Current Lack of Evidence on Treatment Strategies and Clinical Outcomes for Osteochondral Lesions of the Subtalar, Talonavicular, and Calcaneocuboid Joints: A Systematic Review.

OBJECTIVE: In contrast to osteochondral lesion (OCL) of the ankle, OCLs in other joints of the foot, such as subtalar joint, talonavicular joint, calcaneocuboid joint, and the midfoot, are rare conditions, but they can also lead to significant morbidity. The objective of this systematic review was to summarize the clinical evidence for the treatment of OCLs of the subtalar, talonavicular, calcaneocuboid, and the other midfoot joints. DESIGN: A systematic search of the MEDLINE, EMBASE, and Cochrane Library databases was performed in January 2021 based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines by 2 independent reviewers. Included studies were evaluated with regard to LOE (level of evidence) and QOE (quality of evidence). Variable reporting outcome data, clinical outcomes, and complications were evaluated. RESULTS: Seventeen studies with 21 patients were included, all of which were case reports (level 5) without any case series reporting greater than 3 patients. There were 5 patients with OCL in the subtalar joint, 15 patients in the talonavicular joint, and 1 patient in the calcaneocuboid joint. Thirteen case reports (4 subtalar joint, 8 talonavicular joint, and 1 calcaneocuboid joint) reported surgical treatment. Surgical procedures mainly included debridement, bone marrow stimulation, fixation, and bone grafting, through open or arthroscopy, all of which resulted in successful outcomes. Four case reports (1 subtalar joint, 3 talonavicular joint) reported successful conservative treatment. Other 13 case reports reported successful surgery after failed conservative treatment. No complications and reoperations were reported. CONCLUSIONS: The current systematic review revealed that there is no available evidence to ascertain clinical outcomes of both conservative and surgical treatments for cartilage lesions in the talonavicular joint, subtalar joint, and the midfoot joints, owing to the extreme paucity of literature. Both nonoperative and operative treatments can be considered, but no treatment strategies have been established.

Outcomes of Selective Arthrodesis Based on Joints Affected in 33 Feet With Müller-Weiss Disease.

No consensus exists regarding operative treatment of Müller-Weiss disease (MWD). Its only classification is based solely on Méary's angle and serves neither as guide to management nor prognosis. We report on 33 feet that underwent surgery following failed conservative management. Treatment was directed towards joint(s) involved, as determined by clinical examination, plain radiography and SPECT-CT. Thus, surgery consisted of isolated talonavicular in 6 feet, triple in 8, subtalar and talonavicular in 7, talonaviculocuneiform in 4, talonaviculocuneiform with interpositional tricortical iliac crest graft in 6 and pantalar arthrodesis in 2. PROMIS scores for pain interference and depression decreased significantly (p < .001) with significant accompanying increase in physical function (p = .003). Union occurred in 31 of 33 feet (94%) with complete resolution of pain at an average follow-up of 84 months. Of the 2 nonunions, 1 had fracture through the lateral navicular, and the other marked sclerosis and avascularity of the lateral navicular. We describe our pathways for selecting arthrodesis based on the joints affected. Isolated talonavicular arthrodesis was performed in early stages of MWD, which begins at the talonavicular articulation. When disease extended to both sides of the navicular, we performed talonaviculocuneiform arthrodesis. When considering isolated talonavicular, double medial or triple arthrodesis, there should be adequate cancellous bone stock remaining in the lateral part of the navicular, as determined on medial oblique radiographs and CT scan. In case of inadequate bone stock or fracture through the lateral navicular, talonaviculocuneiform arthrodesis with interpositional iliac crest bone graft is recommended.

Foot biomechanics in patients with advanced subtalar- and mid-tarsal joint osteoarthritis and poorly responding to conservative treatment.

BACKGROUND: A comprehensive insight into the effects of subtalar- and mid-tarsal joint osteoarthritis on lower limb's biomechanical characteristics during walking is lacking. Our goal was to assess joint kinematics and kinetics and compensatory mechanisms in patients with subtalar and mid-tarsal joint osteoarthritis. METHODS: Patients with symptomatic and radiographically confirmed osteoarthritis of the subtalar and mid-tarsal (n = 10) and an asymptomatic control group (n = 10) were compared. Foot joint kinematics and kinetics during the stance phase of walking were quantified using a four-segment foot model. RESULTS: During pre-swing phase, the tibio-talar range of motion in the sagittal plane of the patient group decreased significantly (P = 0.001), whereas the tarso-metatarsal joint range of motion in the sagittal plane was greater in the pre-swing phase (P = 0.003). The mid-tarsal joint showed lower transverse plane range of motion in the patient group during the loading response and pre-swing phase (P < 0.001 resp. P = 0.002). The patient group showed a lower Tibio-talar joint peak plantarflexion moment (P = 0.004), peak plantarflexion velocity (P < 0.001) and peak power generation in the sagittal plane (P < 0.001), and a lower mid-tarsal joint peak adduction and abduction velocity (P < 0.001 resp. P < 0.001) and peak power absorption (P < 0.001). CONCLUSIONS: These findings suggest that patients with subtalar and mid-tarsal joint osteoarthritis adopt a cautious walking strategy potentially dictated by pain, muscle weakness, kinesiophobia and stiffness. Since this poorly responding population faces surgical intervention on the short term, we recommend careful follow-up after fusion surgery since biomechanical outcome measures associated to this post-surgical stage is lacking.

Quantifying increased lateral column instability in Adult Acquired Flatfoot Deformity (AAFD).

AAFD comprises ligamentous failure and tendon overload, mainly focused on the symptomatic posterior tibial tendon and the spring ligament. Increased lateral column (LC) instability arising in AAFD is not defined or quantified. This study aims to quantify the increased LC motion in unilateral symptomatic planus feet, using the contralateral unaffected asymptomatic foot as an internal control. In this case matched analysis, 15 patients with unilateral stage 2 AAFD foot and an unaffected contralateral foot were included. Lateral foot translation was measured as a guide to spring ligament competency. Medial and LC dorsal sagittal instability were assessed by direct measurement of dorsal 1st and 4th/5th metatarsal head motion and further video analysis. The mean increase in dorsal LC sagittal motion (between affected vs unaffected foot) was 5.6 mm (95% CI [4.63-6.55], p < 0.001). The mean increase in the lateral translation score was 42.8 mm (95% CI [37.48-48.03], p < 0.001). The mean increase in medial column dorsal sagittal motion was 6.8 mm (95% CI [5.7-7.8], p < 0.001). Video analysis also showed a statistically significant increase in LC dorsal sagittal motion between affected and unaffected sides (p < 0.001). This is the first study that quantifies a statistically significant increased LC dorsal motion in feet with AAFD. Understanding its pathogenesis and its link to talonavicular/spring ligament laxity improves foot assessment and may allow the development of future preventative treatment strategies.

Small Joint Arthroscopy of the Foot.

Recently, there have been new advances in the arthroscopic approach to small joints of the foot. This is directly related to the improvement of surgical equipment, new techniques, and publications. These improvements led to broadening indications as well as minimizing complications. Several articles recently presented the uses of arthroscopic surgery in the small joints of the foot; however, the use is still relatively limited. Arthroscopic evaluation of the small joints of the foot includes the first metatarsophalangeal, lesser metatarsophalangeal, tarsometatarsal, talonavicular, and calcaneocuboid joints as well as the interphalangeal joint to the great toe and lesser toes.

Talonavicular arthrodesis: Does the IOFiX system provide safe and reliable fixation?

AIMS: Talonavicular (TN) arthrodesis is a common procedure to treat arthritis of the TN joint.It can also form part of a wider triple fusion to restore the architecture of the foot.Traditional methods of arthrodesis are not universally successful. The aim of this study was to evaluate the clinical and radiological outcomes of those who had a TN fusion using the IOFiX system. Data was collected retrospectively from the hospital operation database. Inclusion criteria included patients who underwent a TN fusion between 2012 and 19 with the IOFiX system. All patients were over 16 years of age and at least one year post operation.Patient demographics were obtained, as well as rate of union and rate of re-operation for analysis. RESULTS: 35 patients were identified. The mean age was 58 years (range 34-85). The most common indication was osteoarthritis of the TN joint (n = 19), followed by acquired adult flat foot (n = 8), rheumatoid arthritis (n = 3), avascular necrosis (n = 2) and a previous nonunion.(n = 1). 9 % (n = 3) of patients did not achieve union by one year and 14 % (n = 5) required another operation subsequent to their initial surgery: four to remove metalwork, and one to treat non-union of the arthrodesis. The use of bone graft did not affect complication rates. TN fusion, when performed as part of a triple fusion, showed a tendency for reducing the rate of non-union, however this did not achieve statical significance. CONCLUSION: This study suggests that the IOFiX system offers a reliable and acceptable alternative technique for patients undergoing a TN fusion. Further work is required to assess if early signs of improved outcome when used in triple fusion, over isolated TN fusion,are significant.

Anatomic Description of the Calcaneocuboid Joint: Implications for Staple Fixation.

Understanding the anatomy of the calcaneocuboid (CCJ) remains essential when selecting staple fixation to optimize osseous purchase during rearfoot procedures. This anatomic study quantitatively describes the CCJ in relation to staple fixation sites. The calcaneus and cuboid from 10 cadavers were dissected. Widths at 5 mm and 10 mm increments away from the joint were measured in dorsal, midline, and plantar thirds of each bone. The widths between each position's 5 mm and 10 mm increments were compared using the Student's t test. The widths among the positions at both distances were compared using an ANOVA then post hoc testing. Statistical significance was set at p ≤ 0.05. The middle (23 ± 3 mm) and plantar third (18 ± 3 mm) of the calcaneus at the 10 mm interval was greater than the 5 mm interval (p = .04). At 5 mm distal to the CCJ, the dorsal third of the cuboid maintained a statistically significant greater width than the plantar third (p = .02). The 5 mm (p = .001) and 10 mm (p = .005) dorsal calcaneus widths as well as the 5 mm (p = .003) and 10 mm (p = .007) middle calcaneus widths were significantly greater than the plantar widths. This investigation supports the use of 20 mm staple 10 mm away from the CCJ in dorsal and midline orientations. Care should be taken when placing a plantar staple within 10 mm proximal to the CCJ as the legs may extend beyond the medial cortex compared to dorsal and midline placements.

Joint coverage analysis in progressive collapsing foot deformity.

Progressive collapsing foot deformity (PCFD) is characterized by a progressive subluxation of the peritalar bones and respective joints. Two-dimensional conventional radiographs are limited in their ability to visualize the peritalar bones and joints with adequate detail to describe the complex three-dimensional deformity. An improved understanding of the relationship between joint coverage and deformity would allow clinicians to use coverage analysis to distinguish among the stages of PCFD. The aim of this study was to analyze the joint coverage of the six articular relationships within the talocrural, subtalar, and Chopart joints using weightbearing computed tomography (WBCT) scans. Ten individuals with a flexible hindfoot and ten individuals with a rigid hindfoot presentation of PCFD were compared to twenty-seven asymptomatic control individuals. The three most relevant findings are: (I) the anterior-medial facet of the subtalar joint contains the greatest reduction in coverage for patients with a rigid deformity, (II) an increase in talonavicular overlap (TNO) moderately correlated with a decreased coverage in the: tibiotalar, anterior-medial subtalar, talonavicular joints, and (III) the calcaneocuboid joint lacks radiographic values to adequately quantify alignment and coverage. To conclude, there were significant differences in coverage area of various articulating regions throughout the hind- and midfoot when comparing PCFD patients to asymptomatic control individuals. Relevant radiographic measures correlating to articular coverage areas of clinical interest were identified, possibly helping to better quantify PCFD in clinical practice.

Double versus Triple Arthrodesis for Flatfoot Deformity: When, Why, and How?

Different types of arthrodesis for flatfoot deformity have a long history in foot and ankle surgery. Arthrodesis of the rearfoot can be a useful tool in helping correct deformity and maintaining that correction with good long-term results. Questions have risen recently however about the necessity of including the calcaneocuboid joint in the traditional rearfoot arthrodesis or triple arthrodesis. The double arthrodesis of the talonavicular and subtalar joints has grown in popularity and this review helps the reader choose with a review of the biomechanics, surgical approaches, fixation techniques and recent literature outcomes of both procedures.

Use of Locking Compression Plate and Locking Compression T-Plate for Surgical Arthrodesis of the Carpometacarpal and Distal Tarsal Joints in 13 Horses.

OBJECTIVE: The aim of this study was to describe the use of the locking compression plate (LCP) and locking compression T-plate (LCTP) in cases of carpometacarpal and distal tarsal arthrodesis for the treatment of osteoarthritis and small carpal or tarsal bone fractures, and to document clinical outcomes. STUDY DESIGN: Case records of horses treated with carpometacarpal or distal tarsal arthrodesis via internal fixation using an LCP or LCTP between 2013 and 2021 were reviewed. All cases were evaluated retrospectively. Follow-up information was gained via phone conversation with owners and referring veterinarians. RESULTS: Data were collected for 13 horses that fulfilled the study criteria. A total of eight horses underwent distal tarsal arthrodesis, and five underwent carpometacarpal arthrodesis. Twelve of thirteen horses went back to some level of athletic performance. Eight of 13 returned to the same level, while 4 of 13 returned to a lower level. Minor postoperative complications were recorded in 3 of 13 cases, with all horses suffering manageable short-term complications returning to the same level of work. Two horses suffered a major complication, with one resulting in euthanasia. CONCLUSION: Carpometacarpal and distal tarsal arthrodesis performed using the LCP and LCTP allowed all surviving horses in the study to obtain immediate postoperative comfort and eventual return to use.

Intraoperative Technical Tips to Improve Fusion Between the First and Second Metatarsals in the Original Lapidus Procedure.

The modified Lapidus procedure (MLP), which consists of fusion between the first metatarsal (M1) and medial cuneiform, has been widely performed with satisfactory clinical outcomes, but it has a variable nonunion rate ranging between 4% and 10% and loss of correction in up to 5.8% of the cases. Excessive motion around the site of tarsometatarsal arthrodesis, specially at the intercuneiform joint, is probably the reason. The original Lapidus procedure (OLP), which includes fusion of the M1 to second metatarsal (M2), may be beneficial in preventing nonunion and recurrence. The objective of this study was to describe intraoperative technical tips in the OLP to improve M1 to M2 fusion, which may prevent complications. Since the Lapidus procedure continues to gain popularity, it is the authors opinion that the OLP requires special attention because it is a more technically demanding surgery compared to the MLP.Level of Evidence: Level V: Expert opinion.

Chopart Joint Injuries: Assessment, Treatment, and 10-Year Results.

OBJECTIVES: To investigate injury patterns and long-term outcomes of midtarsal (Chopart) injuries in a sizeable number of patients. DESIGN: Prospective study. SETTING: Level 1 trauma center. PATIENTS: One hundred twenty-two patients (average age 37.6 years) with 128 Chopart injuries over a 15-year period, 27% of who were polytraumatized. In 47%, more than 1 of the 4 bones of the midtarsal joint was fractured. The navicular and cuboid were fractured most often. Purely ligamentous dislocations occurred in 4%. INTERVENTIONS: Operative treatment tailored to the individual fracture pattern was performed in 91.4%. MAIN OUTCOME MEASUREMENTS: Foot Function Index, American Orthopaedic Foot and Ankle Society score, SF-36 physical (PCS) and mental component summary (MCS). RESULTS: Seventy-three patients with 75 Chopart injuries were available for follow-up at an average of 10.1 years. The Foot Function Index averaged 26.9, the American Orthopaedic Foot and Ankle Society score averaged 71.5, and the SF-36 PCS and MCS averaged 43.5 and 51.2, respectively. Negative prognostic factors were a high injury severity score, work-related accidents, open and multiple fractures, purely ligamentous dislocations, staged surgery, delay of treatment >4 weeks, postoperative infection, and primary or secondary fusion. Open reduction and internal fixation led to significantly better results than attempted closed reduction and percutaneous fixation. Radiographic signs of posttraumatic arthritis were observed in 93%, but only 4.7% of cases required a late fusion at the Chopart joint. CONCLUSIONS: Chopart joint injuries lead to functional restrictions in the long term. Purely ligamentous dislocations have the worst prognosis, whereas fractures of a single bone have a favorable outcome after anatomic reduction and internal fixation. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Cubonavicular Coalition in a Middle-Aged Woman: A Case Report.

Cubonavicular coalition is a rare type of tarsal coalition that can be described as osseous or nonosseous (fibrous, cartilaginous, or fibrocartilaginous). Typically, it manifests symptoms during adolescence, as it presents with pain at the Mid-hindfoot and with decreased range of motion at the midtarsal joints, hindfoot valgus deformity, or peroneal spasm. Here, we present a rare case of cubonavicular coalition in a middle-aged woman with atypical presentation and a review of the literature. We conclude that this abnormality should be taken into account in the differential diagnosis of mid-hindfoot pain, even in middle-aged adults.

Double and Triple Tarsal Fusions in the Severe Rigid Flatfoot Deformity.

A flatfoot deformity is a multiplanar foot deformity characterized by forefoot abduction and supination and hindfoot valgus. With progressive pathology, a rigid deformity may develop. In the setting of a rigid deformity, the appropriate procedure to use is not without controversy. The extent of joints to involve in the arthrodesis depends on the ability to obtain a plantigrade foot. Both double and triple arthrodesis have been suggested. Care must be taken to avoid lateral column shortening and loss of foot reduction when fusing the CC joint. The concerns about lateral skin breakdown led some surgeons to describe a single medial incision for a triple or modified double arthrodesis. The necessity of bone grafting has been controversial. Implant selection is essential to achieve solid stabilization of the arthrodesis sites. To decrease the risk of overcorrection and malunion, the surgeon should be familiar with the hindfoot biomechanics and generate, based on the clinical examination and imaging, a meticulous preoperative plan to address and balance both the soft tissue and bony deformity.

Pantalar Arthrodesis.

A triple arthrodesis is comprised of subtalar, talonavicular, and calcaneocuboid joints arthrodesis. A pantalar arthrodesis is triple arthrodesis combined with tibiotalar arthrodesis. The goal of the procedure is to obtain a correction of deformity and achieve a plantigrade, functional, painless, stable, weightbearing foot that can be used to ambulate. This is done by creating an osseous continuity across the ankle, subtalar, and talonavicular, and calcaneocuboid joints. There are several approaches and fixation strategies that result in successful clinical union and should be chosen to match the clinical situation. Modern techniques result in high rates of union and pain relief.

Delayed Treatment of a Medial Swivel Talonavicular Dislocation.

This case describes delayed treatment of a medial talonavicular dislocation with a shear fracture of the talar head, a comminuted posterior talar process fracture, and an intra-articular cuboid fracture with subtle medial displacement of the calcaneocuboid joint and the associated treatment. The injury was sustained in a 35-year-old man following a high-energy motor vehicle accident. Three weeks following the injury, delayed treatment was achieved following an attempted closed reduction under general anesthesia followed by open reduction and percutaneous Kirschner wire fixation. After a 12-month follow-up, the patient was able to return to work and regular activities pain-free without complications. Several associated injuries have been described with isolated talonavicular dislocations. This case reviews the technique and care surrounding this injury pattern and its delayed treatment.

Significance of the anatomical relationship between the flexor digitorum longus and sustentaculum tali for reconsideration of the talocalcaneonavicular joint stability mechanism.

The talocalcaneonavicular joint (TCN-j) is supported by the spring ligament, which has recently been revealed to be part of the joint capsule complex, along with the tendinous sheath of the tibialis posterior and flexor digitorum longus (FDL). Nonetheless, the FDL's role in TCN-j stability has received limited attention. This study aimed to elucidate the positional relationships between the FDL and sustentaculum tali, which comprises the TCN-j. We hypothesized that the FDL runs medial to the sustentaculum tali, and its course significantly changes from the sitting to the standing position. Six ankles from six body donors were investigated, and seven ankles from seven volunteers were assessed using ultrasonography. The FDL was three-dimensionally located inferomedial to the sustentaculum tali. The FDL tendinous sheath was attached to the sustentaculum tali or connected by the tibialis posterior via the tendinous sheath. Based on the in vivo ultrasound image, the FDL location relative to the sustentaculum tali was maintained; however, the curvature of the FDL course was significantly more prominent in standing than in sitting. The FDL force against the bending moment may prevent the excessive eversion of the foot and aid the conventional spring ligament's contribution to TCN-j stability for maintaining the longitudinal arch.

Las coaliciones tarsianas como causa de dolor en el pie infantil: opciones terapéuticas / Tarsal coalitions as a cause of pain in the foot of children: Therapeutic options

Antecedentes y objetivo: La coalición tarsiana puede ser causa de dolor de medio-retropié en niños mayores. El objetivo es analizar los tipos de coalición tratados en nuestro centro hospitalario de 2010 a 2019 así como el tratamiento realizado. Material y método: Estudio observacional, descriptivo y retrospectivo de 18 pacientes con coalición tarsiana, 8 mujeres y 10 hombres, de 11,9±2,6 años de edad. Se recogieron datos epidemiológicos, hallazgos clínicos y de pruebas de imagen y tratamiento realizado. Resultados: Se revisaron 25 pies (38,8% bilaterales). El principal síntoma fue el dolor. Un 64% se asociaba a pie plano-valgo. El 52% se localizaba en la articulación calcáneo-escafoidea, y un 40% en la calcáneo-astragalina. El tratamiento fue conservador en un 44,4% de los casos y quirúrgico en el 56% (resección de la coalición). Se produjo un solo caso de recidiva. Los resultados fueron mayoritariamente excelentes o buenos (88%) tras un periodo medio de seguimiento de 4 años. Conclusiones: El tipo de coalición tarsiana diagnosticada con mayor frecuencia fue la localizada en la articulación calcáneo-escafoidea seguida de la calcáneo-astragalina, pero puede aparecer en cualquier articulación del pie. Casi la mitad respondieron bien al tratamiento conservador con resultados mayoritariamente buenos, pero el resto requirieron tratamiento quirúrgico por persistencia de la clínica, cuyos resultados fueron excelentes en todos los casos excepto en uno que sufrió una recidiva. En los casos de coaliciones calcáneo-astragalinas asociadas a valgo severo de retropié, la corrección de esta deformidad, asociada o no a la resección de la coalición, es recomendable.(AU)

Background and objective: The tarsal coalition can be a cause of mid-hindfoot pain in older children. The objective is to analyze the types of coalition treated in our hospital from 2010 to 2019 as well as the treatment carried out. Material and method: Observational, descriptive and retrospective study of 18 patients with tarsal coalition, 8 women and 10 men, aged 11.9±2.6 years. Epidemiological data, clinical findings and imaging tests, and treatment performed were collected. Results: Twenty-five feet (38.8% bilateral) were reviewed. The main symptom was pain. Sixty-four percent were associated with flat-valgus foot. Fifty-two percent were located in the calcaneal-scaphoid joint, and 40% in the calcaneal-talar joint. Treatment was conservative in 44.4% of cases and surgical in 56% (coalition resection). There was only one case of recurrence. The results were mostly excellent or good (88%) after a mean follow-up period of 4 years. Conclusions: The most frequently diagnosed type of tarsal coalition was that located in the calcaneal-scaphoid joint followed by the calcaneal-talar joint, but they can appear in any joint of the foot. Almost half responded well to conservative treatment with mostly good results, but the rest required surgical treatment due to persistence of the symptoms, the results of which were excellent in all cases except one who suffered a recurrence. In cases of calcaneal-talar coalitions associated with severe hindfoot valgus, correction of this deformity, associated or not with resection of the coalition, is recommended.(AU)