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.

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.

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.

Long-term Outcomes of Talonavicular Arthrodesis for the Treatment of Planovalgus Foot in Children With Cerebral Palsy.

BACKGROUND: Planovalgus foot (PVF) in cerebral palsy (CP) tends toward progression and rigidity in adolescence, especially in patients with greater functional impairment. Deformity at the talonavicular joint justifies the use of talonavicular arthrodesis as a corrective surgical technique. This study aims to assess patient or caregiver functional satisfaction and radiographic outcomes of talonavicular arthrodesis for PVF in CP patients with assisted ambulation in the long-term. METHODS: Retrospective comparative study of level III and level IV pediatric CP patients who underwent talonavicular arthrodesis for PVF between 1999 and 2010 as part of multilevel surgery and with a minimum follow-up of 10 years. Radiologic correction at 10 years was compared with preintervention values, and functional impact at 10 years was measured by the foot function index (FFI); correlation between radiologic measurements and FFI were obtained, and complications were recorded. RESULTS: Forty-nine PVFs in 25 patients with CP (72% level III and 28% level IV) were included; 52% were male. The patients had a median age of 12 years at the time of surgery (range: 11 to 15) and 23 years at the time of the study (21 to 26). Significant (P<0.01) pre-post radiologic improvements were obtained in Meary angle (37.86±10.7/8.37±5.5 degrees), calcaneal pitch (3.20±8.1/13.22±5.6 degrees), lateral talocalcaneus angle (42.18±12.1/25.29±2.9 degrees), Moreau-Costa-Bartani angle (167.04±8/146.12±7.1 degrees), talus-first metatarsal angle (27.92±13.9/9.69±4.4 degrees), anteroposterior talocalcaneal angle (37.61±7.4/22.61±2.4 degrees), and talus coverage angle (37.04±11.11/2.45±2.5 degrees). At 10 years postoperatively, functional outcome measured with the FFI was satisfactory (33.9±15.2%) and the mean maximum pain was 3.04; 56% of cases had mild pain. All patients were able to wear an ankle-foot orthosis and 8 no longer needed the device. A significant correlation was found between the talofirst metatarsal angle and the FFI (P=0.024). There were 8% of cases with screw protrusion and 14% presented pseudarthrosis, most of them asymptomatic. CONCLUSIONS: The adequate functional outcome, as well as the persistence of long-term radiologic correction and acceptable number of complications, enables us to recommend talonavicular arthrodesis as an alternative treatment to consider in level III and level IV CP patients with PVF. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Coronal Hindfoot Alignment in Midfoot Charcot Neuroarthropathy.

Coronal plane hindfoot malalignment produces abnormal compensatory forces within the midfoot and forefoot. The primary aim of this study is to compare radiographic hindfoot alignment in patients with a midfoot Charcot event, and identify patterns associated with breakdown. A retrospective review of 43 patients (48 limbs) with midfoot Charcot neuroarthropathy were compared between the coronal hindfoot alignments and Charcot joint involvement. Coronal hindfoot alignment was classified as neutral (n = 15), valgus (n = 16), and varus (n = 17) utilizing the Saltzman hindfoot alignment radiograph. Charcot joint breakdown was classified as isolated tarsometatarsal joint (n = 8), combination of tarsometatarsal and naviculocuneiform joints (n = 22), and midtarsal joints including talonavicular and calcaneocuboid joints (n = 18). Patients exhibiting varus hindfoot alignment had 5.8 times greater risk of breakdown at the tarsometatarsal and naviculocuneiform joints (odds ratio 5.8, 95% confidence interval 1.7-22.9, p < .01). Hindfoot varus induces external rotation of the talus, resulting in compensation through the naviculocuneiform and tarsometatarsal joint, which correlates with our findings of a 6-fold increase in naviculocuneiform and tarsometatarsal joint collapse. Patients exhibiting valgus hindfoot alignment had 27 times greater risk of breakdown at the midtarsal joint (odds ratio 27.0; 95% confidence interval 5.6-207.0, p < .01). Hindfoot valgus induces internal rotation of the talonavicular joint, which correlates with our findings of a 27-fold increase in midtarsal joint breakdown. Varus and valgus hindfoot alignment are associated with different midfoot injury patterns, which may have implications in surgical management and allow for focused surveillance in neuropathic patients presenting with early-stage clinical findings consistent with Charcot neuroarthropathy.

Radiographic Outcomes of Talonavicular Joint Arthrodesis With Varying Fixation Techniques in Stage III Adult Acquired Flatfoot Reconstruction.

Utilization of the talonavicular joint (TN) arthrodesis as an isolated procedure or in combination with hindfoot arthrodesis has been described in the literature for treatment of numerous hindfoot conditions. When used in isolation or with concomitant hindfoot arthrodesis, the TN joint has demonstrated nonunion rates reported as high as 37% in the literature. Despite previous research, there remains a lack of agreement upon the ideal fixation technique for TN joint arthrodesis with and without concomitant subtalar joint arthrodesis. The purpose of this study was to retrospectively compare the radiographic and clinical results of TN joint arthrodesis as part of double arthrodesis procedure utilizing 4 separate fixation constructs in the treatment of advanced hindfoot malalignment in stage III adult-acquired flatfoot deformity. We retrospectively reviewed 105 patients who underwent TN joint arthrodesis as part of double arthrodesis procedure utilizing 4 separate fixation constructs. Our results demonstrated a nonunion rate of 16.2%, with 17 nonunions identified within our patient population. One (2.4%) nonunion was observed in the 3-screw cohort, 7 (33.3%) nonunions were observed in the 2-screw cohort, 4 (16.0%) nonunions were observed in the 2-screw plus plate cohort, and 5 (29.4%) nonunions were observed in the 1-screw plus plate cohort. The difference in nonunion rate between the 4 cohorts was statistically significant. Based on these results, we conclude that the use of a 3-screw construct for TN joint arthrodesis as part of double arthrodesis procedure demonstrates a statistically significant reduction in nonunion rate and should be considered a superior fixation construct for this procedure.

Weightbearing CT Analysis of the Transverse Tarsal Joint During Eversion and Inversion.

BACKGROUND: Understanding of the movement and function of the transverse tarsal joint (TTJt) continues to evolve. Most studies have been done in cadavers or under nonphysiologic conditions. Weightbearing computed tomographic (WBCT) scans may provide more accurate information about the position of the TTJt when the hindfoot is in valgus or varus. METHODS: Five volunteers underwent bilateral weightbearing CT scans while standing on a platform that positioned both hindfeet in 20 degrees of valgus and 20 degrees of varus. Each bone of the foot was segmented, and the joint surfaces of the talus, calcaneus, cuboid, and navicular were identified. The principal axes for each joint surface were determined and used to calculate the angles and distances between the bones with the foot in valgus or varus. RESULTS: In the coronal plane, the angle between the talus and calcaneus rotated 17.1 degrees as the hindfoot moved from valgus to varus. The distance between the centers of the talus and calcaneus decreased 7.1 mm. The cuboid translated 3.9 mm medially relative to the calcaneus. There was no change in angle or distance between the cuboid and navicular. The navicular rotated 25.4 degrees into varus relative to the talus. CONCLUSION: The TTJt locking mechanism was previously thought to occur from the talonavicular and calcaneocuboid joint axes moving from parallel to divergent as the hindfoot inverts. The current data show a more complex interaction between the four bones that comprise the TTJt and suggests that the locking mechanism may occur because of tightening of the ligaments and joint capsules. CLINICAL RELEVANCE: This study uses weight bearing CT scans of healthy, asymptomatic volunteers standing on valgus and varus platforms to characterize the normal motion of the transverse tarsal joint of the foot. A better understanding of how the transverse tarsal joint functions may assist clinicians in both the conservative and surgical management of hindfoot pathology.

Load to Failure of the Ankle Joint Complex After Fusion of the Subtalar and Talonavicular Joints: A Cadaveric Study.

Recent literature has proposed that restriction of joints in the rearfoot secondary to coalitions may lead to increased risk for severe ankle fracture after trauma. There is a paucity of literature regarding the rigidity of the ankle joint after arthrodesis of the subtalar and talonavicular joints. In this study, load-to-failure testing of cadaveric ankle joints with and without fusion of the subtalar and talonavicular joints was performed to determine if clinically relevant fracture patterns could be reproduced. Of the 3 fixation patterns studied, combined subtalar and talonavicular joint fusion resulted in a measurable increase in joint stiffness; however, this was not statistically significant. Clinical and radiographic examination postloading revealed that all tested ankle joints sustained a dislocation type injury rather than a specific bone fracture pattern. It was determined that a pure low-speed bending and compression model does not produce clinically relevant fracture patterns, and that higher energy mechanisms are required.

Pure isolated medial talonavicular joint dislocation following low-energy trauma: a case report.

Midtarsal dislocations are relatively rare injuries secondary to high-energy trauma and are typically accompanied by disruption of ligamentous structures and fractures of the midfoot. We herein present a case of a pure isolated medial swivel dislocation of the talonavicular joint (TNJ) that was sustained following low-energy trauma without an associated fracture. A 78-year-old woman visited our emergency department with severe pain in the midfoot area of the right foot without neurovascular deficits. She had sustained this injury after severe ankle inversion while going downstairs. Plain radiographs of the right foot showed that the navicular was dislocated medially on the talus; no other malalignments were present. Three-dimensional computed tomography revealed dislocation of the TNJ, but no other tarsal or midtarsal bone fractures or dislocations. A medial dorsal incision was made to expose the TNJ. The dorsal talonavicular ligament was ruptured and interposed between the navicular and talus. The ligament was removed and the TNJ was reduced. The clinical outcome at the 1-year follow-up was satisfactory with no limitations in daily activities. In summary, we have reported an extremely rare case of a pure isolated medial TNJ dislocation in which the interposed dorsal talonavicular ligament served as an obstacle to reduction.

Persistent instability in pure ligamentous Lisfranc joint injuries.

INTRODUCTION: Lisfranc injuries refer to a specific group of injuries which lead to instability of the tarsalmetatarsal joint. Our hypothesis is that persistent instability is permanent and asymptomatic in subtle unstable injuries of the medial column which have been fixed percutaneously. OBJECTIVE: To describe the persistent instability of pure ligamentous Lisfranc joint injuries treated with anatomic reduction and percutaneous screws fixation by comparative radiographs of both feet. MATERIALS AND METHODS: Between 2014 and 2018, 14 patients diagnosed with subtle unstable Lisfranc injury were evaluated. Indications for surgery included widening (diastasis) greater than 2mm between the first and second metatarsal bases, and subluxation greater than 1mm of a metatarsal base from its respective tarsal bone. RESULTS: Persistent instability was found on the stress radiographs of 11 patients (78.57% 95% CI: 48.60-95.07%) but without clinical connotations. The average AOFAS score evaluated at 18 months post-operatively was of 97.14 (SD±4.68) points. The median follow-up was 24 (RIQ: 18-24) months. In all patients, anatomical reduction on radiographs was evident. CONCLUSION: We observed a persistent instability of the Lisfranc joint, without clinical connotations. Subtle unstable Lisfranc injuries treated with percutaneous screw fixation have a good clinical and functional outcome. LEVEL OF EVIDENCE: IV.

Loss of Mechanical Ankle Function Is Not Compensated by the Distal Foot Joints in Patients with Ankle Osteoarthritis.

BACKGROUND: Patients with isolated ankle osteoarthritis (OA) often demonstrate disturbed ankle biomechanics during walking. Clinicians often believe that this triggers the distal foot joints to compensate these altered ankle biomechanics and that these foot joints are consequently subjected to degenerative joint diseases due to overuse. QUESTIONS/PURPOSES: Do patients with isolated ankle OA differ from those without ankle OA in terms of (1) ankle and foot joint kinematics and (2) ankle and foot joint kinetics as measured using three-dimensional (3-D) gait analysis? (3) Do these patients demonstrate compensatory strategies in their Chopart, Lisfranc, or first metatarsophalangeal joints in terms of increased joint kinematic and kinetic outputs? METHODS: Between 2015 and 2018, we treated 110 patients with unilateral ankle OA, and invited all of them to participate in the gait analysis laboratory. Of those, 47% (52) of patients did so, and of these, 16 patients met the inclusion criteria for this study, which were (1) diagnosis of unilateral ankle OA; (2) absence of radiographical signs of OA in the contralateral foot or lower limbs; (3) ability to walk at least 100 m without rest; and (4) being older than 18 years of age. A control group (n = 25) was recruited through intranet advertisements at the University Hospitals of Leuven. Participants were included if their age matched the age-range of the patient group and if they had no history of OA in any of the lower limb joints. Patients were slightly older (55.9 ± 11.2 years), with a slightly higher BMI (28 ± 6 kg/m2) than the control group participants (47.2 ± 4.4 years; p = 0.01 and 25 ± 3 kg/m2; p = 0.05). All participants underwent a 3-D gait analysis, during which a multisegment foot model was used to quantify the kinematic parameters (joint angles and ROM) and the kinetic parameters (rotational forces or moments), as well as power generation and absorption in the ankle, Chopart, Lisfranc, and first metatarsophalangeal joints during the stance phase of walking. Peak values were the maximum and minimum values of waveforms and the latter were time-normalized to 100% of the stance phase. RESULTS: Regarding joint kinematics, patients demonstrated a sagittal plane ankle, Chopart, Lisfranc, and first metatarsophalangeal joint ROM of 11.4 ± 3.1°, 9.7 ± 2.7°, 8.6 ± 2.3° and 34.6 ± 8.1°, respectively, compared with 18.0 ± 2.7° (p < 0.001), 13.9 ± 3.2° (p < 0.001), 7.1 ± 2.0° (p = 0.046) and 38.1 ± 6.5° (p = 0.15), respectively, in the control group during the stance phase of walking. With regard to joint kinetics in the patient group, we found a mean decrease of 1.3 W/kg (95% CI confidence interval 1.0 to 1.6) (control group mean: 2.4 ± 0.4 W/kg, patient group mean: 1.1 ± 0.5 W/kg) and 0.8 W/kg (95% CI 0.4 to 1.0) (control group mean: 1.5 ± 0.3 W/kg, patient group mean: 0.7 ± 0.5 W/kg) of ankle (p < 0.001) and Chopart (p < 0.001) joint peak power generation. No changes in kinetic parameters (joint moment or power) were observed in any of the distal foot joints. CONCLUSION: The findings of this study showed a decrease in ankle kinematics and kinetics of patients with isolated ankle OA during walking, whereas no change in kinematic or kinetic functions were observed in the distal foot joints, demonstrating that these do not compensate for the mechanical dysfunction of the ankle. CLINICAL RELEVANCE: The current findings suggest that future experimental laboratory studies should look at whether tibiotalar joint fusion or total ankle replacement influence the biomechanical functioning of these distal joints.

Resultados funcionales del tratamiento quirúrgico percutáneo de las lesiones sutiles del complejo tarso-metatarsiano / Study of the functional results of the percutaneous surgical treatment of subtle injuries of the tarso-metatarsian complex

INTRODUCCIÓN Y OBJETIVOS: El concepto Lisfranc sutil define lesiones por baja energía del complejo articular tarso-metatarsiano (CTM) que suponen inestabilidad articular. Con frecuencia pasan desapercibidas, con secuelas a largo plazo. El objetivo es evaluar los resultados clínico-funcionales de los pacientes con lesiones CTM ligamentosas grado II-III (clasificación de Nunley y Vertullo) tratados con cirugía percutánea. MATERIAL Y MÉTODOS: Estudio retrospectivo sobre 16 pacientes intervenidos percutáneamente por lesión ligamentosa CTM. Se recogieron datos demográficos, días de demora del diagnóstico, técnica quirúrgica, reducción articular en carga (adecuada si espacio C1-M2 menor de 2 mm) y puntuación de la escala Manchester-Oxford (MOXFQ). Muestra constituida por nueve varones y siete mujeres, edad media de 43,6 años (17-71) y seguimiento medio 22 meses (12-28). RESULTADOS: El diagnóstico se demoró más de 24 horas en cuatro pacientes (3-6 días). En 11 pacientes el tratamiento consistió en reducción cerrada y síntesis percutánea con tornillos canulados desde M2 a C1 y desde C1 a C2. En tres pacientes se suplementó con agujas Kirschner en los radios laterales. Dos pacientes se trataron con único tornillo M2 a C1. No se consiguió una reducción anatómica en seis pacientes, con una media de 2,6 mm entre C1-M2 (2,1-3 mm); la puntuación media funcional MOXFQ de estos pacientes fue 41,1% (IC 95% 23,1-59,1%), peores resultados comparando con la reducción anatómica: 17,2% (IC 95% 5,7-28,7); diferencia estadísticamente significativa (p < 0,01). CONCLUSIÓN: Las lesiones sutiles del CTM son poco frecuentes y pueden pasar desapercibidas. El tratamiento quirúrgico con síntesis percutánea ofrece buenos resultados clínico-funcionales a medio plazo. La reducción anatómica es un factor determinante para el buen resultado funcional de nuestros pacientes

INTRODUCTION AND OBJECTIVES: The concept subtle Lisfranc defines low energy lesions of the tarsometatarsal joint complex (TMC) that involve joint instability. Often unnoticed, with long-term sequelae. The objective is to evaluate the clinical-functional results of patients with MTC ligament damage grade II-III (Nunley and Vertullo classification) treated with percutaneous surgery. MATERIAL AND METHODS: Retrospective study of 16 patients who underwent percutaneous surgery for MLC ligament damage. Demographic data, days of delay in diagnosis, surgical technique, joint reduction in load (adequate if C1-M2 space is less than 2 mm) and Manchester-Oxford scale (MOXFQ) score were collected. The sample consisted of nine males and seven females, mean age 43.6 years (17-71) and mean follow-up of 22 months (12-28). RESULTS: Diagnosis was delayed for more than 24 hours in four patients (3-6 days). In 11 patients the treatment consisted of closed reduction and percutaneous synthesis with cannulated screws from M2 to C1 and from C1 to C2. In three patients it was supplemented with Kirschner wires in the lateral radii. Two patients were treated with only M2 to C1 screws. An anatomical reduction was not achieved in six patients, with a mean of 2.6 mm between C1-M2 (2.1-3 mm); the mean functional MOXFQ score of these patients was 41.1% (IC 95% 23.1-59.1%), worse results compared to the anatomical reduction: 17.2% (IC 95% 5.7-28.7); statistically significant difference (p < 0.01). CONCLUSION: Subtle injuries from MTC are rare and can go unnoticed. Surgical treatment with percutaneous synthesis offers good clinical-functional results in the medium term. The anatomical reduction is a determining factor for the good functional result of our patients

Change in the First Cuneiform-Second Metatarsal Distance After Simulated Ligamentous Lisfranc Injury Evaluated by Weightbearing CT Scans.

BACKGROUND: This study aimed to investigate the widening between the first cuneiform (C1) and second metatarsal (M2) in a Lisfranc ligamentous complex (LLC) joint injury model subjected to successive ligament dissections evaluated by weightbearing computed tomography (CT) scans. METHODS: Twenty-four intact cadaveric feet served as the control (condition 1). Each component of the LLC (dorsal, interosseous, and plantar ligaments-conditions 2, 3, and 4, respectively) were then sequentially dissected. The specimens were equally randomized to 1 of 3 additional dissections (first or second tarsometatarsal [TMT] joint capsule or first-second intercuneiform ligament [ICL]-conditions 5a, 5b, and 5c, respectively). One additional ligament was then randomly transected (eg, condition 6ac-transection of the first TMT capsule and ICL). Finally, the remaining ligament was transected (condition 7). After each dissection, CT scans were acquired under nonweightbearing (NWB, 0 kg), partial-weightbearing (PWB, 40 kg), and full-weightbearing (FWB, 80 kg) conditions. The distance between the lateral border of C1 and the medial border of M2 was assessed to evaluate diastasis. Linear regressions with 95% CIs and converted q values were used to compare the measured data. RESULTS: No significant differences were found within the control. In condition 4, an average axial plane widening relative to control of 1.6 mm (95% CI, 1.5-1.8) and 2.1 mm (95% CI, 1.9-2.2) was observed under PWB and FWB. A coronal plane widening of 1.5 mm (95% CI, 1.3-1.6) and 1.9 mm (95% CI, 1.7-2.1) under PWB and FWB, respectively, was measured. A 95% CI of at least a 2-mm widening during PWB was demonstrated in 5c, 6ac, 6bc, and 7. CONCLUSIONS: Weightbearing computed tomography (WBCT) scans were used to detect ligamentous Lisfranc injuries in a cadaveric model. Relative axial widening greater than 1.5 mm under PWB conditions could indicate a complete LLC injury. Complete transection of the intercuneiform 1-2 ligament was required to detect a 2-mm widening in the nonweightbearing condition. CLINICAL RELEVANCE: This study provides insight on the detection of various severities of LLC injuries using WBCT imaging.

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

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

A Novel Technique in Treatment of Calcaneocuboid Dislocation with Bifurcate Ligament Reconstruction Using a Semitendinosus Allograft: A Case Report.

CASE: A 19-year-old woman sustained a plantar flexion-inversion injury to her right ankle after a low-speed motor vehicle collision. Clinical examination demonstrated supinated, adducted deformity of the foot, and prominent calcaneus laterally. Radiographs revealed dislocation of the calcaneocuboid joint, a rare injury, which was successfully stabilized by a novel technique using a hamstring allograft. The presentations and clinical and surgical management of this rare condition are discussed. CONCLUSION: We present a technique that has shown good long-term results in a young patient with recurrent calcaneocuboid joint dislocations. Our novel ligament reconstruction technique using a semitendinosus allograft seems to be a promising treatment option in young patients with unstable calcaneocuboid joints.

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

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

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

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

Radiographic changes of the mid-tarsal joint after calcaneal lengthening for planovalgus foot deformity.

BACKGROUND: This study evaluate the radiographic changes in the mid-tarsal joint, including the calcaneocuboid and talonavicular (TN) joints after calcaneal lengthening for planovalgus deformity in children. METHODS: This study included 38 patients (68 feet) who underwent calcaneal lengthening for planovalgus deformity. Radiographic osteoarthritic changes at the CC or TN joint were defined as modified Kellgren-Lawrence grade of ≥1. RESULTS: Among the 68 feet, 31 feet (45.6%) showed radiographic osteoarthritic changes at the CC joint and 20 (29.4%) showed changes at the TN joint. Risk of radiographic osteoarthritic changes at the CC joint was associated with increased age at surgery (OR = 1.2, p = 0.038). Risk of radiographic osteoarthritic changes at the TN joint was associated with increased age at surgery (OR = 2.2; p = 0.002), preoperative AP talus-1st metatarsal angle (OR = 1.1; p = 0.044), and degree of CC subluxation (OR = 2.1; p = 0.007). CONCLUSIONS: Surgeons should consider the risk factors in the surgical correction of planovalgus deformity to prevent mid-tarsal arthritis.

Rates of Displacement and Patient-Reported Outcomes Following Conservative Treatment of Minimally Displaced Lisfranc Injury.

BACKGROUND: While surgery is indicated in Lisfranc fracture-dislocations, the natural history and optimal management of minimally displaced injures are unclear. The aim of this study was to define the rate of subsequent displacement and to determine the clinical outcome after conservative treatment of minimally displaced Lisfranc injuries. METHODS: Over a 5-year period (2011-2016), 26 consecutive patients with minimally displaced Lisfranc injuries presenting to a single university teaching hospital were identified retrospectively using hospital electronic records. Patient demographics, injury mechanism, and radiological outcomes were recorded. Patient-reported outcome scores (PROMS) were collated at least 1 year postinjury and included the American Orthopaedic Foot & Ankle Society (AOFAS) midfoot score and Manchester Oxford Foot Questionnaire (MOXFQ). RESULTS: The rate of displacement was 54% (14/26). The median time to displacement was 18 days (range, 2-141 days). Forty-six percent (12/26) of the Lisfranc injuries remained minimally displaced after 12 weeks of conservative treatment. Initial weightbearing status was not associated with the risk of subsequent displacement (P = .9). At a mean follow-up of 54 months, PROMS were comparable between patients whose injury remained minimally displaced and those that required surgery for further displacement, despite the delay to surgery (AOFAS 78.0 vs 75.9, MOXFQ 24.8 vs 26.3, P > .1). CONCLUSION: There was a high rate of displacement after initial conservative management of the minimally displaced Lisfranc injuries. Subsequent surgical management of displaced injuries resulted in outcomes comparable to those that remained minimally displaced. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

Medial Swivel Dislocation of the Talonavicular Joint with Associated Cuboid Fracture.

Medial talonavicular dislocation associated with cuboid fracture is rare. We report an 18-year-old man with this injury who exhibited excellent results after open reduction and stabilization of the joint with temporary Kirshner wires.