Operative treatment of Lisfranc injuries in elite athletes: 2024 international foot and ankle sports consensus and systematic review

Purpose: Lisfranc injuries are potentially career-threatening for athletes, yet optimal management of unstable ligament and fracture-dislocation injury patterns remains debated. This study integrates an international expert consensus with a systematic review to evaluate current surgical strategies and outcomes, aiming to establish evidence-based recommendations for the treatment of elite athletes and to optimize recovery and return to play. Methods: A systematic review evaluated post-operative outcomes following suture button fixation (SBF), open reduction internal fixation (ORIF) and arthrodesis of unstable ligament and fracture-dislocation Lisfranc injuries. In addition, a consensus process was conducted using a modified Delphi technique. All consensus questions were generated by an initial survey sent to the expert panel. General consensus was defined as 75%–85% agreement, strong consensus as 86%–99% agreement and unanimous consensus as 100% agreement. Results: Sixteen studies (n = 406 athletes) were included. In the unstable ligament group, SBF (n = 46) versus ORIF (n = 203) yielded higher American Orthopaedic Foot and Ankle Society (95.5 vs. 89.4), lower complications (10.9% vs. 18.2%), zero failures (0% vs. 4.9%) and fewer secondary procedures (0% vs. 30.5%), with 93.5% of ORIF reoperations being hardware removal. In fracture-dislocation injury patterns, ORIF (n = 123) and arthrodesis (n = 31) showed similar complication (30.8% vs. 35.5%) and failure rates (13.8% vs. 12.9%), with secondary procedures more frequent after ORIF (90.2% vs. 22.6%). The consensus process generated 16 statements: 12 achieved unanimous agreement and 4 achieved strong consensus. Conclusion: Elite athletes who present with unstable ligament Lisfranc injuries and indications for surgical intervention should undergo fixation rather than fusion. For bony and fracture-dislocation Lisfranc injuries, ORIF is preferred when joint surfaces are salvageable and arthrodesis when long-term preservation is not feasible. However, the findings of this study underscore the importance of individualized treatment strategies to optimize surgical outcomes and functional recovery. Level of Evidence: Level V.