with associated chronic pain, deformity, and disability[23-27]. Historically, surgical intervention for ligamentous Lisfranc injuries primarily included arthrodesis or ORIF. Although these surgical procedures may provide a stable Lisfranc joint, these rigid fixation methods may reduce medial foot column motion causing heightened pain and extended recovery periods. Additionally, these procedures are associated with significant morbidity associated with wound complications, symptomatic hardware, and subsequent hardware removal[6-9]. Suture button fixation offers an alternative to rigid fixation. By providing a more flexible, anatomic reduction, this procedure facilitates adequate motion across the midfoot, potentially decreasing post-operative midfoot stiffness and adjacent joint arthritis[10,11]. This systematic review found improvements in subjective clinical outcomes following suture button fixation for ligamentous Lisfranc injuries, regardless of the patient reported outcome measurement (PROM) utilized. However, none of the PROMs utilized across the included studies have been validated for ligamentous Lisfranc injuries to date. Thus, these early promising results must be interpreted with caution.

A major limitation associated with rigid fixation for Lisfranc injuries is its deleterious impact on the athletic population. A meta-analysis by Bolk et al[28] evaluated the impact of rigid fixation techniques such as ORIF and arthrodesis on participation in sporting activities following Lisfranc injuries in a cohort of 615 patients. The authors reported a mean return-to-sport rate of 94% following rigid fixation. However, only 86% of the ORIF cohort and 74% of the arthrodesis cohort returned to their preinjury level[28]. Conversely, this current systematic review found that 100% of patients returned to sporting activity following suture button fixation for ligamentous Lisfranc injuries. In addition, 100% of these patients were able to return to their preinjury level, indicating that suture button fixation for ligamentous Lisfranc injuries can be beneficial for athletes. Furthermore, this current systematic review also demonstrated superior time to return-to-sport following suture button fixation in comparison to rigid fixation. Deol et al[29] assessed return-to-sport data following screw fixation for Lisfranc injuries in an athletic population of 17 patients. The authors recorded that the mean time to return-to-sport was 25.3 weeks (range, 21-31 weeks). However, this current systematic review found significantly faster return to sporting activity, with a weighed mean time to return-to-play of 16.8 weeks.

This current systematic review demonstrated that suture button fixation for ligamentous Lisfranc injuries produced a low complication rate of 5.3%, underpinning the inherent safety and low morbidity of this procedure. This contrasts with the high complication rates associated with ORIF and arthrodesis, with complication rates of 23.1% and 30.2% reported in the literature, respectively[30]. Frequently encountered complications associated with these rigid fixation techniques include impaired wound healing, painful hardware, and midfoot osteoarthritis[7,8,31-33]. This current systematic review found a 0% secondary surgical procedure rate following suture button fixation for the treatment of ligamentous Lisfranc injuries. In contrast, secondary surgical procedures are frequently performed following ORIF or midfoot arthrodesis for ligamentous Lisfranc injuries, the most common of which is removal of hardware. Barnds et al[30] found a removal of hardware rate of 43.6% of patients who underwent ORIF and 18.4% of patients who underwent arthrodesis. By preventing motion at the medial column of the foot, these techniques often result in midfoot pain and/or screw breakage during strenuous physical activity[6]. In addition, this systematic review demonstrated a 0% failure rate following suture button fixation, which may be attributed to the reduced soft tissue injury and more physiological reduction associated with this technique, facilitating adequate micromotion across the joint[34]. However, the weighted mean follow-up time for this study was 27.2 ± 10.2 months. Thus, the long-term survivorship of this fixation construct is yet to be determined.

Several limitations exist with regards to this review. Firstly, this study is limited by the lack of high quality LOE I or II studies. Secondly, there is marked heterogeneity and under-reporting of data across numerous domains: Only 4 studies reported the time to surgery or the time to full weightbearing, and only 4 studies included at least 1 extractable pre- and post-operative AOFAS or VAS score. Additionally, the lack of radiological characterization both pre- and post-operatively limit our ability to accurately comment on joint healing and maintenance of reduction. Lastly, the sample size of patients was relatively small, with the average cohort for each study being less than 12 patients.

CONCLUSION

This systematic review demonstrated that suture button fixation for ligamentous Lisfranc injuries produced improved clinical outcomes at short-term follow-up. In addition, there was an excellent return-to-sport rate (100%) at a weighted mean time of 16.8 weeks. This review highlights that suture button fixation is a potent surgical treatment strategy for ligamentous Lisfranc injuries; however, caution should be taken when evaluating this data in light of the lack of high quality, comparative studies, and short-term follow-up.