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Preoperative Patient Care
Operative Techniques
E

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
  • identify if a dual incision approach needed

3

List potential complications and steps to avoid them

F

Room Preparation

1

Surgical instrumentation needed

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

2

Room setup and equipment

  • standard radiolucent operative table
  • fluoroscopy

3

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
G

Dorsal Midfoot Approach

1

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

2

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

3

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
H

Articular Surface Assessment

1

Prepare fracture

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

2

Identify the extent of chondral damage

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

Provisional Reduction

1

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

2

Confirm reduction

  • use fluoroscopy to confirm the reduction
  • may use contralateral films to confirm anatomic 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 for lisfranc screw
J

Final Fixation

1

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

2

Place additional 3.5 cortical screws across each unstable joint

K

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
Postoperative Patient Care
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