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.     

Temporary bridge plating of the medial column in severe midfoot injuries

Severe crush injuries to the midfoot often involve comminuted cuneiform or tarsal navicular fractures. Treatment principles for the bony injury of the crushed midfoot include maintenance of the medial column length and alignment, as well as appropriate stable fixation after open or closed fracture reductions. This is especially important because outcomes after midfoot injuries are related to the stability of the medial longitudinal arch of the foot. Treatment options include closed reduction and isolated K-wire fixation, limited open reduction and internal fixation with K-wires, screw fixation directed from the navicular to the cuneiforms, spanning external fixation between the talus and the first metatarsal, or combinations of these techniques. Limited internal fixation combined with external fixation may be difficult or impossible in comminuted fractures secondary to the small size and large number of bony fragments. Also, the external fixator is a potential source of pin tract infections. We propose a temporary internal bridge plating technique of the medial column of the foot using an 8- to 10-hole, 2.7-mm reconstruction plate between the talar neck and the first metatarsal, which may provide adequate temporary internal stabilization until bony healing occurs.     

Treatment of residual clubfoot deformity--the "bean-shaped" foot--by opening wedge medial cuneiform osteotomy and closing wedge cuboid osteotomy. Clinical review and cadaver correlations

Six patients (seven feet) previously treated surgically for clubfoot had a "bean-shaped" foot. Opening wedge medial cuneiform and closing wedge cuboid osteotomies were done, resulting in good resolution of the prominent midfoot supination and forefoot adductus without significant soft tissue dissection and invasion of growing areas in the foot. Cadaver reproductions show that the cuboid closing wedge is responsible for the change in the midfoot, whereas the cuboid and cuneiform osteotomies both contribute to the change in the forefoot.     

Midfoot fractures

Fractures of the midfoot are uncommon because of the constrained configuration of multiple articular surfaces, which is augmented by capsular attachments and strong ligaments and tendons. Injury patterns usually involve more than one structure, although isolated fractures, dislocations, and sprains can occur. The key to optimal treatment of midfoot fractures is a high index of clinical suspicion because of their rareness. The traumatic midfoot injuries described in this article are categorized as Chopart joint injuries, tarsal scaphoid fractures, cuboid fractures, cuneiform fractures, and Lisfranc joint injuries.     

Decompressive Medial Cuneiform Exostectomy for Resistant Tibialis Anterior Insertional Tendinopathy

Distal tibialis anterior tendinopathy, as a clinical entity, has only recently been documented in foot and ankle studies. We report our experience with medial cuneiform decompressive exostectomy and superficial tendon debridement in 14 cases of recalcitrant tibilalis anterior insertional pain. We reviewed 13 patients (14 feet; 12 females, 1 male; mean age 67.9 ± 7.5; range 55 to 80 years) in whom conservative treatment had failed who had undergone debridement of the insertional tibialis anterior tendon and decompressive exostectomy of the medial cuneiform. Pre- and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) midfoot scale and visual analog scale (VAS) pain scores, local clinical findings, and dorsiflexion power at an average follow-up period of 28?±?17.9 (range 6 to 55) months were assessed. All patients had experienced burning, nocturnal, medial midfoot pain and disability. The symptom longevity preoperatively was 8.5?±?3.1 (range 6 to 17) months. Peritendinous or intrasubstance signal changes were noted on magnetic resonance imaging in 10 feet (71%). The mean preoperative VAS pain score was 8.7?±?1.3 (range 5 to10), whereas postoperative it was 0.4?±?0.5 (range 0 to1) (p?=?.001). The mean preoperative and postoperative AOFAS midfoot scale score was 54?±?14.5 (range 20 to 70) and 91?±?6.8 (range 79 to 100), respectively (p?=?.001). Postoperative ankle dorsiflexion power was normal and local tenderness had resolved in all patients. One patient (7.1%) stumbled at 2 weeks, resulting in avulsion of the tibialis anterior tendon, requiring transosseous fixation and gastrocnemius recession. All patients reported satisfaction with the surgical outcome and willingness to undergo the surgery again if necessary. A combination of medial cuneiform mechanical decompression and insertional tendon debridement can offer successful outcomes in resistant insertional tibialis anterior tendinopathy.     

Symptomatic Os Infranaviculare

The author observed a new accessory bone of the foot in the distal portion of navicular, which articulated with the medial cuneiform and the intermediate cuneiform, and named it os infranaviculare. A degenerative change was observed between the accessory bone and the navicular; this caused midfoot pain to the patient during weight-bearing. Thus, the patient was treated by excision of the accessory bone. The symptom was relieved at one-year postoperative.     

Naviculocuneiform Dislocations Treated With Immediate Arthrodesis: A Report of 2 Cases

The authors report on 2 patients who sustained naviculocuneiform dislocations and intercuneiform diastasis, and who were treated with immediate arthrodesis of the midfoot complex. Injury patterns in both cases involved damage to the medial facet of the distal navicular articular surface, separation of the first and second cuneiforms, and an unstable first ray. At the 15- and 18-month follow-up, respectively, both patients attained a stable, solid fusion with maintenance of the medial longitudinal architecture. Both patients returned to their preinjury activity levels with no disability.     

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.     

'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.     

Enchondroma as a cause of midfoot pain.

Enchondroma is a common bone tumor of the foot. It is often reported in the phalanges and distal metatarsals. The authors, however, present a rare case study of two patients with enchodromas as the cause of midfoot pain. One case presented in the lateral cuneiform which to the authors' knowledge is the first reported case in the literature. Two cases are presented with their surgical management including autogenous calcaneal graft and follow-up.     

Midfoot Arthrodesis Using a Locking Anterior Cervical Plate as Adjunctive Fixation: Early Experience With a New Implant

A retrospective review was performed on 14 patients (20 arthrodeses) who had undergone midfoot arthrodesis with a semi-constrained, locking anterior cervical plate as a form of adjunctive fixation. Fusion sites where the plate was used for the purpose of arthrodesis included the talonavicular joint, medial naviculocuneiform joints, first metatarsal cuneiform joint, and the calcaneal cuboid joint. All arthrodesis sites used one other type of fixation for the purpose of axial compression. Twenty midfoot arthrodesis sites went on to radiographic union at a mean of 9.1+/-1.5 weeks. A single complication of hardware irritation occurred in one patient that resolved after plate removal. This semi-constrained, locking anterior cervical plate appears to be a viable adjunct to fixation constructs for the purpose of midfoot arthrodesis.     

Management of Complex Open Fracture Injuries of the Midfoot With External Fixation

Ten patients (11 feet) with severe, high-velocity, open injuries to the midfoot were treated with uniplanar external fixation. The mean patient age was 38 years. Five wounds measured >10 cm, and 3 had extensive degloving of the foot extending into the lower leg. All had grossly comminuted fractures of the tarsal and metatarsal bones: 9 patients had a fractured cuboid; 6 had a fractured navicular; 7 had a fractured cuneiform; and all had metatarsal fractures. Lisfranc joint dislocations were present in 7 feet, and intertarsal dislocations were seen in 3 cases. Six patients underwent split-thickness skin grafting, and 1 required a myocutaneous flap. The average duration of fixator use was 9 weeks (range, 6-15 weeks). Clinically, patients were evaluated 1 year after fixator removal for any residual pain in the foot, ability to stand on tiptoe, presence of a limp, deformity of an arch, and range of motion at the ankle, subtalar, and metatarsophalangeal joints. Each parameter was graded as good, fair, or poor. All patients had sensate plantigrade feet, with 2 patients who experienced pain on weight bearing, 5 who had difficulty standing comfortably on tiptoe, and 2 who limped because of pain. Three patients exhibited flatfoot deformity, whereas 4 had cavus deformity. All demonstrated stiffness at the midfoot and restriction of subtalar and forefoot motion, with 5 also having restricted ankle motion. Radiographically, all fractures were healed at the time of follow-up; 4 were malunited, with 1 demonstrating ankylosis across the tarsometatarsal joint. These results suggest that crush injuries to the midfoot often result in persistent morbidity despite early comprehensive management with external fixation.     

Dorsomedial Fracture Dislocation of the First Ray and Medial Cuneiform: A Case Report

Isolated dislocation of the medial cuneiform is a rare injury. A favorable outcome relies on an accurate and stable reduction. Evidence of residual instability can be subtle. We present 1 such injury whose true extent was not fully appreciated at presentation, despite multiple plain films. Occult fracture of the medial cuneiform contributed to residual instability of the first ray and persistent and progressive symptoms and ultimately necessitated operative stabilization of the medial arch. We recommend the use of computed tomography as an adjunct to plain radiography for all midfoot dislocations to more accurately define the extent of the injury.     

足部X形AO锁定钢板治疗肱骨大结节骨折

目的 探讨足部X形AO锁定钢板治疗肱骨大结节骨折的临床疗效.方法 对2009年5月至2010年9月我院应用足部X形AO锁定钢板治疗的19例肱骨大结节骨折患者进行回顾性分析.所有病例均为闭合性损伤且骨折移位均＞5 mm,其中11例伴肩关节前脱位,受伤到手术时间为2～5 d(平均3.5 d).对骨折愈合时间、术后肩关节...     

复杂中足损伤的临床治疗

目的 回顾复杂中足损伤的临床治疗,评价其临床治疗的特点及要点.方法 2003年6月至2008年6月问收治22例复杂中足损伤患者,其中开放性骨折8例,伴有软组织缺损者5例.急诊收治患者13例,另9例为外院已处理的患者.急诊患者中仅1例行舟骨和中间、外侧楔骨的关节融合,其余均行复位和内固定.转诊患者:2例行距舟关节融合,3例行Lisfranc关节融合伴1例行趾近节截除,1例行舟楔火节融合,1例行跗横火节融合,1例行内侧柱截除,1例行外侧柱重建.5例伴软组织缺损的患者,4例行游离前锯肌移植,1例行腓肠神绛伴行血管逆行岛状皮瓣移植修复.结果 全部患者术后随访5～44个月,平均17.5个月.急诊患者随访时的主要后遗症状为长时问行走后疼痛,2例患者经应用局部封闭及非甾体类镇痛药治疗后症状缓解.转诊患者中,2例行走时易疲劳、酸痛;2例外侧第4、5跖骨头跖侧胼胝伴疼痛;1例前、中、后足僵硬,同时存在足内肌较广泛的萎缩,有较重的行走疼痛;内侧柱截除的患者有足弓塌陷、后足外翻的表现,使用特制鞋行走.急诊收治患者AOFAS评分为(80.3±8.7)分,转诊患者为(60.1±16.3)分.结论 复杂的中足损伤应在允分了解功能解剖、创伤病理的基础上早期手术,解剖复位和牢靠同定是获得良好疗效的关键.     

Fixation of the Lapidus arthrodesis with a plantar interfragmentary screw and medial low profile locking plate

The Lapidus arthrodesis can be used to correct pathology within the forefoot or midfoot, and severe hallux valgus deformities as well as hypermobility of the medial column may be amenable to correction with this procedure. Many different skeletal fixation methods have been described for this procedure, and one form that appears to provide enough construct stability to allow patients to bear weight early in the postoperative period is described herein. This construct consists of an interfragmental compression screw oriented from the plantar aspect of the first metatarsal to the superior aspect of the medial cuneiform, with medial locking plate augmentation.     

The lateral column lengthening and medial column stabilization procedures

The results of medial column stabilization, lateral column lengthening, and combined medial and lateral procedures were reviewed in the treatment of adult acquired flatfoot secondary to posterior tibialis tendon insufficiency. All bony procedures were accompanied by transfer of the flexor digitorum longus tendon to the medial cuneiform or stump of the posterior tibialis tendon and tendoachilles lengthening or gastrocnemius recession. Medial column fusion was performed for naviculocuneiform and cuneiform first metatarsal sag; lateral column lengthening was performed for calcaneovalgus deformity with a flat pitch angle; and combined procedures were performed for complex combined deformities. At 1 to 4 year followup of 65 feet, 88% of the feet that had lateral column lengthening, 80% that had medial column stabilization, and 88% of the feet that had medial and lateral procedures had a decrease in pain or were pain free. The lateral talar first metatarsal angle improved by 16 degrees in the patients in the lateral column lengthening group, 20 degrees in the patients in the medial column stabilization group, and 24 degrees in the patients in the combined medial and lateral procedures group. The anteroposterior talonavicular coverage angle improved by 14 degrees in the patients in the lateral column lengthening group, 10 degrees in the patients in the medial column stabilization group, and 14 degrees in the patients in the combined medial and lateral procedures group. These techniques effectively correct deformity without disrupting the essential joints of the hindfoot and midfoot.     

Osteotomies in the midfoot and the calcaneal part of the foot in relapsed clubfoot

There are no clear guidelines on the treatment of relapsed clubfoot, which is a relatively frequent and difficult problem in paediatric orthopaedics. Numerous operative interventions are mentioned in the literature as suitable for correction of a residual deformity of the food. There are numerous soft tissue procedures (release operations, tendon extensions, tendon transfers and redressement by means of a fixateur externe) and osseous interventions (osteotomies, arthrodeses) that can be carried out in isolation or in combination. In the present article two types of osteotomy are described that make it possible to correct the most frequent forms of relapsed clubfoot: combined closing wedge cuboid and opening wedge cuneiform osteotomy for correction of adductus and supination of the forefoot and the calcaneal osteotomy after Dwyer for correction of varus position of the calcaneal part of the foot. The combined osteotomy in the midfoot involves shortening of the lateral ray with simultaneous lengthening of the medial ray, with the wedge out of the cuboid bone inserted into the medial cuneiform bone, which leads mainly to correction of the adductus, but does also make it possible to achieve partial correction of the supination with an osteotomy right through the cuneiform bone. In the case of rigid foot deformities it is advisable to carry out preliminary stretching by means of a fixateur externe, while in the case of a bean-shaped foot a combination of osteotomy and medial and lateral release is recommended. Results of a follow-up study of our own patients treated with this operation have shown that no revision operations were necessary in any of the patients with idiopathic clubfoot. Other types of osteotomy described in the literature as suitable for correction of residual forefoot adductus and supination are also mentioned in this paper. Thecalcaneal osteotomy after Dwyer, for which a lateral approach is always used, generally leads to satisfactory correction of varus position of the calcaneal part of the foot. It the calcaneus is found to have a short posterior part this osteotomy is modified so that instead of taking the form of a wedge osteotomy with lateral closing it is followed by a lateral displacement. In this way it is possible to prevent making the already short posterior calcaneus even shorter. Both the combined midfoot osteotomy and the calcaneal osteotomy after Dwyer can be performed alone or in combination with each other or with different operative interventions.     

Reconstruction of the cuboid in compression fractures: short to midterm results in 12 patients

Cuboid compression fractures are rare injuries, usually occurring in combination with medial midfoot fractures or dislocations. During a three year period 12 patients with cuboid fractures were operatively treated at our institution. Eleven patients had involvement of the tarsometatarsal 4 and 5 joints, four of the calcaneocuboid joint, and three of both the proximal and distal joints. The lateral column was shortened in five patients. Open reduction was facilitated using a distracting external fixator. Iliac crest corticocancellous grafts were necessary in seven patients. Single or double plate fixation was performed in eight, screw fixation alone in four patients. Follow-up ranged from 12 to 47 months. Results were good with respect to restoration of length, reconstruction of the joint facets and overall return to function. Minor residual symptoms were noted in one (of four) injured calcaneocuboid joints, in none (of 11) of the tarsometatarsal joints 4 and in two (of 11) of the tarsometatarsal joints 5. More frequently and to a greater extent symptoms arose from the associated midfoot injuries. Deformity and disability from cuboid compression fractures can effectively be prevented by immediate aggressive treatment consisting of open reduction and internal fixation.     

Our results in the treatment of fractures dislocations of Lisfranc's joint

The authors report their experience in the treatment of traumatic injuries of Lisfranc's joint based on 30 cases treated by surgery between 1984 and 1999. All of the patients were re-evaluated clinically and radiographically. What emerges from the study is the need for surgical stabilization with percutaneous Kirschner wires or by open procedure in cases where there are doubts or where reduction is impossible. The prognosis is worse in injuries of the medial column and in exposed fractures or when mortification of the soft tissues is present.