Preoperative Patient Care A Intermediate Evaluation and Management 1 Obtains focused history and performs focused exam 2 Orders appropriate imaging studies AP, lateral and oblique of the affected foot Bilateral weight-bearing views if non-weight-bearing views are inconclusive B Advanced Evaluation and Management 1 Recognizes indications for non-operative management and provides appropriate treatment identifies indications for nonoperative treatment non-displaced injuries that are stable with weight bearing nonoperative candidates: nonambulatory patients, presence of serious vascular disease treatment cast placement and close radiographic followup 2 Appropriately orders and interprets advanced imaging studies 3 Provides a comprehensive assessment of most fractures on imaging studies 4 Recognizes soft tissue swelling amendable to acute versus delayed surgical fixation C 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 plantar foot ecchymosis 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 and evaluate appropriate basic imaging studies order triplanar non-weightbearing views AP check for discontinuity of a line drawn from the medial base of the 2nd metatarsal to the medial side of the middle cuneiform check for widening of the interval between the 1st and 2nd ray lateral check for dorsal displacement of the proximal base of the 1st or 2nd metatarsal oblique check for discontinuity of line drawn from medial side of the base of the 4th metatarsal to the medial side of cuboid if the injury is subtle, obtain bilateral weight-bearing views 3 Perform operative consent describe complications of surgery including infection nonunion malunion high likelihood of hardware removal 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 O 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 P Basic Postoperative Outpatient Evaluation and Management 1 2-week post-op visit Wound check and suture removal as necessary Recognize early complications (wound infection) Transition to convert to venous compression stocking and fracture boot Start early progressive range of motion Q Advanced Postoperative Outpatient Evaluation and Managementanagement 1 6-week post-op visit Check radiographs for alignment 2 3-month post-op visit Check weight-bearing radiographs for alignment If stable weight-bearing radiographs, allow for weight-bearing as tolerated Advance to regular shoes and activity as tolerated R Complex Patient Care 1 Develops unique, complex post-operative management plans 2 Order and interpret advanced imaging studies to complete preoperative plan with alternatives
A Intermediate Evaluation and Management 1 Obtains focused history and performs focused exam 2 Orders appropriate imaging studies AP, lateral and oblique of the affected foot Bilateral weight-bearing views if non-weight-bearing views are inconclusive B Advanced Evaluation and Management 1 Recognizes indications for non-operative management and provides appropriate treatment identifies indications for nonoperative treatment non-displaced injuries that are stable with weight bearing nonoperative candidates: nonambulatory patients, presence of serious vascular disease treatment cast placement and close radiographic followup 2 Appropriately orders and interprets advanced imaging studies 3 Provides a comprehensive assessment of most fractures on imaging studies 4 Recognizes soft tissue swelling amendable to acute versus delayed surgical fixation C 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 plantar foot ecchymosis 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 and evaluate appropriate basic imaging studies order triplanar non-weightbearing views AP check for discontinuity of a line drawn from the medial base of the 2nd metatarsal to the medial side of the middle cuneiform check for widening of the interval between the 1st and 2nd ray lateral check for dorsal displacement of the proximal base of the 1st or 2nd metatarsal oblique check for discontinuity of line drawn from medial side of the base of the 4th metatarsal to the medial side of cuboid if the injury is subtle, obtain bilateral weight-bearing views 3 Perform operative consent describe complications of surgery including infection nonunion malunion high likelihood of hardware removal
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
O 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 P Basic Postoperative Outpatient Evaluation and Management 1 2-week post-op visit Wound check and suture removal as necessary Recognize early complications (wound infection) Transition to convert to venous compression stocking and fracture boot Start early progressive range of motion Q Advanced Postoperative Outpatient Evaluation and Managementanagement 1 6-week post-op visit Check radiographs for alignment 2 3-month post-op visit Check weight-bearing radiographs for alignment If stable weight-bearing radiographs, allow for weight-bearing as tolerated Advance to regular shoes and activity as tolerated R Complex Patient Care 1 Develops unique, complex post-operative management plans 2 Order and interpret advanced imaging studies to complete preoperative plan with alternatives