Excision of extensive midfoot pigmented villonodular synovitis with microvascular anastamosis of iliac crest bone graft using external fixation: a case report

Pigmented villonodular synovitis (PVNS) is a relatively rare lesion in the foot and ankle, most commonly involving the ankle joint and atypically, the subtalar and midtarsal joints. It is a benign proliferative disease characterized by an increase in villous or nodular synovium in joints. Resection of the tumor is often indicated in most cases because of the potentially aggressive joint destructive nature of this lesion. This report presents a case of chronic enlarging pervasive midtarsal and metatarsal-cuneiform joint PVNS in a 28-year-old male. This patient had a midtarsal mass that enlarged over a period of 2 years, causing increased pain, deformity, and difficulty with ambulation. Cross-sectional imaging studies identified evidence of erosive disease through much of the midfoot articulations, with biopsy confirming the mass as PVNS. The dimensions of the mass approximated 5.5 cm × 4.1 cm × 2.8 cm. Simple resection was problematic because of the size and multiple joints involved. Amputation was most commonly advised by multiple consultants. The patient preferred attempt at limb salvage. En bloc resection and placement of a revascularized iliac crest bone graft was used to fill the defect. The graft was microvascularly anastamosed and fixated with standard external fixation. Pathologic and histologic specimens from surgical biopsy reconfirmed the diagnosis of PVNS postoperatively. Second-stage arthrodesis was performed when the patient was stable and disease free. The patient was followed postoperatively for 10 years without recurrence and was able to return to full function and partake in moderate athletic activity at last visit. This case describes a retrospective review of the procedure and reconstruction, as well as an overview of current surgical management of PVNS.     

Complete Medial Dislocation of the Tarsal Navicular without Fracture: Report of a Rare Injury

Complete dislocation of the tarsal navicular, without fracture of the navicular, is an uncommon injury. A review of the published data revealed only 15 previous reported cases. The rarity of this injury can be attributed to the rigid bony and ligamentous support surrounding the navicular, which usually undergoes fracture and dislocation rather than pure dislocation of the navicular. The mechanism and appropriate treatment of this injury remains unclear. In the present report, we describe the case of a 29-year-old male who sustained complete dislocation of the tarsal navicular, without fracture of the navicular, along with fractures of the cuboid and calcaneus, when he was involved in a motor vehicle collision. The proposed mechanism of injury in this case was that of a pronation-abduction force applied to the midfoot, resulting in a transient midtarsal dislocation and disruption of the ligamentous support of the navicular, with medial dislocation of the navicular when the midtarsal dislocation was reduced. The anterolateral calcaneus and cuboid fractures were likely from an avulsion injury through the bifurcate ligament. The patient was treated successfully with closed reduction and Kirschner wire fixation of the navicular combined with application of a spanning external fixator. The pins and external fixator were removed at 7 weeks postoperatively, and the navicular was stable at that time. The patient was lost to follow-up shortly thereafter.     

Isolated dorsal midtarsal (Chopart) dislocation: a case report

A case of isolated dorsal midtarsal (Chopart) dislocation resulting from blunt trauma is reported. The mechanism of injury, management, and long-term outcome are discussed. A 45-year-old inebriated man fell from a 4-m height and landed on his feet. He had immediate bilateral foot and back pain. Radiographs showed a burst fracture of the second lumbar vertebra, a left Pott's fracture, and an isolated dorsal dislocation of the right midtarsal (Chopart) joint. No neurovascular deficits or signs of compartment syndrome were noted. The image intensifier showed the unstable midtarsal joint with dorsal translation of the navicular and cuboid from the talus and calcaneum, respectively. Closed reduction of the midtarsal joint was performed with 2 transfixing 3.5-mm AO cortical screws. The right foot was immobilised in a short leg cast for 6 weeks; screws were removed 14 weeks later. At 76-month follow-up, the patient had returned to work as a construction worker, but still had right midfoot pain on prolonged walking or standing, because of persistent plantar opening up and dorsal ossification of the midtarsal joints and degenerative change at the talonavicular joint. With hindsight, open reduction may have led to a better outcome through repair of the plantar ligamentous structures, especially the plantar calcaneonavicular (spring) ligament.     

Ligamentous injuries about the ankle and subtalar joints

Ligamentous injuries at the ankle and subtalar joint range from simple sprains to severe talar dislocations. While lateral ankle sprains are among the most frequently encountered injuries and do not pose a greater diagnostic problem, the surgeon must be suspicious not to overlook associated ligamentous injuries at the subtalar and midtarsal level that may result in chronic painful conditions. Syndesmotic instabilities with or without ankle fractures must be assessed carefully and treated properly, since these are prearthrotic conditions. In the treatment of chronic ankle or subtalar instability tenodeses provide mechanical stability while reducing subtalar mobility. Anatomic reconstruction methods therefore should be considered for both conditions.     

Luxation dorsale médiotarsienne (Chopart) isolée

Dislocations of the midtarsal joint (Chopart) are rare. Dorsal displacement is also very rare. We report a case of isolated dorsal dislocation of the midtarsal joint. A closed reduction was realized with fixation by pinning. The functional result was good at two years of follow-up. We discuss the mechanisms of the dislocation and its management.     

A literature review of midtarsal joint function

This article focuses on nearly 50 years of research by various authors documenting function and motion of the midtarsal joint. Subtalar joint control of the midtarsal joint, axes of motion, and quantification of range of motion are examined. The evolution of the joint from primates to man and the associated changes in functional requirements are considered.     

Occult midtarsal subluxation

Of 14 patients with navicular tuberosity avulsion, seven had damage to the anterior process of the calcaneum at the calcaneocuboid joint--possibly the result of an occult subluxation of the midtarsal joint. These patients were all middle-aged women who had slipped or fallen a short distance. They were unable to bear full weight because of pain on the medial and lateral aspects of the foot. The associated midtarsal injury was initially missed in five of seven patients because of failure to interpret the radiographic appearance. All seven patients had prolonged symptoms, and three had persistent but not disabling pain at least three years after injury. Degenerative arthritis had developed in the calcaneocuboid joint in four of the five patients at follow-up examinations. Patients with occult subluxation of the midtarsal joint should be managed initially by a period of non-weight-bearing followed by application of a walking cast. The need for early surgical treatment is open to question.     

Talonavicular arthrodesis for correction of posterior tibial tendon dysfunction.

The awareness of PTTD has increased because of the efforts of McGlamry and Mueller. The treatment for PTTD depends on the patient's age and weight, systemic factors, length of time of the disease course, and the extent of foot collapse. The period of time from injury to diagnosis often is delayed because of the gradual progression of the condition. The patient that presents with an acute injury often responds well to a soft-tissue procedure. The delay in treatment usually necessitates the performance of an osseous procedure to correct the deformity and align the foot. The talonavicular arthrodesis is indicated in the flexible flatfoot deformity when degenerative changes of the subtalar joint are not present. The talonavicular arthrodesis is effective for correcting the flexible flatfoot deformity because it reduces the forefoot abduction, increases the height of the arch, stabilizes the medial column, and prevents excessive subtalar joint pronation. The primary complications associated with the talonavicular arthrodesis are nonunions and development of arthritis in adjacent joints. The incidence of nonunion can be directly attributed to poor surgical technique and early weight bearing during the postoperative period. The degenerative changes that occur in adjacent joints are often present preoperatively because of the long-standing valgus deformity. The procedure effectively maintains the correction of the flatfoot over a long period of time, and allows the patient to return to a pain-free lifestyle. The talonavicular arthrodesis is the procedure of choice in the flexible flatfoot deformity because the procedure corrects the malalignment of the subtalar and midtarsal joints and prevents excessive subtalar joint pronation.     

Primary Intraosseous Malignant Peripheral Nerve Sheath Tumor of the Medial Cuneiform: A Case Report and Review of the Literature

Peripheral nerve sheath tumors (benign and malignant) usually arise in the soft tissues and are unusual in bone. Intraosseous peripheral nerve sheath tumors are usually benign and constitute approximately 0.2% of all bone tumors. Intraosseous malignant peripheral nerve sheath tumors (MPNSTs) are uncommon and usually result from secondary invasion. Only a few cases of primary intraosseous MPNSTs have been reported in published studies, and these were localized mostly in the mandible (approximately 50%) or maxilla, spine, and, occasionally, in the appendicular skeleton. To the best of our knowledge, we report the first case of primary intraosseous MPNST involving a midtarsal bone (medial cuneiform). The patient was a 62-year-old female who presented with pain and tenderness but without swelling. Imaging revealed nonspecific findings, and the preoperative computed tomography-guided biopsy findings were consistent with MPNST. The patient was treated with neoadjuvant radiotherapy, followed by wide local excision and allograft reconstruction. At the final follow-up examination (24 months), the graft had been incorporated without evidence of local recurrence or distant disease. The patient with primary intraosseous MPNST of the medial cuneiform described in the present report presented with nonspecific clinical and radiologic findings. Thus, a high index of suspicion and histopathologic examination, including immunohistochemistry, are necessary for an accurate diagnosis.     

Midtarsal dislocations in children.

Four children with midtarsal dislocations are described. Two of the four patients had a delay in diagnosis because of associated midtarsal injuries detracting from the main pathology. The key pathology was a dislocation or subluxation of the calcaneocuboid joint. The lateral radiograph was the most consistent view in making the diagnosis.     

The midtarsal joint locking mechanism

BACKGROUND: The midtarsal joint, consisting of the talo-navicular and the calcaneocuboid joints, is presumed to be responsible for the foot being both flexible and rigid during different parts of the stance phase of gait. However, this mechanism has never been well quantified. This study explores the midtarsal joint locking mechanism by comparing the effect of hindfoot inversion and eversion on midfoot and forefoot mobility. METHODS: Motion of the tibia, talus, calcaneus, navicular, cuboid and the first, second, and fifth metatarsals were measured in nine cadaver feet using Polhemus Fastrak electromagnetic sensors (EST GmbH and Co. KG, Kaiserslautern, Germany). The talus was fixed to the tibia, and then the forefoot was maximally dorsiflexed, plantarflexed, inverted, and everted, with the hindfoot in maximal eversion and inversion, for a total of eight test positions. The range of motion of the individual bones between maximal forefoot dorsiflexion and plantarflexion and between maximal forefoot inversion and eversion was calculated for the hindfoot in maximal eversion and inversion. RESULTS: For the range of motion from maximal dorsiflexion to maximal plantarflexion there was significantly increased movement of the first, second, and fifth metatarsals in the sagittal plane (p-value = 0.003, 0.007, and 0.002, respectively) when the calcaneus was maximally everted compared to when the calcaneus was maximally inverted. No significant differences were detected for the range of motion from forefoot inversion to eversion for the two hindfoot positions. CONCLUSIONS: This study demonstrated that motion in the forefoot is influenced by hindfoot position through the midtarsal joint. Specifically, the sagittal plane range of motion of the metatarsals is increased when the hindfoot is in valgus.     

Intramedullary foot fixation for midfoot Charcot neuroarthropathy

Midfoot Charcot collapse commonly occurs through the tarsometatarsal and/or midtarsal joints, which creates the characteristic "rocker bottom" deformity. Intramedullary metatarsal fixation spanning the tarsus into the talus and/or calcaneus is a recently developed method for addressing unstable midfoot Charcot deformity. The intramedullary foot fixation technique has various advantages when addressing midfoot Charcot deformity in the neuropathic patient. These advantages include anatomical realignment, minimally invasive fixation technique, formal multiple joint fusion, adjacent joint fixation beyond the level of Charcot collapse, rigid interosseus fixation, and preservation of foot length. The goals of the intramedullary foot fixation procedure are to create a stable, plantigrade, and ulcer-free foot, which allows the patient to ambulate with custom-molded orthotics and shoes.     

新鲜闭合跗中关节骨折脱位的治疗

目的探讨新鲜闭合跗中关节骨折脱位的治疗方法及疗效。方法 2004年4月-2011年4月,收治73例(75足)新鲜闭合跗中关节骨折脱位,行闭合整复结合切开复位内固定治疗。男56例(58足),女17例(17足);年龄19～62岁,平均35.8岁。高处坠落伤35例,扭伤4例,机器皮带绞伤5例,重物砸伤9例,交通事故伤20例。伤后至入院时间为1 h 30 min～48 h,平均4.5 h。跗中关节损伤根据Main等分型标准:纵向压缩型6足,内侧移位型33足,外侧移位型17足,跖屈型9足,碾压损伤型10足。合并中足骨折脱位34足,舟骨骨折6足,骰骨压缩骨折18足,跟骨骨折8足,距骨骨折7足,胫距关节脱位2足,距下关节脱位2足,内踝骨折1足。合并足急性筋膜室综合征3足。结果术后65例(67足)切口Ⅰ期愈合,8例(8足)Ⅱ期愈合。62例(62足)获随访,随访时间11个月～7年11个月,平均3年6个月。术后26足步行时足部疼痛,36足步行时自觉伤足僵硬或不适。X线片复查示,59足跗中关节骨折脱位及其合并伤均复位良好,无再脱位及骨折不愈合发生;3足发生足舟骨坏死,继发扁平足,均行关节融合术。末次随访时,按照美国矫形足踝协会(AOFAS)标准评价足功能,为77～90分,平均88.6分。结论根据术前对损伤的评估,采用手法整复结合内固定(微型接骨板桥式支撑、空心螺钉联合克氏针内固定)治疗存在不同合并损伤的跗中关节骨折脱位疗效良好。     

High Union Rates and Function Scores at Midterm Followup With Ankle Arthrodesis Using a Four Screw Technique

When evaluating the role of ankle arthrodesis in the treatment of severe ankle arthritis, postoperative infection, nonunion, and the development of arthritis at the adjacent joints are major issues when considering treatment alternatives. We evaluated the rate of complications, the functional outcome, and compensatory range of motion at the midtarsal joint at medium-term followup after ankle arthrodesis with four cancellous screws. We performed 94 ankle fusions in 92 patients; 12 patients were lost to followup and eight declined to participate, leaving 72 patients (76%) for evaluation. The minimum followup was 4.8 years (mean, 5.9; range, 4.8–7.8 years). No patient developed a deep infection; three patients developed postoperative hematoma which we operatively drained. Union occurred in 93 of the 94 patients (99%). The sagittal motion at the midtarsal joint averaged 24°. Secondary arthritis of the subtalar and talonavicular joints developed during the followup period in 17% and 11%, respectively. Progression of preexisting arthritis occurred in 13 of 43 patients (30%) at the subtalar joint and five of 26 patients (19%) at the talonavicular joint. None of these patients had fusion of an adjacent joint. The average American Orthopaedic Foot and Ankle Society score increased from 36 preoperatively to 85 at followup. Ankle arthrodesis with screws provides high rates of union, reliable pain relief, and favorable functional medium-term results.     

The effects on subtalar contact and pressure following talonavicular and midtarsal joint arthrodesis.

Many clinical studies have demonstrated the effectiveness of both isolated talonavicular and complete midtarsal joint arthrodesis as an alternative to triple arthrodesis. However, in many cases, controversy exists as to which procedure to utilize. Evidence of degenerative radiographic changes and stiffness of the subtalar joint have been reported postoperatively. A cadaveric study at two different loading values, utilizing low-range pressure film transducers and digital scanning, was performed to quantify articular contact effects on the subtalar joint following isolated talonavicular joint arthrodesis and complete midtarsal joint arthrodesis as compared to the intact specimen. Statistically significant differences were found at p < .05 in this study regarding maximum contact pressure and in location of the applied pressures. Results of this study suggest complete midtarsal joint arthrodesis may be favored over isolated talonavicular joint arthrodesis, especially in the setting of a flatfoot deformity.     

The influence of foot position on stretching of the plantar fascia

BACKGROUND: A recent study found nonweightbearing stretching exercises specific to the plantar fascia to be superior to the standard program of weightbearing Achilles tendon-stretching exercises in patients with chronic plantar fasciitis. The present study used a cadaver model to demonstrate the influence of foot and ankle position on stretching of the plantar fascia. METHODS: Twelve fresh-frozen lower-leg specimens were tested in 15 different configurations representing various combinations of ankle and metatarsophalangeal (MTP) joint dorsiflexion, midtarsal transverse plane abduction and adduction, and forefoot varus and valgus. Measurements were recorded by a differential variable reluctance transducer (DVRT) implanted into the medial band of the plantar fascia, and primary measurement was a percent deformation of the plantar fascia (stretch) with respect to a reference position (90 degrees ankle dorsiflexion, 0 degrees midtarsal and forefoot orientation, and 0 degrees MTP dorsiflexion). RESULTS: Ankle and MTP joint dorsiflexion produced a significant increase (14.91%) in stretch compared to the position of either ankle dorsiflexion alone (9.31% increase, p < 0.001) or MTP dorsiflexion alone (7.33% increase, p < 0.01). There was no significant increase in stretch with positions of abduction or varus (2.49%, p = 0.27 and 0.55%, p = 0.79). CONCLUSION: This study provides a mechanical explanation for enhanced outcomes in recent clinical trials using plantar fascia tissue-specific stretching exercises and lends support to the use of ankle and MTP joint dorsiflexion when employing stretching protocols for nonoperative treatment in patients with chronic proximal plantar fasciitis.     

Total ankle arthroplasty using biological fixation components compared to ankle arthrodesis

When conservative measures fail to alleviate pain and disability of ankle joint disease, tibiotalar arthrodesis is the present accepted surgical treatment. Unfortunately, ankle arthrodesis also carries a significant rate of complications and the success rate does not parallel the results of hip and knee joint arthroplasties. A large percentage of ankle arthrodeses remain painful, and function is not normal. There is no satisfactory "salvage procedure" to a painful ankle fusion. Patients with primary ankle arthritis tend to develop bilateral ankle involvement as well as involvement of the subtalar and midtarsal joints; bilateral ankle fusion results in a severe handicap to gait and function. Ankle fusion with involvement of the subtalar or midtarsal joints might well result in a painful fusion. Maintenance of tibiotalar motion appears essential in both instances. It is apparent that all ankle problems cannot be dealt with by fusion and a successful long-term ankle arthroplasty is needed. Total ankle arthroplasty using cement fixation remains controversial. Continued use of polymethylmethacrylate and additional design changes do not appear to be the answer to possible ankle joint replacement. Initial success using the PCA concept of biological cementless fixation of the Scholz total ankle prosthetic components appears to offer a new dimension in the success of total ankle arthroplasty.     

Neglected Irreducible Dislocation of the Interphalangeal Joint of the Great Toe: A Case Report

Irreducible dorsal dislocation of the interphalangeal joint of the great toe is rare. We report a case of a 58-year-old man with an irreducible interphalangeal joint of the great toe that had been untreated for 4 years. The mechanism of this injury was thought to be a combination of axial loading with a hyperextension force when the patient hit his great toe against a pipe. Invagination of the sesamoid became a barrier for manual reduction attempted after the initial injury. The patient did not seek treatment because of the minor deformity of the affected great toe and lack of severe symptoms. One year later, symptoms eventually developed on the plantar aspect of the great toe, particularly when the patient was walking upstairs. He decided to seek treatment as pain worsened and he became more active when he changed occupations 4 years later. Manual reduction was impossible. The patient was treated with operative exploration of the joint and arthrodesis of the great toe. The operative course was uneventful. At 4 years after surgery, the patient could walk, run, and walk up and down stairs without discomfort.     

Planar dominance. A major determinant in flatfoot stabilization.

For treatment of a symptomatic flat foot in a child or an acquired flatfoot from posterior tibial dysfunction in the adult, an understanding of the biomechanics and function of the foot and leg is essential to achieve an excellent outcome. Evaluation of supramalleolar deformity directly influences the procedure choice and eventual success of the procedure. An understanding of the level of deformity also indicates the procedure to be used. Subtalar and midtarsal joint function, although related, have their own primary source of deformity. Correction through the subtalar and midtarsal joints must be individualized. Augmentation of the primary repair must be performed when overall instability is present, such as an elongated or deformed posterior tibial tendon or medial ligamentous structure. Evaluation of the gross deforming force of the triceps suri also must be evaluated to provide and ensure predicted outcomes.     

An artificial ankle joint.

Ankle fusion has been the time-honored treatment for painful debilitating conditions of the ankle due to osteoarthritis and rheumatoid arthritis. It is not a uniformly successful operation and has a high complication rate. If there is pre-existing disease in the knee or midtarsal joints, the pain is frequently made worse by ankle fusion. If there is no pre-existing disease, then painful degenerative changes frequently occur in the midtarsal joints subsequently. An artificial ankle joint has been used successfully since 1973 in patients who otherwise would require ankle fusion. The design of the prosthesis allows unrestricted motion in all planes. It also allows imperfect placement of the device without compromising results. The dome of the talus is not resected during insertion of the prosthesis. Only 1 cm of distal tibia is resected, thus allowing fusion without difficulty should it later become necessary. The superior position of the polyethylene device decreases wear from particulate matter which might settle by gravity. Study of 50 total ankle arthroplasty cases shows that predictably good results can be obtained in ankles with good stability, reasonably normal anatomy, and rheumatoids who are not on long-term steroid therapy.