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A Complex midtarsal dislocation of the foot following a supination abduction injury: A case report

by Rajesh Kumar Chopra1, Narendran Pushpasekaran2*, Sathyamurthy Palanisamy2, Balu Ravi2

The Foot and Ankle Online Journal 10 (4): 5

Closed midfoot dislocations are not uncommon injuries. The key to good functional outcomes is stable concentric reduction by understanding the injury pattern and early intervention to maintain the biomechanics of the foot. We report on a 20-year-old male, the presentation of a complex pattern of closed traumatic dislocation of the midfoot, managed by open reduction and internal fixation with Kirschner wires for six weeks. He did not show any evidence of instability or arthritis and had a foot function index of 94% at 14 months. The unique presentation of this midfoot dislocation is the separation of naviculocuneiform and calcaneocuboid joints. An entity that requires reporting in literature as it remains unclassified and to add to the spectrum of injuries caused by the deforming forces of foot.

Keywords: foot injuries, tarsal bones, open reduction, arthritis, foot function index

ISSN 1941-6806
doi: 10.3827/faoj.2017.1004.0005

1 – M.S.(Ortho), professor, department of orthopaedics, vardhaman mahavir medical college and safdarjang hospital, new delhi, india.
2 – M.S.(Ortho), resident, department of orthopaedics, vardhaman mahavir medical college and safdarjang hospital, new delhi, india.
* – Corresponding author: drnaren247ortho@gmail.com


Closed traumatic dislocations of the midfoot are common injuries in level 1 and 2 trauma care [1]. Apart from the common Lisfranc, Chopart and talonavicular dislocations, swivel-type dislocations of the medial column involving the talus, navicular and cuneiforms, and lateral columns involving the calcaneus and cuboid bones have rarely been reported [2-4]. The proposed injury mechanisms to cause such injuries are dorsiflexion, plantar flexion, abduction and adduction forces or a combination of them [5]. However, involvement of both columns in the form of complete disruption of the naviculocuneiform and calcaneocuboid joints has been infrequently reported in the literature. We report this complex presentation sustained following a supination-abduction force.

Case report

A 20-year-old male, presented to the emergency department after a motor vehicle collision. He sustained a supination-abduction injury in a dorsiflexed foot and developed pain, deformity and swelling in the right foot. The forefoot was depressed and supinated in relation to the hindfoot with mild contusion and skin necrosis over the talonavicular prominence. An abnormal prominence was noted dorsally and medially at the naviculocuneiform joint. (Figures 1A and B). Distal pulses, toe movements and neurological examination were normal. There were no associated injuries in the body. The patient had no medical illness or neuropathies. Radiographs of the foot and ankle showed complete dislocation between the naviculo-cuneiform and calcaneocuboid joints with disruption of the calcaneo-navicular articulation. (Figures 2A and B). This pattern of injury has not been included in any classifications  available in literature.

Figure 1 showing the deformities-step at the naviculocuneiform  junction, forefoot supinated in relation to hindfoot. Pressure necrosis is seen over the navicular site.

Figure 2 Anteroposterior and Oblique views of right foot and ankle showing dislocation of the naviculocuneiform and calcaneocuboid joints (white arrow). Chip fracture of the navicular (black arrow), the site of attachment of calcaneonavicular ligament.

Under general anaesthesia, closed reductions were attempted with the knee flexed and the ankle in 15 degree plantar flexion. The deformity was initially exaggerated and reduction attempted by traction and manipulation opposite to the deforming forces. However, incongruent reduction required an open reduction through Ollier’s approach. The dorsal midtarsal ligament, lateral and plantar cuboideonavicular ligaments were found to be ruptured. Congruent stable reduction was achieved and secured with two 2mm Kirschner wires (K-wires) stabilizing the calcaneocuboid joint and two k wires fixating the medial two cuneiforms and the navicular under image intensifier control (Figures 3A and B). The ruptured ligaments were meticulously repaired. Additional immobilisation by below knee cast and non weight bearing was maintained for 6 weeks. With the removal of the K-wires, physiotherapy, partial weight bearing, medial arch support and controlled ankle motion boot were instituted. The patient had full weight bearing and a plantigrade foot at his 4 month follow-up. The patient had a mild restriction of subtalar motion and restriction of dorsiflexion by 5 degrees. He had no clinical or radiological signs of instability or arthritis and foot function index of 94% at 14 months (Figures 4A and B).

Figure 3 AP and oblique views of the foot and ankle. The navicular, the three cuneiforms and calcaneocuboid joints are concentrically reduced and fixed with K-wires.

Figure 4 Anteroposterior and oblique views of foot and ankle at 14 months follow-up showing normal alignment of arches and no arthritis.

Discussion

Closed midfoot dislocations are not uncommon presentations in level 1 or 2 trauma centers [1]. Apart from the common complex dislocations of Lisfranc and Chopart, isolated and swivel-type fractures and dislocations involving the medial column (talus, navicular and cuneiforms) and lateral column (calcaneus and cuboid) have rarely been reported [2-4]. However, the midfoot dislocations involving the separation of naviculocuneiform and calcaneocuboid joints are rare pattern of injuries infrequently reported in the literature (Table 1).

  Report Patient details Mode of injury Pattern Treatment Follow up Outcomes
1 Q. Choudry et al in 2007 [6]. 34/ male Fall of motorized palate over foot Naviculo- cuneiform subluxation and calcaneocuboid dislocation Closed reduction and immobilization for 6 weeks 15 weeks Good
2 y. chen et al in 2012 [7]. 64/ male Run over by car cuboid, medial and intermediate cuneiform fractures with naviculo-cuneiform and calcaneocuboid dislocation Open reduction and internal fixation of fractures 6 months Good
3 y. chen et al in 2012 [7]. 59/female Car accident left navicular, medial cuneiform and calcaneal fractures with calcaneal–cuboid, navicular–cuneiform and first tarsometatarsal joint dislocations Open reduction and internal fixation 3 months Chronic pain due to calcaneo cuboid instability
4 Our patient 20/male Fall from bike Isolated calcaneal–cuboid, navicular–cuneiform dislocation Open reduction and stabilization 14 months Good

Table 1 Review of reported naviculocuneiform and calcaneocuboid disruptions.

Main and Jowett had extensively studied the mechanisms of midtarsal injuries and proposed the various deforming forces causing the midtarsal fractures and dislocations [5] (Table 2).

Deforming forces Spectrum of midfoot injuries
1 Medial Fracture-sprains, fracture- subluxations or dislocations, swivel dislocations (talonavicular).
2 Longitudinal In plantar flexed foot- navicular fractures.

In dorsiflexed foot- talus fractures, dorsal navicular dislocations.

3 Lateral Fracture-sprains, fracture- subluxations or dislocations, swivel dislocations (talonavicular or naviculocuneiform with intact calcaneo-cuboid).
4 Plantar Fracture-sprains, fracture- subluxations or dislocations (chopart), plantar swivel dislocations.
5 Crush Fractures of mid tarsals.

Table 2 Mechanism of midfoot injuries [5].

Our case presents an unusual and complex pattern of injury in which plantar-abduction force at the midfoot caused the injury path through naviculocuneiform joint and calcaneocuboid joints causing complete dislocation of the three cuneiforms and cuboid articulations. This extends the spectrum of injury pattern caused by abduction deforming forces.

Obtaining concentric and stable reduction is of paramount importance to restore the biomechanics of the foot and prevent debilitating arthritis [8]. The management and prognosis of such complex midtarsal injuries in the literature have not been elaborated, except for a few case reports favoring open reduction and internal fixation [9]. In our case, the patient had good outcomes treated by open reduction and Kirschner wire fixation.

Conclusion

We report this case of traumatic closed dislocation of naviculocuneiform and calcaneocuboid joints following supination abduction deforming forces. Such injuries require further reporting to understand the spectrum of midfoot injuries. Congruent and stable fixation is of paramount importance to maintain proper biomechanics of foot.

References

  1. Hanlon DP. Leg, ankle, and foot injuries: Emerg Med Clin North Am 2010; 28(4):885-905.
  2. Davis CA, Lubowitz J, Thordarson DB. Midtarsal Fracture-Subluxation; Case Report and Review of the Literature: Clin Orthop Relat Res 1993; 292: 264-268.
  3. Dhillon MS, Nagi ON. Total dislocations of the navicular: are they ever isolated injuries?: J Bone Joint Surg [Br] 1999; 81:881-885.
  4. Kollmansberger A, De Boer P. Isolated calcaneocuboid dislocation: a brief report: JBJS [Br] 1970; 71:323-325.
  5. Main BJ, Jowett RL. Injuries of the midtarsal joint: JBJS [Br] 1975; 57:89–97.
  6. Choudry Q, Akhtar S, Kumar R. Calcaneocuboid and naviculocuneiform dislocation: An unusual pattern of injury: J Foot Ankle Surg 2007;13:48–50.
  7. Cheng Y, Yang H, Sun Z, Ni L, Zhang H. A Rare Midfoot Injury Pattern: Navicular–Cuneiform and Calcaneal– Cuboid Fracture–Dislocation: J Int Med Res 2012; 40(2):824-31.
  8. Richter M, Wippermann B, Krettek C, Schratt HE, Huefner T, Thermann H: Fractures and fracture dislocations of the midfoot: occurrence, causes and long-term results. Foot Ankle Int 2001; 22:392–8.
  9. Richter M, Thermann H, Huefner T, Schmidt U, Goesling T, Krettek C: Chopart joint fracture-dislocation: initial open reduction provides better outcome than closed reduction. Foot Ankle Int 2004; 25:340–8.

Ankle arthrodesis as a salvage procedure: A case of secondary ankle arthritis using Charnley’s compression device

by Narayana B.S. Gowda, D Ortho, DNB Ortho, MNAMS, Mohan J. Kumar, MS Ortho

The Foot and Ankle Online Journal 5 (2): 1

Ankle arthrodesis is commonly considered to be the standard operative treatment for end stage ankle arthritis. The purpose of this study was to perform a clinical and radiographic review to determine functional outcome for a group of patients in whom an ankle arthrodesis had been performed using Charnley’s compression device. A functional assessment of fifteen patients after ankle arthrodesis for post traumatic arthritis was carried out by means of an extensive clinical evaluation after an average follow up of 2 years and 8 months.

Key words: Ankle arthrodesis, ankle arthritis, Charnley’s compression device, secondary arthritis ankle.

Accepted: January, 2012
Published: February, 2012

ISSN 1941-6806
doi: 10.3827/faoj.2012.0502.0001


Ankle arthrodesis is considered by many to be the standard operative treatment for end stage ankle arthritis. [1] A patient with ankle arthritis and deformity can experience severe pain and functional disability. Treatment options include the use of walking aids, orthotic devices, intra-articular steroids, open rather than arthroscopic debridement, periarticular osteotomy, and arthroplasty, all of which have provided inconsistent relief. Ankle arthrodesis has been accepted by many as yielding good long term clinical results. [2]

Since 1879, when Albert first described arthrodesis of the ankle [8], more than thirty different techniques have been described. The open technique with compression and internal fixation is still widely used for ankle arthrodesis with major deformity. [9] Ankle arthrodesis is an alternative for cases with intact subtalar joint. [10] This study presents intermediate term follow up functional outcome of patients with ankle arthrodesis performed using Charnley’s compression device.

Materials and methods

We reviewed fifteen patients, 10 males and 5 females, who had undergone ankle arthrodesis between January 2006 to December 2009 at the People’s Education Society (PES) Medical College and Research Center, Kuppam, Andhra Pradesh (AP), India (6 cases of post traumatic AVN talus (Fig. 1), 4 cases malunited bimalleolar fracture, 3 cases of distal tibial plafond fractures, 2 cases of medial malleoli non-union). All the fifteen patients who had secondary ankle arthritis have undergone open ankle fusion with anterolateral approach (Fig. 2) in supine position under tourniquet control and spinal anaesthesia.

Figure 1  Preoperative radiograph right ankle showing arthritic changes secondary to non union talar neck fracture.

Figure 2  Intraoperative photo showing anterolateral approach to ankle.

Compression was achieved using Charnley’s compression device and a calcaneotibial Steinman pin was applied to maintain the alignment and to increase the stability of fixation (Figs. 3 and 4). Suction drain was removed after 48 hours and the patient was made ambulant with non weight on operated site. All the patients were evaluated clinically and radiologically at 6 weeks and tibiocalcaneal Steinman pin was removed and the patients were allowed to bear weight as tolerated. All the fixators were removed after 12 weeks once the arthrodesis site was united radiologically. We had 3 cases of cellulitis of ankle and foot which was treated successfully with antibiotics, and 5 cases of superficial pin tract infection which were healed completely after fixator removal. None of these pin tract infections caused osteomyelitis. The mean age at the time of surgery was 40.52 years (24 – 56 years) and the time interval between the date of fusion and date of follow up examination ranged from 1 year to 5 years and 7 months, the average being 2 years 8 months.

Figure 3  Immediate post operative radiograph showing Charnley’s compression device.

Figure 4  Clinical photo showing Charnley’s compression device.

Clinical Evaluation

The clinical evaluation was based on a personal interview and physical examination. The patients were questioned as to their pain during daily activities such as running or walking on the level ground and going up and down the hills and stairs. A complete orthopaedic examination evaluated stance, gait, limb length discrepancy, circumference, range of motion of the knees, ankles, and subtalar joints; neurovascular status muscle strength and presence or absence of tenderness and swelling. Special attention was directed to the position of the fused ankle and the motion of the subtalar and mid tarsal joints. Any valgus or varus deformities of the heel and the presence of the callosities were also determined. The contralateral extremity was used as a control. Ankle anterior posterior and lateral radiographs were taken to assess the fusion and position of the arthrodesis (Fig. 5).

Figure 5   Two year follow up radiographs shows solid union at the arthrodesis site.

To quantitate the results of the clinical examination the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scale was used. The main emphasis of this system was on pain and the functional activities. A normal person would score 100 points. Because of lack of ankle motion, the maximum score that the patient with an ankle fusion could have was 92, since they could not earn the 8 points given for the full range of motion.

A score of 80 to 92 was considered an excellent result: 70 to 79, a good result; 60 to 69, a fair result; and score less than 60 was considered a poor result.

Results

All patients studied had a solidly fused ankle and had no complications related to the surgery (Fig 6). They were all improved as a result of ankle fusion and returned to their pre injury activities. Wearing shoes with appropriate heels, all the patients could walk on level ground without support. All the patients stated that they could walk up and down the stairs without much difficulty. Limb length discrepancies were insignificant (0.5 to 1.5 cm) except in one patient who had 2.5 cm secondarily due to distal tibial plafond fracture. The radiographs showed that 6 cases showed some evidence of degenerative changes in the subtalar joints which did not correlate with the symptoms.

Figure 6  Two year follow up clinical photo of right ankle arthrodesis showing very litte difference compared to left normal side.

Scoring the patients with the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scale, we found that eleven of the 15 had excellent results; two good; and two fair results. All of them could walk with relatively good velocity and with a consistently rhythmic gait.

Discussion

The patients with solid ankle fusion in this study functioned very well during the activities of normal daily living. All of them could walk on the level ground without pain. The fusion had permitted them to return to their former occupations and recreational activities. On this basis all the patients could be classified as having very satisfactory results.

Based on the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scale, these patients had appreciable limitations when walking barefoot but only mild to moderate limitations when wearing proper footwear. Patients were assessed not only under normal conditions but also under stressful conditions such as walking long distances, climbing up and down the stairs, and running. Six of the 15 could not run. Three had some minor discomfort after walking long distance.

When good surgical technique is used in carefully selected patients, ankle arthrodesis can be a reliable procedure for the relief of functionally disabling ankle arthritis, deformity, and pain. [9] As a fused ankle provides a painless ankle joint with limited functional disability, ankle arthrodesis is still the treatment of choice for most disabling ankle arthritis. [10]

Charnley’s compression devise is still a simple, cost effective and excellent external fixator which can be used easily by every orthopaedic surgeon. After removal of the fixator, there is no indication for additional surgery to remove the implant compared to internal fixation. There are no hardware problems as all the hardware was removed. The high level of satisfaction in this group of patients reinforces the view that open arthrodesis using Charnley’s compression device, as opposed to ankle replacement or arthroscopic arthrodesis, continues to be the treatment of choice when there is severe varus or valgus deformity associated with the arthritis. [11] Although ankle arthrodesis may provide good early relief of pain, it is associated with premature deterioration of other joints of the foot and eventual arthritis, pain, and dysfunction. [12-13] In studies ranging in size from 12 to 101 patients, rates of successful primary ankle fusion of 80% to 100% have been reported earlier. [14-18] However an average follow up time of 2 years and 8 months is relatively short to comment on the future secondary osteoarthritic changes in the subtalar and mid foot joints.

To be considered as an alternative preferable to arthrodesis, a total ankle replacement should give better results than those presented here, without other disadvantages. Patients with rheumatoid arthritis and involvement of ankle may not meet the criteria for an ankle arthrodesis may be because they have involvement not only of the ankle but also of the small joints of the foot, so that these joints cannot compensate for the fused ankle. Therefore, patients with rheumatoid arthritis may be better candidates for the total ankle replacement. [19]

Conclusion

Subjectively and objectively, the patients with ankle fusion function quite well in activities of daily living provided that, they have enough compensatory motion in the Chopart’s and Lisfranc joints of the foot, the other ankle has a normal range of motion, they wear footwear with appropriate height. On the basis of these results, patients should be counseled that an ankle fusion will help to relieve pain and to improve overall function; however, it is a salvage procedure that will cause persistent alterations in gait with a potential for deterioration due to the development of ipsilateral hindfoot arthritis. Charnley’s compression device can still be considered as the fixator of choice compared to other modalities available with respect to cost, simplicity and good outcome.

References

1. Coester LM, Saltzman CL, Leupold J, Pontarelli W. Long-term results following ankle arthrodesis for post-traumatic arthritis. JBJS 2001 83A: 219-28. [PubMed]
2. Mazur JM, Schwartz E, Simon SR Ankle arthrodesis, long term follow up with gait analysis. JBJS 1979 61A: 964-975. [PubMed]
3. Helm R, Stevens J. Long-term results of total ankle replacement. J Arthroplasty 1986 1: 271-277. [PubMed]
4. Kofoed H, Lundberg-Jensen A. Ankle arthroplasty in patients younger and older than 50 years: a prospective series with long-term follow-up. Foot Ankle Int 1999 20: 501-506. [PubMed]
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6. Huang PJ, Fu YC, Lu CC, Wu WL, Cheng YM. Hindfoot arthrodesis for neuropathic deformity. Kaohsiung J Med Sci 2007 23: 120-127.[PubMed]
7. Mazur JM, Schwartz E, Simon SR. Ankle arthrodesis: Long-term follow-up with gait analysis. JBJS 1979 61A: 964-975. [PubMed]
8. Albert E. Zur Resektion des Kniegelenkes. Wien Med. Press, 1879 20: 705-708.
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11. Smith R, Wood PLR. Arthrodesis of the ankle in the presence of a large deformity in the coronal plane. JBJS 2007 89B: 615-619. [JBJS, Full article]
12. Ahlberg A, Henricson AS. Late results of ankle fusion. Acta Orthop Scand 1981 52: 103-105. [PubMed]
13. Boobbyer GN. The long-term results of ankle arthrodesis. Acta Orthop Scand 1981 52: 107-110. [PubMed]
14. Ahlberg A, Henricson AS. Late results of ankle fusion. Acta Orthop Scand 1981 52: 103-105. [PubMed]
15. Bishop AT, Wood MB, Sheetz KK. Arthrodesis of the ankle with a free vascularized autogenous bone graft: Reconstruction of segmental loss of bone secondary to osteomyelitis, tumor, or trauma. JBJS 1995 77A: 1867-1875. [PubMed]
16. Boobbyer GN. The long-term results of ankle arthrodesis. Acta Orthop Scand 1981 52: 107-110. [PubMed]
17. Buck P, Morrey BF, Chao EYS. The optimum position of arthrodesis of the ankle: A gait study of the knee and ankle. JBJS 1987 69A: 1052-1062. [PubMed]
18. Lynch AF, Bourne RB, Rorabeck CH. The long-term results of ankle arthrodesis. JBJS 1988 70B: 113-116. [PubMed]
19. Hopgood P, Kumar R, Wood PLR. Ankle arthrodesis for failed total ankle replacement. JBJS 2006 88B: 1032-1038. [PubMed]


Address correspondence to: Asst Professor, Dept of Orthopaedics, PES Medical College, Kuppam, Chittore dist, Andra Pradesh, India, 517425. Email: drnarayan999@yahoo.com, Mob: 00 91 7702990696

1  Asst. Professor, Dept. of Orthopaedics, PES Medical College, Kuppam, Chittore dist., Andra Pradesh, India, 517425.
2  Asst. Professor, Dept. of Orthopaedics, PES Medical College, Kuppam, Chittore dist., Andra Pradesh, India, 517425.

© The Foot and Ankle Online Journal, 2012