'Ostoesynthesis' of a symptomatic bipartite medial cuneiform

Bipartition of the medial cuneiform is uncommon and often not recognized on plain radiographs. It is usually asymptomatic and rarely, if ever, requires surgery. Injury to the synchondrosis of a bipartite medial cuneiform is rare and has, to our knowledge, been reported only once. We describe such a case with chronic disabling midfoot pain after remote trauma.     

Medial column procedures in the correction of adult acquired flatfoot deformity

AAFD is a complex problem with a wide variety of treatment options. No single procedure or group of procedures can be applied to all patients with AAFD because of the variety of underlying etiology and grades of deformity. As the posture of the foot progresses into hindfoot valgus and forefoot abduction through attenuation of the medial structures of the foot, the medial column begins to change shape. The first ray elevates and the joints of the medial column may begin to collapse. Careful physical examination and review of weight-bearing radiographs determines which patients have an associated forefoot varus deformity that may require correction at the time of flatfoot reconstruction. Correction of an AAFD requires a combination of soft-tissue procedures to restore dynamic inversion power and bony procedures to correct the hindfoot and midfoot malalignments. If after these corrections forefoot varus deformity remains, the surgeon should consider use of a medial column procedure to recreate the “triangle of support” of the foot that Cotton described.5 If the elevation of the medial column is identified to be at the first NC or the first TMT joint, then the joint should be carefully examined for evidence of instability, hypermobility, or arthritic change. If none of these problems exist, then the surgeon can consider use of the joint-sparing Cotton medial cuneiform osteotomy to correct residual forefoot varus. However, if instability, hypermobility, or arthritic change is present, then the surgeon should consider use of an arthrodesis of the involved joint to correct residual forefoot varus. Either procedure provides a safe and predictable correction to the medial column as part of a comprehensive surgical correction of AAFD.     

Isolated medial cuneiform fractures: report of two cases and review of the literature

Although fractures of the midfoot are common, cuneiform fractures are rarely seen. These fractures are frequently associated with other fractures of the midfoot such as Lisfranc fracture-dislocations. However, isolated cuneiform fractures are extremely rare, with few cases reported in the relevant literature. Herein, the authors report 2 cases of isolated medial cuneiform fractures. One of the patients was treated with headless screw fixation due to displacement in fracture configuration, and the other was treated conservatively. Fractures were united without any complication in both patients. In this report, the authors discuss the mechanism of injury, diagnostic challenges, and treatment options of isolated medial cuneiform fractures.     

Micro-CT Density Analysis of the Medial Wall of the Human Medial Cuneiform

The human medial cuneiform is incompletely characterized with regard to anatomical morphology, including mineral density and bone quality. Clinically, we have observed failures of fixation by pull-through of devices through relatively soft medial bone. Defining patterns of relative density may provide valuable information regarding implant placement as higher cortical density bone may offer better resistance to such failures. We sought to identify an area of greatest density along the medial wall of the medial cuneiform.Ten fresh-frozen human cadaveric medial cuneiforms underwent micro-computed tomography imaging. Images were analyzed to obtain densities in 4 quadrants along the medial wall of the medial cuneiform. Seven of 10 specimens revealed a maximum density in the plantar distal quadrant of the medial wall of the medial cuneiform. Chi-square goodness-of-fit testing indicated that the density of this quadrant was significantly different from 3 other quadrants (P<.009). Using the Principle of Standard Residuals, the density of the plantar distal quadrant was significantly different than the other 3.We conclude that the plantar distal quadrant of the medial cuneiform contains bone of maximal density when compared to 3 other quadrants. Surgeons who place implants in this region should be aware that this area might offer better resistance to fixation failure.     

The “L-shaped” intermediate cuneiform

We present the case of a 44-year-old lady with an ‘L-shaped’ intermediate cuneiform. Plain radiography did not identify the anomaly but showed osteoarthritic changes in her tarsometatarsal joint. At the time of sugical fusion, an ‘L-shaped’ intermediate cuneiform was observed, preventing the medial cuneiform articulating with the navicular bone. Fusion of the medial through the intermediate, to the navicular bone was successful at resolving her midfoot pain.     

Seltene, im Nativröntgen nicht erkennbare schwere Kombinationsverletzung der Fußwurzel

We report a rare case of a 35-year-old man who sustained a severe injury of the tarso-metatarsal joint. An isolated fracture of the medial cuneiform was seen on initial radiographs; final diagnosis was made by CT-scan.     

Isolated medial cuneiform fracture: review of the literature and report of two cases

The authors present two unusual cases of isolated medial cuneiform fracture. Both fractures were difficult to see on plain films and therefore diagnosed with ancillary tests (computed tomography and magnetic resonance imaging). Treatment was nonweightbearing cast immobilization, in which both patients healed within twelve weeks of treatment without complication and returned to full work related activities.     

Subtle injuries to the lisfranc joint

The tarsometatarsal joint complex is an osseous and capsuloligamentous network that includes the 5 metatarsals, their articulations with the cuneiforms and cuboid, and the Lisfranc ligament, a strong interosseous attachment between the medial cuneiform and second metatarsal. A multitude of injury patterns exist involving the tarsometatarsal joint complex; a Lisfranc injury does not delineate a specific injury, but instead a spectrum of processes involving the tarsometatarsal joint complex.     

Treatment of severe residual clubfoot deformity by trans-midtarsal osteotomy.

This study reviews the preliminary results of transmidtarsal osteotomy performed on 11 patients (12 feet) who previously underwent surgery for resistant clubfoot and needed further surgery for severe residual deformities. Opening wedge medial cuneiform osteotomy, closing wedge cuboid osteotomy, and truncated wedge middle and lateral cuneiform osteotomy were performed. The procedure was performed initially on normal cadaver feet. The average improvement of anteroposterior talo-first metatarsal angle was 20 degrees and lateral calcaneo-first metatarsal angle was 16 degrees. The authors conclude that with this simple procedure, angular and rotational correction in three planes can be obtained simultaneously in severe residual clubfoot deformity without the need for extensive soft tissue release.     

Lateral column calcaneal lengthening, flexor digitorum longus transfer, and opening wedge medial cuneiform osteotomy for flexible flatfoot: a biomechanical study

BACKGROUND: Lengthening of the lateral column is commonly used for reconstruction of the adult and pediatric flatfoot, but can result in supination of the foot and symptomatic lateral column overload. The addition of a medial cuneiform osteotomy has been used to redistribute forces to the medial column. The combined use of a lateral column lengthening and medial cuneiform osteotomy in a reproducible cadaver flatfoot model was evaluated. METHODS: Twelve cadaver specimens were physiologically loaded and each was evaluated radiographically and pedobarographically in the following conditions: 1) intact, 2) severe flatfoot, 3) lateral column lengthening with simulated flexor digitorum longus transfer, and 4) lateral column lengthening and flexor digitorum longus (FDL) transfer with added medial cuneiform osteotomy. The lateral column lengthening was performed with a 10-mm foam bone wedge through the anterior process of the calcaneus, and the medial cuneiform osteotomy was performed with a dorsally placed 6-mm wedge. RESULTS: Lateral column lengthening with simulated FDL transfer on a severe flatfoot model resulted in a significant change as compared with the flatfoot deformity in three measurements: in lateral talus-first metatarsal angle (-17 to -7 degrees; p<0.001), talonavicular angle (46 to 24 degrees; p<0.001), and medial cuneiform height (16 to 20 mm; p<0.001). Lateral forefoot pressure increased from 24.6 to 33.9 kPa (p<0.001) after these corrections as compared with the flatfoot. Adding a medial cuneiform osteotomy decreased the lateral talar-first metatarsal angle from -7 to -4 degrees, decreased the talonavicular coverage angle from 24 to 20 degrees, and increased the medial cuneiform height from 20 to 25 mm. After added medial cuneiform osteotomy, lateral pressure was significantly different from that of the flatfoot (p=0.01) and was not significantly different from that of the intact foot (p=0.14). Medial forefoot pressure was overcorrected as compared with the intact foot with added medial cuneiform osteotomy. CONCLUSIONS: Lateral column lengthening increased lateral forefoot pressures in a severe flatfoot model. An added medial cuneiform osteotomy provided increased deformity correction and decreased pressure under the lateral forefoot.     

Complete Medial Dislocation of the First Cuneiform: A Case Report

Isolated dislocation of the first cuneiform bone is an extremely rare lesion that can usually be diagnosed on plain radiography. Few cases of this injury have been previously described in the literature. The case presented here resulted from a torsion injury and was treated by means of closed reduction with the aid of pointed reduction forceps. After fixation with Kirschner wires, the foot was immobilized for 6 weeks. The patient recovered uneventfully and remains asymptomatic 3 years later.     

Nonunion of a medial malleolar stress fracture in an adolescent athlete secondary to lateral ankle instability: A case report

IntroductionMedial malleolar stress fractures are relatively uncommon. This report describes the successful treatment of nonunion of a medial malleolar stress fracture due to chronic lateral ankle instability.Presentation of caseA 13-year-old middle school student who belonged to a football club presented to our clinic with chronic medial left ankle pain lasting over a year. He had sprained his left ankle several times 6 years earlier. A plain anteroposterior ankle radiograph showed a vertical fracture line in the medial malleolus involving the epiphyseal plate, and computed tomography demonstrated the vertical fracture seen on the plain radiographs and bone sclerosis at the fracture site. We performed internal fixation for nonunion of the medial malleolar stress fracture with arthroscopic modified Broström for lateral ankle instability. Two years after surgery, the Self-Administered Foot Evaluation Questionnaire improved in all parameters, and both the anterior drawer and varus stress tests were negative.DiscussionEarly diagnosis of medial malleolar stress fracture is important for a rapid return to sports. Magnetic resonance imaging is helpful for early diagnosis. Because lateral ankle instability can cause medial malleolar stress fracture, arthroscopic modified Broström procedure is meaningful for medial malleolar stress fracture with lateral ankle instability.ConclusionInternal fixation and the arthroscopic modified Broström procedure could achieve good clinical outcomes for medial malleolar stress fractures with lateral ankle instability.     

Symptomatic bipartite medial cuneiform in an adult athlete: a case report

We present the case of a 32-year-old female marathon runner with a symptomatic bipartite medial cuneiform. The bipartite articulation was best visualized on a 30 degress external oblique radiograph of the foot. Surgical exploration revealed a noncartilaginous articulation between the two osseous segments. The smaller medial segment was excised. Postoperatively the patient's symptoms resolved, and at one-year follow-up she remains asymptomatic and has returned to competitive running. This case demonstrates that surgical excision is indicated for a symptomatic bipartite medial cuneiform that fails to respond to nonoperative measures.     

Anatomic Description of the Distal and Intercuneiform Articulations: A Cadaveric Study

The medial, intermediate, and lateral cuneiforms play a pivotal role in foot biomechanics. When correcting deformities of this joint complex understanding the clinical anatomy remains imperative to provide both anatomic reduction and appropriately sized fixation. This study qualitatively and quantitatively describes the distal and intercuneiform articulations and their clinical implications. The cuneiform complex of 10 fresh-frozen cadavers was dissected, and the width of the complex was measured with digital calipers. Following further dissection, the distal articular surface shapes of each cuneiform were described, and the individual heights and widths were measured. The intercuneiform articular facets were described and the protrusion distances, between the medial and lateral cuneiforms with the intermediate cuneiform, were measured. The width of the joint complex was 44.74 ± 3.40 mm. The medial cuneiform height, width, dorsal anterior, and plantar protrusion distances were 32.58 ± 2.77 mm, 14.08 ± 2.26 mm, 8.51 ± 2.17 mm, and 6.66 ± 1.21 mm, respectively. The intermediate cuneiform height and width was 23.05 ± 1.92 mm and 9.59 ± 1.85 mm, respectively. The lateral cuneiform height, width, dorsal, and plantar anterior protrusion distances were 23.38 ± 2.67 mm, 10.98 ± 3.01 mm, and 6.76 ± 1.43 mm, and 4.19 ± 1.10 mm respectively. The anterior surface of the medial, intermediate, and lateral cuneiforms was described as reniform, triangular, and triangular, respectively. The majority of intermediate cuneiforms shared an inverted L-shaped articulation with the medial cuneiform, and a B-shaped articulation with the lateral cuneiform. The shapes and sizes of distal and intercuneiform articulations were described with shared anatomical features across cadavers. Understanding the dimensions of the respective surfaces allows for anatomically appropriate fixation size.     

Relationship Between Grading With Magnetic Resonance Imaging and Radiographic Parameters in Posterior Tibial Tendon Dysfunction

The objective of the present study was to elucidate the relationship between the state of the posterior tibial tendon (PTT) on magnetic resonance images and foot deformity. The cases included 34 feet in 27 patients with PTT deformity and the controls included 18 feet in 12 patients who had undergone magnetic resonance imaging for other foot diseases. The PTT was closely examined on the magnetic resonance images and classified using the Conti classification. The control feet with no injury to the PTT were classified as grade 0. The talonavicular coverage angle, lateral talo-first metatarsal angle, medial cuneiform to fifth metatarsal height, calcaneal pitch angle, and varus–valgus angle were measured as radiographic parameters for flatfoot deformation, and the relation between the Conti classification and each parameter was examined statistically. A significant difference was observed in the talonavicular coverage angle between grade 0 and the other grades; the lateral talo-first metatarsal angle between grade 0 and the other grades and between grades 1 and 3; the medial cuneiform to fifth metatarsal height among grades 0, 2, and 3 and grades 1, 2, and 3; the calcaneal pitch angle between grades 1 and 3; and the varus–valgus angle among grades 0, 2, and 3 and between grades 1 and 3. Eversion of the forefoot was observed, along with an advanced collapse in the medial longitudinal arch, from an early stage of PTT injury.     

Rupture of the anterior tibial tendon: three clinical cases, anatomical study, and literature review

BACKGROUND: We report three cases of anterior tibial tendon ruptures and the results of an anatomical study in regard to the tendon's insertion site and a literature review. METHODS: Three patients were referred to our hospital with anterior tibial tendon ruptures. In the anatomical study, 53 feet were dissected, looking in particular for variants of the bony insertion of the tendon. RESULTS: Two patients had surgical treatment (one primary repair and one semimembranosus tendon graft) and one conservative treatment. After a mean followup of 14 weeks all patients had satisfactory outcomes. In the anatomical study, we noted three different insertion sites: in 36 feet the tendon inserted into the medial side of the cuneiform and the base of the first metatarsal bone and in 13 feet only into the medial side of the cuneiform bone. In the remaining four feet the tendon inserted into the cuneiform and the first metatarsal bone, but an additional tendon was noted taking its origin from the anterior tibial tendon near its insertion into the medial cuneiform and attaching to the proximal part of the first metatarsal. CONCLUSIONS: According to literature, surgical repair is the treatment of choice for acute ruptures and for patients with high activity levels. For chronic ruptures and patients with low demands, conservative management may lead to an equally good outcome. Knowledge of the anatomy in this region may be helpful for diagnosis and for the interpretation of intraoperative findings and choosing the most appropriate surgical procedure.     

Isolated plantar dislocation of the middle cuneiform: a case report

Isolated plantar dislocation of the cuneiform was reported in only two cases in the literature. We report a 57-year-old man with plantar dislocation of the cuneiform when the foot was struck by a large concrete block during construction of a building. Tarsometatarsal injuries are frequently overlooked. Therefore, plain computed tomography (CT) and three-dimensional CT are useful for adequate evaluation.     

Type four fracture of the medial epicondyle: a true indication for surgical intervention

Fourteen consecutive cases with type 4 fracture of the medial epicondyle were evaluated following open reduction and internal fixation of the displaced medial epicondyle. The mean age was 9.7 years (range 6–16) and the mean follow-up was 17.2 months (range 12–24). Operative treatment yielded excellent results with no loss of functional range of motion, residual deformity or instability. There were three cases with pre-operative symptoms of ulnar nerve injury which made a good recovery following neurolysis of the ulnar nerve. Type 4 fractures are commonly associated with intra-articular entrapment of the ulnar nerve and result from serious damage to the soft tissues on the medial side of the elbow. Assessing instability is therefore of key importance, as is the intra-operative gravity stress–valgus test in assessing instability.     

Radiographic comparison of standing medial cuneiform arch height in adults with and without acquired flatfoot deformity

BACKGROUND: Adult acquired flatfoot (AAF) is characterized by decreased arch height, talar depression, medial arch depression and elongation, and forefoot abduction. We have measured standing arch height in AAF patients and in a control group of patients using the standing lateral medial cuneiform arch height radiographic measurement. METHODS: Fifteen (25 feet) patients were selected with the clinical diagnosis of symptomatic AAF with no secondary diagnoses. A control group consisted of 36 (72 feet) patients with no foot deformities or prior foot surgeries. Arch height was measured in millimeters using the standing medial cuneiform height on the lateral radiographic view. RESULTS: The mean standing medial cuneiform arch height in the control group was 18.38 mm. The mean arch height in the AAF group was 11.04 mm (p < 0.001). There were no differences between right and left feet in the control group or symptomatic and contralateral feet in the AAF group. Body mass index (BMI) in the control group was 26.17 and in the AAF 33.74. (p = 0.007). CONCLUSION: These data provide a control value for the arch height using the medial cuneiform as reference. The decrease in arch height is a strong indicator of AAF. A study with larger numbers of patients is necessary.     

Treatment of residual adduction deformity in clubfoot: the double osteotomy.

Forefoot adduction is the most common residual deformity after clubfoot surgery. Surgical treatment of this deformity is often required for moderate and severe cases. This study reports the results of a closing wedge osteotomy of the cuboid and opening wedge osteotomy of the medial cuneiform in 39 feet. The average follow-up was 4.8 years. Clinical and radiographic improvement was seen in all patients, and no complications were seen. Surgery is advocated in children older than age 4, or when the medial cuneiform ossific nucleus is well developed.