Outcomes of Flexible Fixation Devices in Purely Ligamentous Lisfranc Injuries: A Systematic Review

Author(s): Praveen Rajan, Srinath Pammi, Himaja Narapareddy, Jithuram Jayaram, Bhargava Krishna Balineni, Meenakshi Bheemavarapu

Background: Purely ligamentous Lisfranc injuries represent a challenging subset of tarsometatarsal trauma and are frequently underdiagnosed. While rigid fixation has traditionally been used, it is associated with implantrelated complications and often requires secondary surgery. Flexible fixation devices have emerged as an alternative aimed at restoring stability while preserving physiological joint motion. This systematic review evaluates the outcomes of flexible fixation devices in the management of purely ligamentous Lisfranc injuries.

Methods: A systematic review was conducted in accordance with the PRISMA guidelines. Electronic databases including PubMed/MEDLINE, Embase, Emcare, Prospero, CINAHL, ICTRP, clinicaltrails.gov, TRIP, Base Bielefeld Academic Search Engine and the Cochrane Library were searched from inception to the October 2025. Studies reporting clinical, functional, and/or radiological outcomes following flexible fixation for purely ligamentous Lisfranc injuries were included. Data extraction and analysis were performed independently by two reviewers and when not in consensus with discussion, third independent reviewer was involved.

Results: Eleven studies encompassing a total of 301 patients were included. All the studies were retrospective studies, with follow-up ranging from 12 weeks to 10 years. Flexible fixation techniques included suture button constructs and internal brace systems, with or without adjunctive fixation. Across studies, postoperative pain improved significantly, with Visual Analogue Scale (VAS) scores decreasing from preoperative values of approximately 5.3–8.4 to 0.6–1.3. Functional outcomes demonstrated marked improvement, measured mainly with postoperative American Orthopaedic Foot & Ankle Society midfoot scores (AOFAS) consistently ranging from 84 to 96. Radiological outcomes showed significant improvement and maintenance of reduction in most studies. Complications were infrequent and generally minor, including transient sensory disturbances, button-site discomfort, and isolated cases of radiographic arthritis. Routine implant removal was rarely required.

Conclusion: Flexible fixation devices for purely ligamentous Lisfranc injuries are associated with excellent pain relief, significant functional improvement, reliable radiological outcomes, and low complication rates. These findings support flexible fixation as a safe and effective alternative to rigid fixation in appropriately selected patients in purely ligamentous Lisfranc injuries, although higher-quality comparative studies with long-term follow-up are needed.