Foot & Ankle International - July 2018 - 805

Mora et al
of fixation even in the setting of comminution. The rationale is that restoring alignment with ORIF facilitates any
future arthrodesis should it progress to posttraumatic arthritis. In addition, arthrodesis in the setting of significant comminution is challenging given the number of intra-articular
and extra-articular fragments and significant malalignment
that is typically associated with these higher energy injuries. Only a small handful of high-energy Lisfranc injuries
in our institution had primary arthrodesis due to severe
comminution.
There are only a limited number of studies looking at the
ability to return to sport and activity in patients with Lisfranc
injuries treated with ORIF. One study looked at elite professional soccer and rugby players who sustained Lisfranc
injuries during training or competitive matches and assessed
the time to return to sports after operative treatment.7
Seventeen players were included in the study, with 15 of
them treated with ORIF with Lisfranc screw, with or without TMT screws or plates. All but 1 of these 15 elite players
(93%) were able to return to training in 20.1 weeks and able
to compete in 25.3 weeks, although the presence of symptoms was not reported. Another study evaluated 28
American National Football League players with Lisfranc
injuries and the time for the players to return to sport.18
Twenty-six (93%) players returned to competition at a
median of 11 months after injury. There was a trend toward
a decrease in performance after the injury, but it did not
reach statistical significance. Only 22 of the 28 players
received operative intervention; however, the authors did
not specify the type of operative treatment given. Recently,
a retrospective study looked at using percutaneous reduction and screw fixation of low-energy Lisfranc injuries and
its functional outcome.25 Thirty-one patients were followed
up for a minimum of 3 years. They reported an average
91.4% subjective recovery compared with their preinjury
functional level, with the mean Foot and Ankle Ability
Measure (FAAM) activities of daily living (ADL) subscale
of 94.2 and sports subscale score of 90.4.
Arthrodesis is also a widely accepted method of treatment for displaced Lisfranc injuries. In a prospective, randomized study, 20 patients with ligamentous Lisfranc joint
injuries treated with ORIF were compared with 21 patients
with similar injuries treated with primary arthrodesis of the
medial 2 or 3 rays.16 At 2-year follow-up, the arthrodesis
group had higher American Orthopaedic Foot & Ankle
Society midfoot score (88 vs 68.6) and higher estimated
postoperative level of activities when compared with preinjury level (92% vs 65%). However, the specific ability of
patients to return to physical activity and sports was not
reported by the authors. In another retrospective study of 32
young, active military personnel who sustained low-energy
Lisfranc injuries, 18 patients treated with ORIF (screw,
plates, or combination) were compared with 14 patients
treated with primary arthrodesis over a mean follow-up

805
time of 32 months.3 There was no difference in return to
duty rates, visual analog scale pain score at final follow-up,
and days to fitness testing. The primary arthrodesis group
returned to full duty on average 2 months sooner. The
authors suggested that the planned removal of implants in
83% of cases in the ORIF group could be the confounding
factor. The FAAM ADL and Sports subscale scores were no
different between the groups.
Lastly, MacMahon et al17 investigated the ability of
young patients to return to sports and physical activities
after primary partial arthrodesis for Lisfranc injuries. They
found that patients were able to return to most of their previous sports and physical activities, including high-impact
ones. However, 34% of the patients experienced increased
difficulty and 26% experienced impaired participation levels in their physical activities.17 Their results were comparable to ours.
In our study, most of our patients (94%) were able to
return to some level of physical activity or sport. Thirtythree percent (11/33) of our patients experienced difficulty
and hence participated less frequently. We investigated this
further by looking at the frequency, intensity, as well as the
residual symptoms while exercising. Sixty-seven percent
(22/33) of patients were able to participate at the same level
or more frequently at sports. Of these 22 patients, 13 were
asymptomatic while exercising, whereas the remaining 9
complained of pain and/or weakness. Thirty-three percent
(11/33) patients participated less frequently at sports.
However, 1 patient could still perform at the same level of
intensity, whereas the other 10 patients performed at a lower
intensity. Five patients were asymptomatic while exercising
but participated less frequently due to lifestyle reasons,
whereas the remaining 6 complained of mainly pain as their
limiting factor. The types of sports that participants returned
to were also evaluated. Most patients were able to return to
sports, but a decrease in participation in high-impact sports,
such as running, soccer, rugby, surfing, and basketball (drop
from 36 down to 24), was noted. There was a similar participation in low-impact sports such as walking, yoga, bike,
swimming, and weights (24 to 22; Table 1).
Regarding the FAOS scores, the mean Sports and
Recreational Activities subscore of 85.9 is comparable with
the score of 85.8 published by the arthrodesis cohort of
MacMahon et al.17 All other subscores, including pain,
symptoms, ADLs, and quality of life, are comparable as
well, suggesting that ORIF is a valid alternative to
arthrodesis.
The strengths of this study include the young patient
cohort, reflecting a physically active group that no doubt
places significant demands on their foot postinjury, combined with good follow-up. There are, however, several
limitations to our study. A small sample size of 33 met the
inclusion criteria and consented to the study. Although no
patients have required conversion to arthrodesis at the



Table of Contents for the Digital Edition of Foot & Ankle International - July 2018

Contents
Foot & Ankle International - July 2018 - Intro
Foot & Ankle International - July 2018 - Cover1
Foot & Ankle International - July 2018 - Cover2
Foot & Ankle International - July 2018 - i
Foot & Ankle International - July 2018 - ii
Foot & Ankle International - July 2018 - Contents
Foot & Ankle International - July 2018 - iv
Foot & Ankle International - July 2018 - v
Foot & Ankle International - July 2018 - vi
Foot & Ankle International - July 2018 - vii
Foot & Ankle International - July 2018 - viii
Foot & Ankle International - July 2018 - 1A
Foot & Ankle International - July 2018 - 1B
Foot & Ankle International - July 2018 - ix
Foot & Ankle International - July 2018 - x
Foot & Ankle International - July 2018 - xi
Foot & Ankle International - July 2018 - xii
Foot & Ankle International - July 2018 - 2A
Foot & Ankle International - July 2018 - 2B
Foot & Ankle International - July 2018 - xiii
Foot & Ankle International - July 2018 - xiv
Foot & Ankle International - July 2018 - xv
Foot & Ankle International - July 2018 - xvi
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Foot & Ankle International - July 2018 - 3A
Foot & Ankle International - July 2018 - 3B
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Foot & Ankle International - July 2018 - Cover3
Foot & Ankle International - July 2018 - Cover4
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