Open reduction and rigid internal fixation of midfoot fracturedislocations

A 53-year-old Caucasian, male, janitorial worker, with type 2 diabetes of 6 years' duration presented to the diabetic foot clinic with the chief complaint of sudden and unexpected swelling of his left foot. There was no history of injury, ankle sprain, tripping or falling. Physical examination revealed moderate to severe redness, swelling and elevated skin temperature, approximately 4°C, of the left foot and ankle. Swelling extended up the leg to the knee. The medial column of the foot was unstable. Pedal pulses were present and there were no breaks in the skin. The patient had a dense peripheral neuropathy with loss of protective sensation, absent deep tendon reflexes at the ankle and elevated vibratory perception threshold > 45. The patient's body mass index was 35 kg/m2. Laboratory data revealed an elevated HbAlc 8.0%, mild anaemia, and normal WBC count. Radiographs revealed fracture-dislocation of Lisfranc's joint, with medial dislocation of the 1st metatarsal, and fracture dislocation of the 2nd metatarsocuneiform joint. In addition, there were dorsally displaced fractures of the 2nd, 3rd and 4th metatarsal heads (Fig. 8.38a,b).

He was initially placed in a well-padded Jones compression dressing and admitted to the medical centre for bed rest and elevation of his left lower extremity. Within

1 week, the swelling began to subside and he was placed in a short-leg non-weightbearing cast. The cast was changed

2 weeks later. Interim evaluation at day 21 revealed resolution of the swelling, redness and elevated skin temperature. The medial column of the foot (1st ray) remained unstable. At this time the process was considered to be subacute, and surgical intervention was advised. The following criteria for surgical intervention were met:

• Foot deformity/instability

• Adequate circulation

• Medically stable

• No evidence of infection.

The patient underwent successful open reduction and rigid internal fixation of his mid-foot fracture-dislocations,

Fig. 8.39 Intraoperative view showing dislocation of the 1st metatarsocuneiform joint.

Fig. 8.40 Anteroposterior radiograph reveals satisfactory under spinal anaesthesia, using a thigh tourniquet for postoperative realignment of the tarsometatarsal joints, haemostasis.

Fig. 8.39 Intraoperative view showing dislocation of the 1st metatarsocuneiform joint.


An 8-cm linear incision was made over the medial aspect of the 1st metatarsal and medial cuneiform. The incision was carried deep to bone and all soft tissues were reflected from the cuneiform and metatarsal, revealing complete medial dislocation of the 1st metatarsal (Fig. 8.39). Manual reduction of the dislocation was not possible because of soft tissue interposed in the joint. A sagittal power saw was used to resect a wafer of bone from the base of the 1st metatarsal, and to remove the articular cartilage from the medial cuneiform. The metatarsal was then easily relocated and fixed with two 4.0 mm cannulated screws, under C-arm fluoroscopy. A four-hole, 1/3 tubular plate was then placed across the 1st metatarsocuneiform articulation and secured with four 3.5 mm cortical screws. Attention was then directed to the fracture-dislocation of the 2nd metatarsocuneiform joint, where a 6-cm linear incision was made over the dorsum of the foot. The base of the metatarsal was resected and the cartilage removed from the intermediate cuneiform. The 2nd metatarsal was placed in proper alignment, secured with a K-wire, and fixed with a 4.0 cannulated screw. Wounds were irrigated thoroughly with normal sterile saline solution, and two closed suction drains were inserted. Deep closure of the soft tissues was obtained using 3-0 absorbable sutures, and the skin was closed with stainless steel staples. Postoperative radiographs revealed satisfactory realignment of Lisfranc's joint (Fig. 8.40).

Dressings and postoperative care

Non-adherent petrolatum gauze was applied to the wounds and covered with a fluffy compression dressing, followed by a plaster splint.

The patient was immobilized in fibreglass non-weight-bearing casts for a period of 3 months. Casts were changed every 3 weeks. The patient was then placed in a walking brace for 1 month, and allowed to gradually return to full weightbearing. Custom-moulded shoes were provided. The postoperative recovery for this patient was essentially uncomplicated. The patient remained ambulatory and lived 4 more years, eventually succumbing to cardiovascular and renal complications.

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