Painful Accessory Navicular and Spring Ligament Injuries in Athletes.

Painful accessory navicular and spring ligament injuries in athletes are different entities from more common posterior tibialis tendon problems seen in older individuals. These injuries typically affect running and jumping athletes, causing medial arch pain and in severe cases a pes planus deformity. Diagnosis requires a detailed physical examination, standing radiographs, and MRI. Initial treatment focuses on rest, immobilization, and restriction from sports. Orthotic insoles may alleviate minor pain, but many patients need surgery to expedite recovery and return to sports. The authors review their approach to these injuries and provide surgical tips along with expected rehabilitation to provide optimal outcomes.

Fluoroscopic and Gait Analyses for the Functional Performance of a Custom-Made Total Talonavicular Replacement.

The present study evaluated the restoration of joint function in a special clinical case: a professional rock climber who underwent an original total talonavicular replacement with a custom-made prosthesis after a complex articular fracture. Full body gait analysis and 3-dimensional joint kinematics using single-plane fluoroscopy were performed on the same day at the 30-month follow-up examination. Gait analysis was performed using stereophotogrammetric, dynamometric, electromyographic, and baropodometric systems. Gait analysis showed good restoration of rotation, as well as moment patterns in the main lower limb and foot joints in the operated leg. At the artificial tibiotalar joint, videofluoroscopic analysis revealed a flexion capability of about 20°, together with a few degrees of motion in the frontal and transverse planes. The neighboring joints of the foot did not present with severe kinematic abnormalities. A full talonavicular replacement can be a viable and effective solution for complex ankle injury sequelae, even in patients with highly demanding functionality.

Osteomyelitis of the accessory and body of the navicular bone: a case report.

A 16-year-old boy developed left foot pain of unknown cause that was unresponsive to conservative treatment, associated with fever and difficulty walking. He was admitted to our hospital with osteomyelitis of the accessory and body of the navicular bone. Surgery could not be performed because the patient had been diagnosed with Wiskott-Aldrich syndrome. After antibiotic therapy, laboratory abnormalities and pain had resolved. One year after treatment, the patient had returned to his original level of sports activity. Both an accessory navicular and the body of the navicular bone may develop osteomyelitis in immunocompromised patients; early diagnosis is important for prescribing effective conservative treatment.

Tarsal Bone Dysplasia in Clubfoot as Measured by Ultrasonography: Can It be Used as a Prognostic Indicator in Congenital Idiopathic Clubfoot? A Prospective Observational Study.

BACKGROUND: Congenital talipes equinovarus (CTEV )/clubfoot is the most common congenital orthopedic condition. The success rate of Ponseti casting in the hands of the legend himself is not 100%. The prediction of difficult to correct foot and recurrences still remains a mystery to be solved. We all know that tarsal bones are dysplastic in clubfoot and considering it; we hypothesize that the amount of tarsal dysplasia can predict management duration and outcome. In literature we were not able to find studies that satisfactorily quantify the amount of tarsal dysplasia. Hence, it was considered worthwhile to quantify the amount of dysplasia in tarsal bone and to correlate these parameters with the duration and outcome of treatment by conventional method. METHODS: A total of 25 infants with unilateral idiopathic clubfoot that have not taken any previous treatment were included in the study. An initial ultrasonography was done before start of treatment in 3 standard planes to measure the maximum length of 3 tarsal bones (talus, calcaneus, and navicular). Ponseti method of treatment was used; pirani scoring was done at each OPD (out patient department) visit. Number of casts required for complete correction and need for any surgical intervention were taken as the outcome parameters. RESULTS: We found that there is a significant correlation between number of casts required and the dysplasia of talus (α error=0.05). We also found a significant negative correlation between relative dysplasia of talus and number of casts required (r=-0.629 sig=0.001, r=-0.552 sig=0.004). CONCLUSIONS: Tarsal bone dysplasia as quantified by using ultrasonography can be used as a prognostic indicator in congenital idiopathic clubfoot. Although promising the method needs further studies and can be more useful after long-term follow-up where recurrences if any can be documented. LEVEL OF EVIDENCE: Level II.

Ankle sprains and instability.

Ankle injuries are among the most common injuries presenting to primary care providers and emergency departments and may cause considerable time lost to injury and long-term disability. Inversion injuries about the ankle involve about 25% of all injuries of the musculoskeletal system and 50% of all sports-related injuries. Medial-sided ankle sprains occur less frequently than those on the lateral side. High ankle sprains occur less frequently in the general population, but do occur commonly in collision sports. Providers should apply the Ottawa ankle rules when radiography is indicated and refer fractures and more severe injuries to orthopedic surgery as needed.

The identification of MAFB mutations in eight patients with multicentric carpo-tarsal osteolysis supports genetic homogeneity but clinical variability.

Multicentric carpo-tarsal osteolysis (MCTO) with or without nephropathy is a rare osteolysis disorder beginning in early childhood and involving mainly carpal and tarsal bones. Renal disease appears later in life in the majority of cases and evolves quickly to end stage renal failure. Autosomal dominant (AD) inheritance has been demonstrated, with a high frequency of sporadic cases. Recently, mutations in a highly conserved region of the MAFB gene (v-maf musculoaponeurotic fibrosarcoma oncogene ortholog B) have been identified in MCTO patients by exome sequencing. MafB, known as a regulator of various developmental processes, is essential for osteoclastogenesis and renal development. We report here the molecular screening of MAFB in eight MCTO patients from six families. We identified MAFB mutations in all, including three novel missense mutations clustering within the hot spot mutation region. Among the eight patients, six only presented renal disease. Our report confirms the genetic homogeneity of MCTO and provides data underlying the clinical variability of this disorder.

Low prevalence of osteoarthritis in patients with congenital clubfoot at more than 60 years' follow-up.

We investigated 60 patients (89 feet) with a mean age of 64 years (61 to 67) treated for congenital clubfoot deformity, using standardised weight-bearing radiographs of both feet and ankles together with a functional evaluation. Talocalcaneal and talonavicular relationships were measured and the degree of osteo-arthritic change in the ankle and talonavicular joints was assessed. The functional results were evaluated using a modified Laaveg-Ponseti score. The talocalcaneal (TC) angles in the clubfeet were significantly lower in both anteroposterior (AP) and lateral projections than in the unaffected feet (p < 0.001 for both views). There was significant medial subluxation of the navicular in the clubfeet compared with the unaffected feet (p < 0.001). Severe osteoarthritis in the ankle joint was seen in seven feet (8%) and in the talonavicular joint in 11 feet (12%). The functional result was excellent or good (≥ 80 points) in 29 patients (48%), and fair or poor (< 80 points) in 31 patients (52%). Patients who had undergone few (0 to 1) surgical procedures had better functional outcomes than those who had undergone two or more procedures (p < 0.001). There was a significant correlation between the functional result and the degree of medial subluxation of the navicular (p < 0.001, r2= 0.164), the talocalcaneal angle on AP projection (p < 0.02, r2 = 0.025) and extent of osteoarthritis in the ankle joint (p < 0.001). We conclude that poor functional outcome in patients with congenital clubfoot occurs more frequently in those with medial displacement of the navicular, osteoarthritis of the talonavicular and ankle joints, and a low talocalcaneal angle on the AP projection, and in patients who have undergone two or more surgical procedures. However, the ankle joint in these patients appeared relatively resistant to the development of osteoarthritis.

Talocalcaneal tarsal coalitions and the calcaneal lengthening osteotomy: the role of deformity correction.

BACKGROUND: Surgical resection of persistently painful talocalcaneal tarsal coalitions may not reliably relieve symptoms in patients with large coalitions associated with excessive hindfoot valgus deformity and subtalar posterior facet narrowing. Since 1991, calcaneal lengthening osteotomy, with or without coalition resection, has been used at our institution to relieve symptoms and to preserve motion at the talonavicular and calcaneocuboid joints. METHODS: We retrospectively reviewed the records for eight patients with thirteen painful talocalcaneal tarsal coalitions who had undergone a calcaneal lengthening osteotomy for deformity correction with or without coalition resection between 1991 and 2005. Preoperative and postoperative clinical, radiographic, and computed tomographic records were reviewed. The duration of clinical follow-up ranged from two to fifteen years. RESULTS: Calcaneal lengthening osteotomy fully corrected the valgus deformity and provided short-to-intermediate term pain relief for the five patients (nine feet) in whom the talocalcaneal tarsal coalition was unresectable. The patient with resectable coalitions but excessive valgus deformities underwent calcaneal lengthening osteotomies along with coalition resections and had excellent deformity correction and pain relief in both feet. One of the two patients who underwent calcaneal lengthening osteotomy years after coalition resection had excellent correction and pain relief. The other patient had a coincident calcaneonavicular coalition and severe degenerative arthritis in the talonavicular joint. He underwent concurrent arthrodesis of the talonavicular joint and, although he had excellent deformity correction, had persistent pain. All feet underwent concurrent gastrocnemius or Achilles tendon lengthening. CONCLUSIONS: It is generally accepted that resection is the treatment of choice for an intractably painful small talocalcaneal tarsal coalition that is associated with a wide, healthy posterior facet and minimal valgus deformity of the hindfoot. Although triple arthrodesis has been recommended for those who do not meet all three criteria, the present study suggests that an algorithmic treatment approach is justified. Treatment of the valgus deformity appears to be as important as that of the coalition. Calcaneal lengthening osteotomy with gastrocnemius or Achilles tendon lengthening is effective for correcting deformity and relieving pain in rigid flatfeet, just as it is in flexible flatfeet.

The salvage of complex hindfoot problems with use of a custom talar total ankle prosthesis.

BACKGROUND: There has been recent interest in the use of a custom long-stemmed talar component for salvage of failed total ankle replacement or for management of combined ankle and hindfoot pathology. The purpose of this study was to retrospectively review prospective data on patients who underwent total ankle arthroplasty with a custom long-stemmed talar prosthesis. METHODS: From November 2004 to February 2006, thirty-three custom total ankle arthroplasties were performed in thirty-two patients. The indication for this prosthesis was stage-IV adult-acquired flatfoot deformity in six patients (19%), failure of a prior total ankle replacement because of severe subsidence and loosening of the talar component in thirteen (41%), and combined arthritis of the ankle and hindfoot joints in thirteen patients (41%; fourteen ankles). Patients were assessed for range of motion, radiographic results, and functional outcomes with use of the Short Form-36 (SF-36) subscale scores, American Orthopaedic Foot & Ankle (AOFAS) hindfoot score, and the Maryland Foot Score (MFS) at a minimum of four years. RESULTS: All patients were followed for an average of 58.6 months (minimum, fifty-two months) There was an overall increase in the total arc of motion following surgery from an average (and standard deviation) of 21.3° ± 14° preoperatively to 32.2° ± 11° postoperatively (p < 0.05). Subsidence (<3 mm) was noted in three patients. One patient had asymptomatic osteolysis around the talar stem. The mean Physical Component Summary score on the SF-36 was 28.2 ± 5.6 preoperatively and increased to 39.7 ± 6.5 postoperatively (p < 0.05). The mean SF-36 Mental Component Summary value increased from 42.2 ± 13.8 preoperatively to 50.8 ± 12.6 postoperatively (p < 0.05). The mean MFS was 47 ± 13 preoperatively and increased to 75 ± 10 postoperatively (p < 0.05). The average AOFAS hindfoot score increased from 41 ± 16 preoperatively to 68 ± 12 postoperatively (p < 0.05). There were three failures at greater than thirty-six months after surgery. CONCLUSIONS: Our data indicate that the use of a custom long-stemmed talar component, either placed primarily in patients with ankle and hindfoot arthritis or used as a revision prosthesis in patients with a failed total ankle replacement, is promising.

Extraosseous talotarsal stabilization devices: a new classification system.

Displacement of the articular facets of talus on the tarsal mechanism, or partial talotarsal dislocation, is a condition seen in children, adult, and geriatric populations. A characteristic of this pathologic condition is a prolonged period of and excessive amount of pronation (hyperpronation) on weightbearing. The ill effects of this condition may lead to a multitude of other foot pathologies and to pathologies associated with the proximal lower extremity musculoskeletal structures. A variety of conservative and operative treatment options have been used to eliminate or minimize hyperpronation. Extraosseous talotarsal stabilization (EOTTS) devices have been used to realign and stabilize the articular facets of the talus on the tarsal mechanism, thereby attempting to restore the normal range of hindfoot motion while eliminating hyperpronation. A multitude of such devices, which are intended for the same purpose, are available for the surgeon to choose from. However, there is no literature discussing the differences among these devices, or the benefits of one device over the other. Based on current understanding and available knowledge base, the goal of this article was to classify EOTTS devices based on their design features and biomechanical functioning. A theoretical description of how these different types of devices function is laid out in an attempt to understand the reason for their success or failure. This new classification system is intended to help researchers and surgeons appreciate the subtle yet important differences among these devices, and to thus help them design future research studies when using these devices.

Recognition and management of Müller-Weiss disease.

BACKGROUND: Müller-Weiss disease (MWD) is an uncommon condition of unclear etiology, characterized by compression of the lateral aspect of the tarsal navicular bone. It presents with chronic mid and hindfoot pain, mostly in middle-aged females. It does not represent persistence of Kohler's disease, which is self-limiting and resolves completely in childhood. METHODS: A total of 12 patients with 19 affected feet, seven of whom had bilateral involvement, presented to a single foot and ankle surgeon over a 10-year period. Diagnosis of MWD was based on radiographic appearances demonstrating compression of the lateral part of the navicular. Affected feet were graded using Maceira classification. RESULTS: The cohort comprised four males and eight females with a mean age of 57.9 years. Only one patient had previously been a manual worker. Mean duration of symptoms was 5.2 years. Of the seven patients who underwent surgery for symptoms related to MWD, five had a triple arthrodesis, one had triple arthrodesis combined with naviculo-cuneiform fusion, and one had a pantalar arthrodesis for associated varus ankle osteoarthritis. Solid union was achieved in all cases. CONCLUSION: We propose that MWD is much more common than previously reported and did not find conditions of extreme environmental stress or poverty in our patients. We advocate surgical management of the condition by triple arthrodesis and extend it to include a naviculocuneiform fusion whenever indicated according to CT findings.

Peri-navicular arthrodesis for the Stage III Müller-Weiss disease.

BACKGROUND: We aimed to report our results of peri-navicular arthrodesis with autologous iliac bone graft for Stage III Müller-Weiss disease. METHODS: Nine cases of Stage III Müller-Weiss disease according to the Maceira classification (four male and five female) with average age of 48.2 (range, 41 to 58) years, had mild or severe midfoot pain with the longitudinal arch collapse. The patients, all of whom had failed conservative treatment for more than 6 months, underwent peri-navicular arthrodesis. All patients were followed up at 3, 6, 9, and 12 months, and then every 6 months with AOFAS ankle-hindfoot scores and radiographic measurements. Mean followup time for radiological and clinical evaluation was 22.4 (rangem 12 to 52) months. RESULTS: All patients were satisfied with their clinical results without pain 12 months after surgery. The mean AOFAS ankle-hindfoot scores improved from 40.1±8.3 preoperatively to 90.9±2.1 at the last followup (p<0.05). A solid fusion was found in all cases at 3 months after surgery by radiographic and clinical evaluation. The average longitudinal arch height increased from 46.1±2.1 mm preoperatively to 53.5±2.3 mm at the last followup (p<0.05) on the lateral weightbearing radiograph. CONCLUSION: The peri-navicular arthrodesis with autologous iliac bone graft resulted in a good outcome for Stage III Müller-Weiss disease with good clinical outcomes, high fusion rate, and obvious improvement of the longitudinal arch height.

Wrist denervation in isolation: a prospective outcome study with patient selection by wrist blockade.

Surgical wrist denervation involves division of the anterior and posterior interosseous nerves and articular branches of the superficial radial nerve. In this outcome study, 37 patients were individually assessed and deemed suitable for denervation surgery due to appreciable symptom resolution following a local anesthetic wrist block. At a mean of 18 months following denervation surgery, median activity pain scores had decreased by 60% (p < 0.001) from initial assessment levels, and more than three quarters (30/37) of patients reported continued improvement in their activity pain (p < 0.001). More than two thirds of patients had a satisfaction VAS of greater than 50, with less postoperative resting pain and a greater reduction in postoperative activity pain as the important predictors of patient satisfaction. Thirty-one out of the 37 patients had not represented to our department for revision wrist surgery by a mean of 10.3 years follow-up. We have found this procedure useful in ameliorating symptoms for some patients who would conventionally have required partial or total wrist fusions with greater residual functional limitation.

Radiographic evaluation of navicular position in the sagittal plane-correction following an extraosseous talotarsal stabilization procedure.

The navicular drop in the sagittal plane on weight-bearing is a valid indicator of foot pronation. Dislocation of the talus on the tarsal mechanism results in hyperpronation, which can lead to excessive navicular drop. The purpose of the present study was to radiographically determine the efficacy of HyProCure(®) in realigning the navicular bone in hyperpronating feet. We hypothesized that following the placement of HyProCure(®), the navicular height would increase significantly compared to its preoperative value. Radiographs of 61 adult patients (86 feet) who received HyProCure(®) without adjunctive hindfoot or midfoot soft tissue or osseous procedures were analyzed. The distance of the navicular with respect to the cuboid was measured from the pre- and postoperative weight-bearing lateral radiographs. Additionally, we measured foot length to normalize the navicular to cuboid distance. The postoperative radiographs were taken at an average follow-up of 17 days. The mean preoperative true navicular to cuboid distance was 19 ± 6 mm as compared to a mean postoperative value of 24 ± 5 mm. The mean pre- and postoperative normalized navicular to cuboid distances were 0.098 ± 0.029 and 0.125 ± 0.027, respectively (± 1 SD). The postoperative increase in the true and normalized navicular to cuboid distance was statistically significant (p < .001). HyProCure(®) was effective in improving the anatomic alignment of the talonavicular joint by reducing excessive navicular drop. This indicates reduction of excessive abnormal pronation and stabilization of the medial column of the foot, which can also lead to reduction in the excessive forces placed on the supporting soft tissue structures.

Load response of the tarsal bones in patients with flatfoot deformity: in vivo 3D study.

BACKGROUND: The objective of this study was to evaluate the bone rotation of each joint in the hindfoot and compare the load response in healthy feet with that in flatfeet by analyzing the reconstructive three-dimensional (3D) CT image data during weightbearing. METHODS: CT scans of 21 healthy feet and 21 feet with flatfoot deformity were taken in non-load condition followed by full-body weightbearing load condition. The images of the hindfoot bones were reconstructed into 3D models. The volume merge method in three planes was used to calculate the position of the talus relative to the tibia in the tibiotalar joint, the navicular relative to the talus in talonavicular joint, and the calcaneus relative to the talus in the talocalcaneal joint. RESULTS: The talar position difference to the load response relative to the tibia in the tibiotalar joint in a flatfoot was 1.7 degrees more plantarflexed in comparison to that in a healthy foot (p = 0.031). The navicular position difference to the load response relative to the talus in the talonavicular joint was 2.3 degrees more everted (p = 0.0034). The calcaneal position difference to the load response relative to the talus in the talocalcaneal joint was 1.1 degrees more dorsiflexed (p = 0.0060) and 1.7 degrees more everted (p = 0.0018). CONCLUSION: Referring to previous cadaver study, regarding not only the cadaveric foot, but also the live foot, joint instability occurred in the hindfoot with load in patients with flatfoot. CLINICAL RELEVANCE: The method used in this study might be applied to clinical analysis of foot diseases such as the staging of flatfoot and to biomechanical analysis to evaluate the effects of foot surgery in the future.

Peritalar destabilisation syndrome (adult flatfoot with degenerative glenopathy).

In cases of adult acquired flatfoot associated with peritalar destabilisation, special reference is made to the plantar calcaneo-navicular (spring) ligament's degenerative disease (degenerative glenopathy) and to the presence of the accessory navicular bone as a possible pathogenic cause. Peritalar destabilization syndrome is proposed for the articular (subtalar and talo-navicular joints) or tendinosis (tibialis posterior tendon) separately or in association with degenerative glenopathy of the coxa pedis. In degenerative glenopathy surgical reconstruction of the glenoid also makes use of a posterior tibial split to create a new tibial-navicular ligament. The concept of pronatory syndrome deemed as the root the pathological subtalar pronation, which is an entirely secondary factor in peritalar destabilisation, must be questioned. We must keep in mind that subtalar pronation and supination are respectively subsequent to opening and closing of the coxa pedis (talo-calcaneo-navicular joint) kinetic chain.

Manejo del retropié plano valgo flexible con la férula tipo UCBL en pacientes pedátricos: [revisión] / Management of the flexible flat hindfoot valvus with orthesis type UCBL in pediatric patients: [review]

El tratamiento de las diversas deformidades del pie varia según las patologías y es precisamente en el niño por su gran plasticidad biológica, en quien se pueden aplicar los diferentes resursos que se poseen para el tratamiento ortopédico conservador. En el presente trabajo se plantea una alternativa para el tratamiento del retropié valgo, con la férula termo formada tipo UCBL (University of California Biomechanics Laboratory. Demostrar la utilidad de la férula tipo UCBL en el tratamiento conservador del retropié valgo para postegar y/o evitar tratamientos quirúrgicos por deformidades severas. La muestra utilizada fue de 15 pacientes (6 niñas, 9 niños, con edades entre 2 años 6 meses y 10 años) con disfunción del brazo de palanca por pérdida de la rigidez ósea, debido a la subluxación de la articulación sub-astragalina (retropié valgo flexible), en quienes se utilizó la férula termoformada tipo UCBL con seguimiento promedio de 12 a 36 meses. Se evaluó clínicamente la flexibilidad del pié y la maniobra de Silverskiold y radiologicamente en bípeda estación estática, el ángulo Costa-Bertani, Astrágalo calcáneo y astrágalo-1er metatarsiano. 10 pacientes presentaron mejoría clínica y radiológica, 5 de los casos no evidenciaron cambios, sin embargo, mantuvieron su flexibilidad. La férula resultó útil, inclusive en los casos donde no se demostró corrección radiológica, ya que evitó estructuración de la deformidad.

The adequate treatment for foot deformities varies depending on the pathology, and because of the high plasticity found in children, it is in this age group where the available conservative treatment resources can be applied. An alternative for the valgus hindfoot treatment is presented in this paper, using the UCBL (University of California Biomechanies Laboratory) thermoshaped orthesis. To prove utility of the thermoformed UCBL type orthesis in the treatment of flexible pes valgus in orden to avoid fuseverity deformities. The study included 15 patients (6 female, 9 male, ages between 2 years 6 months and 10 years) with lever-arm dysfunction due to loss of bony rigidity with sub-astragaline joint subluxation (flexible valgus hindfoot), in whom UCBL thermoshaped orthesis was indicated with an average follow up between 12 to 36 monts. Foot flexibility was clinical evaluated; also Silverskiold maneuver and static bipedestation x-rays angles were measured. Ten patients showed clinical and radiological improvement, 5 patients showed no change, although flexibility was maintained. The UCBL orthesis was useful, even in cases were no radiological change was observed, because it avoided structuration of bony deformity.

The influence of talonavicular versus double arthrodesis on load dependent motion of the midtarsal joint.

BACKGROUND: Today the most frequently used operative procedures in advanced arthritis of the hindfoot joints are isolated talonavicular arthrodesis and double arthrodesis (involving the talonavicular and calcaneocuboid joints, i.e. the Chopart joint). This in vitro study investigates whether the fusion of the talonavicular joint alone can provide the hindfoot, as well as a midfoot, with comparable biomechanical stability as the double arthrodesis does. Hence with the less-invasive intervention the same benefit in terms of pain reduction and better functionality could be achieved. METHODS: In a series of ten fresh cadaver feet without any radiological pathologies, we measured the range of motion of different tarsal bones in three planes under axial stress. Every foot was loaded without arthrodesis, after talonavicular and after double arthrodesis, by charging tibia and fibula with a force of 350 N using a calibrated Instron® load frame. Each tarsal bone was marked with a K-wire and its motion was measured by registering the movement of the wire's shade that was projected onto the surrounding walls of the trial box. RESULTS: Both operative procedures led to a considerable reduction of the motion of every marked bone to a mean of 18% of the preoperative value. In direct comparison of the two simulated arthrodeses we found for every bone and in every plane only minimal differences of the mean excursions of 1.0 mm on average. Both fusions lead to equal residual tarsal bone motion postoperatively, and provide the midtarsal joint as well as the subtalar joint with comparable biomechanical stability. CONCLUSIONS: Isolated talonavicular arthrodesis is a useful and effective alternative to double arthrodesis. It is the less complicated, less-invasive and functionally equivalent operative option for arthritic alterations of the hindfoot and transverse tarsal joint.

Reconstruction of multiplanar ankle and hindfoot deformity with intramedullary techniques.

The goal of ankle and hindfoot reconstruction should be to address the presenting concerns of the patient and the deformity and to achieve a stable, functional, and plantigrade foot. These goals are accomplished by using appropriate preoperative patient assessment and planning and using meticulous intraoperative technique and aftercare. An algorithmic approach to multiplanar hindfoot deformity is presented in this article along with the author's preferred method of treatment, aftercare, and management of complications. Great emphasis is given to preoperative planning in order to ensure the best possible postoperative outcomes.

Determining the strongest orientation for "Lisfranc's screw" in transverse plane tarsometatarsal injuries: a cadaveric study.

UNLABELLED: The treatment of tarsometatarsal joint fracture-dislocations generally consists of realignment followed by stabilization with rigid internal fixation. The purpose of this study was to determine the strongest orientation for the "Lisfranc's screw" for repair of disruption of the articulation between the first and second metatarsals and the medial and intermediate cuneiforms. To this end, Lisfranc's ligament was sectioned in 6 pairs of fresh-frozen, human cadaver feet, after which a 3.5-mm partially threaded, cannulated screw was placed across the Lisfranc joint in 1 of 2 opposing directions. In one group, the screw was oriented in the more traditional medial cuneiform to second metatarsal base direction. In the other group, the screw was oriented from the second metatarsal base to the medial cuneiform. After fixation, each construct was pulled to transverse plane failure at the tarsometatarsal joint with a servohydraulic mechanical testing system. The overall force to failure was 157.04 +/- 54.79 N (range, 96.8-249.2 N). For the traditional medial cuneiform to second metatarsal base screw orientation group, the mean force to failure was 148.97 +/- 54.93 N, whereas for the second metatarsal base to medial cuneiform group the mean force to failure was 165.12 +/- 58.57 N, and this difference was not statistically significant (P = .2475). Although not statistically significantly different in regard to force to failure strength, the authors describe an alternative approach to the orientation of "Lisfranc's screw" for stabilization of the relationship of the medial cuneiform to the second metatarsal. LEVEL OF CLINICAL EVIDENCE: 5.