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Preoperative Patient Care
Operative Techniques

Preoperative Plan


Radiographic templating

  • template the fracture with instrumentation


Execute surgical walkthrough

  • describe steps of the procedure verbally prior to the start of the case
  • identify if a dual incision approach needed


List potential complications and steps to avoid them


Room Preparation


Surgical instrumentation needed

  • K wire
  • pointed reduction forceps
  • 3.5 mm cortical screws
  • Anatomic lisfranc plate as needed


Room setup and equipment

  • standard radiolucent operative table
  • fluoroscopy


Patient positioning

  • patient is placed in the supine position with a bump/bolster beneath the ipsilateral hip
  • thigh or calf tourniquet
  • place a sterile bolster/triangle beneath the operative limb at the knee to facilitate access to the midfoot and intraoperative fluoroscopy

Dorsal Midfoot Approach


Identify anatomic landmarks and draw incision

  • identify the EHL and center the dorsomedial incision over the first tarsometatarsal joint between the EHL and EDL tendons
  • identify the lateral border of the third tarsometatarsal joint for the dorsolateral incision


Dorsomedial incision

  • Make incision centered over the 1st TMT joint between the EHL and EDL tendons
  • Take care to protect the deep peroneal neurovascular bundle
  • incise the EHL tendon sheath dorsally
  • retract the EHL medially
  • create full thickness flaps
  • perform subperiosteal dissection extending to the 1st TMT joint and produce a full thickness flap
  • use soft tissue flap to protect the neurovascular bundle
  • identify the intercuneiform joint capsules and test the stability of 1st TMT joint, 2nd TMT joint, lisfranc joint and intercuneiform joint


Dorsolateral incision (if necessary)

  • make skin incision over the lateral border of the third tarsometatarsal joint
  • expose the third tarsometatarsal joint
  • identify the extensor retinaculum
  • expose the EDL tendon and the medial margin of the EDB muscle
  • retract the EDL and the EDB laterally
  • create full thickness flap
  • perform a subperiosteal dissection directed medially towards the lateral portion of the of the second tarsometatarsal joint and laterally towards the fourth and fifth tarsometatarsal joint when needed

Articular Surface Assessment


Prepare fracture

  • debride the fracture and articular surface of residual scar, callus, and hematoma


Identify the extent of chondral damage

  • if > 50% articular comminution noted, arthrodesis should be considered

Provisional Reduction


Perform reduction

  • place pointed reduction forceps
  • for 1st TMT joint, may need to create a unicortical hole in the proximal 1st metatarsal (using a drill bit) to place tine of reduction forceps in
  • for lisfranc joint, place forceps from the medial cuneiform to the lateral border of the second metatarsal


Confirm reduction

  • use fluoroscopy to confirm the reduction
  • may use contralateral films to confirm anatomic reduction


Place a K wire

  • place K wire in the intended path of the screw to provide rotational control


Identify the cortical shelf on the medial cuneiform

  • this shelf provides an excellent buttress for screw purchase for lisfranc screw

Final Fixation


Place 3.5 mm cortical screw

  • lisfranc screw placement
  • make stab incision directly over the cortical shelf medially
  • place screw in the cortical shelf medially
  • angle screw towards the proximal metaphysis of the second metatarsal
  • remove the K wire
  • confirm placement of screw with fluoroscopy


Place additional 3.5 cortical screws across each unstable joint


Wound Closure


Irrigate the wounds

  • irrigate the wound


Deep closure

  • close the subperiosteal flaps and the floor of the EHL sheath with 0-vicryl
  • close the EHL tendon sheath with 0-vicryl


Superficial closure

  • close the subcutaneous tissue with 2-0 vicryl
  • close the skin with 3-0 monocryl



  • place in bulky jones dressings and weber splint
Postoperative Patient Care
Private Note

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