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Background: The gold standard for diagnosis of Lisfranc instability is direct visualization in the operation room while the examination techniques is still unstandardized and non-reproducible. We aimed to introduce a novel reproducible intraoperative mechanical testing method (Listract test) for intraoperative isolated Lisfranc instability assessment. Methods: The Lisfranc ligament between the first cuneiform (C1) and second metatarsus (M2) in eight lower leg cadaveric specimens were dissected to replicate C1-M2 Lisfranc instability by eight foot and ankle surgeons. The 50N distraction force was applied in the direction of the C1-M2 ligament. Three methods of fixation - flexible fixation, metal screw, and bio-absorbable screw- were used to fix the injury, and Listract test was applied again after fixation. Besides intraoperative assessment, C1-M2 diastasis and area were measured using radiographs for assessment of Lisfranc instability. Results: The sensitivity and specificity of the Listract test for detection of C1-M2 instability were 100% and 100% intraoperatively, 33.3% and 95.2% using radiographic diastasis measurement, and 63.2% and 38% using area measurement, respectively. The Listract test had a specificity and sensitivity of 100% and 96% for intraoperative assessment, 87.5% and 64.3 for radiographic C1-M2 diastasis, and 48% and 50% for radiographic area. Conclusion: The Listract test is a simple, reproducible, and replicable intraoperative method for evaluating the Lisfranc joint for instability. Developing a device with this mechanism can help clinicians confirm the diagnosis and provide appropriate treatment particularly for equivocal diagnoses.

Category: Other; Ankle Introduction/Purpose: Over the last decade, simultaneous or overlapping procedures in orthopedic surgery have come under increased media attention and public scrutiny. While little is known about what surgeons consider to be 'critical portions' of the myriad of foot and ankle procedures performed, even less is known about the expectations and opinions of patients themselves. In this study we aimed to elucidate patients' expectations of foot and ankle surgeons regarding their presence at different portions of a given surgery and what portions of a surgery they considered to be 'critical'. Methods: In this survey, data was collected using a questionnaire that was filled out by 49 patients presenting to an orthopedic foot and ankle tertiary referral clinic. The questions were designed around three common foot and ankle procedures: open reduction, internal fixation of fractures (ORIF), Achilles tendon repair, and ankle arthroscopy. For each procedure, the key steps were identified, and the responding patient was asked to characterize each step as 'Always Critical' 'Often Critical' 'Sometimes Critical' 'Rarely Critical' or 'Never Critical.' Additionally, demographics, education level, number of prior surgeries, and profession were also collected from the patients. Data were described using means, ranges, and percentages. Results: Of the 49 patients surveyed, the average age was 52.9 years old; 59% were female and 41% were male; 76% of respondents were college graduates, 8% completed some college, and 12% were high school graduates. Overall, 12% of respondents work in a healthcare related field. The average number of previous surgeries was 2.0, with a minimum of 0 and a maximum of 14. In all three procedures, the steps for which more than 50% of the patients identified as 'Always Critical' were discussion of risks, benefits, and alternatives, marking the surgical site, pre-operative time-out, skin incision for ORIF, soft tissue dissection, reduction of fracture, fracture fixation with hardware, repair of the tendon, and scoping the ankle. Across all three procedures, transferring the patient between operating table and bed, applying a sterile bandage, and applying a splint were categorized as the least critical portions of the procedure (Figure 1). Conclusion: The result of this study offers insight on what the most critical portion of three common foot and ankle procedures from the patient's perspective. Generally speaking, patients perceived initial dissection and even closure to be critical, in addition to procedural elements such as fracture reduction. Ongoing research aims to correlate these findings with the perceptions of foot and ankle surgeons themselves. Nonetheless, it highlights the potential discrepancy in perceptions between clinicians and patients as it pertains to 'critical portions' of a given procedure.