AP and lateral radiograph of homolateral Lisfranc

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AP and lateral radiograph of homolateral
Lisfranc (tarso-metatarsal joint) dislocation
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Fluoroscopic radiograph in the operating room
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With adduction the tarso-metatarsal joints fall
into general alignment. However, there is still
significant dorsal displacement which is palpable.
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The incision is placed between the second and
third metatarsals. This allows access from the
second to the fourth tarsal metatarsal joints, as
well as the lateral aspect of the first
metatarsal joint.
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DORSALIS PEDIS ARTERY
This incision is preferred as opposed to an
incision between one and two, which is where the
dorsalis pedis artery is located.
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Oblique view of the foot, demonstrating the
incision.
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The skin incision is brought down through the
level of the subcutaneous tissue.
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The short extensor muscles are retracted bluntly.
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2nd METATARSAL BASE
With very little dissection required, the
dislocated tarso-metatarsal joints are obvious.
This figure demonstrates the base of the second
and third metatarsals, dorsally displaced from
the middle and lateral cuneiform. Note that the
second metatarsal base is located more proximally
than the third, and is the keystone of the
configuration. With manipulation of the foot and
direct pressure on the metatarsal bases, a
reduction is usually effective.
LATERAL CUNEIFORM
3rd METATARSAL BASE
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REDUCTION
The reduction of the second and third metatarsal
bases back to their associated cuneiforms.
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2nd METATARSAL BASE
MIDDLE CUNEIFORM
3rd METATARSAL BASE
Closeup of the reduction of the second metatarsal
base to the middle cuneiform and the
third metatarsal base to the lateral cuneiform.
LATERAL CUNEIFORM
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2nd METATARSAL BASE
PLANNED LOCATION OF SCREW
MIDDLE CUNEIFORM
LOCATION FOR TEMPORARY K-WIRE
Once the reduction is obtained, a K-wire is
placed across the reduction in an area that will
not interfere with screw fixation.
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TAP
K-WIRE
After drilling across from the base of the second
metatarsal into the middle cuneiform, the entire
hole is tapped. This screw is a position screw,
not a lag screw, thus no overdrilling of the
metatarsal base is required.
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TAP
K-WIRE
It is very important to keep the hand almost
parallel with the dorsal aspect of the foot in
order to place the screw in the center of the
cuneiform. Notice the K-wire placed in a
position that does not interfere with screw
placement.
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Because of the very sharp angle with respect to
the bone, the countersink should be used to
create a hole in the metatarsal base.
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If this is not done, then the posterior aspect of
the screw head will abut the base of the
metatarsal before it is engaged in the hole and
has the potential to displace the joint.
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The screw being placed into the countersunk hole.
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SCREW IN 2nd METATARSAL
REDUCTION
SCREW IN 3rd METATARSAL
The screw once seated. A second screw has been
placed between the third metatarsal base and the
lateral cuneiform.
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SCREW IN 2nd METATARSAL
REDUCTION
SCREW IN 3rd METATARSAL
Once the dorsal incision has been utilized to
gain good stability of the 2nd and 3rd
(depending on the case) metatarsal bones back to
the cuneiforms, there may still be instability
on the medial aspect of the foot.
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SCREW IN 2nd METATARSAL
REDUCTION
SCREW IN 3rd METATARSAL
In this case, the first tarsal metatarsal joint
was unstable and was addressed. A second
incision, which is very short, is made
directly over the tarsal metatarsal joint
medially.
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MEDIAL CUNEIFORM
1st METATARSAL BASE
Closeup of the first metatarsal base and
medial cuneiform joint.
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The reduction is obtained. In similar fashion to
the dorsal incision, a K-wire is placed, then
screw fixation is achieved.
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The reduction is obtained. In similar fashion to
the dorsal incision, a K-wire is placed, then
screw fixation is achieved.
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60o
The fifth metatarsal base is reduced and pinned
to the cuboid using a K-wire from the metatarsal
into the cuboid more proximal than the planned
screw
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60o
Imaging in the oblique radiograph helps with pin
placement. As viewed from the top of the foot,
the K-wire and drill should be approximately 60o
from the horizontal axis.
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60o
This is necessary as the base of the fifth
metatarsal is located significantly inferior to
the cuboid.
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30 - 45o
As viewed from the side, the angle is
approximately 30-45o from distal to proximal
through the base of the metaphysis of the fifth
metatarsal.
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CUBOID
K-WIRE
DRILL
X-ray demonstrating the K-wire holding the
reduction and the percutaneously placed drill,
which is across the center of the fifth
tarso-metatarsal joint. This drill hole is then
tapped, and an appropriate-length screw is placed.
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CUBOID
K-WIRE
DRILL
Standard-layer closure of the foot is performed,
typically using nylon sutures for the skin. The
patient is placed in a short-leg cast.
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Postoperative AP and lateral radiographs
demonstrating anatomic reduction and stable
internal fixation of the tarsal metatarsal joints.