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Percutaneous Pinning of Lisfranc frx

- Discussion:
    - anatomy of the midfoot:
    - many orthopaedists have moved away from pin fixation because fixation must be rigid enough to prevent transverse plane & dorsoplantar motion of TMT joint and be maintained for at least 12-16 weeks;
          - this exceeds the length of time that pins can be left in place;
    - an alternative, is percutaneous insertion of cannulated screws, which allows rigid fixation, w/o risking wound slough which may occur following open reduction;

- Radiographs:
    - w/ questionable injury, consider wt bearing AP view to assess 1-2 interval;
         - if standing AP is unacceptable to the patient then consider CT scan;

- Fixation:
    - technique of reduction:
    - fixation is performed w/ 0.062 inch K wires;
    - isolated dislocation of 1st metatarsal:
           - consider placement of 2 K wires thru the shaft into the cuneiforms;
    - homolateral and divergent dislocations:
           - insert one K wire medially thru 1st metatarsal into cuneiform;
           - insert one K wire laterally thru 5th metatrsal into cunboid or into the calcaneus;
           - non wt bearing cast is worn for 6 weeks;
    - as an option, cannulated screws can be placed over the K wires, for more reliable fixation;

- Case Examples:
    - 25 year old athelete who was injured during a pile up on the field;
          - standard radiographs were interpreted as normal, but this wt bearing film clearly shows the injury;
          - small incisions were made over the base of the second metatarsal and medial cuneiform;
          - a large tenaculum clamp was used to oppose the base of the second metatarsal to the cuneiform;
          - after adequacy of the reduction had been confirmed, a cannulated screw was inserted