Nonunion Rate Following Primary Arthrodesis for Acute Lisfranc Injuries.

Injury to the tarsometatarsal joint (TMT) results in instability throughout the midfoot that does not often improve with conservative management. If instability is identified, surgical intervention is frequently recommended, either open reduction and internal fixation (ORIF) or primary arthrodesis (PA). These 2 treatment options have been compared in the literature multiple times, often reporting similar outcomes. Due to this, as well as the need for subsequent hardware removal after ORIF has led many surgeons towards PA at the index surgery. Concern for nonunion is a leading concern with surgeons who advocate instead for ORIF. The purpose of this study is to review patients who underwent PA and observe nonunion rates. Nonunion at the TMT has been previously studied, but only in the chronic setting. We performed a retrospective study of 34 patients who had PA in the management of an acute Lisfranc injury. The average age in our study was 43.9 years old (range 19-72, SD 17.4) with an average follow-up of 9.4 months (range 4-33, SD 6.2). Radiographs were evaluated for signs of nonunion at regular postoperative intervals. Within the patients included in the study, a total of 71 TMT joints were fused. Overall successful fusion rate was 95.8% at an average of 7.9 weeks (range 6-12, SD 1.4) postoperatively. Individual nonunion rates at the first, second, and third TMT were 0%, 1.4% and 2.8% respectively. Our study demonstrates that primary arthrodesis provides a predictable outcome with low nonunion rates in the management of acute Lisfranc injury.

Ultrasound Imaging Guide for Assessment of the Intrinsic Ligaments Stabilizing the Subtalar and Midtarsal Joints.

Ligament injuries around the subtalar, talocalcaneonavicular, and calcaneocuboid joints are often underestimated on clinical and imaging findings during investigation of patients with ankle and foot injuries. Because a delayed diagnosis of midtarsal ligament tears may lead to chronic pain and functional disability, an in-depth knowledge of the complex regional anatomy and of the appropriate ultrasound scanning technique is a prerequisite for evaluating these structures and avoiding misdiagnoses. The objective of this article is twofold: to describe the relevant anatomy and biomechanics related to the ligaments that stabilize the subtalar, talocalcaneonavicular, and calcaneocuboid joints, and to illustrate reasoned landmark-based scanning techniques to provide a systematic examination of these ligaments and thus make ultrasound an effective tool for assessment of patients with suspected subtalar or midtarsal sprain.

Validity and internal consistency of the American Orthopaedic Foot and Ankle Society Midfoot Scale in patients with Lisfranc injury.

BACKGROUND: The American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot Scale is an extensively used outcome measure instrument for evaluating outcomes after foot and ankle surgery or trauma. METHODS: In total, 117 patients with Lisfranc injury completed the AOFAS Midfoot Scale and the Visual Analogue Scale Foot and Ankle (VAS-FA) instruments. Internal consistency (correlation between different items), floor and ceiling values, convergent validity, item threshold distribution, and the coverage (item difficulty) of the AOFAS Midfoot scale were tested. RESULTS: AOFAS Midfoot Scale had high convergent validity and acceptable internal consistency (Cronbach's alpha >0.70). The ceiling effect was confirmed. The person-item distribution indicated that the scale had a lack of coverage and targeting in our sample. CONCLUSIONS: Our data suggests that the AOFAS Midfoot Scale has acceptable validity and internal consistency. However, due to the lack of coverage and targeting, it should not be the primary outcome measure to be used to evaluate the outcomes after Lisfranc injury in the future studies.

Lisfranc injuries: Incidence, mechanisms of injury and predictors of instability.

BACKGROUND: In Lisfranc injuries the stability of the tarsometatarsal joints guides the treatment of the injury. Determining the stability, especially in the subtle Lisfranc injuries, can be challenging. The purpose of this study was to identify incidence, mechanisms of injury and predictors for instability in Lisfranc injuries. METHODS: Eighty-four Lisfranc injuries presenting at Oslo University Hospital between September 2014 and August 2015 were included. The diagnosis was based on radiologically verified injuries to the tarsometatarsal joints. Associations between radiographic findings and stability were examined. RESULTS: The incidence of Lisfranc injuries was 14/100,000 person-years, and only 31% were high-energy injuries. The incidence of unstable injuries was 6/100,000 person-years, and these were more common in women than men (P = 0.016). Intraarticular fractures in the two lateral tarsometatarsal joints increased the risk of instability (P = 0.007). The height of the second tarsometatarsal joint was less in the unstable injuries than in the stable injuries (P = 0.036). CONCLUSION: The incidence of Lisfranc injuries in the present study is higher than previously published. The most common mechanism of injury is low-energy trauma. Intraarticular fractures in the two lateral tarsometatarsal joints, female gender and shorter second tarsometatarsal joint height increase the risk of an unstable injury. LEVEL OF EVIDENCE: Level III, cross-sectional study.

Comparative analysis of clinical outcomes of fixed-angle versus variable-angle locking compression plate for the treatment of Lisfranc injuries.

BACKGROUND: Fixed-angle locking compression plate (LCP) and variable-angle LCP are utilized for internal fixation of Lisfranc injuries. However, studies regarding the difference of clinical outcomes of these two plates are limited. The purpose of present study was to compare postoperative outcomes between these two plate types in Lisfranc injuries. METHODS: A total of 45 consecutive patients (22 patients with fixed-angle LCP and 23 patients with variable-angle LCP) who underwent surgical treatment for Lisfranc injury were reviewed for this retrospective study. The Foot Function Index (FFI), numerical rating scale (NRS) for pain, development of complications, operative time, and patient satisfaction for current activity were compared. RESULTS: There were no significant differences in FFI and NRS for pain at three months and 12 months following surgery. Postoperative complication rate was similar between two groups. Patients with variable-angle LCP had an 18 min shorter mean length of operation (p = 0.040). Patient satisfaction for current activity was not differ between two groups. CONCLUSIONS: The use of variable-angle LCP for treatment of Lisfranc injuries did not show superiority in functional outcomes, pain, complication rates, or patient satisfaction to fixed-angle LCP, but operative time was shorter with variable-angle LCP. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Normal Anatomy and Traumatic Injury of the Midtarsal (Chopart) Joint Complex: An Imaging Primer.

The midtarsal (Chopart) joint complex consists of the talonavicular and calcaneocuboid joints and their stabilizing ligaments. Detailed assessment of this complex at MRI can be challenging owing to frequent anatomic variation and the small size of the structures involved. Nevertheless, a wide spectrum of pathologic conditions affect the joint complex, and its imaging evaluation deserves more thorough consideration. This review focuses on MRI evaluation of normal ligamentous anatomy and common variations about the Chopart joint, presenting practical imaging tips and potential diagnostic pitfalls. Imaging findings across a spectrum of traumatic Chopart joint injuries are also reviewed, from midtarsal sprains to Chopart fracture-dislocations. Midtarsal sprains-commonly associated with ankle inversion injuries-are emphasized, along with their often predictable radiographic and MRI injury patterns. Online DICOM image stacks are available for this article. ©RSNA, 2018.

Undisplaced subtle ligamentous Lisfranc injuries, conservative or surgical treatment with percutaneous position screws?

PURPOSE: Undisplaced subtle ligamentous Lisfranc injuries are easy to miss or underestimate, and many cases are treated without surgical fixation. It has not yet widely known whether conservative treatment for undisplaced subtle ligamentous Lisfranc injuries may lead to a poor outcome. The purpose of this study is to compare the outcomes of conservative versus surgical management (percutaneous position screw) of undisplaced subtle ligamentous Lisfranc injury. METHODS: We analysed 61 cases in this retrospective study, including 38 males and 23 females. Forty-one patients were managed conservatively, while 20 patients received surgical treatment involving minimal invasive percutaneous position screw. American orthopaedic foot &ankle society (AOFAS), foot function index (FFI, including FFI disability, FFI pain score and activity limitation scale) scores, Maryland foot score and short form-36 (SF-36) were recorded and compared after a follow-up of 10-16 months (average 12.3). RESULTS: Patients in the surgical management group had higher scores in all evaluation methods (p < 0.05). The complications in the conservative management group had higher incidence, mainly including secondary diastasis (34.1% vs. 5.0%), joint stiffness after 3 months (82.9% vs. 0%), and secondary arthrodesis (12.2% vs. 0%). The highest rate of complication in surgical management group was temporary forefoot pain (55.0%). CONCLUSION: The results of this study suggest that the outcomes of the surgical management with percutaneous position screw fixation are better than the conservative management to treat undisplaced subtle ligamentous Lisfranc injuries. This study can serve as a resource for orthopaedic surgeons in recognizing and managing such injuries.

Is Routine Hardware Removal Following Open Reduction Internal Fixation of Tarsometatarsal Joint Fracture/Dislocation Necessary?

Open reduction internal fixation (ORIF) is an accepted treatment for displaced tarsometatarsal joint (TMTJ) fracture dislocations. In general, hardware is routinely removed after 4 months to allow restoration of joint motion and avoid complications of hardware failure. Because few studies report outcomes of TMTJ fractures with retained hardware, there is little consensus regarding the optimal time for hardware removal or if hardware retention leads to adverse outcomes. We retrospectively reviewed the radiographic outcomes of retained hardware after ORIF of TMTJ fractures/dislocations in 61 patients. The mean age at the time of operation was 37.3 ± 14.9 years. ORIF was performed with 3.5 fully threaded cortical screws. Assessment of clinical and radiographic results was performed at 2 weeks, 6 weeks, 3 months, 6 months, and 12 months after surgical treatment. Out of the 61 patients that were included in this study, only 2 demographic variables demonstrated a trend for an adverse outcome. Older age correlated with lost reduction and elevated body mass index correlated with hardware failure. The presence of diabetes was correlated with an increased risk of postoperative infection but not hardware failure. During our follow-up period there were 49 patients (80.3 %) without failure of fixation. In conclusion, our study suggests that routine removal of hardware following open reduction and internal fixation of Lisfranc injuries in patients may not be necessary.

Osteochondral Defect of the Calcaneocuboid Joint: A Case Study.

Osteochondral lesions (OCLs) are injuries affecting the articular cartilage surface of a joint. OCLs are well reported in the literature to affect the knee, talus, tibia, navicular, and first metatarsal. This rare case of a bipolar osteochondral lesion of the cuboid and calcaneus presented as lateral heel pain after a traumatic injury. After an unsuccessful course of conservative therapy, the lesion was treated with curettage and application juvenile particulate cartilage allograft. Eight months postoperatively, the patient was ambulating in supportive shoe gear without pain. The mechanism of injury leading to calcaneocuboid joint osteochondral lesions is not clearly understood. It is also questionable whether anatomic variances are contributory. Regardless of causality, OCLs should be included in the differential diagnoses for patients presenting with calcaneocuboid joint or lateral hindfoot pain.

Imaging of Chopart (Midtarsal) Joint Complex: Normal Anatomy and Posttraumatic Findings.

OBJECTIVE: The objective of this article is to review the normal anatomy and posttraumatic findings of the Chopart joint complex. Key imaging features of the normal ligaments and patterns of ligamentous and osseous injuries are discussed. CONCLUSION: Traumatic midtarsal injuries, particularly midtarsal sprain, are often overlooked clinically and on imaging but are relatively common and typically are associated with inversion ankle injuries. Radiologists should be familiar with Chopart joint anatomy and the imaging features of midtarsal injuries because early diagnosis may help optimize clinical management.

Acute Fracture of the Anterior Process of Calcaneus: Does It Herald a More Advanced Injury to Chopart Joint?

OBJECTIVE: Injuries at the calcaneocuboid and talonavicular joint have been described as two distinct, unrelated entities in the radiology literature. Our purpose was to assess the coexistence of these injuries using radiography and MRI and to correlate our findings with radiologic and clinical diagnoses. MATERIALS AND METHODS: Twenty-one patients with injury at the anterior calcaneal process on radiographs or MR images were retrospectively assessed for concomitant injury at the talonavicular joint. Radiologic and clinical diagnoses and treatment were documented. McNemar and kappa statistics were calculated; p values < 0.05 were considered statistically significant. RESULTS: Radiographic and MRI rates of detection of injuries across the Chopart joint were statistically different. Calcaneocuboid avulsion fractures were evident on 48% of radiographs and 100% of MR images (p = 0.001). Talonavicular joint injuries were evident on 38% of radiographs and 76% of MR images (p = 0.008). Concomitant injury at both joints was evident on 14% of radiographs and 76% of MR images (p < 0.0001). Interrater agreement was 0.488-0.637 and 0.286-0.364 for talonavicular and 0.144-0.538 and 0.976-1 for calcaneocuboid injuries on radiography and MRI, respectively. Sixty percent of calcaneocuboid fractures were prospectively missed on radiography (none on MRI), whereas 38% and 25% of talonavicular findings were missed on radiography and MRI, respectively. Sixty percent of injuries were clinically misdiagnosed as ankle sprains. Chopart joint injury was never mentioned in prospective clinical or imaging diagnoses. CONCLUSION: Calcaneocuboid and talonavicular injuries commonly coexist. Radiographs underestimate severity of injury; MR images show more subtle abnormalities. Lack of mention of Chopart joint injury clinically and on imaging reports underlies the need for greater familiarity with this entity.

Stabilization of the Fourth Metatarsal-Cuboid Lateral Lisfranc Injury: Early Results of an Innovative Technique Using Suture Anchors.

This report presents an innovative surgical technique for the correction of cuboid-metatarsal subluxation at the level of the lateral Lisfranc joint. This stabilization technique reinforces the dorsal fourth tarsometatarsal ligament by incorporating sutures and anchors, establishing a more stable joint. The data from 5 female patients undergoing stabilization using a suture anchor construct were reviewed. All 5 patients were able to resume their activities, including the adolescent athletes. Anatomic reconstruction of the dorsal fourth tarsometatarsal ligament complex can lead to full mechanical and functional stability, which ultimately allows for a return to activity, even in highly demanding sports and athletes.

Cross-Sectional Area Measurement of the Central Tarsometatarsal Articulation: A Review of Computed Tomography Scans.

Currently, disagreement exists regarding the superior method for repairing a ligamentous Lisfranc injury regarding whether to use arthrodesis or open reduction internal fixation. The 2 procedures differ in the amount of articular cartilage destroyed. Arthrodesis removes all the articular cartilage, and open reduction internal fixation places transarticular screws, essentially destroying a portion of cartilage. We performed a review of 30 consecutive computed tomography scans that included both foot length and undamaged first, second, and third tarsometatarsal joints to quantify the amount of articular surface area destroyed by placement of standardized 4-mm diameter screws. Measurements were performed using a freeform tool. The calculated surface area of the screws was subtracted from the measured surface area of the joint to yield the amount of surface area occupied by the screws. Our results demonstrated that the average amount of articular surface area destroyed in the first, second, and third tarsometatarsal joints was 4.87%, 4.79%, and 4.86% respectively, with a standard deviation of <1% for each of the joints. Our results have demonstrated that screw placement accounts for only a small percentage of articular surface destroyed. They also showed that the articular surface damage was comparable among the first 3 tarsometatarsal joints. Additionally, our results were similar to the articular surface area calculated from cadaveric specimens in a previous biomechanical study, demonstrating that computed tomography can allow for reliable and accurate assessments of articular surface areas in the foot.

A Novel Technique for Extracapsular Repair of the Intertarsal Joint in a Duck.

The intertarsal joint is a synovial roll-and-glide joint. Ligament damage and luxations of this joint are often the result of traumatic injury or growth deformities and result in significant functional impairment. A 9-month-old female Pekin duck ( Anas platyrhynchos domesticus) was examined because of progressive, nonweight-bearing lameness of the left leg. Moderate effusive swelling was present at the level of the left intertarsal joint, without radiographic evidence of bone involvement. The duck failed to respond to nonsteroidal anti-inflammatory medications and analgesia and was diagnosed with rupture of the medial collateral ligament. Extracapsular surgical correction using bone tunnels and circumferential nylon suture on the medial aspect of the intertarsal joint led to a complete clinical resolution with normal return to function 2 weeks after surgery. This report reviews the anatomy and function of the intertarsal joint in the duck and details a simple extracapsular repair technique useful in the correction of collateral ligament rupture in this joint of ducks.

Is Pes Cavus Alignment Associated With Lisfranc Injuries of the Foot?

BACKGROUND: Lisfranc (tarsometatarsal joint) injuries are relatively rare, accounting for less than 1% of all fractures, and as many as 20% of subtle Lisfranc injuries are missed at the initial patient presentation. An undiagnosed Lisfranc injury can have devastating consequences to the patient. Therefore, any factor that can raise a clinician's index of suspicion to make this diagnosis is potentially important. The cavus foot has been associated with various maladies of the lower extremity, but to our knowledge, it has not been reported to be associated with Lisfranc injury. QUESTIONS/PURPOSES: Do patients who experience a low-energy Lisfranc injury have greater talar head coverage and a greater talo-first metatarsal angle than control subjects? METHODS: A retrospective, case-control study was conducted from September 2011 to December 2014 to identify patients diagnosed and treated for a low-energy Lisfranc injury. Twenty-three adult patients with an average age of 42.6 years (SD, 16.3 years) were identified and compared with 61 adult control subjects with an average age of 49.4 years (SD, 14.1 years). Control subjects came from the practice of a fellowship-trained foot and ankle orthopaedic surgeon. Control subjects underwent a history and physical, clinical examination, and diagnostic imaging to confirm that they had no prior foot disorder, no prior foot surgeries, were within 3 years of age of a patient with a Lisfranc injury, and were independent ambulators. Two authors (DSD and JDP) measured the talonavicular and talo-first metatarsal angles on weightbearing AP and lateral radiographs of the foot. The intrarater reliability and interrater reliability for the talo-first metatarsal angle and the talonavicular angle showed high agreement. The intrarater intraclass correlation coefficients (ICC) of the talo-first metatarsal angle were 0.94 (95% CI, 0.91-0.96) and 0.93 (95% CI, 0.9-0.96). For the talonavicular angle the ICCs were 0.83 (95% CI, 0.75-0.89) and 0.88 (95% CI, 0.81-0.92) for Raters 1 and 2 respectively. The interrater ICCs were 0.91 (95% CI, 0.69-0.96) for the talo-first metatarsal angle and 0.9 (95% CI, 0.85-0.94) for the talonavicular angle. The patients and controls were compared to determine if the patients who sustained a Lisfranc injury were more likely to have a pes cavus foot alignment. We performed a mixed modeling analysis to control for potential cofounding variables and determine if there was an association of Lisfranc injury with the talo-first metatarsal angle and the talonavicular angle. RESULTS: After controlling for confounding variables such as the effect of the measurement round effect and the effect of the rater, our repeated measures analysis via mixed model showed patients were associated with a higher talo-first metatarsal angle than control subjects (adjusted least square mean for patients = 3.05; for controls = -2.65; mean difference, 5.7; p = 0.001). Repeated measures analysis via mixed model showed that patients also were associated with a more positive talonavicular angle than control subjects (adjusted least square mean for patients = -4.83, for controls = -11; mean difference, 6.17; p = 0.002). Patients with Lisfranc injuries had a higher mean talo-first metatarsal angle than did control subjects (1.9° ± 7.9° versus -2.2° ± 7.3°; mean difference, 4.1°; 95% CI, -7.7° to -0.5°; p = 0.028), and less talar uncovering (-4.2° ± 9.7° versus -11° ± 8°; mean difference, 6.7°; 95% CI, -6.7° to -10.8°; p = 0.001). CONCLUSIONS: We found that cavus midfoot alignment was more prevalent among patients with Lisfranc injuries than among individuals with no foot injury or disorder. Although this does not suggest that cavus alignment causes or predisposes patients to this injury, we believe the finding is important because this provides a radiographic parameter that clinicians can use to raise their index of suspicion for a Lisfranc injury and aggressively pursue this diagnosis. Future studies would benefit from obtaining contralateral foot imaging at the time of injury in all patients with Lisfranc injury or prospectively following patients with foot imaging and recording the incidence of future foot injury. LEVEL OF EVIDENCE: Level III, prognostic study.

Resection of Small Avulsion Fractures of the Anterior Process of the Calcaneus for Refractory Complaints.

Minor injuries of the anterior process of the calcaneus occur frequently and most heal uneventfully. The present series reports on 6 patients with persistent complaints after anterior process avulsion fractures. The avulsed fragments of the anterior process at the calcaneocuboid joint were surgically excised in all, which resolved the complaints completely in 4 patients and reduced the complaints significantly in 2. If conservative measures fail and the complaints are refractory, debridement of the anterior process avulsion fractures at the calcaneocuboid joint could be a viable option.

Lisfranc injuries.

BACKGROUND: Injury to the tarsometatarsal joint is a relatively rare occurrence that is commonly missed, leading to debilitating outcomes. For this reason, it is considered a red flag in general practice. OBJECTIVE: This article reviews the current literature on tarsometatarsal injuries and describes clinical assessment, imaging and management. DISCUSSION: Lisfranc injuries refer to the displacement of the metatarsals from the tarsus, with special attention placed on the second tarsometa-tarsal joint and Lisfranc ligament. These injuries can occur in numerous circumstances, such as motor vehicle accidents, crush inju-ries and falls. Indirect mechanisms include axial force through the foot or twisting on a plantar flexed foot. Suggestive examination signs include plantar ecchymosis, mid-foot pain and positive findings in the provocative tests described in the article. Weight-bearing radiographs are vital for diagnosis. Correct and prompt management is key to avoiding posttraumatic arthritis, a devastating but common complication of Lisfranc injuries.

Injuries to the Chopart joint complex: a current review.

Chopart complex injuries (CCIs) are thought to be uncommon; however, recent literature states the rate of misdiagnosis to be between 20 and 41%. Chopart complex injuries are not ankle injuries, with which they are initially confused due to a similar mechanism of trauma in many cases. Injury to the Chopart complex commonly affects multiple structures. The key to optimal treatment is a high index of clinical suspicion combined with timely accurate imaging studies. Careful diagnostic workup with high-quality radiographs of the foot in neutral position should be obtained. Computed tomography (CT) and/or magnetic resonance imaging (MRI) are recommended to accurately assess bone and soft tissue injury. CCI frequently leads to prolonged swelling, pain and disability. In some cases, it may result in a posttraumatic flatfoot deformity.

Comparison of Arthroscopic Lavage and Needle Lavage Techniques, and Lavage Volume on the Recovery of Colored Microspheres From the Tarsocrural Joints of Cadaver Horses.

OBJECTIVE: To quantify recovery of colored microspheres from normal cadaver tarsocrural joints using arthroscopic or needle lavage with 1-5 L of fluid. STUDY DESIGN: Ex vivo experimental study. ANIMALS: Adult Quarter Horse cadavers (n = 8). METHODS: After euthanasia, 1.5 × 10(6) colored microspheres were injected into each tarsocrural joint. Each joint was randomly assigned to receive lavage (5 L 0.9% NaCl) with an arthroscope (dorsomedial arthroscope and dorsolateral egress cannula) or three 14 g needles (dorsomedial ingress, dorsolateral, and plantarolateral egress). Egress fluid from each liter was collected separately over time and the number of microspheres present in each recovered liter determined by spectrophotometry. RESULTS: A significant interaction was present between treatment group and liter of fluid (P < .01). The number of microspheres recovered in the first liter of lavage fluid was significantly higher in the needle lavage group than in the arthroscopic lavage group (P < .01). For both groups, the number of microspheres recovered in the first liter of lavage fluid represented a majority of the total microspheres collected and was significantly different from each subsequent liter collected (P < .01). The number of microspheres recovered did not differ between liters 2, 3, 4, and 5 within or between treatment groups. CONCLUSION: In this model, tarsocrural lavage with three 14 g needles was more effective at removing colored microspheres from the joint than arthroscopic lavage, suggesting that the number or placement of portals present may be more important than portal size and flow rate. No difference in microsphere recovery was seen with lavage volumes >1 L.

An Alternative, Direct Approach for Arthroscopic Removal of Osteochondral Fragments in the Dorsal Pouch of the Proximal Intertarsal Joint of Horses.

OBJECTIVE: To describe an alternative technique and resulting outcomes for arthroscopic removal of osteochondral (OC) fragments from the proximal intertarsal joint (PIJ) using a direct approach without resection of the membrane between the tarsocrural joint (TCJ) and the PIJ. STUDY DESIGN: Retrospective case series. ANIMALS: Client owned horses (n = 11) with Category 1 OC fragments in the PIJ. METHODS: Arthroscopic examination of the dorsal pouch of the TCJ was performed with horses positioned in dorsal recumbency using routine portals. A hook probe placed through one of the standard portals was used to lift the edge of the communication between TCJ and PIJ to help pass the arthroscope into the PIJ from the opposite standard portal. A third direct portal into the PIJ was created under arthroscopic visualization, and loose OC fragments (Category 1) were removed using the direct portal. Medical records, race records, and owner surveys were reviewed for case details and outcome. RESULTS: The described technique allowed removal of all fragments in all 11 cases. No complications associated with the procedure were observed. Of the 9 horses with long term follow-up available, 7 were used as intended (4/4 riding horses, 3/5 racehorses). Two horses did not enter an athletic career because of reasons unrelated to fragment removal. CONCLUSION: A direct approach for arthroscopic removal of OC fragments of the PIJ using a third portal into this joint, without resection of the membrane between the TCJ and PIJ is a good alternative for removal of fragments at this site.