Radiographic Outcomes of Open Reduction and Kirschner-Wire Fixation Versus Screw or Plate Fixation for Lisfranc Injuries: A Propensity Score-Weighted Comparative Study.

Background/Objectives: Accurate anatomic reduction is a major determinant of outcomes after Lisfranc injury, but the optimal fixation method remains controversial. Although screws/plates are commonly used, Kirschner-wire (K-wire) fixation may provide adequate stability after precise open reduction. Methods: We retrospectively reviewed 62 patients who underwent surgery for acute unstable Lisfranc injuries at a single institution between 2002 and 2024. Fifty patients underwent open reduction and K-wire fixation, and 12 underwent screw/plate fixation. Propensity score overlap weighting was performed using age, sex, body mass index, time from injury to surgery, and injury mechanism. The primary outcome was final follow-up medial cuneiform-second metatarsal (C1-M2) gap; Post-traumatic osteoarthritic change was the secondary outcome. Results: After overlap weighting, baseline covariates were well balanced. The K-wire group had a significantly smaller final C1-M2 gap than the screw/plate group (1.919 ± 0.115 mm vs. 2.536 ± 0.279 mm, p = 0.046; weighted mean difference, 0.617 mm; 95% confidence interval, 0.013-1.220). Post-traumatic osteoarthritic changes were less frequent in the K-wire group (29.6% vs. 57.7%), although the difference was not significant (p = 0.091). Conclusions: When accurate open reduction was achieved, K-wire fixation provided radiographic outcomes comparable to and, regarding the C1-M2 gap, potentially more favorable than screw/plate fixation. Despite reduced construct rigidity, multiple K-wire fixations appeared to provide sufficient stability to maintain anatomic reduction and may reduce subtle reduction loss during screw/plate insertion. These findings suggest that K-wire fixation is a reasonable, less articular-invasive fixation option for acute unstable Lisfranc injuries.