2.1

To conduct this systematic review and meta-analysis , we used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). We followed all the steps mentioned in Cochrane’s Handbook of Systematic Reviews of Interventions .

2.2

We searched four databases (Scopus, PubMed, WoS, and Medline via WoS) for studies on CT and Lisfranc injuries from 1996 (when CBCT was first published) up to Oct 9, 2024. The review included studies using WBCT or conventional CT to assess Lisfranc injuries, comparing radiological parameters (e.g., M1-M2 base distance, TMT1 dorsal step-off, Lisfranc joint area) between injured and uninjured conditions, with subgroup analyses for each CT type. This study also analyzed data on the diagnostic accuracy and observer reliability of conventional and WBCT imaging for Lisfranc injuries. Included studies reported intra- and inter-observer reliability (e.g., kappa coefficients) and diagnostic accuracy (e.g., sensitivity, specificity, PPV, NPV, AUC). We focused on diagnosing Lisfranc injuries and postoperative assessments using these imaging methods. (Supp file 1)

2.3

We removed duplicates with Endnote (X-9) and screened studies in two steps: title/abstract screening and full-text review. Two authors screened independently, with a third resolving conflicts.

2.4

We extracted data using Excel in two sheets: a summary and baseline sheet, and an outcome sheet, by two separate authors, and the third author solved the conflict.

2.5

The methodological index for non-randomized studies (MINORS) criteria was employed .

2.6

We conducted this meta-analysis using R Studio (version 2024.09.0 +375), employing the meta and metafor packages for computations and the forestplot and grid packages for creating detailed visualizations .

2.7

All outcomes compared injured and uninjured conditions and included subgroup analyses to assess differences between conventional and WBCT methods where data was available . Key outcomes included M1-M2 Base Distance, M2-C1 Base Distance, TMT2 Dorsal Step-off, Axial Lisfranc Joint Area, and Axial Lisfranc Joint Volume. Continuous variables were analyzed as mean differences (MD) with corresponding standard errors (SE). Forest plots were generated to display study-specific effects (represented by navy blue squares) and pooled estimates (depicted as navy diamonds). Subgroup analyses for all double-arm outcomes were conducted using fixed-effects and random-effects models based on the DerSimonian method, with subgroup differences between conventional CT and MRI assessed using chi-square (χ²) tests .

2.8

The results underwent a comprehensive stratification process based on several key factors. Diagnostic features, such as the “Mercedes sign” (a three-pointed star appearance on axial CT views indicating C1-M2 diastasis) and “Peeking cuneiform sign” (visualization of the medial cuneiform between the first and second metatarsal bases on anteroposterior views), were used as primary classification criteria to organize the findings. Additionally, different imaging planes, including axial and coronal views, served as secondary stratification parameters. Study-specific characteristics were also considered to ensure appropriate categorization of results. For the interpretation of reliability metrics, a structured framework was implemented. Results showing a Kappa value of 0.80 or greater were classified as having excellent agreement, representing the highest level of reliability. Those with Kappa values between 0.60 and 0.79 were determined to have moderate agreement, indicating good but not optimal reliability. Fair agreement was assigned to results with Kappa values ranging from 0.40 to 0.59, suggesting limited but acceptable reliability. Finally, any results with a Kappa value below 0.40 were categorized as having poor agreement, indicating minimal reliability that might not be suitable for clinical decision-making.

Diagnostic accuracy outcomes were presented as reported, with AUC values interpreted according to standard thresholds: ≥ 0.90 as excellent, 0.80–0.89 as good, 0.70–0.79 as fair, 0.60–0.69 as poor, and < 0.60 as failed. Sensitivity and specificity were summarized as percentages with 95 % confidence intervals when available.

2.9

Heterogeneity was assessed using the I² statistic and categorized as follows: 0–40 % (unimportant), 30–60 % (moderate), 50–90 % (substantial), and 75–100 % (considerable). When significant heterogeneity was detected (I² > 50 % and p < 0.1), random-effect models were applied.

2.10

Leave-one-out sensitivity analyses were conducted to assess the impact of individual studies on the overall effect size and identify outliers causing heterogeneity. Publication bias was evaluated using funnel plots with color-coded significance contours (e.g., p < 0.1, p < 0.05) and visual inspection of plot symmetry.

3.1

A literature search across PubMed, Scopus, WOS, and Medline identified 736 articles, with 305 duplicates. After screening 431 titles and abstracts, 127 articles underwent full-text review. Ultimately, 16 studies were included in the systematic review, and 7 in the meta-analysis. ( Fig. 1 ).

Study flow diagram illustrating the selection process for the systematic review and meta-analysis. A total of 736 articles were identified through database searches (PubMed, Scopus, WOS, and Medline), with 305 duplicates removed. Screening of titles and abstracts was conducted for 431 articles, and 127 full-text articles were reviewed. Sixteen studies were included in the systematic review, with seven studies proceeding to meta-analysis.

3.2

Conventional CT studies were mostly retrospective single-center cohorts (1991–2022), primarily from China and the U.S., with patients aged 32–57 years and approximately 300 female participants. WBCT studies combined cadaveric and retrospective cohorts (2015–2024), all single-center from the U.S. and Switzerland, with predominantly male participants aged 32–76 years. Reported BMI ranged from 24 to 30 kg/m² ( Table 1 ).

3.3

As shown in Table 2 , the assessment of the included studies using the MINORS scale demonstrated high methodological quality, with scores ranging from 16 to 23 out of a possible 24 points ( Table 2 ).

Table 2

Assessment of the quality of studies through methodological index for Non-Randomized studies (MINORS).

Study ID	Clearly Stated Aim	Consecutive Patients	Prospective Collection of Data	Endpoints	Assessment of Endpoint	Follow-up Period	Loss < 5 %	Study Size	Adequate Control Group	Contemporary Group	Baseline Control	Statistical Analyses	MINORS Score
Tang et al. (2024)	2	2	1	2	2	2	2	1	0	0	0	2	16
Chen et al. (2023)	2	2	1	2	2	2	2	2	2	2	2	2	23
Tamir et al. (2023)	2	2	1	2	2	2	2	2	2	2	2	2	23
Essa et al. (2022)	2	2	1	2	2	2	2	1	2	2	2	2	22
Rikken et al. (2022)	2	2	1	2	2	2	2	1	2	2	2	2	22
Shim et al. (2022)	2	2	1	2	2	2	2	2	2	2	2	2	23
Ponkilainen et al. (2020)	2	2	1	2	2	2	2	2	2	2	2	2	23
Clements et al. 2018	2	2	1	2	2	2	2	1	2	2	2	2	22
Kunas et al. (2017)	2	2	1	2	2	2	2	1	2	2	2	2	22
Li et al. (2017)	2	2	1	2	2	2	2	1	0	0	0	2	22
WBCT
Bhimani et al. (2024)	2	2	2	2	2	1	2	1	0	0	0	2	16
Falcon et al. (2023)	2	2	1	2	2	2	2	1	2	2	2	2	22
Bhimani et al. (2020)	2	2	1	2	2	2	2	1	2	2	2	2	22
Penev et al. (2020)	2	2	2	2	2	1	2	1	0	0	0	2	16
Sripanich et al. (2020a)	2	2	2	2	2	1	2	1	0	0	0	2	16
Sripanich et al. (2020b)	2	2	2	2	2	1	2	1	0	0	0	2	16

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