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Staged management of high-energy Lisfranc injuries with temporary fixation: A systematic review of post-operative outcomes
*Corresponding author: Philip P. Ratnasamy, Department of Orthopedics and Rehabilitation, Yale School of Medicine, New Haven, United States. philip.ratnasamy@yale.edu
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Received: ,
Accepted: ,
How to cite this article: Ratnasamy PP, Cox HM, Salameh MH. Staged management of high-energy Lisfranc injuries with temporary fixation: A systematic review of post-operative outcomes. J Musculoskelet Surg Res. 2026;10:3-13. doi: 10.25259/JMSR_279_2025
Abstract
We assessed the impact of temporary stabilization on outcomes in the management of high-energy Lisfranc injuries through a systematic review. Studies were included if they reported post-operative complications or patient-reported outcomes following external fixation or percutaneous pinning before delayed definitive fixation. The search yielded 227 records through databases and 12 through manual identification. After screening, 19 studies underwent full-text review, with six included in the final analysis. Data from six eligible studies comprising 147 patients were extracted and analyzed using descriptive synthesis and limited random-effects meta-analysis for pooled complication rates. This review protocol was registered with The International Prospective Register of Systematic Reviews (PROSPERO) (CRD42025631978). Of the 147 patients, 122 underwent temporary stabilization while 25 did not. Most patients were males (66.7%) with a mean age of 43.4 years. Acute post-operative complications occurred in 11.6% of patients, all within the temporized cohort. Post-traumatic arthritis (PTOA) was more frequently reported in temporized patients (13.9%) than in those without temporization (8%), although follow-up duration varied substantially across studies. Pooled mean patient-reported outcomes showed a mean post-operative Visual Analog Scale (VAS) of 2.44 and an American Orthopaedic Foot and Ankle Society (AOFAS) midfoot score of 77.56. Patients receiving temporary stabilization showed numerically lower post-operative pain and higher functional scores (VAS 2.16; AOFAS 79.67) compared with patients without temporization (VAS 3.20; AOFAS 71.71). Temporary stabilization before definitive fixation was associated with higher acute complication rates but comparable or modestly improved functional outcomes. These findings should be interpreted cautiously, given heterogeneity in follow-up, outcome definitions, and confounding by injury severity.
Keywords
Dislocation
External fixation
Fracture
Lisfranc
Percutaneous pinning
INTRODUCTION
Lisfranc injuries involve disruption of the midfoot, typically centered on the second tarsometatarsal joint, and may be exclusively ligamentous or involve both ligamentous and osseous structures.[1] Injuries at the Lisfranc joint are rare, making up only 0.2% of all fractures; however, they are frequently missed, leading to long-term pain and functional impairment for patients who do not receive appropriate management.[2] These injuries are most commonly closed and often occur in athletes due to low-energy trauma.[3,4] However, high-energy trauma, such as motor vehicle accidents, extreme sports, or crush injuries, can also result in Lisfranc injuries and are often associated with significant soft tissue injury.[5]
Management of high-energy Lisfranc injuries requires delayed definitive fixation, such as open reduction and internal fixation (ORIF) or arthrodesis, to allow for soft tissue recovery. During this delay period, stabilization is historically achieved through splinting and conservative measures, including rest, ice, compression, and elevation (RICE); however, recent practice has expanded to include percutaneous pinning or the application of external fixation at the initial presentation of injury.[5,6]
Importantly, the orthopedic literature exploring the treatment of Lisfranc injuries is sparse, particularly regarding outcomes of staged management of these injuries. A critical clinical question arises regarding the impact of these interim management strategies on post-operative complication rates. Specifically, it is unclear whether patients with high-energy Lisfranc injuries who undergo delayed ORIF experience differing complication rates and long-term outcomes based on whether they received percutaneous pinning, external fixation, or conservative measures during the delay period. The present systematic review aimed to address this gap in the literature by aggregating existing data regarding staged management of high-energy Lisfranc injuries using percutaneous pinning or external fixation.
MATERIALS AND METHODS
This systematic review and limited meta-analysis were conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, provided in the supplemental materials.[7]
Study selection
Studies were eligible if they evaluated staged surgical treatment for high-energy Lisfranc fracture-dislocations and reported at least one of the following outcomes: (1) Acute post-operative complication rates, (2) long-term complications, and (3) patient-reported outcome measures (PROMs). High-energy Lisfranc injuries were defined as those resulting from high-velocity trauma (motor vehicle collision, crush injury, or fall >2 meters) or presenting with open fracture-dislocation patterns. Exclusion criteria included non-English full texts, studies lacking outcomes of interest, and studies involving immediate definitive fixation.
Search strategy
A comprehensive literature search was conducted across MEDLINE (PubMed), Embase, Web of Science, and the Cochrane Library, from database inception to November 2024. Search terms and Boolean combinations included Lisfranc, tarsometatarsal, fracture-dislocation, staged fixation, external fixation, percutaneous pinning, and complications. The search strategy was developed in consultation with a medical librarian at the Yale Medical Library to ensure appropriate use of controlled vocabulary and comprehensive database coverage. Reference lists of review articles were also manually screened to identify additional eligible articles. All retrieved records were imported into the Rayyan systematic review platform for deduplication and screening.[8] Two investigators independently reviewed all titles, abstracts, and full texts. Any disagreements were resolved unblinded within the review team and with input from the senior author. A total of 227 database records and 12 manually identified records were screened. Nineteen studies underwent a full-text review, and six studies met the inclusion criteria [Figure 1].
- Study selection process executed through preferred reporting items for systematic reviews and meta-analyses guidelines.
Data collection and availability
Two authors independently collected data into a standardized form and reconciled differences after unblinding. The data extracted included study characteristics (title, author, year, study design, level of evidence, purpose), patient demographics, injury features (open vs. closed), staging method, time to definitive fixation, follow-up duration, complications, and PROMS (American Orthopaedic Foot and Ankle Society [AOFAS], Visual Analog Scale [VAS]). Where outcomes were not stratified by injury type, subgroups were extracted accordingly. If an outcome was not explicitly reported, it was recorded as “none reported” rather than assumed to be zero. All extracted data are available upon request.[9]
Data synthesis and analysis
Statistical analysis was performed by two independent statistical methodologists (OJ and JC), who conducted all quantitative pooling and verified analytic decisions. There was significant clinical and methodological heterogeneity among studies. A limited random-effects meta-analysis was performed for pooled proportions of major complications (e.g., superficial and deep infection, thromboembolic events, post-traumatic osteoarthritis, total complications) and pooled means of patient-reported outcomes (VAS and AOFAS scores). For all studies, where standard deviations were not reported, they were imputed with available summary statistics (e.g., standard error, confidence intervals, interquartile ranges, or medians and ranges) in accordance with Cochrane-recommended formulas. This imputation was applied uniformly across all included studies to permit quantitative synthesis.
Random-effects models were calculated using the DerSimonian-Laird method with 95% confidence intervals, implemented through the statsmodels Python package. Between-study heterogeneity was quantified using the I2 statistic. Outcomes reported in fewer than three studies were summarized descriptively. No generative AI tools were used in any stage of the statistical analysis.
Risk of bias assessment
The risk of bias was assessed independently by two reviewers using the Risk of Bias in Non-Randomized Studies – of interventions (ROBINS-I) tool, which evaluates seven domains: Confounding, participant selection, intervention classification, deviations from intended interventions, missing data, measurement of outcomes, and selection of reported results. Disagreements were resolved through open discussion and a consensus-based approach. Each study was assigned an overall risk-of-bias rating (low, moderate, serious, or critical) in accordance with ROBINS-I criteria. Common confounders such as open injury, polytrauma, diabetes, and smoking were documented where available.
Certainty assessment
Formal assessment of certainty using GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) was not performed due to substantial heterogeneity and the predominance of retrospective observational designs.
Registration and protocol
This review was prospectively registered with the PROSPERO database (CRD42025631978). The full review protocol is available in the supplementary materials. No amendments were made to the information provided at registration or in the protocol.
RESULTS
Study selection
A total of six non-randomized cohort studies met the inclusion criteria and were included in the final qualitative synthesis.[10-15] These studies spanned both open and closed high-energy Lisfranc injuries and employed various staged treatment protocols. Across the six included studies, two included only closed injuries, two included only open injuries, and two did not stratify their results [Table 1]. All studies used a two-stage approach using either temporary external fixation or percutaneous pinning before definitive fixation. Due to substantial heterogeneity in surgical techniques, fixation methods, and outcome reporting, a meta-analysis was not performed [Table 1].
| Study | Country | Design | Level of evidence | N | Inclusion criteria | Treatment |
|---|---|---|---|---|---|---|
| Arvesen et al., 2019[10] | USA | Retrospective cohort | 4 | 27 | Open and closed high-energy Lisfranc fracture dislocations | External fixator followed by definitive fixation |
| Herscovici Jr. and Scaduto, 2018[11] | USA | Retrospective cohort | 4 | 15 | Open and closed high-energy Lisfranc fracture dislocations | K-wire followed by definitive fixation |
| Kadow et al., 2014[12] | USA | Retrospective cohort | 3 | 18 | Closed high-energy Lisfranc fracture dislocations | External fixator followed by definitive fixation |
| He et al., 2022[15] | China | Prospective cohort | 2 | 48 | Closed high-energy Lisfranc fracture dislocations | 23 K-wire followed by definitive fixation 25 definitive fixation without temporary stabilization |
| Gu and Shi, 2017[13] | China | Retrospective cohort | 3 | 18 | Open high-energy Lisfranc fracture dislocations | 14 K-wire followed by definitive fixation 4 K-wire and external fixator, followed by definitive fixation |
| Liu et al., 2020[14] | China | Retrospective cohort | 3 | 21 | Open high-energy Lisfranc fracture dislocations | External fixation followed by definitive fixation |
Quality assessment
ROBINS-I assessments are summarized per study in Figure 2 and as domain-level proportions in Figure 3 [Table 2]. Most studies were judged to have a moderate overall risk of bias, driven primarily by residual confounding (limited adjustment for injury severity/comorbidities and likely confounding by indication). The selection and classification of interventions were generally low risk, and deviations from the intended interventions were uncommon. Missing data and measurement of outcomes were typically of moderate risk due to variable follow-up and lack of blinded assessors. Two single-arm cohorts were rated serious for confounding, whereas comparative designs (e.g., staged vs. single-stage or ORIF vs. arthrodesis) remained moderate without multivariable adjustment. Overall, these patterns suggest that confounding and outcome measurement limitations are the primary threats to validity in the current evidence base [Figures 2 and 3].
- Risk of bias analysis stratified by each included study and domains.
- Risk of bias analysis of included studies, showing the percentage of studies at each risk level per domain.
| Author (Year) | Confounding | Selection of participants | Classification of interventions | Deviations from intended interventions | Missing data | Measurement of outcomes | Selection of the reported result | Overall | Notes |
|---|---|---|---|---|---|---|---|---|---|
| Herscovici Jr. and Scaduto (2018)[11] | Moderate | Low | Low | Low | Moderate | Moderate | Moderate | Moderate | No adjustment for confounders; variability in follow-up length |
| Kadow et al. (2014)[12] | Moderate | Low | Low | Low | Moderate | Moderate | Moderate | Moderate | No adjustment for comorbid confounders; minimal selection bias and objective radiographic outcomes |
| Gu and Shi (2017)[13] | Serious | Low | Low | Low | Moderate | Moderate | Moderate | Serious | No adjustment for comorbid confounders; 22% loss to follow-up but long follow-up for those included |
| Liu et al. (2020)[14] | Serious | Low | Low | Low | Moderate | Moderate | Moderate | Moderate | No adjustment for comorbid confounders |
| He et al. (2022)[15] | Moderate | Low | Low | Low | Moderate | Moderate | Low | Moderate | No adjustment for comorbid confounders; variation in follow-up duration |
| Arvesen et al. (2019)[10] | Moderate | Low | Low | Low | Moderate | Moderate | Low | Moderate | No adjustment for comorbid confounders; variation in follow-up duration |
Patient characteristics
Table 3 presents patient demographics and surgical timing, as well as follow-up information, across the included studies. Six studies comprising 147 patients with high-energy Lisfranc injuries were included. Most patients (66.7%) were males. The pooled mean age across all staged Lisfranc injury cohorts was 42.4 years (95% CI, 38.1–46.7) with substantial heterogeneity between studies (I2 = 73.3%, P = 0.002). Individual study mean ages ranged from 37 to 49.5 years. Among these, 43 patients (29.3%) presented with open injuries, while 104 patients (70.7%) had closed injuries. The pooled mean follow-up duration was 20.3 months (95% CI, 11.6–29.1), although follow-up periods varied markedly across studies (I2 = 99.3%, P < 0.001). Individual cohorts reported follow-up ranging from approximately 6 to 51 months, reflecting substantial heterogeneity in long-term assessment and limiting direct comparison of long-term complications such as PTOA. The pooled mean time from injury to definitive fixation was 15.98 days (95% CI, 10.3–21.7), although substantial heterogeneity was observed (I2 = 92.5%, P < 0.001).
| Patient demographics | n(%) |
|---|---|
| Total patients | 147 |
| Open injuries | 43 (29.3%) |
| Closed injuries | 104 (70.7%) |
| Male | 98 (66.7%) |
| Female | 49 (33.3%) |
| Pooled mean age (I2=73.3%, P=0.002) | 42.4 years (95% CI, 38.1–46.7) |
| Individual study mean age range | 37–49.5 years |
| Surgical timing and follow-up | |
| Pooled mean time to definitive fixation (I2=92.5%, Q=26.697, P<0.001) | 15.98 days (95% CI 10.25–21.70) |
| Time to fixation range across studies | 2–144 days |
| Pooled mean follow-up duration (I2=99.3%, Q=613.886, P<0.001) | 20.33 months (95% CI, 11.61–29.06) |
| Follow-up range across studies | 2.1–60 months |
| Surgical treatment characteristics | |
| Fixation type/pre-op intervention | n(%) |
| Open reduction internal fixation | 113 (76.9) |
| Arthrodesis | 19 (13.0) |
| Unknown fixation | 15 (10.2) |
| External fixator before surgery | 66 (44.9) |
| Pinning before surgery | 52 (35.4) |
| External fixator and pinning before surgery | 4 (2.7) |
| No temporary stabilization | 25 (17.0) |
CI: Confidence interval, I2: I-squared test (Index of heterogeneity), Q: Cochran’s Q statistic
Treatment and recovery characteristics
Table 3 shows surgical treatment characteristics across the included studies. Of 147 patients, 122 underwent interval pinning/ex-fix during staged treatment of Lisfranc injury, while 25 did not. Timing varied widely between studies, reflecting differences in soft-tissue condition and institutional protocols for staged management. Most patients underwent ORIF (76.9%), while a smaller subset (13.0%) received primary arthrodesis treatment. Temporary stabilization strategies included an external fixator only in 44.9% of patients, percutaneous pinning only in 35.4%, and a combination of external fixator and percutaneous pinning in 2.7%.
Patient-reported outcomes (PROMS)
Table 4 shows patient-reported outcomes and time to weight-bearing following surgery. Time to full weight bearing averaged 3.6 months (95% CI, 2.8–4.4) (I2 = 82.6%, P = 0.003), again demonstrating variation in post-operative rehabilitation pathways. Post-operative pain and function were reported using the VAS and the AOFAS midfoot score in the studies by He et al., Gu and Shi, and Liu et al.[13-15] Across three studies, the pooled mean VAS pain score at final follow-up was 2.5 (95% CI, 2.2–2.8), with no detectable heterogeneity (I2 = 0.0%, P = 0.658), indicating generally low residual pain. The pooled AOFAS midfoot score was 76.9 (95% CI, 74.2–79.7) with moderate heterogeneity (I2 = 49.1%, P = 0.14). While these suggest satisfactory function, interpretation is limited by the AOFAS scale’s ceiling effect, inclusion of clinician-assessed components, and lack of MCID thresholds across studies.[9,16]
| Factor | Pooled mean (95% CI) | I2 across studies (%) | P-value across studies |
|---|---|---|---|
| Time to full weight-bearing | 3.6 months (2.8–4.4) | 82.60 | 0.0030 |
| VAS pain score at final follow-up | 2.5 (2.2–2.8) | 0.00 | 0.6580 |
| AOFAS midfoot score at final follow-up | 76.9 (74.2–79.7) | 49.10 | 0.1400 |
CI: Confidence interval, P<0.05: Significant, VAS: Visual analog scale, AOFAS: American Orthopaedic Foot and Ankle Society score, I2: I-squared test (Index of heterogeneity).
Acute complications
Acute outcomes were reported inconsistently across included studies and are shown in Table 5. Acute complications generally reflected perioperative events, while long-term complications (e.g., PTOA depended on variable follow-up durations, ranging from 2.1 to 60 months [Table 3]. The pooled overall complication rate was 13.1% (95% CI, 4.4–25.5), with substantial heterogeneity (I2 = 73.1%, P = 0.002), largely concentrated within staged fixation.
| Complication | n=147 |
|---|---|
| Total complications (Q=18.607, I2=73.1, P=0.002) | 17 (13.08%, 95% CI 4.39–25.48%) |
| Acute | |
| VTE (DVT/PE) | 6 |
| Superficial infection | 5 |
| Deep infection | 2 |
| Wound dehiscence | 1 |
| Bleeding requiring transfusion | NR |
| Mortality | NR |
| Long-term | |
| Post-traumatic arthritis | 21 |
| Need for orthotic device | 9 |
| Non-union | 3 |
| Mortality | NR |
VTE: Venous thromboembolism, DVT: Deep vein thrombosis, PE: Pulmonary embolism. NR: None reported, CI: Confidence interval. Due to inconsistent follow-up duration and reporting across studies, apparent zero values should not be interpreted as a true absence of complications. Acute and long-term categorization based on reporting in individual studies, I2: I-squared test (Index of heterogeneity), Q: Cochran’s Q statistic
Superficial infection occurred in 4.6% (95% CI, 1.3–9.9) (I2 = 20.7%, P = 0.283). Deep infection was less frequent at 2.5% (95% CI, 2.1–11.7) (I2 = 33.9%, P = 0.182). Several studies reported no infections; however, the lack of standardized definitions or routine microbiologic assessment may have led to underreporting rather than a true absence of events.
The pooled incidence of thromboembolic events (DVT/PE) was 5.0% (95% CI, 1.4–10.7), with modest heterogeneity (I2 = 42.1%, P = 0.125). No study employed routine screening, so rates likely reflect symptomatic events only.
Long-term structural and functional outcomes
Long-term outcomes were similarly inconsistently reported across studies and are shown in Table 5. PTOA was reported in only three studies, yielding a pooled rate of 21.4% (95% CI, 2.0–53.4), with extreme heterogeneity (I2 = 91.1%, P < 0.001). Rates ranged from 4% to 62%, corresponding directly to follow-up duration (short-term vs. >4 years). These findings are hypothesis-generating and cannot be interpreted as causal.
The pooled rate of orthotic device prescription was 10.4% (95% CI, 0.01–36.2) (I2 = 83.9%, P = 0.002), although only one study systematically reported this endpoint. Other cohorts listed “0%,” likely reflecting non-reporting rather than true absence. The pooled nonunion rate was 3.2% (95% CI, 1.0–6.6%) (I2 = 0.0%, P = 0.424).
Outcomes stratified by interval stabilization
Outcomes stratified by fixation type are shown in Table 6. All 17 complications occurred in the 122 patients who received staged temporizing treatment with pinning or external fixation, corresponding to a complication rate of 13.9%. In comparison, none of the 25 patients who underwent delayed fixation without pre-operative stabilization experienced post-operative complications. In terms of long-term complications, 19 (13.9%) patients who underwent interval pinning/ex-fix developed posttraumatic arthritis (PTOA), compared to 2 (8%) patients among those who did not.
| Measure | All patients | Pin/ex-fix | No pin/ex-fix |
|---|---|---|---|
| N | 147 | 122 | 25 |
| Complications | 17 | 17 | NR |
| PTOA | 21 | 19 | 2 |
| Post-op VAS (SD) (range) | 2.44 (1.34) (0–6) | 2.16 (1.32) (0–6) | 3.20 (1.17) (0.9–5.5) |
| Post-op AOFAS (SD) (range) | 77.56 (7.28) (56–97) | 79.67 (9.17) (56–97) | 71.72 (5.46) (60.8–82.6) |
PTOA: Post-traumatic arthritis, VAS: Visual analog scale, AOFAS: American Orthopaedic Foot and Ankle Society, NR: None reported, N: Number, SD: Standard deviation
The study by He et al. uniquely included a head-to-head comparison of two groups: A staged approach with initial pinning (n = 23) and a single-stage approach with delayed ORIF performed once soft tissue swelling had subsided (n = 25).[15] At 1 year postoperatively, patients in the staged with pinning group demonstrated superior outcomes, with a mean AOFAS midfoot score of 86.87 (SD 4.24) and a mean VAS score of 1.91 (SD 0.78). Notably, there were no cases of joint re-dislocation, secondary surgery, or PTOA in this group. In contrast, the group that underwent delayed ORIF without initial pinning had a lower mean AOFAS score of 71.72 (SD 5.46) and a higher VAS score of 3.20 (SD 1.17), with two patients developing PTOA. This aggregate summary is hypothesis-generating and should be interpreted with caution, given the small sample size, heterogeneity across studies, and incomplete study-level correction for confounding.
Complications stratified by open versus closed wounds
Complications were additionally stratified by injury type (open vs. closed) when data were available and shown in Table 7. Four studies reported outcomes exclusively for either open or closed injuries, of which two studies included mixed cohorts without stratified reporting and were therefore excluded from this result. Among the 39 patients with open injuries, the acute complication rate was higher (17.9%) compared to closed injuries (3.0%). Notably, PTOA was only reported in open injuries (48.7%), while superficial infection and hardware removal were rare events in both groups. These findings are hypothesis-generating and should be interpreted with caution, given the small sample size, heterogeneity across studies, and incomplete stratification of outcomes.
| Complication | Open (n=39) | Closed (n=66) |
|---|---|---|
| Total complications (acute) | 7 | 2 |
| Acute | ||
| VTE (DVT/PE) | 3 | NR |
| Superficial infection | 2 | 1 |
| Deep infection | 1 | NR |
| Wound dehiscence | NR | NR |
| Bleeding requiring transfusion | NR | NR |
| Mortality | NR | NR |
| Skin tenting | NR | 1 (1.5%) |
| Skin necrosis | 1 | NR |
| Long-term | ||
| Post-traumatic arthritis | 19 | NR |
| Need for orthotic device | NR | NR |
| Non-union | NR | NR |
| Need for hardware removal | NR | 1 |
| Mortality | NR | NR |
VTE: Venous thromboembolism, DVT: Deep vein thrombosis, PE: Pulmonary embolism, NR: None reported. Due to inconsistent follow-up duration and reporting across studies, apparent zero values should not be interpreted as a true absence of complications. Acute and long-term categorization based on reporting in individual studies. These findings are descriptive and hypothesis-generating only
DISCUSSION
High-energy Lisfranc injuries represent a complex subset of midfoot trauma, frequently associated with polytrauma, extensive soft tissue compromise, and delayed feasibility of definitive fixation.[2] In such settings, temporary stabilization through percutaneous pinning or external fixation is commonly used to maintain alignment while soft tissues recover.[2] However, despite its widespread use, literature evaluating outcomes of temporary stabilization before definitive fixation remains limited and heterogeneous, with the largest published series including only 76 patients.[17] Few studies directly compare temporarily stabilized versus non-stabilized high-energy Lisfranc injuries, and no high-quality comparative studies currently exist.
This systematic review and pooled analysis aimed to synthesize the available data on staged management and to examine patient-reported outcomes and complication profiles in this uniquely vulnerable population.
Across six studies including 147 patients, staged stabilization was predominantly used in younger, predominantly male patients exposed to high-energy mechanisms such as motor-vehicle collisions or falls. The pooled mean time to definitive fixation was approximately 2 weeks, reflecting the clinical priority of soft-tissue optimization before final reconstruction. Time to full weight bearing averaged nearly 4 months, indicative of prolonged rehabilitation trajectories typical of high-energy injury patterns rather than fixation strategy alone.
The pooled mean VAS pain score (2.5/10) and AOFAS midfoot score (76.9/100) suggested generally acceptable long-term function among patients treated with staged fixation. However, interpretation of these scores must be tempered by several limitations. First, the AOFAS scale combines clinician-derived and patient-reported components and is subject to ceiling effects.[16] MCID thresholds were not uniformly reported or exceeded across studies. Second, the absence of comparator cohorts prevents the determination of whether these outcomes result from staging itself or reflect broader recovery patterns in severe Lisfranc injuries. Thus, while PROM values indicate satisfactory pain and functional status, they should not be construed as evidence of superiority for staged management. He et al.’s study echoed these findings, demonstrating improved pain and function at 1 year in patients treated with a staged approach.[15] While these trends suggest potential benefit, the current evidence is insufficient to definitively conclude that staged treatment improves outcomes due to the confounding influence of injury severity.
Temporary stabilization before definitive fixation was common in this cohort, with 82.9% of patients undergoing either external fixation, percutaneous pinning, or both. Definitive fixation was achieved with ORIF in 76.9% of cases, consistent with existing literature – a large retrospective database study comprised of 7,268 operatively managed Lisfranc fracture dislocations reported ORIF in 78.3% of cases compared to arthrodesis in 21.7%.[18] In sum, these findings suggest that Lisfranc injuries requiring temporary stabilization are ultimately managed similarly to those that do not.
There was inconsistent and likely incomplete reporting of acute post-operative complications in the temporary stabilization group. The pooled overall complication rate of 13.1% (95% CI, 4.4–25.5) was calculated, with substantial heterogeneity (I2 = 73.1%; P = 0.002). In contrast, none of the 25 patients treated with delayed fixation alone experienced post-operative complications. Clinical conclusions cannot be drawn from this data and further standardized reporting is needed in this research area. PTOA was also more common in the temporized group (13.9% vs. 8%) but only reported in three studies for a pooled rate of 21.4% (95% CI, 2.0–53.4) with extreme heterogeneity (I2 = 91.1%, P < 0.001). These findings likely reflect greater injury severity among patients requiring temporization and inconsistencies in patient follow-up rather than a causal effect of temporary stabilization itself.[19] In line with this finding, He et al. – although limited by sample size – found that patients undergoing staged fixation with initial pinning experienced fewer complications compared to those treated with delayed ORIF alone.[15] However, as a single-center retrospective analysis with a relatively small sample size, its findings are subject to significant confounding and bias, making them difficult to interpret in relation to our aggregate results.
We stratified complication outcomes by open versus closed injuries when reported [Table 5]. However, only four of the six included studies permitted such stratification; the remaining two reported mixed cohorts without separate outcome data. This incomplete reporting limits the strength of comparison between open and closed injuries, underscoring the need for future studies to distinguish outcomes by wound type consistently. The descriptive differences observed here are hypothesis-generating but should be interpreted with caution, as heterogeneity in injury severity, reporting practices, comorbidities, and treatment allocation confounds direct comparisons.
A major limitation of this review is the small number of studies and their methodological heterogeneity. Notably, none of the included studies utilized random assignment to treatment groups and did not report or standardize for patient-level confounding factors such as diabetes or other pre-existing conditions. Treatment allocation was based on clinical judgment or patient preference, introducing the possibility of selection bias and confounding by indication. For example, in Kadow et al.,[12] “eighteen polytrauma patients were selectively treated with a staged protocol.” As a result, differences in baseline characteristics – such as patient age, comorbidities, or fracture severity – may have influenced outcomes independently of the treatments themselves. Consequently, the findings from this review should be interpreted as associated rather than causal. This methodological heterogeneity was further exacerbated by inconsistent reported outcome variables across studies, making direct comparisons of findings challenging.
In addition, there was significant inconsistency in the inclusion criteria related to polytrauma and fracture type. Some studies included both open and closed fractures, while others explicitly excluded open fractures. Variation in the inclusion criteria, especially open versus closed injuries and the presence or absence of polytrauma, affects both the comparability and generalizability of these findings. Future research should aim to clearly define fracture types and polytrauma and consider stratifying outcomes accordingly.
Beyond differences in PTOA, infection represents another critical complication of high-energy Lisfranc injuries, particularly when associated with open wounds or soft-tissue degloving. In our stratified analysis, infections were more common in open injuries, with both superficial and deep infections reported [Table 5]. This finding is consistent with prior literature, which shows that open midfoot injuries carry a higher risk of infection due to contamination and the difficulty of achieving durable soft tissue coverage. Importantly, the risk of infection in open injuries may influence the overall complication profile of staged management and confound comparisons with closed injuries. These observations reinforce the importance of future studies to more clearly distinguish between open and closed injuries, both to account for differential infection risks and to enhance the interpretability of pooled outcome data.
While our stratified analysis demonstrated that infections were more frequent among open injuries compared to closed injuries, the included studies did not consistently report which type of temporary stabilization (pinning vs. external fixation) was used within each wound subgroup. As a result, we were unable to further distinguish outcomes by both wound classification and stabilization method simultaneously. These descriptive findings should therefore be considered hypothesis-generating and interpreted with caution due to the heterogeneity and incomplete reporting of the primary studies.
Another notable limitation is the incomplete reporting of potential confounding variables in the primary studies. Key factors such as perioperative antibiotic prophylaxis and patient comorbidities were inconsistently reported or unreported entirely, limiting our ability to assess or adjust for their influence. Importantly, this review cannot definitively establish a causal relationship between pre-operative stabilization and outcomes due to the presence of selection bias and the lack of randomization in the included studies. High-quality observational studies and randomized trials should prioritize the reporting of relevant baseline characteristics and perioperative and post-operative protocols and employ statistical methods that control for confounding.
Despite these limitations, this review highlights key gaps in the literature. It suggests that interval fixation is of growing interest for high-energy Lisfranc fractures involving soft tissue injury or polytrauma that limits the viability of definitive fixation. Clinicians should be cautious when applying these findings to practice, as the current evidence lacks the methodological rigor necessary to support definitive treatment recommendations.
CONCLUSION
This systematic review synthesizes the limited available evidence on the use of temporary stabilization before definitive fixation in high-energy Lisfranc fracture dislocations. While complication rates and patient-reported outcomes suggest that staged treatment can provide meaningful short-term symptom relief and restoration of mobility, these findings must be interpreted with caution, given the study’s limitations, including the lack of randomization, small sample sizes, inconsistent reporting, and progressive structural changes (such as PTOA) observed during long-term radiographic follow-up. The apparent discrepancy between functional gains and structural deterioration likely reflects disparities in outcomes that develop over time, with early symptomatic recovery not necessarily predictive of long-term outcomes. These findings are also confounded by heterogeneity in injury severity, surgical technique, patient selection, and duration of follow-up, all of which importantly limit the ability to draw causal conclusions regarding any possible protective benefit conferred by temporary stabilization.
Acknowledgment:
We thank medical students Om Jahagirdar and James Cross as they conducted a detailed review of the manuscript, performed independent statistical verification reanalyzed complication data, and refined methods in accordance with PRISMA and ROBINS-I standards.
Recommendations:
Temporary stabilization before definitive fixation in high-energy Lisfranc injuries appears to facilitate early alignment maintenance and modestly improve short-term functional outcomes but is associated with higher acute complication rates, underscoring the need for standardized, high-quality comparative studies to clarify its long-term efficacy and safety.
Authors’ contributions:
MHS: Conceived, defined, and supervised all research conducted for the study; PPR and MHS: Designed the protocol, conducted a literature search with the assistance of a librarian, performed screening and data extraction, and drafted the initial manuscript; PPR and HMC: Integrated revisions and coordinated response to reviewers. All authors contributed to critical manuscript revision, approved the final version, and accept responsibility for the integrity and accuracy of the work.
Ethical approval:
Institutional review board approval was not required.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Conflicts of interest:
There are no conflicting relationships or activities.
Financial support and sponsorship: This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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