Lisfranc Injury Pathway Updated: 10/4/2016
CPT Codes: 28306 Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; first metatarsal

Lisfranc Open Reduction and Internal Fixation

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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

3

List potential complications and steps to avoid them

F

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
G

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
H

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
I

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
J

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

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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