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Tarsalmetatarsal Arthrodesis

Planning

B

Preoperative Plan

1

Radiographic templating

  • triplanar radiographs of the foot
  • CT scan
  • determines configuration of the Lisfranc complex

2

Execute surgical walkthrough

  • describe the steps of the procedure verbally to the attending prior to the start of the case
  • describe potential complications and steps to avoid them
C

Room Preparation

1

Surgical instrumentation

  • K wires
  • 3,4 or 5 mm cortical screws
  • plating systems(optional)

2

Room setup and equipment

  • standard OR table
  • bring fluoroscopy from the contralateral side

3

Patient positioning

  • supine position
  • align sole of the foot with the end of the bed
  • place tourniquet around the upper thigh

Technique

D

Approach

1

Mark and make incision

  • inflate thigh tourniquet.
  • mark the first incision between the first and second metatarsal to access the first TMT joint and most of the second
  • make a 6 cm incision just lateral to the EHL tendon
  • if needed make the second incision centered around the over the fourth metatarsal

2

Identify neurovascular structures

  • identify and protect the superficial and deep peroneal nerves as well as the dorsalis pedis artery with a retractor
  • the distal 3 cm of the incision should be centered around the TMT joint
  • cauterize the vein that is found crossing the field
E

Joint Preparation

1

Expose the the TMT joint

  • evacuate the hematoma for exposure and visualization

2

Determine the joint instability

  • determine the joints which are involved in the instability pattern by using fluoroscopy
  • stabilize the hindfoot while the forefoot is manipulated with abduction and adduction followed by plantarflexion and dorsiflexion stress
  • when DJD is present there is often significant deformity of the TMT joints with lateral abduction as well as dorsiflexion
  • perform significant soft tissue release around the involved joints to mobilize the joint for reduction in all planes
F

Arthordesis Preparation

1

Debride the joint of all loose pieces of cartilage

  • remove the articular cartilage from the opposing surfaces of the joints using a rongeur, curettes and osteotome
  • the goal is to remove only cartilage and exposed subchondral bone

2

Fully expose joint

  • place a small laminate spreader to allow visualization of the entire joint
  • if the full joint is not exposed there is a tendency to fuse the joint in dorsiflexion

3

Create a vascular channel

  • use a small diameter drill or small osteotomes on the opposing surfaces to create vascular channels

4

Perform reduction

  • secure and reduce the first TMT joint
  • check alignment with fluoroscopy

5

Temporarily place a K wire to stabilize the joint

G

Fixation

1

Stabilize medial column

  • place a 3,4 or 5 mm cortical screw from the medial cuneiform into the first metatarsal
  • this stabilizes the medial column as a foundation for the remaining metatarsals to be secured

2

Reduce the second metatarsal into the keystone position

  • use a clamp to pull the metatarsal base onto the lateral aspect of the first metatarsal and adjacent cuneiform
  • check alignment radiographically

3

Place second cortical screw

  • insert the second screw from the medial cuneiform into the base of the second metatarsal
  • placement of remaining fixation and placement is dependent on the individual situation
  • placement of one more point of fixation is needed
  • the simplest method is to use compression staples
H

Treat Intraoperative and Immediate Postoperative Complications

1

Step 1 in treating intraoperative complications

2

Step 2 in treating intraoperative complications

I

Wound Closure

1

Irrigation, and hemostasis

  • ensure hemostasis using cautery

2

Superficial closure

  • use 3-0 nylon for skin

3

Deep closure

  • use 2-0 vicryl for the subcutaneous layer

4

Dressing and immediate immobilization

  • place in well padded non-weightbearing short leg plaster cast
  • split cast in recovery room to allow for post op swelling

Patient Care

K

Preoperative H & P

1

Obtain history and perform basic physical exam

  • check neurovascular status
  • identify medical co-morbidities that might impact surgical treatment
  • diabetes, smoking and previous surgery all affect union rates

2

Order basic imaging studies

  • order weight-bearing triplanar radiographs of the foot

3

Perform operative consent

  • describe complications of surgery including
  • infection
  • nonunion
  • malalignment
  • symptomatic hardware
  • superficial wound breakdown
L

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • pain meds
  • IV fluids
  • DVT prophylaxis
  • advance diet as tolerated
  • check appropriate labs
  • foley out when ambulating
  • wound care
  • check postoperative films
  • physical therapy
  • non-weightbearing
  • strict elevation

2

Discharges patient appropriately

  • pain meds
  • wound care
  • outpatient PT
  • schedule follow up in 2 weeks
M

Outpatient Evaluation and Management

1

Obtains focused history and performs focused exam and gait analysis

  • check neurovascular status

2

Appropriately orders and interprets advanced imaging studies/lab studies

  • radiographs
  • AP, lateral and obliques of the foot
  • stress radiograph
  • may be helpful to show instability when non-weight bearing radiographs are normal and there is high suspicion
  • weight-bearing radiographs with comparison view may be necessary to confirm diagnosis
  • CT scan
  • determines the the configuration of the Lisfranc complex
  • complex mimics a "Roman Arch"

3

Prescribes nonoperative treatment

  • cast immobilization for 8 weeks
  • indications
  • no displacement on weight-bearing and stress radiographs and no evidence of bony injury on CT (usually dorsal sprains)

4

Makes informed decision to proceed with operative treatment

  • describes accepted indications and contraindications for surgical intervention

5

Provides post-operative management and rehabilitation

  • postop: 2-3 week postoperative visit
  • wound check
  • remove sutures
  • remove cast
  • place in a pneumatic boot walker
  • continue non-weightbearing
  • remove boot several times a day for active ROM exercises of the ankle
  • diagnose and management of early complications
  • wound healing
  • infection
  • DVT
  • postop: ~ 6 week postoperative visit
  • obtain radiographs
  • remove cast
  • weight bearing flat footed in the walker boot
  • start physical therapy
  • diagnosis and management of late complications
  • postop: 12 week post operative visit
  • obtain radiographs to confirm union
  • discontinue the boot
  • start proprioception, endurance and agility training
N

Advanced Patient Care and Management

1

Modifies and adjusts post-operative treatment plan as needed

2

Provides patient specific non-operative treatment

  • diagnostic injections
O

Complex Patient Care

1

Develops unique, complex post-operative management plans

 

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