A medial-column distractor may be used to restore the length of the medial column.
If the medial distraction creates an abduction deformity, applying a lateral distractor may help minimize the angulation.
It is helpful to have comparative x-rays from the uninjured side, allowing proper length and morphology to be judged.
The proximal pin is inserted into the neck of the talus through a stab incision. Image intensification can be used to ensure correct pin placement outside the articular surfaces. The correct insertion point is often located 1–2 cm posterior to the navicular tubercle.
The distal pin is inserted in the first metatarsal.
4. Irrigation and debridement
Irrigate the fracture site using a syringe.
Displaced fracture fragments are debrided and mobilized with a dental pick or Freer elevator.
Once adequate visualization has been achieved and the joint thoroughly irrigated, examine the extent of articular surface involvement to validate the preoperative plan of primary fusion versus ORIF.
If joint fragmentation is not extensive and tarsometatarsal instability is absent, it may be possible to perform fixation.
5. Preparation of joint for fusion
Preparation of joint for fusion
Remove the cartilage on both sides using a curette.
Penetrate the subchondral bone using a high-speed burr to promote bone growth.
The application of bone graft, allograft, or bone substitute may be required to fill a small gap in such a length-stable situation.
6. Temporary fixation
Compress the arthrodesis site and secure the compression with K-wires.
7. Lag screw fixation
Ideally, two 3.5 lag screws are inserted. One comes from the distodorsal to proximal plantar. One comes from proximal dorsal to distal plantar.