A Outpatient Evaluation and Management 1 Obtains focused history and performs focused exam and gait analysis check neurovascular status 2 Appropriately orders and interprets advanced imaging studies/lab studies radiographs AP, lateral and obliques of the foot stress radiograph may be helpful to show instability when non-weight bearing radiographs are normal and there is high suspicion weight-bearing radiographs with comparison view may be necessary to confirm diagnosis CT scan determines the the configuration of the Lisfranc complex complex mimics a "Roman Arch" 3 Prescribes nonoperative treatment cast immobilization for 8 weeks indications no displacement on weight-bearing and stress radiographs and no evidence of bony injury on CT (usually dorsal sprains) 4 Makes informed decision to proceed with operative treatment describes accepted indications and contraindications for surgical intervention 5 Provides post-operative management and rehabilitation postop: 2-3 week postoperative visit wound check remove sutures remove cast place in a pneumatic boot walker continue non-weightbearing remove boot several times a day for active ROM exercises of the ankle diagnose and management of early complications<br /> wound healing infection DVT postop: ~ 6 week postoperative visit obtain radiographs remove cast weight bearing flat footed in the walker boot start physical therapy diagnosis and management of late complications postop: 12 week post operative visit obtain radiographs to confirm union discontinue the boot start proprioception, endurance and agility training B Advanced Patient Care and Management 1 Modifies and adjusts post-operative treatment plan as needed 2 Provides patient specific non-operative treatment diagnostic injections C Preoperative H & P 1 Obtain history and perform basic physical exam check neurovascular status identify medical co-morbidities that might impact surgical treatment diabetes, smoking and previous surgery all affect union rates 2 Order basic imaging studies order weight-bearing triplanar radiographs of the foot 3 Perform operative consent describe complications of surgery including infection nonunion malalignment symptomatic hardware superficial wound breakdown
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
O Perioperative Inpatient Management 1 Write comprehensive admission orders pain meds IV fluids DVT prophylaxis advance diet as tolerated check appropriate labs foley out when ambulating wound care check postoperative films physical therapy non-weightbearing strict elevation 2 Discharges patient appropriately pain meds wound care outpatient PT schedule follow up in 2 weeks R Complex Patient Care 1 Develops unique, complex post-operative management plans