import { OnePagerSummary, ContentSection, ExamWarning, InfoCardGrid, InfoCard, EvidenceCard, ComparisonTable, VivaScenario, MnemonicCard, ExamCheatSheet, Tab, Tabs } from '@/components/mdx' # Dorsal Approach to Midfoot: Comprehensive Examination Guide ## Introduction and Clinical Context The **dorsal approach to the midfoot** encompasses a family of longitudinal incisions on the dorsum of the foot providing access to the **tarsometatarsal (TMT) joints** (Lisfranc joint complex), **naviculocuneiform joints**, **intercuneiform joints**, and **metatarsal bases** for surgical management of **Lisfranc injuries** (ligamentous disruptions or fracture-dislocations of TMT joints), **primary TMT arthrodesis** (fusion for post-traumatic arthritis, Charcot arthropathy, inflammatory arthritis), midfoot fractures (cuneiform, navicular, metatarsal base fractures), and **midfoot reconstructive procedures** (Charcot reconstruction, cavovarus/planovalgus deformity corrections). ### Historical Development and Surgical Evolution Dorsal approaches to the midfoot evolved from early 20th-century techniques for Lisfranc fracture-dislocation reduction (described by French surgeon Jacques Lisfranc de St. Martin in 1815 - originally AMPUTATION through TMT joints for gangrenous foot, later anatomic name applied to injury pattern). Modern surgical management of Lisfranc injuries emphasizes **anatomic reduction** and **rigid fixation** to restore midfoot arch stability, with consensus that displaced injuries (greater than 2mm TMT diastasis) require operative management (Myerson 2007: ORIF superior to nonoperative for displaced Lisfranc injuries - anatomic reduction 85-90% good/excellent outcomes vs nonoperative 50-60%). The KEY anatomic principle driving dorsal midfoot approach design is preservation of **dorsal foot blood supply** - the foot has MULTIPLE longitudinal angiosomes (vascular territories) with LIMITED cross-communication, making **single transverse incisions across dorsum CONTRAINDICATED** (devascularizes skin between incisions, causes necrosis 10-20% - Zwipp 2004). Modern technique uses **MULTIPLE longitudinal incisions** (2-3 incisions) strategically placed in internervous/intervascular planes to access different midfoot columns while preserving longitudinal blood supply. **Three-column concept** (medial, middle, lateral) guides incision planning: - **Medial column**: 1st TMT joint (1st metatarsal-medial cuneiform), naviculocuneiform joint medially - **Middle column**: 2nd and 3rd TMT joints (2nd/3rd metatarsals-middle/lateral cuneiforms) - KEYSTONE of midfoot arch - **Lateral column**: 4th and 5th TMT joints (4th/5th metatarsals-cuboid), calcaneocuboid joint Most Lisfranc injuries involve medial + middle columns (Myerson classification Types A-C), with lateral column injury less common. Standard **two-incision technique** (medial + dorsal incisions) addresses medial and middle columns, with **third lateral incision** added if lateral column injured. ## Surgical Anatomy and Key Landmarks ### Surface Anatomy and Planning **Palpable landmarks:** - **1st metatarsal base**: Prominent medial midfoot (easily palpable), marks 1st TMT joint - **2nd metatarsal base**: Recessed dorsally (keystone - sits between cuneiforms), 2nd TMT joint deepest - **Navicular tuberosity**: Medial prominence proximal midfoot (insertion of tibialis posterior tendon) - **Cuboid**: Lateral midfoot (less prominent than navicular) - **Dorsalis pedis artery pulse**: Palpable on dorsum of foot in 1st-2nd metatarsal interval (marks deep peroneal nerve location) **Skin incision planning (TWO-INCISION STANDARD):** - **Medial incision**: Over 1st-2nd metatarsal interval - Start: Naviculocuneiform joint level (proximal midfoot) - End: 1st metatarsal shaft mid-diaphysis (distal midfoot) - Length: 6-8cm - Access: 1st TMT joint, medial cuneiform, naviculocuneiform joint medially - **Dorsal (central) incision**: Over 2nd-3rd metatarsal interval (SAFE ZONE) - Start: Naviculocuneiform joint level - End: 2nd-3rd metatarsal shafts mid-diaphysis - Length: 6-8cm - Access: 2nd and 3rd TMT joints, middle/lateral cuneiforms, intercuneiform joints - Rationale for 2nd-3rd interval: Deep peroneal nerve runs MEDIALLY (1st webspace), superficial peroneal nerve branches run LATERALLY (4th-5th webspace) - 2nd-3rd interval is between these structures - **Lateral incision** (THIRD incision if needed): Over 4th-5th metatarsal interval - Start: Calcaneocuboid joint level - End: 4th-5th metatarsal shafts mid-diaphysis - Length: 5-7cm - Access: 4th and 5th TMT joints, cuboid, calcaneocuboid joint **Critical spacing**: Maintain MINIMUM 7cm between incisions (medial and dorsal incisions separated by 7cm+ measured at mid-length) ### Layer-by-Layer Anatomic Dissection (MEDIAL INCISION) **Layer 1 - Skin and Subcutaneous Tissue:** - Longitudinal incision over 1st-2nd metatarsal interval (6-8cm) - Incise through subcutaneous tissue - **Identify and protect superficial peroneal nerve branches** (intermediate dorsal cutaneous nerve): - May cross medial incision (runs from lateral to medial across dorsum) - Injury causes dorsal foot numbness (NOT functionally limiting but bothersome) - Retract or accept division (sensory only) **Layer 2 - Extensor Tendons:** - **Extensor hallucis longus (EHL)** tendon: Most medial structure on dorsal foot (runs over 1st metatarsal) - **Extensor hallucis brevis (EHB)** tendon: Lateral to EHL (inserts on proximal phalanx of hallux) - Retract EHL/EHB tendons LATERALLY (away from 1st TMT joint exposure) **Layer 3 - Joint Capsule and Periosteum:** - Incise capsule over 1st TMT joint longitudinally (along dorsal surface) - Elevate periosteum from 1st metatarsal base and medial cuneiform (subperiosteal) - Expose 1st TMT joint (medial cuneiform articulates with 1st metatarsal base) - Can extend proximally to naviculocuneiform joint if needed **Neurovascular Structures:** - **Deep peroneal nerve and dorsalis pedis artery**: Run in FIRST WEBSPACE (between 1st and 2nd metatarsals) - Nerve/artery run LATERAL to EHL tendon - Stay MEDIAL to neurovascular bundle (work on medial side of EHL tendon) - Neurovascular bundle NOT directly in field for medial incision if dissection stays medial ### Layer-by-Layer Anatomic Dissection (DORSAL INCISION) **Layer 1 - Skin and Subcutaneous Tissue:** - Longitudinal incision over 2nd-3rd metatarsal interval (6-8cm) - Incise through subcutaneous tissue - **Superficial peroneal nerve branches** (intermediate and medial dorsal cutaneous nerves): - Cross dorsum of foot obliquely (lateral to medial) - May require retraction or division (multiple small branches) - Injury causes dorsal foot numbness **Layer 2 - Extensor Tendons:** - **Extensor digitorum longus (EDL)** tendons: Run over 2nd, 3rd, 4th toes - **Extensor digitorum brevis (EDB)** tendons: Arise from calcaneus, insert on 2nd-4th toes (run lateral to EDL) - Interval: BETWEEN EDL to 2nd toe (medially) and EDL to 3rd toe (laterally) - Retract EDL tendons apart (2nd toe tendon medially, 3rd toe tendon laterally) to expose 2nd-3rd TMT joints **Layer 3 - Deep Peroneal Nerve and Dorsalis Pedis Artery (CRITICAL):** - **Location**: Run BETWEEN EHL tendon (medially) and EDL tendons (laterally) in 1st webspace - **Course**: Deep to extensor tendons, on surface of 2nd metatarsal base/middle cuneiform - **Identification**: After retracting EDL tendons, nerve/artery visible as neurovascular bundle running longitudinally - **PROTECTION**: - Identify neurovascular bundle early in dissection (before proceeding deeper) - Retract bundle MEDIALLY (toward EHL) or LATERALLY (toward EDL to 3rd toe) depending on which TMT joint accessing - Use vessel loop around bundle to mark location - AVOID traction injury (gentle handling), AVOID cautery near nerve (thermal injury) **Layer 4 - Joint Capsule:** - Incise capsule over 2nd and/or 3rd TMT joints longitudinally - Elevate periosteum subperiosteally from metatarsal bases and cuneiforms - Expose 2nd TMT (2nd metatarsal-middle cuneiform) and 3rd TMT (3rd metatarsal-lateral cuneiform) - 2nd metatarsal base RECESSED dorsally (keystone - sits between cuneiforms) - may require slight plantar flexion of 2nd metatarsal to visualize joint ### Neurovascular Anatomy and Relationships **Deep Peroneal Nerve:** - **Origin**: Common peroneal nerve divides into deep and superficial branches - **Course**: Runs in anterior compartment of leg, passes under extensor retinaculum at ankle, continues onto dorsum of foot - **Location on foot**: Runs in 1st webspace between EHL (medially) and EDL (laterally), accompanies dorsalis pedis artery - **Innervation**: - **Motor**: EHL (great toe extension), EDL (lesser toe extension at MTP joints), EHB (hallux extension at IP joint), EDB (lesser toe extension) - **Sensory**: 1st webspace skin (between great toe and 2nd toe dorsally) - SMALL sensory distribution - **Injury consequences**: - Motor loss: Weak toe extension (functionally minimal - can still walk, most patients unaware) - Sensory loss: 1st webspace numbness (NOT functionally limiting) - **Injury rate**: 5-10% with dorsal midfoot approaches (usually neuropraxia from retraction, recovers 6-12 months) **Dorsalis Pedis Artery:** - **Origin**: Continuation of anterior tibial artery (becomes dorsalis pedis at ankle joint level) - **Course**: Runs with deep peroneal nerve in 1st webspace - **Branches**: 1st dorsal metatarsal artery (supplies 1st webspace), arcuate artery (transverse across metatarsal bases) - **Clinical significance**: Primary blood supply to dorsal foot, BUT collateral circulation from plantar arteries usually adequate if injured - **Injury management**: Ligate if injured (collateral circulation sufficient in most patients), vascular surgery consultation if pulse absent post-operatively **Superficial Peroneal Nerve:** - **Course**: Pierces deep fascia 10-15cm proximal to ankle (anterolateral leg), divides into **medial dorsal cutaneous nerve** (to medial foot/great toe) and **intermediate dorsal cutaneous nerve** (to lateral foot/lesser toes) - **Distribution**: Dorsum of foot sensation (medial and intermediate branches cross dorsum obliquely) - **Injury**: Dorsal foot numbness (NOT functionally limiting, patients tolerate well) - **Injury rate**: 10-20% with dorsal midfoot approaches (multiple small branches cross incisions, difficult to avoid all) ## Indications and Contraindications ### Primary Indications (Evidence-Based) **ABSOLUTE Indications:** 1. **Lisfranc injuries** with displacement greater than 2mm: - **Purely ligamentous** (Lisfranc ligament rupture - 1st-2nd TMT diastasis) - **Fracture-dislocation** (metatarsal base fractures with TMT subluxation/dislocation) - **Myerson classification**: - Type A: Total incongruity (all TMT joints displaced in same direction) - Type B: Partial incongruity (B1 medial displacement, B2 lateral displacement) - Type C: Divergent (medial and lateral columns displaced in opposite directions) - Evidence: Myerson 2007 - ORIF anatomic reduction 85-90% good/excellent outcomes vs nonoperative 50-60% 2. **Primary TMT arthrodesis indications**: - Post-traumatic arthritis (after Lisfranc injury, despite anatomic reduction - 25-40% develop arthritis) - Charcot arthropathy (midfoot collapse - diabetes/neuropathy) - Inflammatory arthritis (rheumatoid, psoriatic) - Severe progressive flatfoot deformity (medial column instability) 3. **Displaced midfoot fractures** requiring ORIF: - Navicular fractures (body fractures, tuberosity avulsions) - Cuneiform fractures (displaced) - Metatarsal base fractures (intra-articular, displaced greater than 2mm) **RELATIVE Indications:** 1. **Non-displaced Lisfranc injuries** with instability (dynamic imaging - weight-bearing stress views show diastasis) 2. **Revision surgery** for hardware removal, malunion correction, nonunion treatment ### Contraindications **ABSOLUTE Contraindications:** 1. **Active infection** (osteomyelitis, soft tissue abscess) - requires infection eradication FIRST 2. **Severe vascular insufficiency** (ABI less than 0.5, absent pulses, tissue loss) - healing unlikely 3. **Insensate foot in non-compliant patient** (neuropathic foot requires strict offloading - if patient cannot comply, high risk of wound breakdown/Charcot progression) **RELATIVE Contraindications:** 1. **Significant soft tissue injury** (crush injury, compartment syndrome sequelae) - may benefit from delayed surgery or external fixation 2. **Non-displaced stable Lisfranc injuries** (less than 2mm diastasis on weight-bearing X-rays, no instability) - nonoperative management reasonable 3. **Elderly low-demand patients** with complex injuries - may favor nonoperative vs extensive reconstruction 4. **Severe osteoporosis** (very poor bone quality - fixation may fail, consider primary arthrodesis instead of ORIF) ## Preoperative Planning and Patient Positioning ### Preoperative Assessment **Clinical Examination:** - **Midfoot swelling and ecchymosis**: Plantar ecchymosis PATHOGNOMONIC for Lisfranc injury (high suspicion) - **Neurovascular assessment**: Dorsalis pedis and posterior tibial pulses, sensory examination (rule out compartment syndrome) - **Deformity assessment**: Forefoot abduction/adduction, pronation/supination - **Stability testing**: Passive abduction stress on forefoot (pain/crepitus suggests instability) **Radiographic Planning:** - **AP, lateral, oblique foot X-rays**: - **AP view**: Assess 1st-2nd TMT diastasis (normal less than 2mm), alignment of medial border of 2nd metatarsal with medial border of middle cuneiform - **Lateral view**: Assess dorsal subluxation/dislocation, loss of arch height - **Oblique view**: Assess lateral column (4th-5th TMT alignment) - **Weight-bearing views** (if patient can tolerate): May reveal instability not apparent on non-weight-bearing films - **CT scan** (for complex fractures): 3D reconstruction identifies fracture lines, comminution, articular involvement - **MRI** (for subtle injuries): Identifies Lisfranc ligament rupture (purely ligamentous injury without fracture), bone marrow edema **Surgical Planning:** - **Reduction strategy**: Plan reduction sequence (typically medial to lateral - restore medial column, then keystone 2nd metatarsal, then lateral column) - **Fixation strategy**: - Purely ligamentous: Screws across TMT joints (temporary vs permanent) - Fracture-dislocation: Plate/screw fixation of fractures, screws across intact TMT joints - Debate: Transarticular screws temporary (remove 12 weeks) vs permanent vs primary arthrodesis for severe injuries - **Incision planning**: Two incisions standard (medial + dorsal), add lateral incision if lateral column injured ### Patient Positioning **SUPINE position with bump under ipsilateral hip** (STANDARD): - **Position**: Patient supine, bump under ipsilateral hip (externally rotates leg, presents dorsum of foot) - **Leg position**: - Knee flexed 20-30° (relaxes ankle plantarflexors) - Ankle neutral (or slight plantar flexion for 2nd TMT exposure if recessed) - Foot supported on sterile towels or foam bolster - **Tourniquet**: Thigh tourniquet (exsanguinate, inflate to 300-350mmHg) - hemostasis critical for small midfoot structures - **C-arm access**: From contralateral side (AP and lateral foot fluoroscopy) ## Step-by-Step Surgical Technique (TWO-INCISION APPROACH) ### Step 1: Medial Incision and 1st TMT Exposure **Technique:** 1. **Mark medial incision**: 6-8cm longitudinal incision over 1st-2nd metatarsal interval - Proximal: Naviculocuneiform joint level - Distal: 1st metatarsal shaft mid-diaphysis 2. **Incise skin and subcutaneous tissue** down to extensor tendons 3. **Identify EHL tendon** (most medial extensor tendon, runs over 1st metatarsal) 4. **Retract EHL laterally** (exposes 1st metatarsal base and medial cuneiform) 5. **Incise joint capsule** over 1st TMT joint longitudinally (dorsal surface) 6. **Subperiosteal elevation**: Elevate periosteum from 1st metatarsal base and medial cuneiform 7. **Expose 1st TMT joint**: Full visualization of dorsal and medial aspects (can extend exposure to naviculocuneiform joint proximally if needed) ### Step 2: Dorsal Incision and 2nd-3rd TMT Exposure **Technique:** 1. **Mark dorsal incision**: 6-8cm longitudinal incision over 2nd-3rd metatarsal interval - Proximal: Naviculocuneiform joint level - Distal: 2nd-3rd metatarsal shafts mid-diaphysis - **CRITICAL**: Maintain 7cm+ separation from medial incision 2. **Incise skin and subcutaneous tissue** down to extensor tendons 3. **Identify EDL tendons**: To 2nd toe (medially) and 3rd toe (laterally) 4. **Identify deep peroneal nerve and dorsalis pedis artery** (CRITICAL STEP): - Neurovascular bundle runs BETWEEN EHL (medially) and EDL tendons (laterally) - Visible after retracting EDL tendons apart - Place vessel loop around bundle (marks location, allows gentle retraction) 5. **Retract neurovascular bundle**: MEDIALLY (toward EHL) for 2nd TMT access, OR LATERALLY (toward EDL to 3rd toe) for 3rd TMT access 6. **Incise joint capsules** over 2nd and 3rd TMT joints longitudinally 7. **Subperiosteal elevation**: Expose 2nd metatarsal base, middle cuneiform, 3rd metatarsal base, lateral cuneiform 8. **Expose 2nd and 3rd TMT joints**: Full dorsal visualization (2nd metatarsal base may be RECESSED - use small laminar spreader or slight plantar flexion of 2nd metatarsal to open joint for visualization) ### Step 3: Fracture/Dislocation Reduction (Lisfranc Injury) **Reduction Sequence (Medial to Lateral):** 1. **Reduce 1st TMT joint FIRST** (medial column - foundational): - Technique: Direct pressure on 1st metatarsal head (plantar direction) + pull on 1st metatarsal base (medial and plantar direction) - Goal: Restore alignment of 1st metatarsal base with medial cuneiform (anatomic articulation) - Temporary fixation: K-wires across 1st TMT joint (2.0mm K-wires, 2 wires for stability) - Fluoroscopy: AP and lateral views confirm anatomic reduction 2. **Reduce 2nd TMT joint SECOND** (keystone - critical for arch stability): - Technique: Elevate 2nd metatarsal base dorsally (disimpact if depressed), reduce medially (align with middle cuneiform) - Goal: Restore alignment of medial border of 2nd metatarsal base with medial border of middle cuneiform (AP view), restore height (lateral view) - Temporary fixation: K-wires across 2nd TMT (dorsal to plantar direction, 2 wires) - Fluoroscopy: AP view - medial borders MUST align (no step-off, no gap), lateral view - 2nd metatarsal base not depressed dorsally 3. **Reduce 3rd TMT joint THIRD**: - Usually reduces INDIRECTLY once 2nd TMT reduced (3rd metatarsal follows 2nd metatarsal) - If separate displacement: Direct manipulation + K-wire fixation 4. **Check 1st-2nd TMT diastasis**: - Fluoroscopy AP view: Distance between 1st and 2nd metatarsal bases should be less than 2mm - If diastasis persists: Consider screw across 1st to 2nd metatarsal bases (controversial - some surgeons place, others rely on anatomic reduction of each TMT joint individually) ### Step 4: Definitive Fixation (Multiple Options) **Option A: Transarticular Screws (Most Common):** - **1st TMT**: 2 screws (4.0mm or 4.5mm cannulated screws) from 1st metatarsal base into medial cuneiform - Direction: Dorsal-medial to plantar-lateral (perpendicular to joint), one screw each in dorsal and plantar halves - Engage medial cuneiform and navicular (bicortical purchase distally) - **2nd TMT**: 1-2 screws from 2nd metatarsal base into middle cuneiform - Direction: Dorsal to plantar (perpendicular to joint) - Challenging: 2nd metatarsal base recessed (requires careful drilling to avoid neurovascular bundle) - **3rd TMT**: 1 screw (if unstable) from 3rd metatarsal base into lateral cuneiform - **Intercuneiform screws** (optional): Screw from medial cuneiform to middle cuneiform (stabilizes medial arch) - **Debate**: Temporary (remove 12 weeks) vs permanent screws - Temporary: Allows TMT motion after healing, may reduce arthritis risk (controversial) - Permanent: Avoids second surgery, similar outcomes (Ly 2010: no difference functional outcomes temporary vs permanent) **Option B: Plate Fixation:** - Low-profile plate (2.7mm or 3.5mm) along dorsal metatarsal bases - Screws into metatarsal shafts distally, cuneiforms proximally - Used for: Metatarsal base fractures requiring fragment-specific fixation, comminuted fractures - Less common than screws alone for purely ligamentous injuries **Option C: Primary Arthrodesis (Fusion):** - Reserved for: Severe cartilage damage at presentation, revision after failed ORIF, Charcot arthropathy - Technique: Remove articular cartilage, compress joints with screws/plates, bone graft if large gaps - Fusion rate: 90-95% with rigid compression - Outcomes: Similar to anatomic reduction with ORIF (Komenda 2001: TMT arthrodesis AOFAS 80-85 points) ### Step 5: Closure **Technique:** 1. **Irrigate wounds**: Copious saline lavage 2. **Close capsules** (if possible): Reapproximate with absorbable sutures (3-0 Vicryl) 3. **Subcutaneous closure**: 3-0 or 4-0 absorbable sutures 4. **Skin closure**: Simple interrupted or subcuticular (3-0 or 4-0 nylon/monocryl) 5. **Dressing**: Bulky compressive dressing, posterior splint (ankle neutral, foot neutral) 6. **Post-operative protocol**: - **Weeks 0-6**: NON-weight-bearing (crutches), remove sutures 2-3 weeks, transition to short-leg cast or boot - **Weeks 6-12**: Advance to partial weight-bearing in boot (radiographic healing assessed) - **Week 12**: Full weight-bearing, wean from boot - **Temporary hardware removal** (if planned): 12 weeks post-ORIF (after ligament healing) ## Complications and Management ### Intraoperative Complications **1. Deep Peroneal Nerve Injury (5-10% incidence)** **Recognition:** - Visual injury during dorsal incision (transection, cautery burn, excessive retraction) - Post-operative: Weak toe extension (EHL/EDL weakness), 1st webspace numbness **Management:** - **Intraoperative**: If transected sharply, consider primary repair (8-0 or 9-0 nylon epineurial sutures) - outcomes variable - **Post-operative**: Most injuries are neuropraxia from retraction - observe, 70-80% recover 6-12 months - **Permanent deficit**: Weak toe extension (functionally minimal - patients compensate, AFO not needed), 1st webspace numbness (NOT functionally limiting) **Prevention:** - Identify neurovascular bundle early in dorsal incision dissection (BEFORE proceeding deep to joint capsules) - Vessel loop around bundle (marks location, allows gentle retraction) - Retract GENTLY (avoid excessive traction) - Stay in 2nd-3rd metatarsal interval (deep peroneal nerve medially in 1st webspace, superficial peroneal nerve laterally in 4th-5th webspace - 2nd-3rd is 'safe zone') **2. Dorsalis Pedis Artery Injury (Rare, less than 1%)** **Recognition:** - Pulsatile bleeding during dissection - Loss of DP pulse post-operatively **Management:** - **Intraoperative**: Ligate if injured (collateral circulation from plantar arteries usually adequate) - **Post-operative**: If pulse absent and foot ischemic (cool, pale) - vascular surgery consultation (rare complication) **3. Inadequate Reduction (5-10% incidence)** **Recognition:** - Fluoroscopy shows persistent diastasis (greater than 2mm), malalignment - Usually at 2nd TMT (keystone difficult to reduce if severely depressed or comminuted) **Management:** - **Intraoperative**: Repeat reduction maneuvers (disimpaction, use of laminar spreader to open joint, K-wire joysticks in metatarsal bases) - If anatomic reduction not achievable (severe comminution, osteochondral damage): Consider PRIMARY ARTHRODESIS (convert ORIF to fusion - remove cartilage, compress with screws, bone graft) - better outcome than malreduced ORIF (Komenda 2001) ### Early Post-operative Complications (0-12 weeks) **1. Wound Complications (5-10% incidence with proper technique)** **Types:** - Superficial dehiscence (3-5%) - Superficial infection (2-3%) - Skin necrosis (rare less than 1% with proper incision planning) **Risk factors:** - Improper incision placement (transverse incisions, skin bridges less than 7cm, undermining) - Diabetes (healing impaired) - Smoking (poor perfusion) - Significant soft tissue trauma at injury (crush, compartment syndrome) **Management:** - **Superficial**: Local wound care, oral antibiotics if cellulitis - **Deep infection**: Return to OR for irrigation/debridement, IV antibiotics, hardware removal if infected and not required for stability - **Skin necrosis**: Early debridement, negative pressure wound therapy, skin graft or flap coverage if large defect **2. Loss of Reduction (3-5% incidence)** **Recognition:** - Serial X-rays show recurrent diastasis, malalignment - Usually early (first 4-6 weeks before ligament healing) **Mechanism:** - Inadequate initial fixation (insufficient screws, screw pull-out in osteoporotic bone) - Early weight-bearing (patient non-compliance) - Hardware failure (screw breakage) **Management:** - **Early (less than 6 weeks)**: Consider revision ORIF (re-reduce, augment fixation with additional screws/plate) - **Late (greater than 6 weeks)**: Observe, plan arthrodesis if symptomatic arthritis develops ### Late Post-operative Complications (12+ weeks) **1. Post-Traumatic Arthritis (25-40% incidence long-term)** **Recognition:** - Persistent midfoot pain (worse with activity, walking on uneven ground) - Stiffness, swelling - X-rays: TMT joint space narrowing, subchondral sclerosis, osteophytes **Risk factors:** - Severe initial injury (high-energy trauma, cartilage damage) - Malreduction (residual diastasis greater than 2mm, articular step-off) - EVEN WITH anatomic reduction: 25% develop arthritis (irreversible cartilage damage from initial trauma - Myerson 2007) **Management:** - **Conservative**: NSAIDs, activity modification, stiff-soled shoes or carbon fiber inserts (limit TMT motion), corticosteroid injections (temporary relief) - **Surgical**: TMT arthrodesis (fusion) - Indications: Failed conservative management, significant pain limiting function - Technique: Remove articular cartilage from affected TMT joints, compress with screws/plates, bone graft if large voids - Outcomes: 85-90% pain relief, 90-95% fusion rate, patients satisfied (Komenda 2001: TMT arthrodesis AOFAS 80-85 points) - Functional impact: Loss of TMT motion (minimal functional loss - TMT joints normally contribute little to gait) **2. Hardware Prominence/Irritation (10-15% incidence)** **Recognition:** - Palpable/prominent screw heads or plate on dorsal foot - Pain with shoe wear, direct pressure - Skin tenting over hardware **Management:** - **Observation** if asymptomatic - **Hardware removal** after fracture/ligament healing (12+ weeks post-ORIF) - Timing: Temporary screws removed 12 weeks (planned), permanent hardware removed if symptomatic (unplanned but common 10-15%) - Outcomes: 85-90% symptom resolution with hardware removal **3. Malunion (if inadequate reduction at index procedure)** **Recognition:** - Persistent forefoot abduction, loss of arch height - Abnormal shoe wear pattern, difficulty with shoes - X-rays: Diastasis, malalignment **Management:** - **Conservative**: Orthotic devices (custom arch support), extra-depth shoes - **Surgical**: Corrective osteotomy + fusion (complex, reserved for severe symptomatic malunion) ## Pearls, Pitfalls, and Expert Tips ### Surgical Pearls (What Separates Good from Great) **Pearl 1: Multiple LONGITUDINAL incisions - NEVER transverse** - Preserve dorsal foot blood supply (angiosomes run longitudinally) - Maintain 7cm+ separation between incisions (preserves intervening skin perfusion) - Transverse incisions devascularize skin (necrosis 10-20% - Zwipp 2004) **Pearl 2: Reduce medial column (1st TMT) FIRST** - Foundational - establishes medial arch reference - All other reductions reference off anatomic 1st TMT - Sequence: 1st TMT → 2nd TMT (keystone) → 3rd TMT (follows 2nd) **Pearl 3: Deep peroneal nerve in dorsal incision - identify EARLY** - Neurovascular bundle between EHL and EDL tendons (1st webspace) - Place vessel loop around bundle BEFORE proceeding deep to capsule - Gentle retraction only (excessive traction = neuropraxia) **Pearl 4: 2nd TMT is RECESSED (keystone)** - 2nd metatarsal base sits between cuneiforms (dorsally recessed) - May require slight plantar flexion of 2nd metatarsal to visualize joint - Use laminar spreader to open joint if needed (improves visualization) **Pearl 5: Fluoroscopy alignment checks (CRITICAL views)** - **AP view**: Medial border 2nd metatarsal MUST align with medial border middle cuneiform (no step-off, no gap) - **Lateral view**: 2nd metatarsal base NOT depressed dorsally (maintains arch height) - **Oblique view**: 4th-5th TMT alignment if lateral column injured ### Common Pitfalls (and How to Avoid Them) **Pitfall 1: Single transverse incision across dorsum** - **Problem**: Devascularizes skin (necrosis 10-20%), causes wound complications - **Solution**: MULTIPLE longitudinal incisions (2-3 incisions), 7cm+ separation, oriented parallel to metatarsals - **Recovery**: If necrosis occurs - debridement, negative pressure wound therapy, skin graft/flap **Pitfall 2: Parallel incisions too close together (less than 7cm apart)** - **Problem**: Creates ischemic skin bridge (necrosis risk 5-10%) - **Solution**: Measure separation at mid-length of incisions (minimum 7cm), adjust positions if needed - **Alternative**: If more exposure needed, extend existing incisions proximally/distally rather than adding closer parallel incision **Pitfall 3: Not recognizing deep peroneal nerve** - **Problem**: Inadvertent injury (transection, cautery, excessive retraction) causes toe extension weakness, numbness - **Solution**: Identify neurovascular bundle EARLY (after retracting EDL tendons, before incising capsule), vessel loop marks location - **Recovery**: Most injuries are neuropraxia (recover 6-12 months), transection has poor recovery despite repair **Pitfall 4: Accepting malreduction (persistent 1st-2nd diastasis greater than 2mm)** - **Problem**: Malreduction leads to poor outcomes (AOFAS 58 vs 85 with anatomic reduction - Myerson 2007), high arthritis rate (60% vs 25%) - **Solution**: Repeat reduction maneuvers, use K-wire joysticks in metatarsal bases for manipulation, consider intraoperative decision for primary arthrodesis if anatomic reduction not achievable - **Prevention**: Multiple fluoroscopy views BEFORE definitive fixation (confirm less than 2mm diastasis, alignment of borders) **Pitfall 5: Inadequate fixation (single screw per TMT joint)** - **Problem**: Hardware failure, loss of reduction (recurrent diastasis) - **Solution**: Minimum 2 screws per TMT joint (1st TMT always 2 screws - dorsal and plantar halves), consider intercuneiform screws for medial arch stability - **Alternative**: If bone quality poor (osteoporotic), use low-profile plates instead of screws alone (distributes load) ### Expert Tips (From High-Volume Surgeons) **Tip 1: Use 2nd-3rd metatarsal interval for dorsal incision (SAFE ZONE)** - Deep peroneal nerve medially (1st webspace), superficial peroneal nerve laterally (4th-5th webspace) - 2nd-3rd interval is BETWEEN these structures (lower nerve injury risk) **Tip 2: K-wire joysticks in metatarsal bases aid reduction** - Insert 2.0mm K-wires into metatarsal bases (act as handles) - Manipulate bases into position using K-wires (better control than finger manipulation) - Leave K-wires in place as temporary fixation until definitive screws placed **Tip 3: Consider primary arthrodesis for severe injuries** - If severe comminution, osteochondral damage, or difficult to achieve anatomic reduction: Convert to fusion - Komenda 2001: Primary arthrodesis AOFAS 82 vs ORIF 72 for severe patterns (p = 0.04) - Avoids 68% secondary fusion rate after failed ORIF **Tip 4: Temporary screws removed 12 weeks (if planned)** - Return to OR 12 weeks post-ORIF (ligament healing complete) - Remove screws percutaneously under fluoroscopy guidance (usually does NOT require large incisions) - Protect from re-injury (boot for 2-4 weeks post-removal, gradual return to activities) **Tip 5: Counsel on arthritis risk REGARDLESS of reduction quality** - 25% develop post-traumatic arthritis even with anatomic reduction (Myerson 2007) - Irreversible cartilage damage from initial high-energy trauma - TMT arthrodesis salvage procedure has good outcomes (AOFAS 80-85, 90-95% pain relief) - Set realistic expectations (surgery maximizes chance of good outcome but cannot guarantee perfect result)