Modifications of the Lisfranc amputation include preservation of the 5th metatarsal base, and the 2nd metatarsal base, in its intercuneiform mortise.
The patient is placed in a supine position with the foot and lower half of the leg prepared and draped in the usual manner. This procedure is performed in a manner similar to the transmetatarsal amputation, with the development of a longer plantar flap and short dorsal flap. The dorsal skin incision is made just distal to the 1st metatarso-cuneiform joint and carried across the dorsum of the foot, ending just distal to the 5th metatarsal base. Occasionally it may be necessary to develop a longer dorsal flap to compensate for devitalized plantar skin. The medial and lateral incisions are carried distally along the metatarsal shafts to the necks of the metatarsals and then curved plantarly across the ball of the foot. The plantar flap is developed to the intended level of disarticulation.
The 1st metatarsal base is disarticulated from the medial cuneiform. Using a power saw, and working from medial to lateral, the 2nd metatarsal is transected at the level of the 1st and 3rd cuneiforms, leaving its base intact in the intercuneiform mortise. The 3rd and 4th metatarsals are then disarticulated, followed by transection of the 5th metatarsal, just distal to its base. Although the 5th metatarsal base will leave a prominence of bone, this generally does not cause a problem. Wound closure is performed in the same manner as described above for a transmetatarsal amputation. Dressings and postoperative care are also the same. High-top shoes or chukka boots with a stump filler and mild rocker sole are well suited for this level of mid-foot amputation.
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