Implementation of a Service-Specific Template Integrating Objective Structured Clinical Examination and Accreditation Council for Graduate Medical Education Milestones: One Institution's Experience.

The Accreditation Council for Graduate Medical Education (ACGME) orthopaedic milestones require detailed, frequent resident evaluations. This institution desired a cost-effective objective structured clinical examination (OSCE) to facilitate these evaluations. Data were collected as a prospective, uncontrolled observational study. The OSCE was completed by residents entering and exiting the foot and ankle rotation during postgraduate years 2 and 4. Physician assistants functioned as standardized patients. Statistical analyses were performed using paired and independent t tests. The OSCE was implemented using reliable, low-cost modalities and has facilitated milestones evaluations. Preliminary data show 4th-year residents performed higher in prerotation global assessment with a standardized patient and written exam (p < .03). Second-year residents showed improvement in the written exam on rotation completion (p = .03). Using this methodology, institutions may establish similar cost-effective OSCEs as feasible evaluative solutions to satisfy milestone requirements. The authors believe this tool may be modified for any specialty. (Journal of Surgical Orthopaedic Advances 26(4):257-261, 2017).

Longitudinal Lisfranc injury.

Most Lisfranc or tarsometatarsal (TMT) joint injuries result from a horizontally directed force in which the metatarsals are displaced relative to the midfoot. The injury pattern that is described in this article is one of a longitudinal force through the first ray and cuneiform. A reliable measure to recognize the longitudinal Lisfranc variant injury has been the height difference between the distal articular surfaces of the first and second cuneiform bones in an anteroposterior (AP) weight-bearing radiograph. This measure helps identify subtle injuries in which there is a proximal and medial subluxation of the first cuneiform-metatarsal complex. Delayed diagnosis and treatment have been associated with poorer results and significant functional consequences. This article describes a simple radiographic measurement to recognize the longitudinal injury pattern and to aid in determining whether operative intervention is required.

Comparison of Outcomes at Midterm Follow-up of Operatively and Nonoperatively Treated Isolated Weber B Ankle Fractures.

OBJECTIVES: A novel protocol was previously presented for nonoperative management of Weber B (OTA/AO 44B) ankle fractures with criteria of medial clear space <7 mm on gravity stress (GS) radiographs and ipsilateral superior clear space and contralateral GS medial clear space within 2 mm. This study recruited an operative cohort for comparison of outcomes. DESIGN: Retrospective cohort study. SETTING: Level 1 academic center. PATIENT SELECTION CRITERIA: The recruited operative cohort consisted of patients who may have been considered for the nonoperative protocol, but underwent surgery instead. OUTCOME MEASURES AND COMPARISONS: Kellgren-Lawrence scale for evaluation of arthritis, American Orthopedic Foot and Ankle Society Hindfoot, Olerud Molander Ankle, Lower Extremity Functional Scale (LEFS), and PROMIS (physical function, depression, pain interference) scores for the current operative cohort were compared with that of the original nonoperative cohort. RESULTS: There were 20 patients in the operative cohort and 29 in the original nonoperative cohort. Mean follow-up was 6.9 and 6.7 years, respectively. The following outcome scores were better for the nonoperative cohort compared with the operative, respectively: LEFS, 75.2 and 68.1 ( P = 0.009); Olerud Molander Ankle, 94.1 and 89.0 ( P = 0.05); American Orthopedic Foot and Ankle Society, 98.5 and 91.7 ( P = 0.0003); PROMIS Physical Function, 58.2 and 50.4 ( P = 0.01); PROMIS Pain Interference, 42.2 and 49.7 ( P = 0.004). The PROMIS Depression, 42.8 and 45.4 ( P = 0.29), was not different between groups. All patients achieved union of their fracture. Surgical complications included implant removal (15%), SPN neurapraxia (5%), and delayed wound healing (5%). CONCLUSIONS: In carefully selected patients with isolated Weber B fractures, nonoperative management may be considered because it can lead to equivalent or superior outcomes with none of the risks typically associated with surgical intervention. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Lateral Talar Subluxation Measurements in Nonoperatively Managed Weber B Ankle Fractures.

Background: Lateral talar subluxation (LTS) was introduced as a measurement tool for evaluating isolated Weber B ankle fractures, with LTS >4 mm on gravity stress (GS) radiographs possibly indicating need for surgery. This study reviews LTS measurements in nonoperatively managed isolated Weber B fibula fractures to further investigate the validity of this previously stated cutoff. Methods: The senior authors previously reported outcomes of a novel algorithm for nonoperative management of isolated Weber B ankle fractures. Outcome scores reported include American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot, Olerud-Molander (OMA), Foot and Ankle Ability Measure for activities of daily living (FAAM/ADL), and visual analog scale (VAS) scores. All patients achieved union of their fracture. LTS was measured on GS radiographs of both injured and contralateral uninjured extremities. Results: Forty-two patients were included with minimum 1-year follow-up. Average age was 49 years (range 19-72). Mean measurements on injury GS radiographs were as follows: medial clear space (MCS) 4.45 mm (SD = 0.93), superior clear space (SCS) 3.46 mm (SD = 0.70), and LTS 2.33 mm (SD = 1.57, range 0-4.7 mm), with 35 (83.3%) patients having injury LTS ≤4 mm. Mean measurements on contralateral (uninjured) GS radiographs were as follows: MCS 3.39 mm (SD = 0.63), SCS 3.15 mm (SD = 0.50), and LTS 1.30 mm (SD = 1.28, range 0-4.8 mm). There was no statistically significant difference in all outcome measures based on amount of LTS (<2 mm, 2-4 mm, >4 mm). Conclusion: Most patients had injury LTS ≤4 mm, although those with LTS >4 mm had excellent outcome scores. LTS measurements on normal ankles reveal a large range. LTS may be a useful adjunct in evaluating isolated Weber B ankle fractures but the 4-mm cutoff may not be entirely reliable. Further studies are required to validate LTS as a decision-making tool. Level of Evidence: Level IV, case series.

Midterm Outcomes of Operatively and Nonoperatively Managed Achilles Tendon Ruptures in Young Adults.

Background: There continues to be controversy regarding treatment options for Achilles tendon ruptures (ATR). The aim of our study is to compare outcomes between operatively and nonoperatively managed Achilles ruptures in young adults (age 18-30 years), which has not been previously evaluated. Methods: At a single institution, all patients aged 18-30 years at time of injury who underwent treatment for an acute ATR from 2014 to 2021 were evaluated. Medical records were reviewed to collect demographics, dates of injury and treatment, smoking status, body mass index (BMI), Charlson Comorbidity Index (CCI), rate of deep venous thrombosis (DVT) after treatment, and rate of rerupture. Patients then completed Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference (PI) questionnaires. Mann-Whitney nonparametric testing was used to evaluate for any statistical differences in PROMIS scores. Results: Sixty-six operative patients qualified and 28 (42%) participated. Thirty-seven nonoperative patients qualified and 14 (38%) participated. All patients had a CCI of 0. One patient in the operative cohort and 2 in the nonoperative reported active smoking. In the operative and nonoperative cohorts, respectively, the average age was 24.4 and 27.8 years; average BMI 26.5 (SD = 4.8) and 27.3 (SD = 4.3, P = .52); DVT rates 4 (6.1%) and 2 (5.4%); and rerupture rates 2 (3.0%) and 1 (2.7%), respectively. PROMIS scores did not differ in the operative and nonoperative groups: PROMIS PF mean of 60.4 (SD = 9.8) and 62.9 (SD = 9.1), respectively (P = .33); as well as PROMIS PI mean of 44.6 (SD = 5.9) and 43.9 (SD = 6.5), respectively (P = .59). Conclusion: This study should be interpreted with the understanding that we had a considerable loss to follow-up rate. In the study cohort, we found that young adults with ATR may be considered for either operative or nonoperative management. Rates of DVT, rates of rerupture, and PROMIS scores were not dissimilar between the 2 cohorts. Level of Evidence: Level III, retrospective cohort study.

Proximal Plantar Plate of Lesser Toe Metatarsophalangeal Joint Vascular Supply.

BACKGROUND: The plantar plate is a major stabilizing structure of the metatarsophalangeal (MTP) joint with instability frequently occurring after a tear or attenuation of this structure. Commonly, a McGlamry elevator is used to strip the plantar plate from the plantar surface of the metatarsal to improve exposure of the MTP joint. The anatomy of the proximal plantar plate and vascular consequence of stripping the plantar plate from the metatarsal is not yet well understood. The purpose of this study is to describe the proximal attachment of the plantar plate anatomically and quantify the relative contribution of blood supply to the proximal plantar plate from both the metatarsal and the plantar fascia. METHODS: For anatomic evaluation, 6 lower extremity cadaver specimens without any gross evidence of foot and ankle deformity were utilized. For imaging analysis, 16 fresh frozen human adult cadaveric lower extremity specimens were used for this study, resulting in 35 MTP joints without deformity and 11 lesser MTP joints with cockup and/or crossover deformities. The specimens were prepared as described previously by Finney et al.5. RESULTS: From gross anatomic dissection, the plantar plate origin consists of a stout fibrous pedicle distinct from the surrounding synovial-type tissue that firmly anchors the plantar plate to the metatarsal. Based on nano-computed tomographic imaging, an average of 63.5% of the vascular supply to the proximal portion of the plantar plate entered from the metatarsal pedicle. The remaining 36.5% of the vascular supply entered from the plantar fascia. CONCLUSION: The proximal attachment of the plantar plate includes a stout fibrous pedicle anchoring the proximal portion of the plantar plate to the notch between the medial and lateral plantar condyles of the metatarsal head. The vascular supply of the proximal plantar plate is supplied from both the metatarsal pedicle and plantar fascia. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Surface Pressures in Lower Extremity Splints: A Biomechanical Study.

Background: Though ubiquitously used in orthopaedic trauma, lower extremity splints may have associated iatrogenic risk of morbidity. Although clinicians pad bony prominences to minimize skin pressure, the effect of joint position on skin pressure and, more specifically, changing joint position, is understudied. The purpose of this biomechanical study is to determine the effect of various short-leg splint application techniques on anterior ankle surface pressure in the development of iatrogenic skin pressure ulcers. Methods: Various constructs of lower extremity, short-leg splints were applied to 3 healthy subjects (6 limbs total) with an underlying pressure transducer (Tekscan I-Scan system) on the skin surface centered on the tibialis anterior tendon at the level of the ankle. All subjects underwent anterior ankle surface pressure assessment when padding was applied in maximum plantar flexion and neutral position for conventional short-leg splints application in clinically relevant patient scenarios. Percentage change from initial contact pressure centered on the tibialis anterior with cast padding were calculated. Results: The percentage change in anterior ankle contact pressure when padding was applied in maximum plantar flexion (PF) and then definitively placed in neutral was increased at least 2-fold without the addition of plaster in lower extremity short-leg splints. Removing anterior ankle padding following final splint application in neutral reduced contact forces at the anterior ankle 46% and 59% in splints applied in maximum PF and neutral ankle position, respectively. Conclusion: The present study is the first of its kind to underscore and quantify clinically relevant technical pearls that can be useful in reducing risk of iatrogenic risk of skin breakdown at the anterior ankle when placing short-leg splints, mainly, that it is imperative to apply padding in the intended final splint position and to remove anterior ankle padding following splint application when able. Level of Evidence: Level IV, biomechanical study with clear hypothesis.

Early Outcomes Following Plantar Condylectomy and Imbrication of Plantar Plate to Metatarsal Neck for Metatarsalgia and Grade 0 Lesser Toe Metatarsophalangeal Joint Instability.

Background: Metatarsalgia and plantar plate tears are characterized by forefoot pain and toe deformity in severe cases. Conservative management may slow progression of symptoms; however, definitive treatment often requires operative intervention. The purpose of this observational study was to evaluate the combination of plantar condylectomy and surgical imbrication of the plantar plate to the metatarsal neck to repair grade 0 plantar plate injuries. Methods: We retrospectively identified 22 patients with metatarsalgia and low-grade plantar plate lesions (grade 0), operated between 2018 and 2021, who underwent operative repair involving plantar metatarsal condylectomy and proximal surgical imbrication of the plantar plate to the metatarsal neck. Fourteen patients underwent concomitant hallux valgus correction. Data collection was performed preoperatively and postoperatively and included Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference (PI) scores. Paired Wilcoxon signed-rank tests compared PROMIS PF and PI scores at patients' preoperative, 6-9-week, 3-4-month, 5-6-month, and ≥9-month follow-up evaluations (P < .05). Results: Compared to their preoperative visit, patients demonstrated modest improvement in their PROMIS (pain and physical function) scores over the first ≥9 months postoperatively (median 13.0 months). Median preoperative and most recent PROMIS physical function scores were 40.5 (95% CI: 36-49) and 44.5 (95% CI: 40-52), respectively. Median PROMIS pain interference scores changed from 62.5 (95% CI: 56-67) to 56.0 (95% CI: 51-62). Improvement in pain and function was sustained in patients available for postoperative follow-up. Conclusion: In this small, early follow-up series, we found that plantar condylectomy and surgical imbrication of the plantar plate to the metatarsal neck was modestly helpful to treat metatarsalgia and grade 0 plantar plate injuries. Level of Evidence: Level IV, retrospective case series.

Return to Sport After First Metatarsophalangeal Arthrodesis: A Systematic Review.

BACKGROUND: First metatarsophalangeal (MTP) arthrodesis is a common surgical intervention for addressing MTP pain and deformity. Despite great interest on the topic of return to sport (RTS) after first MTP arthrodesis in the literature, no systematic review exists on this topic. The purpose of this systematic review is to investigate RTS after first MTP arthrodesis. METHODS: This study is a systematic review using PubMed, Web of Science, CINAHL, and MEDLINE from database inception until May 10, 2023. Search algorithm used was (MTPJ OR MTP OR "hallux rigidus" OR cheilectomy OR metatarsal OR metatarsophalangeal) AND (arthrodesis OR fusion) AND sport. Inclusion criteria were surgical intervention of first MTP arthrodesis and outcomes related to sport. RESULTS: Ten articles were included out of 249 articles initially retrieved. Patients (n = 450) had a frequency weighted mean (FWM) age of 58.6 ± 5.1 years with a FWM follow-up time of 32.1 ± 18.9 months. A total of 153 patients (reported in 34.0% of patients) had a FWM postoperative Foot and Ankle Ability Measure Sport score of 70.4 ± 21.8 at final follow-up. For sporting activities reported by multiple studies (running, yoga, golf, hiking, tennis, elliptical, and biking), about 9.8% to 28.1% of patients (n = 69 reports) stated that sporting activity difficulty decreased, 67.2% to 87.5% of patients (n = 340 reports) stated that sporting activity remained the same, and 1.8% to 8.5% of patients (n = 23 reports) stated that sporting activity difficulty increased after first MTP arthrodesis depending on the sporting activity. One article reported RTS time of 11.7 ± 5.1 weeks after first MTP arthrodesis (n = 39). CONCLUSION: RTS after first MTP arthrodesis is highly variable depending on patient and sport. Numerous different sporting activities have high rates of RTS after first MTP arthrodesis, with a majority of patients reporting similar or increased ability to perform sporting activities after surgery.

Comparison of k-wire insertion using oscillatory and unidirectional drilling modes under constant thrust force.

Heat generation during the Kirschner wire (K-wire) insertion process, under either unidirectional or oscillatory drilling mode, places bone at risk of thermal osteonecrosis which can lead to infection. There is a lack of quantitative understanding of the heat generation difference between the two drilling modes and knowledge of optimal thrust force level under each mode is missing. The goal of this study is to investigate the effects of drilling modes and thrust force levels on the bone drilling outcomes. Controlled machine-based constant thrust force K-wire insertion experiments were conducted with key process parameters monitored and compared quantitatively. Statistical analysis showed that the oscillatory mode consumed 2.6 times more electricity than the unidirectional mode but generated 53% less thermal energy and 23% lower peak temperature. However, the oscillation also led to 18% higher peak torque in the transient drilling stage and 23% shallower drilling depth. The optimal choice of the drilling mode depends on specific surgical needs to minimize bone damage (control of peak temperature vs. exposure time and torque control). Heat generation was dominated by the torque and corresponding rotational power under both modes. To minimize the bone temperature while keeping high drilling speed efficiency, a moderate thrust force is preferred under the unidirectional mode to balance between feed force and compressed debris resistance. For oscillatory mode, a small thrust force to keep the K-wire engaged with the bone is optimal.

Medial Ankle Instability: Review of Anatomy, Evaluation, and Treatment.

The medial ankle ligamentous complex, which includes the deltoid, talocalcaneal, and calcaneonavicular ligaments, functions to provide stability to the medial ankle. Injuries to the deltoid ligament can lead to medial-sided ankle pain, subsequent instability, and posttraumatic osteoarthritis given the altered biomechanics of the ankle joint. After completing a thorough physical examination, imaging modalities such as stress radiographs and magnetic resonance imaging can be used to confirm the diagnosis. Acute injuries to the deltoid ligament should be managed conservatively with a short course of immobilization. For patients with continued pain and instability following a regimen of nonoperative management, surgical intervention can be considered. Primary repair using suture anchor fixation to the medial malleolus can be utilized if sufficient tissue remains. However, if reconstruction is necessitated, autograft or allograft can be utilized in several described techniques.Levels of Evidence: Therapeutic.

Perioperative Management of Antirheumatic Medications in Patients with RA and SLE Undergoing Elective Foot and Ankle Surgery: A Critical Analysis Review.

¼: Recent literature has shown that continued use rather than discontinuation of various antirheumatic agents throughout the perioperative period may present an opportunity to mitigate the risks of elective surgery. ¼: For patients with rheumatoid arthritis and systemic lupus erythematosus, perioperative management of medication weighs the risk of infection against the risk of disease flare when immunosuppressive medications are withheld. ¼: Broadly speaking, current evidence, although limited in quality, supports perioperative continuation of disease-modifying antirheumatic drugs, whereas biologic drugs should be withheld perioperatively, based on the dosing interval of the specific drug. ¼: For any withheld biologic drug, it is generally safe to restart these medications approximately 2 weeks after surgery, once the wound shows evidence of healing, all sutures and staples have been removed, and there is no clinical evidence of infection. The focus of this recommendation applies to the optimization of wound-healing, not bone-healing. ¼: In most cases, the usual daily dose of glucocorticoids is administered in the perioperative period rather than administering "stress-dose steroids" on the day of surgery.

First Metatarsophalangeal Lateral Collateral Ligament Repair in an Athlete: A Case Report.

CASE: Evidence-based surgical strategies to reconstruct the collateral ligament complex of the first metatarsophalangeal (MTP) joint are not available. We report a case of first MTP lateral collateral ligament insufficiency in a young, female gymnast with varus laxity and subsequent satisfactory mid-term and long-term outcomes. CONCLUSION: This case report describes an efficient suture anchor technique for restoring stability of the first MTP joint because of chronic varus laxity with acceptable results both clinically and with patient-reported outcome scores at mid-term and long-term follow-ups. We suggest that our strategy is a viable option for addressing chronic varus laxity of the first MTP joint. LEVEL OF EVIDENCE: Level IV, case report.

Percutaneous Fixation of a Fifth Metatarsal Base Fracture.

SUMMARY: Owing to a vascular watershed, zone II and III fifth metatarsal base fractures commonly progress to nonunion without operative intervention. This article and the accompanying video demonstrate the use of intramedullary screw fixation for a fifth metatarsal base fracture and review treatment decisions involved with management of these injuries.

Irreducible Fractures and Dislocations of the Ankle Associated With Entrapment of the Posterior Tibial Tendon Within the Tibiofibular Interosseous Space: A Case Series and Literature Review.

Level of Evidence: Level IV, case series.

Long-term Follow-up of Lisfranc Injuries Treated With Open Reduction Internal Fixation Patient-Reported Outcomes.

BACKGROUND: There remains a paucity of data regarding long-term patient-reported outcomes following Lisfranc injuries. We sought to collect long-term clinical outcome data following Lisfranc injuries using PROMIS Physical Function (PROMIS-PF) and visual analog scale-foot and ankle (VAS-FA). METHODS: A chart review was performed to identify all patients who had surgical treatment of an acute Lisfranc injury at our institution from 2005 to 2014. Of the 45 patients identified, we were able to recruit 19 for a follow-up clinic visit consisting of physical examination, administration of questionnaires addressing pain and medication usage, radiographs, and completion of outcome surveys including PROMIS-Physical Function and visual analog scale-foot and ankle. RESULTS: There were 14 female and 5 male patients enrolled in the study with a mean time of 6.25 years from the time of injury. Within this cohort, the mean PROMIS-PF score was 52.4±8.2 and the mean VAS-foot and ankle score was 76.6±22.3. CONCLUSION: We report satisfactory long-term patient-reported outcomes using PROMIS-PF and VAS-FA. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Presence of Neovascularization in Torn Plantar Plates of the Lesser Metatarsophalangeal Joints.

BACKGROUND: Recent surgical techniques have focused on anatomic repair of lesser toe metatarsophalangeal (MTP) plantar plate tears, yet it remains unknown whether the plantar plate has the biological capacity to heal these repairs. Therefore, a better understanding of the plantar plate vasculature in response to injury may provide further insight into the potential for healing after anatomic plantar plate repair. Recently, a study demonstrated that the microvasculature of the normal plantar plate is densest at the proximal and distal attachments. The purpose of this study was to compare the intact plantar plate microvasculature network to the microvasculature network of plantar plates in the presence of toe deformity using similar perfusion and nano-computed tomographic (CT) imaging methods. METHODS: Seven fresh-frozen human cadaveric lower extremities with lesser toe deformities including hammertoe or crossover toe were perfused using a barium solution. The soft tissues of each foot were counterstained with phosphomolybdic acid (PMA). Then using nano-CT imaging, the second through fourth toe metatarsophalangeal joints of 7 feet were imaged. These images were then reconstructed, plantar plate tears were identified, and 11 toes remained. The plantar plate microvasculature for these 11 toes was analyzed, and calculation of vascular density along the plantar plate was performed. Using analysis of variance (ANOVA), this experimental group was compared to a control group of 35 toes from cadaveric feet without deformity and the vascular density compared between quartiles of plantar plate length proximal to distal. A power analysis was performed, determining that 11 experimental toes and 35 control toes would be adequate to provide 80% power with an alpha of 0.05. RESULTS: Significantly greater vascular density (vascular volume/tissue volume) was found along the entire length of the plantar plate for the torn plantar plates compared to intact plantar plates (ANOVA, P < .001). For the first quartile of length (proximal to distal), the vascular density for the torn plantar plates was 0.365 (SD 0.058) compared to 0.281 (SD 0.036) for intact plantar plates; in the second quartile it was 0.300 (SD 0.044) vs 0.175 (SD 0.025); third quartile it was 0.326 (SD 0.051) vs 0.117 (SD 0.015); and fourth (most distal) quartile was 0.600 (SD 0.183) vs 0.319 (SD 0.082). CONCLUSION: Torn plantar plates showed increased vascular density throughout the length of the plantar plate with an increase in density most notable in the region at or just proximal to the attachment to the proximal phalanx. Our analysis revealed that torn plantar plates exhibit neovascularization around the site of a plantar plate tear that does not exist in normal plantar plates. CLINICAL RELEVANCE: The clinical significance of the increased vascularity of torn plantar plates is unknown at this time. However, the increase in vasculature may suggest that the plantar plate is a structure that is attempting to heal.

Ankle Arthrodesis Through an Anterior Approach.

Ankle arthritis occurs primarily because of trauma and has a huge impact on patient's quality of life. Ankle arthrodesis is indicated for patients with end-stage ankle arthritis who fail conservative management. High rates of fusion can be achieved through an anterior approach. This video demonstrates an ankle arthrodesis using an anterior approach to the ankle in a patient with posttraumatic ankle arthritis.

Initial Displacement Does Not Affect Loss of Reduction After Lisfranc Fracture Dislocations.

We sought to determine whether significantly displaced Lisfranc injuries had a higher rate of loss of reduction after fixation compared to those with low displacement. Forty-five patients who had fixation of an acute Lisfranc injury from 2005 to 2014 were retrospectively reviewed. All patients underwent subsequent hardware removal at 3 to 15 months after their index procedure. Radiographs were reviewed from the time of injury, 2 weeks, and 6 months postoperative. Lisfranc joint reduction was assessed using criteria previously described in the literature and graded as malreduced if displacement was >2 mm. We used a cutoff of 4 mm for high initial displacement. Those patients with ≥4 mm of initial displacement did not have an increased rate of loss of reduction after hardware removal compared to those patients with <4 mm initial displacement (40% and 27%, respectively; P = .362). Anatomic reduction was achieved immediately postoperative in 89% of cases. A high degree of displacement in Lisfranc injuries does not preclude achievement and maintenance of adequate reduction after fixation of these injuries. Levels of Evidence: Prognostic study, Level II: Retrospective.