Early Outcomes of Lisfranc Injuries Treated with Arthrex InternalBrace: A Case Series.

Introduction: The treatment of Lisfranc injuries continues to evolve with time. The purpose of this study was to report early outcomes of patients with Lisfranc ligamentous injuries treated with the Arthrex InternalBrace, which has benefits to other previously described techniques. Materials and methods: We retrospectively identified 15 adult patients with Lisfranc injuries that were treated via open reduction internal fixation with the Arthrex InternalBrace (Naples, Fl). These patients were identified at two separate United States institutions between 2019 and 2022. Demographic data, mechanism of injury, and concomitant foot injuries were recorded. Outcomes were assessed by return-to-work or sport and time to weight-bearing. Secondary complications or revision surgeries were noted. Results: The mean patient age was 35 years. Eight patients had isolated Lisfranc ligamentous injuries and seven had additional intercuneiform instability, which required a supplemental limb of the fixation device. The most common mechanism of injury was a cutting/pivoting maneuver (n = 5) followed by fall (n = 4). The mean radiographic follow-up time was 7.3 months. The average time to weight-bearing as tolerated was 6.6 weeks (± 2.2). The average time to return-to-work/sport as tolerated was 14.1 weeks (± 3.6). Only two minor complications were noted at follow-up but no major complications or revision surgeries occurred. Conclusions: The outcomes of this case series suggest that the Arthrex InternalBrace is a viable option when performing open reduction and internal fixation of Lisfranc ligamentous injuries. Future prospective studies are needed to directly compare this device with alternative fixation methods.

Open vs Minimally Invasive Resection of the First Metatarsocuneiform Joint: An Anatomical Study.

BACKGROUND: The modified Lapidus arthrodesis is a standard procedure to correct middle to severe hallux valgus (HV) deformities. Recently, minimally invasive techniques of first metatarsocuneiform joint (MCJ) resection using a Shannon burr were described. The primary goal of this study is to compare the anatomical efficacy and safety of first MCJ resection using a straight 2 × 13-mm Shannon burr and minimally invasive technique (MIS) vs an open technique using an oscillating saw. METHODS: Ten pairs of fresh frozen cadaveric feet were randomly assigned to open or MIS first MCJ resection with subsequent systematic dissection. For the MIS procedure, a dorsomedial approach was used and for the open procedure a medioplantar approach was used. Cartilage removal was investigated by analyzing standardized scaled photographs of the resected articular surfaces with ImageJ software. Nearby structures at risk were analyzed for iatrogenic violation: tibialis anterior (TA), extensor hallucis longus (EHL) and peroneus longus (PL) tendons, and the Lisfranc ligament complex (LLC). RESULTS: In the MIS group, the median cartilage resection was 85.9% at the cuneiform and 85.6% at the metatarsal bone compared to 100% cartilage resection in open technique (P < .01). Iatrogenic damage of the LLC, EHL, and TA tendons was not found in any group. The PL tendon was thinned out (<25% of tendon thickness) in 4 cases (40%) in the open group and in 1 case (10%) in the MIS group. A safe zone of 3.0 mm between the articular surface of the cuneiform bone and the LLC was identified, which can be resected without putting the LLC at risk when performing lateral-based wedge resections. CONCLUSION: In this cadaver study with the procedures performed by an experienced foot and ankle surgeon, and using 2 different surgical approaches, we found general parity between the Shannon burr MIS technique vs oscillating saw open technique techniques with more risk to the PL with our open technique and approximately 15% less cartilage resection with our MIS technique. LEVEL OF EVIDENCE: Level V, cadaver study.

First Tarsometatarsal Joint Fusion for Hallux Valgus Deformity: A Retrospective Comparison of Two Fixation Constructs Regarding Initial Maintenance of Correction and Complications: Traditional Crossing Screw Fixation Versus Dorsomedial Locking Plate and Intercuneiform Compression Screw.

Various fixation constructs exist to address hallux valgus when performing a first tarsometatarsal joint arthrodesis. The goal of this present study is to compare complication rates, and degree and maintenance of angular correction between a dorsomedial locking plate with intercuneiform compression screw construct versus traditional crossing solid screw fixation construct. The plate plus intercuneiform compression screw construct fixation utilized a combined sagittal saw and curette method of joint preparation while the crossed screw fixation group utilized a curette and bur technique. A retrospective review was conducted of consecutive patients who underwent a midfoot fusion using either constructs. Sixty four total feet in 56 patients were enrolled in the study. Twenty four consecutive patients (32 feet) who underwent a midfoot arthrodesis using the locking plate and intercuneiform fixation were fully fused (100%) by 10 weeks postoperatively, with no incidents of nonunion and one deep vein thrombosis event. Thirty two consecutive patients (32 feet) who underwent midfoot arthrodesis with crossing screw fixation had 2 nonunion events, one that was asymptomatic and the other that required a revision midfoot fusion. There was a statistically significant improvement from the pre-operative intermetatarsal angle, hallux abductus angle compared to the 10 week and 1 year radiographs (p < .05) for the entire cohort for both fixation constructs. There was a statistically significant increase in American College of Foot and Ankle Surgery first ray scores from pre-op to 1 year follow-up for both fixation constructs. Overall, the dorsomedial locking plate plus intercuneiform compression screw fixation construct better maintains Intermetatarsal angle (IMA) correction at midterm follow-up compared to the traditional crossing screw construct. Both cohorts overall demonstrate similar fusion rates at 10 weeks, nonunion events, incidences of broken hardware, hardware removal, deep vein thrombosis, neuritis at 1 year postoperatively, and hallux varus.

First Tarsometatarsal Joint Arthrodesis for Hallux Valgus With and Without Intermetatarsal Screw Fixation: A Comparison of Correction and Maintenance of Correction.

Tarsometatarsal joint arthrodesis is a commonly accepted procedure for hallux valgus associated with severe deformity and first ray hypermobility or medial column instability. This study evaluates the correction of hallux valgus deformity and the maintenance of correction with and without the use of a stabilization screw between the first and second metatarsal bases. Through retrospective review of first tarsometatarsal joint arthrodesis within our institution we evaluated 63 patients. Twenty-seven patients did not have a first to second metatarsal base screw and were placed into the no screw cohort. Thirty-six patients did have a first to second metatarsal base screw and were placed into the screw cohort. This study population had an osseous union rate of 95%. Clinical and radiographic recurrence occurred in 5 of 63 patients (8%). At 1-y postop the measurements demonstrated that the screw cohort had an average intermetatarsal angle correction of 11.6 degrees while the no screw cohort had an average correction of 7.8 degrees. Additionally, at 1-y postop the screw cohort had greater maintenance of the intermetatarsal angle correction with an average change of 0.5 degrees compared to 2.3 degrees in the no screw cohort. We conclude that the addition of the stabilization screw improves the first tarsometatarsal joint arthrodesis construct resulting in a greater degree of realignment and maintenance of correction.

Rotational Ankle Fracture Dislocation With Associated Lisfranc Fracture.

While ankle fractures most often result from a rotational injury, Lisfranc injuries are more commonly associated with an axial load on a plantarflexed foot. Due to differing mechanisms of injury, rotational ankle fractures with Lisfranc injuries are uncommon and rarely discussed in the literature. Here we present a case of a rotational ankle fracture-dislocation with a concomitant Lisfranc injury. The Lisfranc injury, which was ultimately treated nonoperatively, was discovered seven weeks after operative fixation of the ankle fracture. At the last follow-up nine months after the initial injury, the patient had mild midfoot soreness with activity but no evidence of deformity or arch collapse. Although no deformity was observed in our patient, missed Lisfranc injuries may result in significant functional deficits indicating the importance of recognizing the possibility of a dual injury.

Guideposts for Inserting Intercuneiform Joint Arthrodesis Screws: Analysis Using Multiplanar Reconstructed Computed Tomography.

Intercuneiform arthrodesis is often required for various midfoot pathologies; however, intercuneiform screw insertion is not easy due to the complicated anatomical structure of cuneiforms. This study aimed to determine the advisable screw entry point and direction using intraoperatively detectable landmarks. The computed tomography (CT) scan data of feet were reformatted using OsiriX software multiplanar reconstruction. First, based on the data of 10 CT scans of normal feet, we determined the advisable screw entry point at the upper one-third in the dorsoplantar direction and center in the anteroposterior direction on the medial aspect of the medial cuneiform and insertion direction toward the outermost point of the base of the fifth metatarsal in the axial plane and parallel to the plantar surface in the coronal plane. Second, we examined the accuracy of these newly designed guideposts in the simulation using other CT scan data of the other 27 normal feet and 12 flat feet. The simulated screw trajectory penetrated the mid three-fifths of all three cuneiforms in 97% of the normal feet and 92% of the flat feet with no cases of cortical wall violation. Levels of Evidence: Level V: Expert opinion.

Symptomatic Os Intercuneiform: A Case Report.

We encountered a case of an accessory bone in the foot in the distal portion of the tarsal navicular and the proximal portion of the intermediate cuneiform, namely an os intercuneiform. The patient presented with a history of pain on the dorsal aspect of the left foot, with tenderness and swelling. Perioperative findings revealed a synfibrotic connection between the accessory bone and the navicular and intermediate cuneiform. After unsuccessful conservative treatment, the accessory bone was excised, leading to postoperative symptomatic relief.

Comparison of Intercuneiform 1-2 Joint Mobility Between Hallux Valgus and Normal Feet Using Weightbearing Computed Tomography and 3-Dimensional Analysis.

BACKGROUND: An association has been reported between hallux valgus and hypermobility of the first ray, but subluxation of the intercuneiform 1-2 joint was also suspected in some cases. However, dynamics of the intercuneiform 1-2 joint has seldom been investigated. This study used weightbearing computed tomography (CT) and a 3-dimensional (3D) analysis system to evaluate displacement of the intercuneiform 1-2 joint, intercuneiform 2-3 joint, and second cuneonavicular joint due to weightbearing in hallux valgus and normal feet. METHODS: Patients were 11 women with hallux valgus (mean age, 56 years; mean hallux valgus angle, 43 degrees; mean first-second intermetatarsal angle, 22 degrees) and 11 women with normal feet (mean age, 57 years; mean hallux valgus angle, 14 degrees; mean first-second intermetatarsal angle, 9 degrees). Each patient was placed supine with the lower limbs extended, and CT was performed under nonweightbearing and weightbearing conditions (load equivalent to body weight). 3D models reconstructed from CT images were used to compare displacement of the intermediate cuneiform relative to the medial cuneiform under nonweightbearing and weightbearing conditions. RESULTS: Relative to the medial cuneiform, the middle cuneiform was displaced by 0.1 and 0.8 degrees due to dorsiflexion, 0.2 and 1.0 degrees due to inversion, and 0.7 and 0.7 degrees due to abduction in normal feet and feet with hallux valgus, respectively, with the latter having significantly greater dorsiflexion ( P = .0067) and inversion ( P = .0019). There was no significant intergroup difference at the intercuneiform 2-3 joint and second cuneonavicular joint. CONCLUSION: This study clarified the detailed load-induced displacement of the cuneiform 3-dimensionally. Compared with normal feet, hallux valgus feet had significantly greater mobility of the intercuneiform 1-2 joint, suggesting hypermobility of this joint. LEVEL OF EVIDENCE: Level III, case-control study.

Intraoperative evaluation of medial intercuneiform instability after Lapidus arthrodesis: intercuneiform hook test.

The presence of intercuneiform instability is not routinely inspected within the overall surgical management of hallux valgus and has therefore been underreported as a potential cause of recurrence. We sought to demonstrate the incidence of this unique type of proximal instability to state its potential importance in the correction and definitive management of hallux valgus in patients with moderate to severe intermetatarsal angles with superimposed hypermobility. A total of 34 patients underwent 38 tarsometatarsal arthrodeses for hallux valgus correction and were retrospectively reviewed for 36 months from May 2007 to May 2010. The incidence of intercuneiform instability was 73.68% and was determined by the findings of the intraoperative "hook" test. The high rate of proximal instability could warrant consideration for routine intermetatarsal arthrodesis as a component of this procedure. A technique for evaluating the presence of intercuneiform instability after Lapidus arthrodesis is also presented.