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Lisfranc Open Reduction and Internal Fixation

Authors:

Planning

B

Preoperative Plan

1

Radiographic templating

  • template the fracture with instrumentation

2

Execute surgical walkthrough

  • describe steps of the procedure verbally prior to the start of the case

3

List potential complications and steps to avoid them

C

Room Preparation

1

Surgical instrumentation

  • K wire
  • pointed reduction forceps
  • 3.5 mm cortical screw

2

Room setup and equipment

  • standard operative table
  • fluoroscopy

3

Patient positioning

  • patient is placed in the supine position with a bolster beneath the ipsilateral hip
  • place protective padding around the contralateral limb to protect the peroneal nerve
  • place a sterile bolster beneath the operative limb at the knee to facilitate access to the midfoot and intraoperative fluoroscopy
  • place tourniquet

Technique

D

Dual Incision Approach

1

Identify anatomic landmarks and draw incision

  • identify the EHL and center medial incision over the first tarsometatarsal joint
  • identify the lateral border of the third tarsometatarsal joint for the lateral incision

2

Medial incision

  • make the skin incision over the first tarsometatarsal joint
  • expose the tarsometatarsal joint
  • incise the EHL tendon sheath dorsally
  • retract the EHL laterally
  • incise the floor of the EHL tendon sheath
  • create full thickness flaps
  • perform subperiosteal dissection extending to the first tarsometatarsal 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 each joint

3

Lateral incision

  • elevate the third tarsometatarsal joint
  • place a freer elevator under the full thickness skin flap to the level of the third tarsometatarsal joint
  • make skin incision
  • make skin incision over the lateral border of the third tarsometatarsal joint
  • expose the third tarsometatarsal joint
  • identify the extensor retinaculum
  • expose the EDC tendon and the medial margin of the EDB muscle
  • retract the EDC 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
E

Articular Surface Assessment

1

Prepare fracture

  • debride the fracture and articular surface of residual hematoma

2

Identify the extent of chondral damage

  • if less than 50% of the articular surface of the medial and middle column joints is involved, then proceed with ORIF
  • if more than 50% involved, proceed with arthrodesis
F

Provisional Reduction

1

Perform reduction

  • place pointed reduction forceps
  • place forceps from the medial cuneiform to the lateral border of the second metatarsal

2

Confirm reduction

  • use fluoroscopy to confirm the reduction

3

Place a K wire

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

4

Identify the cortical shelf on the medial cuneiform

  • this shelf provides an excellent buttress for screw purchase
G

Final Fixation

1

Place 3.5 mm cortical screw

  • 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

2

Confirm placement of screw with fluoroscopy

H

Wound Closure

1

Irrigate the wounds

  • irrigate the wound

2

Deep closure

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

3

Superficial closure

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

4

Dressings

  • place in bulky jones dressings and weber splint

Patient Care

K

Preoperative H & P

1

Performs basic history and physical

  • history
  • identify mechanism of trauma
  • position of the foot
  • direction of the force
  • extent of the energy involved
  • physical exam
  • assess for associated injuries
  • check for diffuse swelling at the midfoot
  • palpate the midfoot joints
  • test midfoot stability
  • perform passive range of motion of the metatarsal heads and passive abduction through the forefoot.

2

Order appropriate basic imaging studies

  • order triplanar non-weightbearing views
  • AP
  • lateral
  • oblique
  • if the injury is subtle, obtain weight-bearing views

3

Perform operative consent

  • describe complications of surgery including
  • infection
  • nonunion
  • malunion
L

Perioperative inpatient management

1

Discharge patient appropriately

  • take xrays of the foot in postop to verify reduction
  • oral pain meds
  • schedule follow up in 2 weeks
M

Intermediate Evaluation and Management

1

Obtains focused history and performs focused exam

2

Appropriately interprets basic imaging studies

3

Prescribes and manages non-operative treatment

  • identifies indications for nonoperative treatment
  • partial Lisfranc injuries
  • non-displaced or minimally displaced extra-articular metatarsal base fractures with no intra-articular involvement
  • treatment
  • venous compression stocking and prefabricated fracture boot

4

Provides post-operative management and rehabilitation

  • postop: 2-3 Week Postoperative Visit
  • wound check
  • diagnose and management of early complications
  • check radiographs for alignment
  • convert to venous compression stocking and prefabricated fracture boot
  • start early progressive range of motion

5

Postop: ~ 3 month Postoperative Visit

  • check weight-bearing radiographs
  • if reduction stable, start weight-bearing
  • advance to regular shoes and activity as tolerated
N

Advanced Evaluation and Management

1

Recognizes indications for and provides non-operative treatment of an unstable fracture

2

Capable of treating complications both intraoperatively and post-operatively

3

Appropriately orders and interprets advanced imaging studies

4

Provides a comprehensive assessment of most fractures on imaging studies

O

Complex Patient Care

1

Develops unique, complex post-operative management plans

2

Order and interpret advanced imaging studies to complete preoperative plan with alternatives

 

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