Tarsalmetatarsal Arthrodesis

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TECHNIQUE STEPS
Preoperative Patient Care
Operative Techniques
E

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
F

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
G

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
H

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
I

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

J

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
K

Treat Intraoperative and Immediate Postoperative Complications

1

Step 1 in treating intraoperative complications

2

Step 2 in treating intraoperative complications

L

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
Postoperative Patient Care
 

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