What should be included in the operative note for a case of left foot Lisfranc injury operated with closed reduction internal fixation using 6 K-wires (Kirschner wires) of 1.2 mm size?

Operative Note for Left Foot Lisfranc Injury with Closed Reduction and Internal Fixation

The optimal surgical management for a Lisfranc injury involves closed reduction with percutaneous K-wire fixation to restore anatomic alignment and joint stability while minimizing soft tissue trauma.

Preoperative Diagnosis

• Left foot Lisfranc injury

Postoperative Diagnosis

• Left foot Lisfranc injury, successfully reduced and internally fixed

Procedure Performed

• Closed reduction and internal fixation (CRIF) of left foot Lisfranc injury using six 1.2 mm Kirschner wires

Anesthesia

• [Specify type: General/Regional/Local]

Surgical Team

• Surgeon: [Name]
• Assistant: [Name]
• Anesthesiologist: [Name]
• Scrub Nurse: [Name]

Preoperative Assessment

• Patient positioned supine on the operating table
• Left foot prepped and draped in standard sterile fashion
• Fluoroscopic stress examination performed to identify all components of instability 1
• Prophylactic antibiotics administered prior to incision (cefazolin recommended for extremity trauma) 2

Operative Findings

• Unstable Lisfranc joint with displacement between the medial cuneiform and base of second metatarsal
• No evidence of open fracture or neurovascular compromise
• Displacement confirmed on fluoroscopic imaging

Operative Procedure

1. Initial Assessment

   • Fluoroscopic examination confirmed Lisfranc injury with displacement at the tarsometatarsal joints 1

2. Closed Reduction

   • Manual traction applied to the forefoot with counter-pressure at the midfoot
   • Reduction maneuver performed with direct pressure over the displaced tarsometatarsal joints
   • Reduction confirmed with fluoroscopic imaging in multiple planes 1
   • Reduction held with a percutaneous clamp

3. K-wire Fixation

   • First K-wire (1.2 mm) inserted from the medial cuneiform to the base of the second metatarsal to stabilize the key Lisfranc joint 3
   • Second K-wire inserted from the medial cuneiform to the intermediate cuneiform
   • Third K-wire placed from the intermediate cuneiform to the base of the second metatarsal
   • Fourth K-wire inserted across the first tarsometatarsal joint
   • Fifth K-wire placed across the third tarsometatarsal joint
   • Sixth K-wire inserted across the fourth tarsometatarsal joint
   • All K-wire placements confirmed with AP, lateral, and oblique fluoroscopic views 4

4. Final Assessment

   • Anatomic reduction achieved and confirmed on multiple fluoroscopic views 5
   • Stability of the fixation tested under direct fluoroscopic visualization
   • K-wires cut and bent at skin level

5. Wound Closure

   • Pin sites cleaned
   • Sterile dressing applied
   • Well-padded short leg splint applied with the foot in neutral position

Estimated Blood Loss

• Minimal

Complications

• None

Postoperative Plan

1. Immediate Care

   • Non-weight bearing on the left lower extremity for 6 weeks 1
   • Elevation of the extremity to minimize swelling
   • Pain management as appropriate
   • Prophylactic antibiotics as indicated 2

2. Follow-up Care

   • First follow-up at 2 weeks for wound check and splint removal
   • Transition to removable boot at 2 weeks 1
   • K-wire removal planned at 6-8 weeks post-surgery
   • Progressive weight bearing to begin at 6 weeks with arch support 1
   • Physical therapy to be initiated after K-wire removal
   • Full weight bearing expected at 12-16 weeks postoperatively 1

3. Long-term Monitoring

   • Regular radiographic assessment to monitor reduction and healing
   • Monitoring for complications including posttraumatic arthritis, which occurs in approximately 25% of cases despite anatomic reduction 5

Clinical Pearls and Pitfalls

• Anatomic reduction is the primary determinant of good outcomes in Lisfranc injuries 5
• Failure to achieve anatomic reduction can lead to post-traumatic arthritis, foot deformities, and significant disability 3
• Percutaneous fixation minimizes soft-tissue trauma compared to open procedures, reducing risk of wound complications 1
• K-wire fixation is particularly useful when there is comminution at the base of the second metatarsal 4
• Early mobilization after appropriate healing period is important to optimize functional outcomes 1