Category Archives: Uncategorized

Winter 2017

Issue 10 (4), 2017


Effects of medial and lateral orthoses on kinetics and tibiocalcaneal kinematics in male runners
by Jonathan Sinclair


The use of unidirectional porous β-tricarcium phosphate in surgery for calcaneal fractures: A report of four cases
by Shigeo Izawa, Toru Funayama, Masashi Iwasashi, Toshinori Tsukanishi, Hiroshi Kumagai, Hiroshi Noguchi, Masashi Yamazaki


Spontaneous double tendon rupture of the ankle
by Jay Kaufman DPM, Alexander Newton DPM, Payel Ghosh DPM, Zachary Ritter DPM


Dual plating technique for comminuted second metatarsal fracture in the diabetic obese patient: A case report
by Sham Persaud DPM, MS, Anthony Chesser DPM, Karl Saltrick DPM


A Complex midtarsal dislocation of the foot following a supination abduction injury: A case report
by Rajesh Kumar Chopra, Narendran Pushpasekaran, Sathyamurthy Palanisamy, Balu Ravi

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.

Dual plating technique for comminuted second metatarsal fracture in the diabetic obese patient: A case report

by Sham Persaud DPM, MS1*, Anthony Chesser DPM1, Karl Saltrick DPM1

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

Metatarsal fractures represent a common fracture type accounting for 35% of all fractures within the foot and 5% of total skeletal fractures annually. Central metatarsal fractures are caused by excess torsional force applied to the bone or direct trauma, with most fractures being attributed to the latter. As with most fractures, minimally displaced fractures of the central metatarsals are amenable to conservative treatment including protected immobilization and RICE therapy. In general, physicians may be accepting of subtle displacement of central metatarsal fractures accepting up to 10 degrees of displacement and 3mm of translation in any direction. When displacement is too great, metatarsal fractures are treated with closed reduction with percutaneous pin fixation or ORIF with pin or single plate fixation. This case report presents a case of a gentleman who suffered from a comminuted metatarsal with a unique fracture pattern that required dual plating technique for proper reduction of the fracture. With this unique fracture type, dual plate technique optimized fixation in order to stabilize an unstable fracture of a second metatarsal in an obese patient with diabetes.

Keywords: metatarsal fracture, stress fracture, diabetes, obesity, metatarsal plate

ISSN 1941-6806
doi: 10.3827/faoj.2017.1004.0004

1 – West Penn Hospital Foot and Ankle Institute, 4800 Friendship Ave, Pittsburgh, PA 15224
* – Corresponding author: shamjoseph.persaud@ahn.org


Metatarsal fractures represent a common fracture type accounting for 35% of all fractures within the foot and 5% of total skeletal fractures annually [1]. These fractures can be isolated injuries, simultaneous fractures with other metatarsals and foot fractures with ligamentous Lisfranc injuries. They can also be either traumatic or caused by prolonged stress across the bone. Most metatarsal fractures are generally a result of low energy trauma, however high energy crush injuries may occur [2].

Metatarsal fractures occur in multiple locations and are generally divided by location into proximal metaphyseal, diaphyseal/shaft, and head/neck fractures. Proximal fractures are generally associated with Lisfranc injuries. Proximal metatarsal fractures generally remain stable and well aligned secondary to the multiple ligamentous and tendinous structures which stabilize the metatarsals [2-4]. Diaphyseal fractures are generally oblique in nature, but can present in many fracture patterns. These fractures are less stable and should be evaluated for shortening and displacement [5]. The diaphyseal region is the most common site for stress fractures of metatarsals, especially the central metatarsals. Stress fractures, if untreated, can progress to complete transverse or oblique fractures. If displacement is present with diaphyseal fractures, it typically occurs plantarly and laterally [1].

Central metatarsal fractures occur considerably more than first metatarsal fractures. These fractures can affect more than one metatarsal as metatarsal 2-4 generally act as a unit. The literature states that 63% of third metatarsal fractures occur with either a second or fourth metatarsal fracture or 28% with both. Therefore, extensive evaluation of radiographs and possibly the use of other imaging modalities should be used if an isolated metatarsal fracture is identified in metatarsals 2-4 [2].

Central metatarsal fractures are caused by excess torsional force applied to the bone or direct trauma, with most fractures being attributed to the latter [1,2]. Direct trauma includes crush injuries or penetrating injuries to the foot. Spiral or oblique fractures are produced by a twisting injury over a fixed forefoot. Secondary to central metatarsal lack of motion, soft tissue attachments, and stable articulations, these fractures are intrinsically stable. However, when displacement occurs, the central metatarsals are more likely to displace as a unit [1,2].

As with most fractures, minimally displaced fractures of the central metatarsals are amenable to conservative treatment including protected immobilization and RICE therapy. In general, physicians may be accepting of subtle displacement of central metatarsal fractures accepting up to 10 degrees of displacement and 3mm of translation in any direction [6-9]. Plantar displacement is often tolerated the least out of all planes of deformity secondary to excessive plantar pressures. Dorsally displaced fractures can cause excessive strain on adjacent metatarsals leading to transfer plantar lesions and possible adjacent stress fractures. Frontal and transverse plane deformity, generally are well tolerated. However, it has been shown that displacement in the frontal or transverse plane may cause nerve irritation in the metatarsal interspaces, as well as, digital deformity over time [6-9].

The goal of central metatarsal fractures is to achieve anatomic alignment of the metatarsal using stable fixation. This goal can be achieved using both open and closed techniques. In patients with significant comorbidities or vascular compromise achieving extra stable reduction utilizing minimally invasive techniques is idea [1].

Percutaneous Kirschner (K-wire) wire pinning can be performed with a variety of techniques for adequate fixation. The most common method includes intramedullary fixation across the fracture site with use of a large diameter k-wire. Crossing multiple k-wires may also be an acceptable technique for fixating metatarsal fractures [10]. Advantages of k-wire fixation include the ability to maintain vascularity to the fractured bone with minimal dissection and soft tissue disruption. The main disadvantage is the inability for direct visualization and manipulation of the fracture [1].

Open reduction internal fixation (ORIF) is also a viable option for treatment of metatarsal fractures, especially if the fracture is significantly displaced or comminution is present. ORIF technique has the advantage of being able to visualize the fracture site in order to achieve complete anatomic reduction with application of more stable fixation [1]. In terms of fixation, screw fixation is possible for oblique type fractures, however, use of screws for central metatarsal fractures may be challenging. If ORIF technique is used, fixation generally consists of either k-wire fixation, or the use of dorsal plate fixation using mini or small fragment plates and screws. Locking plates may also be beneficial in patients with significant comorbidities or poor bone stock [1].  

Complications are relatively uncommon with either technique. Common complications with fixation of central metatarsal fractures include delayed or non-union, malunion, metatarsalgia, or digital deformity. In general delayed union or malunion complications are secondary to poor blood supply due to dissection techniques or comorbidities, or excess stress secondary to chronic stress fracture and foot deformity [1].

Biomechanical studies have shown that biplane fixation has increased stiffness as well as a decrease chance of hardware failure resulting in a more stable construct. Dayton et al in their biomechanical study showed that biplane plating showed to have superior or equivalent stability in multiplanar orientations as compared to a single plate with interfragmentary screw. However, dual plating is not without its drawbacks; Increased soft tissue dissection, periosteal stripping, theoretical increased operating room time, increased chance of hardware irritation, and increased cost are several disadvantages to dual plating [11].

There have been numerous studies that reference orthogonal/dual plating throughout the body for fracture reduction and stabilization [11-23]. However; there have been no studies for dual plating lesser metatarsals for acute fractures. The purpose of this case study was to provide a scenario where the application of dual plating technique to an unstable lesser metatarsal fracture was warranted.

Case Report

A 52-year-old male presented with acute tenderness to the 2nd metatarsal of the right foot. The pain began approximately one week prior to presenting to us. He denied any injury to his recollection. He initially thought it was a gout flare up secondary to his history of gout flare ups and was prescribed a Medrol dose pack by his PCP which provided no relief. Therefore, the patient went to the emergency room in which radiographs were taken which demonstrated the patient had a displaced mid-diaphyseal fracture to the second metatarsal of the right foot (Figure 1). The patient also stated that within the last week he had also noticed lateral deviation of his second digit which was progressive. This was confirmed via physical exam as a flexible deformity secondary to displacement of the metatarsal fracture site. Physical exam revealed acute swelling and warmth about the midfoot and forefoot of the right foot focused about the second metatarsal. No ecchymosis was present. There was also point tenderness to the second metatarsal with reducible lateral deviation of the second digit at the level of the second metatarsophalangeal joint (MTPJ). With the radiographic displacement present and the patient’s medical history including diabetes, obesity, gout and other associated medical ailments it was decided the best course of action for the patient was to schedule the patient for ORIF of the second metatarsal with capsulotomy and extensor tendon lengthening to the second digit all right foot. Until the surgery the patient was placed in a Jones compression dressing and placed in a CAM walking boot.

Figure 1 Pre-operative radiographs AP, oblique, lateral.

One week after initial presentation, the patient underwent ORIF of the second metatarsal with capsulotomy and extensor tendon lengthening of the second MTPJ of the right foot. Incision placement was made on the dorsal aspect of the second metatarsal beginning at level of the proximal third of the metatarsal extending distally past the second MTPJ. Dissection was carried down to the level of the extensor tendons in which a Z-tenotomy of the extensor digitorum longus tendon, as well as, a complete tenotomy of the extensor digitorum brevis tendon was performed.

At this time, attention was focused to the fracture site. Using standard techniques all bone callus was debrided and the fracture was reduced by joystick technique utilizing a 0.062 K-wire in the capital fragment in order reduce the fracture and pull the metatarsal out to length. Once adequate reduction was achieved, the fracture sites were fixated provisionally with 0.045 K-wires. With further evaluation and thought, it was determined that two plate fixation would be optimal fixation with the current fracture pattern. This was achieved utilizing two 6-hole mini-fragment locking plates oriented obliquely into the bone and staggered for proper locking screw placement (Figure 2). With the two plate construct, both medial and lateral dorsal fragments were fixated to the constant plantar fragment achieving stable fixation.

Figure 2 Intraoperative radiographs AP, oblique, lateral.

After fixating the fracture site, soft tissue balancing for the lateral deviation of the second digit was performed. With reduction of the fracture, the digit deviation had decreased dramatically. The remaining deformity was addressed by performing a lateral capsulotomy at the level of the MTPJ and repairing the extensor longus tendon in an elongated state providing no tension to the digit at the level of the second MTPJ.

Post-operatively the patient remained non-weight bearing in a CAM walking boot for 4 weeks. After 4 weeks, the patient began to progressively bear weight on his right foot in a CAM boot only. After 2 weeks of weight bearing in a CAM boot the patient was transitioned into a tennis shoe comfortably. At that time, serial radiographs were obtained showing adequate consolidation of the fracture site with maintained reduction and position (Figure 3). The patient was able to return to work in full capacity at 8 weeks with no restrictions.  

Figure 3 Post-op clinical pictures and radiographs AP, oblique and lateral.

Discussion

Comminuted fractures of any long bone can be challenging to treat surgically. Though there are many techniques which have been shown to be viable options for such fracture types, dual plating has been shown to provide adequate stability and maintain correction of complex fractures of long bones.

As stated, Dayton et al were able to show that a dual locking plate technique with single cortex locking screws, when compared to single locking plate with interfragmentary screw fixation, showed superior or equivalent stability in multiplanar orientations of force application in both static and fatigue testing. Though this study was used primarily to show stability at fusion sites such as the first tarsometatarsal joint, the results are very applicable to complex fractures of long bones [11].

Dual plating has also been documented as a viable option for fracture fixation within the literature. There have been many studies within orthopedic literature showing the successful use of dual plating technique for fracture ORIF of fractures not within the foot and ankle [18-23]. However, there is also extensive literature is the use of dual plating for complex ankle fractures [12-17].

Kwaadu et al. evaluated the use of dual plate technique for the repair of complex fibular fractures on 25 patients. All 25 patients underwent benign postoperative courses with eight patients having complications all of which were wound complications. No additional operations were performed as a result of this technique. No patient undergoing this technique complained of any hardware irritation, and no hardware removal was required. The average time to radiological healing confirmed via radiograph was 7.5 weeks [12]. Vance et al. reviewed 12 consecutive patients who underwent ORIF of fibular fractures utilizing two 1/3 tubular plates for fixation. All fractures healed both clinically and radiographically. Only one patient required hardware removal. FAOS scores were obtained at a mean of 25.6 months after surgery and showed results of pain (87.6, SD = 9.5), activities of daily living (90.4, SD = 14.5), symptoms (93.3, SD = 9.5), sports (89.5, SD = 18.1), and quality of life (57.4, SD = 21.3) [13].

Our case report demonstrated successful use of dual plating technique for ORIF of a comminuted metatarsal fracture. It is our belief that this technique provides added support which was needed secondary to the fracture pattern presented. Dual plating is warranted in cases when traditional fixation techniques (i.e. K-wire fixation, screw, single plate) will not allow for appropriate reduction or stabilization of the fracture segment. This fixation technique can be another tool in the surgeon’s armamentarium.  While this case study was not the first to incorporate dual plating in fracture cases, it is the first to document dual plate technique for lesser metatarsal fractures.

References

  1. Buddecke D, Polk M, Barp E. Metatarsal fractures. Clin Podiatr Med Surg. 2010 Oct;27(4):601-24.
  2. Petrisor B, Ekrol I, Court-Brown C. The epidemiology of metatarsal fractures. Foot Ankle Int 2006;27:172–5.
  3. Maskill J, Bohay D, Anderson J. First ray injuries. Foot Ankle Clin N Am 2006;11: 143–63.
  4. Pearson J. Fractures of the base of the metatarsals. BMJ 1962;1:1052–4.
  5. Maxwell J. Open or closed treatment of metatarsal fractures: indications and techniques. J Am Podiatry Assoc 1983;73:100–6.
  6. Hansen ST. Foot injuries. In: Browner BD, Jupiter JB, Levine AM, et al, editors. Skeletal trauma. Philadelphia: WB Saunders Company; 1998. p. 2405–38.
  7. Early J. Metatarsal fractures. In: Bucholz R, Heckman J, Rockwood C, et al, editors. Rockwood and green’s fractures in adults. Lippincott, Williams, & Wilkins; 2001. p. 2215.
  8. Shereff M. Complex fractures of the metatarsals. Orthopedics 1990;13(8):875–82.
  9. Armagan O, Shereff M. Injuries to the toes and metatarsals. Orthop Clin North Am 2001;32(1):1–10.
  10. Donahue M, Manoli A. Technical tip: transverse percutaneous pinning of metatarsal neck fractures. Foot Ankle Int 2004;25(6):438–9.
  11. Dayton P, Ferguson J, Hatch D, Santrock R, Scanlan S, Smith B. Comparison of the mechanical characteristics of a universal small biplane plating technique without compression screw and single anatomic plate with compression screw. J Foot Ankle Surg. 2016 May-Jun;55(3):567-71.
  12. Kwaadu KY, Fleming JJ, Lin D. Management of complex fibular fractures: double plating of fibular fractures. J Foot Ankle Surg. 2015 May-Jun;54(3):288-94.
  13. Vance DD, Vosseller JT. Double Plating of Distal Fibula Fractures. Foot Ankle Spec. 2017 Feb 1:1938640017692416.
  14. Singh SK, Wilson MG. A Double Plate Technique for the Management of Difficult Fibula Fractures. Techniques in Foot & Ankle Surgery. 2005:4(4); 235-239.
  15. Savage TJ, Stone PA, McGarry JJ. Internal fixation of distal fibula fractures: a case presentation demonstrating a unique technique for a severely comminuted fibula. J Foot Ankle Surg. 1995 Nov-Dec;34(6):587-92; discussion 596.
  16. Lowe JA, Tejwani N, Yoo BJ, Wolinsky PR. Surgical techniques for complex proximal tibial fractures. J Bone Joint Surg Am. 2011 Aug 17;93(16):1548-59.
  17. Wykes PR, Eccles K, Thennavan B, Barrie JL. Improvement in the treatment of stable ankle fractures: an audit based approach. Injury. 2004 Aug;35(8):799-804.
  18. Helfet DL1, Hotchkiss RN. Internal fixation of the distal humerus: a biomechanical comparison of methods. J Orthop Trauma. 1990;4(3):260-4.
  19. Shin SJ, Sohn HS, Do NH. A clinical comparison of two different double plating methods for intraarticular distal humerus fractures. J Shoulder Elbow Surg. 2010 Jan;19(1):2-9.
  20. Nauth A, McKee MD, Ristevski B, Hall J, Schemitsch EH. Distal humeral fractures in adults. J Bone Joint Surg Am. 2011 Apr 6;93(7):686-700.
  21. Kaipel M, Majewski M, Regazzoni P. Double-plate fixation in lateral clavicle fractures-a new strategy. J Trauma. 2010 Oct;69(4):896-900.
  22. Prasarn ML, Meyers KN, Wilkin G, Wellman DS, Chan DB, Ahn J, Lorich DG, Helfet DL. Dual mini-fragment plating for midshaft clavicle fractures: a clinical and biomechanical investigation. Arch Orthop Trauma Surg. 2015 Dec;135(12):1655-62.
  23. Hirvensalo E, Lindahl J, Kiljunen V. Modified and new approaches for pelvic and acetabular surgery. Injury. 2007 Apr;38(4):431-41.

Spontaneous double tendon rupture of the ankle

by Jay Kaufman DPM1, Alexander Newton DPM2*, Payel Ghosh DPM3, Zachary Ritter DPM4

The Foot and Ankle Online Journal 10 (4): 3

We present an independent case study of a 54-year-old woman that underwent arthroscopic ankle synovectomy with an open Broström lateral ankle stabilization who eventually suffered a spontaneous tendon rupture of both the extensor digitorum longus (EDL) and extensor hallucis longus (EHL) during the post-operative period. Though the postoperative course was initially uneventful, the patient began experiencing pain and swelling about the ankle joint upon transition to full weight bearing three weeks following surgery, but prior to physical therapy implementation. She was subsequently diagnosed with a combined EHL and EDL tendon rupture as well as chronic tendinosis of both tendons. We present this case as a rare complication following arthroscopy directly related to chronic tendinosis, resulting in potentially detrimental implications during postoperative recovery period.

Keywords: spontaneous, extensor tendon rupture, arthroscopy

ISSN 1941-6806
doi: 10.3827/faoj.2017.1004.0003

1 – Physician; OAA Orthopedic Specialists, Allentown, PA
2 – Resident Physician; Department of Podiatric Surgery, St. Luke’s University Hospital, Allentown, PA
3 – Physician; Syracuse Podiatry, East Syracuse, NY
4 – Physician; Department of Foot and Ankle Surgery, Wound Care, and Podiatry. UPMC Susquehanna Hospital, Williamsport, PA
* – Corresponding author: anewton434@gmail.com


The incidence of tendon rupture following arthroscopic ankle intervention is rare. Spontaneous tendon rupture, with or without intervention, is uncommon. Generally, spontaneous tendon rupture is directly correlated with a combination of mild trauma and chronic degeneration of a tendon. Other contributing factors are systemic diseases, biomechanical abnormalities, fluoroquinolone use, and steroid usage. The Achilles tendon is the most common tendon to experience spontaneous rupture, followed by the patellar tendon, and the Tibialis Anterior (TA).

Specifically, a pes planovalgus foot type can cause excessive recruitment of the muscles required for ankle joint dorsiflexion, the long extensor tendons and the TA. Concomitant factors such as ankle equinus and obesity should be considered during the preoperative examination.

If tendon pathology is expected, a Magnetic Resonance Imaging (MRI) should be obtained. An increase in T2 signal intensity surrounding the tendon is consistent with tenosynovitis. Tendinosis, on the other hand would be delineated by tendon thickening on both T1 and T2 weighted images with increased T2 signal [1]. If the MRI is contraindicated, an ultrasound is a viable option.

Case Presentation

We report the case of a 54-year-old female, who sought a second opinion for continued lateral ankle pain and instability. She had an ankle MRI performed about one year prior to presentation and continued to have nearly daily recurrent left ankle sprains as well as constant aching left ankle pain. Pertinent findings on physical exam were a mild hindfoot varus deformity, a BMI of 40.4, intact manual muscle testing, lateral ankle instability, and tenderness on palpation of the lateral ankle including the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL), and the sinus tarsi. After failing prior conservative treatment, surgical intervention was pursued via ankle arthroscopy and lateral ankle stabilization. Ankle arthroscopy was performed uneventfully through a standard anteromedial and anterolateral ankle portal. Postoperatively, she was placed in a posterior splint with the hindfoot placed in slight valgus position.

The postoperative course passed uneventfully until the patient was transitioned from a posterior splint to an ankle brace weight bearing as tolerated one month postoperatively. She was instructed to use assistive devices as necessary and given a prescription for rehabilitative therapy. A few days following weight bearing, the patient noted sudden increased swelling surrounding the ankle joint, along with stiffness and burning within her first three digits. Radiographs and labs to rule out fracture, infectious or inflammatory process were negative. With clinical improvement, she proceeded to complete several weeks of physical therapy with resolution of ankle instability; however, in addition to stiffness and weakness of her lesser toes she began to complain of great toe weakness.

An MRI of the left ankle and left foot was obtained approximately 3.5 months postoperatively. Imaging at the level of the ankle demonstrated a ruptured EDL and EHL retracting proximally above the tibiotalar joint without violation of the anterior joint capsule. MRI at the level of the foot demonstrated tendinosis of the same tendons distal to the level of the ruptures.

Discussion

In 2012, Zengerink et al reviewed complications in ankle arthroscopy. He found neurologic injury to be the most common finding, followed by infection in a review of 1176 patients. Zengerink et al reported no tendon rupture following arthroscopic surgery within their follow up of approximately 7.5 years [2]. To our knowledge, there are only a small collection of prior reported incidences of tendon rupture following arthroscopy of the ankle joint. In 2010 Tuncer et al reported an incident of extensor hallucis longus and extensor digitorum longus insufficiency following radiofrequency ablation during ankle arthroscopy. Of note, intraoperatively both tendons were noted to be intact while the anterior capsule had been affected. However 10 weeks postoperatively, the patient did feel a “pop” and dual tendon rupture was then diagnosed [3].

Single tendon rupture following ankle arthroscopy is a rarity. Rupture of two tendons simultaneously without consideration of iatrogenic injury is improbable. The initial MRI, performed in 2010 prior to any surgical intervention, demonstrated an intact EHL, EDL, and TA. To further solidify our findings of this rare complication, a musculoskeletal radiologist was consulted (Figure 1). On MRI following any surgery, micrometallic debris can be detected in the soft tissues. This causes a susceptibility artifact in the tissues, which appears as multiple small foci of decreased signal on MRI. Figure 2 shows the metallic artifact surrounding the region of repair in the lateral ankle. No artifact is present in the anterior tissues surrounding the ruptured extensor tendons. Lack of metallic artifact as well as no anterior surgical track strongly argues against any kind of surgically induced laceration of the tendons.

Figure 1 MRI of normal ankle anatomy.

Figure 2 Micrometallic debris at site of lateral ankle repair.

Figure 3 demonstrates thickening and increased signal intensity of the long extensor tendons distal to the level of the rupture, consistent with tendinosis. If the tendons had been lacerated during surgery, the cut edges of the tendons would be expected to be sharply demarcated without thickening or increase in signal intensity.

Figure 3 MRI demonstrating absent extensor tendons at rupture site.

Figure 4 MRI demonstrating tendonitis distal to rupture.

Figure 4 demonstrates the lack of the long extensor tendons near the level of the ankle joint. The TA has remained intact. Figures 5 and 6 demonstrate the intact articular surface of the lateral aspect of the joint showing no issues with ingress or egress flow allowing us to further conclude that the articular capsule remains intact.

Figure 5 Intact intra-articular surface of the lateral shoulder of talus and fibula.

Figure 6 Distal tip of fibula and lateral talus.

If iatrogenic causes are ruled out, predisposing factors for tendon rupture must be considered. When an MRI is ordered for evaluation, chronic conditions can be missed as a result of being focused on acute pathologies. In general, chronic tendinosis and extensor tendon pathology are underreported in MRI reports [1]. This patient had multiple predisposing factors for increased strain on her extensor tendons: morbid obesity with a BMI of 40.4, pes planovalgus foot type, equinus strain following immobilization from surgery, and recurrent ankle sprains all likely contributed to rupture in the postoperative period. Additionally, patients bear weight differently on weight-bearing joints following surgery.

In the postoperative period, altered stress across the ankle joint in combination with a period of immobilization likely led to spontaneous rupture, due to the underlying tendinosis now appreciated on the postoperative MRI. In addition to noted EHL and EDL tendinosis, there was noted metallic artifact lateral about the Broström site as would be expected, however, there was no metallic artifact within the anterior soft tissues surrounding the extensor tendons, nor a surgical tract from the ankle joint to the anterior ankle tendons.

Conclusion

Spontaneous lower extremity tendon rupture, while rare, is a real possibility. We do not believe that the rupture of the long extensor tendons was due to iatrogenic injury. Rather, we believe that the combination of chronic tendinosis, immobility following surgery, and changing stresses on an already unhealthy tendon lead to tendon rupture as the patient’s physical therapy regimen was escalated. We believe that prevention of this hinges on proper diagnosis of chronic tendon pathology pre-operatively. When a patient presents preoperatively with gait dysfunction, a thorough evaluation of tendon pathology should not be overlooked prior to any surgical planning.

References

  1. Tsao LY. “Ankle Extensor Tendon Pathology.” www.radsource.us/ankle-extensor-tendon-pathology-2. Radsource MRI Web Clinic. July 2014.
  2. Zegerink M, van Dijk CN. “Complications in Ankle Arthroscopy.” Knee Surgery Sports Traumatology Arthroscopy. 2012 Aug; 20 (8): 1420-31.
  3. Tuncer S, Aksu N, Isiklar U. Delayed rupture of the extensor hallucis longus and extensor digitorum communis tendons after breaching the anterior capsule with a radiofrequency probe during ankle arthroscopy: a case report. Journal of Foot and Ankle Surgery 2010; Sep-Oct; 49(5).

The use of unidirectional porous β-tricarcium phosphate in surgery for calcaneal fractures: A report of four cases

by Shigeo Izawa1*, Toru Funayama2, Masashi Iwasashi1, Toshinori Tsukanishi3, Hiroshi Kumagai2, Hiroshi Noguchi2, Masashi Yamazaki2

The Foot and Ankle Online Journal 10 (4): 2

Affinos@ (Kuraray) is a unidirectional porous β-tricarcium phosphate (UDPTCP). We investigated four patients (four feet) who underwent invasive surgery using UDPTCP to treat calcaneal fractures that were accompanied by a bone defect. The mean age was 63.8±6.4 years old, and the mean observation period was 9.3±3.2 months. We evaluated the changes of UDPTCP over time and correction loss due to its use. In all patients, favorable material absorption and bone substitution were obtained, and their clinical courses were also favorable.

Keywords bone graft , unidirectional porous β-tricarcium phosphate, calcaneus fractures

ISSN 1941-6806
doi: 10.3827/faoj.2017.1004.0002

1 – Department of Orthopedics, Tsukuba Medical Center Hospital. Tsukuba, Japan
2 – Department of Orthopedics, Faculty of Medicine, University of Tsukuba , Japan
3 – Department of Orthopedics, Kenpoku Medical Center Takahagi Kyodo Hospital, Takahagi, Japan
* – Corresponding author: shigeo.izawa.1109@gmail.com


Bone grafting is often required to treat bone fractures that are accompanied by a bone defect. It is apparent that autogenous bone is optimal for bone grafting, but it has disadvantages due to problems with the procedures and quantity of bone graft. Thus, various types of artificial bones have been developed and clinically applied. Affinos@ (Kuraray) is a unidirectional porous β-tricarcium phosphate (UDPTCP) consisting of a novel porous artificial bone with a porosity of 57%, in which communication holes of 25-300 μm are arranged in one direction. It is characterized by balanced artificial bone resorption and replacement of autologous bone [1]. However, only a few clinical outcomes have been reported using this type of UDPTCP. We reported the outcomes of invasive surgeries using UDPTCP in four patients with calcaneus fractures that were accompanied by a bone defect.

Case presentation

Patients and procedures

The subjects were four patients (four feet) who underwent invasive treatments in one of two facilities between February and September 2015. The mean age was 63.8±6.4 years old, and the mean observation period was 9.3±3.2 months. All injuries occurred due to falling accidents, and the radiographic Essex-Lopresti classification was depression type in three patients and tongue type in one patient (Table 1).

During the surgery, a small incision was made on the lateral side of the calcaneus to reduce the fracture area, and a UDPTCP block (two patients) or granules (two patients) was used to fill the bone defect area, depending on its size. A plate (two patients), Steinmann pin (one patient), or K-wire (one patient) was used for internal fixation. The block was installed so that the communication hole was parallel to the load axis. Partial weight bearing was started after 4-6 weeks of non-weight bearing, and full-body weight bearing was allowed at 9-12 weeks.

Plain radiographs were taken before and immediately after the surgery, as well as 1, 3, and 6 months postoperatively to evaluate changes of the UDPTCP and corrective loss over time. The corrective loss was evaluated using the Bohler angle. In one patient in whom granules were used, plain computed tomography (CT) was performed at 3, 6, and 12 months postoperatively to observe the material absorption and bone neogenesis over time in detail.

Case Age

(yr)

Sex Type of fracture Artificial bone Material used for internal fixation
1 67 M Depression type Ⅱ° Block Plate
2 60 M Depression type Ⅲ° Granule Steinmann pin
3 71 F Tongue type Ⅱ° Granule K-wire
4 57 M Depression  type Ⅱ° Block Plate

Table 1 Radiographic Essex-Lopresti classification of each case.

As seen on a plain radiography image, absorption of the UDPTCP progressed within 3 months postoperatively, the majority of the material was absorbed within 6 months postoperatively, and substitution for the bone progressed. On average, the Bohler angle was 5.9° before the operation, 24.5° immediately after, and 21.3° at the final assessment, demonstrating that there was little correction loss after the surgery (Figure 1). Similar changes over time were observed on plain CT images, and the majority of the material had substituted for bone 1 year postoperatively.

Figure 1 Changes of the Bohler angle over time.

Case 1 (Figure 2, 3)

The patient in Case 1 was a 67-year-old man, and he was injured due to falling from a step ladder during pruning work. He underwent surgery 17 days after the injury. The type of fracture was depression type Ⅱ°. The surgical approach was via a lateral skin incision, and the articular surface was reduced by raising the depressed bone fragment. Part of the UDPTCP block was trimmed to the bone defect part, and three blocks were used to fill the defect. Then, plate fixation was performed.

Partial weight bearing was started at 6 weeks postoperatively, and full-body weight bearing was allowed at 10 weeks. During clinical examination, the Bohler angles were as follows: before the surgery: 0°, immediately postoperatively: 25°, and at the final observation (6 months postoperatively): 22°.

After the surgery, no complications occurred, and, as seen on a plain radiography image, artificial bone was absorbed at 3 months postoperatively. In a plain radiography image that was taken 6 months postoperatively, artificial bone was found to have substituted for the natural bone, and the shadow of the artificial bone almost disappeared (Figure 3).

Figure 2 Plain radiography images, from left: at the time of injury, immediately after the surgery, 3 months postoperatively, and 6 months postoperatively.

Figure 3 Plain radiography images (zoom). Left: 3 months postoperatively; Right: 6 months postoperatively.

Case 2 (Figure 4, 5)

The patient in Case 2 was a 60-year-old man who was injured by falling from a truck loading platform. The patient underwent surgery 6 days after the injury. The type of fracture was depression type Ⅲ°.

During the surgery, the approach was via a skin incision, and the articular surface was reduced by raising the depressed bone fragment. The bone defect area was filled with 2 g of UDPTCP granules. Then, a Steinmann pin was inserted from behind.

Partial weight bearing was started at 6 weeks postoperatively, and full-body weight bearing was allowed at 10 weeks. On clinical examination, the Bohler angles were: before the surgery: 1°, immediately after the surgery: 18°, and at final observation (one year postoperatively): 13°.

No complications occurred following the surgery, and the Steinmann pin was removed 6 weeks postoperatively. As seen on a plain CT image one year after the surgery, the artificial bone was almost substituted for the natural bone, and the trabecular structure was located inside it (Figure 5).

Figure 4 A plain radiography image. Left panel: at the time of injury, middle panel: immediately after the surgery, right panel: 6 months after the surgery.

Figure 5 Plain CT images, from left: immediately after the surgery, 3 months after the surgery, 6 months after the surgery, and one year after the surgery.

Discussion

Calcaneal fractures that occur due to falling accidents often result in crushed cancellous bone and bone defects after reduction. Furthermore, bone atrophy and joint contracture occur following long-term non-weight bearing and fixation, complicating the treatment. A biomechanical study by Inoue et al reported that performing bone grafting to treat a calcaneal fracture is useful to maintain repaired bone fragments [2] .  Takai et al.examined the use of β-TCP artificial bone in 5 patients (5 feet) in older patients (aged ≥ 70 years) with calcaneus fractures, and the mean change of the Bohler angle postoperatively was 1°, demonstrating that the procedure has favorable results [3]. Nakagawa et al found that β-TCP has advantages, because it is easy to penetrate β-TCP with a K-wire after grafting [4]. It can also be applied easily in young adults because it can be completely absorbed. However, in some cases, grafted granular β-TCP leaked into the subtalar joint, and was not absorbed even after 1 year or more; therefore, the authors recommended performing grafting with blocked β-TCP instead of granules in patients with comminuted fractures.

Regarding UDPTCP, Makihara et al. used rabbit bone defect models and reported that UDPTCP leads to superior absorption and substitution for autologous bone [1]. In the present study, favorable absorption and bone substitution were confirmed for both UDPTCP block and granules, and no patient had an infection or foreign body reaction, indicating that the postoperative outcomes of the procedure are favorable. Furthermore, the correction loss was small, even after weight bearing was started, suggesting that UDPTCP had sufficient strength to withstand early weight bearing. Regarding the speed of replacement for autogenous bone, a report5) using Osferion (porosity 75%; Olympus), which is a common β-TCP that is used in Japan, showed that, on average, assimilated shadows of the surrounding bone and trabecular bone formation appeared at 8 weeks postoperatively, and the shadow of absorbed artificial bone disappeared at 8 months postoperatively. In our study, absorption of artificial bone was observed at 3 months postoperatively in all cases, and the artificial bone was absorbed almost completely and replaced with autogenous bone at 6 months postoperatively in the earliest case. Although the substitution speed varies depending on the amount and site of grafted artificial bone and the patient’s age, the substitution speed of the UDPTCP was comparable with that of conventional β-TCP, suggesting that UDPTCP is a useful bone filling material in the treatment of calcaneal fracture.

In conclusion, we performed surgery using UDPTCP in patients with calcaneus fractures. In all cases, favorable material absorption and bone substitution were observed, and the clinical outcomes were favorable.

References

  1. Takeshi M. The balance between bone formation and material resorption in unidirectional porous β-tricalcium phosphate implanted in a rabbit tibia. Key Engineering Materials, 696:177-182, 2016.
  2. Nozomu I. The usefulness of combining bone grafts in open surgery of calcaneus fracture. Fracture, 12:173-177, 1990.
  3. Hirokazu T. Open reduction and internal fixation with artificial bone grafts for calcaneus fractures in elderly people. Journal of Orthopedics & Traumatology, 61:765-768, 2012.
  4. Yusuke N. Treatment outcomes of open reduction and fixation using granularβ-TCP by lateral scalpel for intra articular calcaneus fractures. Fracture, 34:446-450, 2012.
  5. Naohiro T. The usefulness of theβ-TCP as bone filling material. Journal of Orthopedics & Traumatology, 63:875-877, 2014.

Effects of medial and lateral orthoses on kinetics and tibiocalcaneal kinematics in male runners

by Jonathan Sinclair1*

The Foot and Ankle Online Journal 10 (4): 1

Background: The aim of the current investigation was to examine the effects of foot orthotic devices with a 5° medial and lateral wedge on kinetics and tibiocalcaneal kinematics during the stance phase of running.
Material and methods: Twelve male participants ran over a force platform at 4.0 m/s in three different conditions (5° medial orthotic, 5° lateral orthotic and no-orthotic). Tibiocalcaneal kinematics were collected using an 8 camera motion capture system and axial tibial accelerations were obtained via an accelerometer mounted to the distal tibia. Biomechanical differences between orthotic conditions were examined using one-way repeated measures of analysis of variance (ANOVA).
Results: The results showed that no differences (P>0.05) in kinetics/tibial accelerations were evident between orthotic conditions. However, it was revealed that the medial orthotic significantly (P<0.05) reduced peak ankle eversion and relative tibial internal rotation range of motion (-10.75 & 4.98°) in relation to the lateral (-14.11 & 6.14°) and no-orthotic (-12.37 & 7.47°) conditions.
Conclusions: The findings from this study indicate, therefore, that medial orthoses may be effective in attenuating tibiocalcaneal kinematic risk factors linked to the etiology of chronic pathologies in runners.

Keywords: running, biomechanics, orthoses, kinetics, kinematics

ISSN 1941-6806
doi: 10.3827/faoj.2017.1004.0001

1 – Center for Applied Sport Exercise and Nutritional Sciences, School of Sport and Wellbeing, Faculty of Health & Wellbeing, University of Central Lancashire, Preston, Lancashire, PR1 2HE.
* – Corresponding author: jksinclair@uclan.ac.uk


Distance running is associated with a significant number of physiological and psychological benefits [1]. However, epidemiological analyses have demonstrated that pathologies of a chronic nature are extremely common in both recreational and competitive runners [2] and as many as 80% of runners will experience a chronic injury as a consequence of their training over a one-year period [2].

Given the high incidence of chronic pathologies in runners, a range of strategies have been investigated and implemented in clinical research in an attempt to mitigate the risk of injury in runners. Foot orthoses are very popular devices that are used extensively by runners [3]. It has been proposed that foot orthoses may be able to attenuate the parameters linked to the etiology of injury in runners, thus they have been cited as a mechanism by which injuries can be prophylactically avoided and also retrospectively treated [4]. The majority of research investigating the biomechanical effects of foot orthoses during running has examined either impact loading or rearfoot eversion parameters which have been linked to the etiology of running injuries. Sinclair et al, [5] showed that an off the shelf orthotic device significantly reduced vertical rates of loading and axial tibial accelerations, but did not alter the magnitude of rearfoot eversion. Butler et al, [6] examined three-dimensional (3D) kinematic/ kinetic data alongside axial tibial accelerations during running, using dual-purpose and a rigid orthoses. Their findings revealed that none of the experimental parameters were differed significantly between the different orthotic conditions.  Laughton et al, [7] showed that foot orthoses significantly reduced the loading rate of the vertical ground reaction force but did not significantly influence rearfoot eversion parameters. Dixon, [8] examined the influence of off the shelf foot orthoses placed inside an military boot on kinetic and 3D kinematic parameters during running. The findings from this investigation revealed that the orthotic device significantly reduced the vertical rate of loading, but no alterations in ankle eversion were reported.

Further to this, because the mechanics of the foot alter the kinetics/kinematics of the proximal lower extremity joints, biomechanical control of the foot with in-shoe orthotic wedges has wide-ranging applications for the treatment of a variety chronic lower extremity conditions. Different combinations of wedges or posts have therefore been used in clinical practice/ research to treat a multitude of chronic pathologies [9]. Both valgus (lateral) and varus (medial) orthoses have been proposed as potentially important low-cost devices for the conservative management of chronic pathologies [10].

Lateral orthoses are utilized extensively in order to reduce the loads experienced by the medial tibiofemoral compartment [10]. Lateral orthoses cause the center of pressure to shift medially thereby moving the medial-lateral ground reaction force vector closer to the knee joint center [11]. This serves to reduce the magnitude of the knee adduction moment which is indicative of compressive loading of the medial aspect of the tibiofemoral joint and its progressive degeneration [12]. Kakihana et al, investigated the biomechanical effects of lateral wedge orthoses on knee joint moments during gait in elderly participants with and without knee osteoarthritis [13]. The lateral wedge significantly reduced the knee adduction moment in both groups when compared with no wedge. Butler et al, examined the effects of a laterally wedged foot orthosis on knee mechanics in patients with medial knee osteoarthritis [14]. The laterally wedged orthotic device significantly reduced the peak adduction moment and also the knee adduction excursion from heel strike to peak adduction compared to the non-wedged device. Kakihana et al, examined the kinematic and kinetic effects of a lateral wedge insole on knee joint mechanics during gait in healthy adults [15]. The wedged insole significantly reduced the knee adduction moment during gait in comparison to the no-wedge condition, although no changes in knee kinematics were evident.

The influence of medially oriented foot orthoses has also been frequently explored in biomechanical literature. Boldt et al, examined the effects of medially wedged foot orthoses on knee and hip joint mechanics during running in females with and without patellofemoral pain syndrome [16]. The findings from this study showed that the peak knee adduction moment increased and hip adduction excursion decreased significantly when wearing medially wedged foot orthoses. Sinclair et al.,  explored the effects of medial foot orthoses on patellofemoral stress during the stance phase of running using a musculoskeletal modelling approach [17]. Their findings showed that medial foot orthoses significantly reduced peak patellofemoral stress loading at this joint during running.

Although the effects of medial/lateral foot orthoses have been explored previously, they have habitually been examined during walking in pathological patients and thus their potential prophylactic effects on the kinetics and tibiocalcaneal kinematics of running have yet to be examined. Therefore, the aim of the current investigation was to examine the effects of foot orthotic devices with a 5° medial and lateral wedge on kinetics and tibiocalcaneal kinematics the during the stance phase of running. A clinical investigation of this nature may provide further insight into the potential efficacy of wedged foot orthoses for the prevention of chronic running injuries.

Methods

Participants

Twelve male runners (age 26.23 ± 5.76 years, height 1.79 ± 0.11 cm and body mass 73.22 ± 6.87 kg) volunteered to take part in this study. All runners were free from musculoskeletal pathology at the time of data collection and were not currently taking any medications. The participants provided written informed consent in accordance with the principles outlined in the Declaration of Helsinki. The procedure utilized for this investigation was approved by the University of Central Lancashire, Science, Technology, Engineering and Mathematics, ethical committee.

Orthoses

Commercially available orthotics (Slimflex Simple, High Density, Full Length, Algeos UK) were examined in the current investigation. The orthoses were made from Ethylene-vinyl acetate and had a shore A rating of 65. The orthoses were able to be modified to either a 5˚ varus or valgus configuration which spanned the full length of the device. The order that participants ran in each orthotic condition was counterbalanced.

Procedure

Participants completed five running trials at 4.0 m/s ± 5%. The participants struck an embedded piezoelectric force platform (Kistler Instruments, Model 9281CA) sampling at 1000 Hz with their right foot. Running velocity was monitored using infrared timing gates (SmartSpeed Ltd UK). The stance phase of the running cycle was delineated as the time over which > 20 N vertical force was applied to the force platform. Kinematic information was collected using an eight-camera optoelectric motion capture system with a capture frequency of 250 Hz. Synchronized kinematic and ground reaction force data were obtained using Qualisys track manager software (Qualisys Medical AB, Goteburg, Sweden).

The calibrated anatomical systems technique (CAST) was utilized to quantify tibiocalcaneal kinematics (18). To define the anatomical frames of the right foot, and shank, retroreflective markers were positioned onto the calcaneus, first and fifth metatarsal heads, medial and lateral malleoli, medial and lateral epicondyle of the femur. A carbon fiber tracking cluster was attached to the shank segment. The foot was tracked using the calcaneus, and first and fifth metatarsal markers. Static calibration trials were obtained with the participant in the anatomical position in order for the positions of the anatomical markers to be referenced in relation to the tracking clusters/markers.

Tibial accelerations were measured using an accelerometer (Biometrics ACL 300, Units 25-26 Nine Mile Point Ind. Est. Cwmfelinfach, Gwent United Kingdom) sampling at 1000 Hz. The device was attached to the tibia 0.08 m above the medial malleolus in alignment with its longitudinal axis (19). Strong adhesive tape was placed over the device and the lower leg to prevent artifact in the acceleration signal.

Processing

The running trials were digitized using Qualisys Track Manager (Qualysis, Sweden) and then exported as C3D files. Kinematic parameters were quantified using Visual 3-D software (C-Motion, USA) after the marker data was smoothed using a low-pass Butterworth 4th order zero-lag filter at a cutoff frequency of 12 Hz. Three-dimensional kinematic parameters were calculated using an XYZ cardan sequence of rotations where X represents the sagittal plane, Y represents the coronal plane and Z represents the transverse plane rotations (Sinclair et al., 2013). Trials were normalized to 100% of the stance phase then processed and averaged. In accordance with previous studies, the foot segment coordinate system was referenced to the tibial segment for ankle kinematics, whilst tibial internal rotation (TIR) was measured as a function of the tibial coordinate system in relation to the foot coordinate axes [21]. The 3-D kinematic tibiocalcaneal measures which were extracted for statistical analysis were: (1) angle at foot strike, (2) peak angle during stance and (3) relative range of motion (ROM) from footstrike to peak angle.

The tibial acceleration signal was filtered using a 60 Hz Butterworth zero lag 4th order low pass filter to prevent any resonance effects on the acceleration signal. Peak tibial acceleration (g) was defined as the highest positive axial acceleration peak measured during the stance phase. Average tibial acceleration slope (g/s) was quantified by dividing peak tibial acceleration by the time taken from footstrike to peak tibial acceleration and instantaneous tibial acceleration slope (g/s) was quantified as the maximum increase in acceleration between frequency intervals. From the force platform all parameters were normalized by dividing the net values by body weight. Instantaneous loading rate (BW/s) was calculated as the maximum increase in vertical force between adjacent data points.

Statistical analyses

Means, standard deviations and 95 % confidence intervals were calculated for each outcome measure for all orthotic conditions. Differences in kinetic and tibiocalcaneal kinematic parameters between orthoses were examined using one-way repeated measures ANOVAs, with significance accepted at the P≤0.05 level. Effect sizes were calculated using partial eta2 (pη2). Post-hoc pairwise comparisons were conducted on all significant main effects. The data was screened for normality using a Shapiro-Wilk which confirmed that the normality assumption was met. All statistical actions were conducted using SPSS v23.0 (SPSS Inc., Chicago, USA).

Results

Tables 1-3 and Figure 1 present differences in kinetics and tibiocalcaneal kinematics as a function of the different orthoses. The results indicate that the experimental orthoses significantly affected orthoses tibiocalcaneal kinematic parameters.

Medial Lateral No-orthotic
Mean SD 95% CI (Lower) 95% CI (Upper) Mean SD 95% CI (Lower) 95% CI (Upper) Mean SD 95% CI (Lower) 95% CI (Upper)
Coronal plane (+ = inversion & – = eversion)
 Angle at footstrike (°) -3.98 5.65 -7.57 -0.39 -3.77 5.64 -7.35 -0.19 -0.66 5.91 -4.41 3.09
 Peak eversion (°) -10.75 5.7 -14.38 -7.13 -14.11 6.48 -18.22 -9.99 -12.37 5.43 -15.82 -8.92
 Relative ROM (°) 6.77 2.78 5.00 8.54 10.34 3.44 8.15 12.53 11.71 3.26 9.64 13.78
Transverse plane (+ = external & – = internal)
 Angle at footstrike (°) -11.78 2.72 -13.51 -10.05 -15.01 2.81 -16.80 -13.22 -14.41 2.97 -16.29 -12.52
 Peak rotation (°) -6.80 3.10 -8.78 -4.83 -5.6 3.94 -8.10 -3.09 -5.05 3.33 -7.17 -2.93
 Relative ROM (°) 4.97 0.86 4.43 5.52 9.41 1.33 8.56 10.26 9.35 1.44 8.44 10.27

Table 1 Ankle kinematics (mean, SD & 95% CI) in the coronal and transverse planes as a function of the different orthotic conditions.

Medial Lateral No-orthotic
Mean SD 95% CI (Lower) 95% CI (Upper) Mean SD 95% CI (Lower) 95% CI (Upper) Mean SD 95% CI (Lower) 95% CI (Upper)
Transverse plane (+ =  internal & – =external)
 Angle at footstrike (°) 8.57 3.16 6.56 10.57 9.74 4.01 7.20 12.29 6.51 3.98 3.98 9.04
 Peak TIR (°) 13.54 4.28 10.82 16.27 15.89 5.65 12.30 19.48 13.98 4.58 11.07 16.89
 Relative ROM (°) 4.98 2.68 3.28 6.68 6.14 3.54 3.89 8.39 7.47 3.75 5.09 9.85

Table 2 Tibial internal rotation parameters (mean, SD & 95% CI) as a function of the different orthotic conditions.

Medial Lateral No-orthotic
Mean SD 95% CI (Lower) 95% CI (Upper) Mean SD 95% CI (Lower) 95% CI (Upper) Mean SD 95% CI (Lower) 95% CI (Upper)
Peak tibial acceleration (g) 9.83 4.50 6.98 12.69 9.97 4.88 6.87 13.07 9.41 4.76 6.38 12.44
Average tibial acceleration slope (g/s) 362.73 196.31 238.01 487.46 367.37 219.63 227.83 506.91 369.52 257.85 205.69 533.35
Instantaneous tibial acceleration slope (g/s) 866.20 459.40 574.31 1158.09 867.71 554.16 515.61 1219.81 776.85 529.86 440.20 1113.51
Instantaneous load rate (BW/s) 156.17 58.72 118.86 193.48 161.77 71.57 116.30 207.25 134.49 44.62 106.14 162.84

Table 3 Kinetic and tibial acceleration parameters (mean, SD & 95% CI) as a function of the different orthotic conditions.

Figure 1 Tibiocalcaneal kinematics as a function of the different orthotic conditions; a= ankle coronal plane angle, b= ankle transverse plane angle & c = tibial internal rotation, (black = lateral, dash = medial & grey = no-orthotic), (IN = inversion, EXT = external & INT = internal).

Kinetics and tibial accelerations

No significant (P>0.05) differences in kinetics/tibial acceleration parameters were observed between orthotic conditions.

Tibiocalcaneal kinematics

In the coronal plane a significant main effect (F (2, 22) = 25.58, P<0.05, pη2 = 0.70) was found for the magnitude of peak eversion. Post-hoc pairwise comparisons showed that peak eversion was significantly larger in the lateral in relation to the medial (P=0.0000007) and no-orthotic (P=0.01) conditions. In addition, it was also revealed that peak eversion was significantly greater in the no-orthotic (P=0.008) in comparison to the medial orthotic condition. In addition, a significant main effect (F (2, 22) = 25.58, P<0.05, pη2 = 0.74) was noted for relative eversion ROM. Post-hoc pairwise comparisons showed that relative eversion ROM was significantly larger in the lateral (P=0.0000006) and no-orthotic (P=0.00001) in relation to the medial condition.

In the transverse plane a significant main effect (F (2, 22) = 116.11, P<0.05, pη2 = 0.91) was noted for relative transverse plane ankle ROM. Post-hoc pairwise comparisons showed that relative transverse plane ankle ROM was significantly larger in the lateral (P=0.0000001) and no-orthotic (P=0.0000008) in relation to the medial condition.

In addition, a significant main effect (F (2, 22) = 5.99, P<0.05, pη2 = 0.36) was found for the magnitude of peak TIR. Post-hoc pairwise comparisons showed that peak TIR was significantly larger in the lateral in relation to the medial (P=0.007) and no-orthotic (P=0.025) conditions. Finally, a significant main effect (F (2, 22) = 7.55, P<0.05, pη2 = 0.41) was noted for relative TIR ROM. Post-hoc pairwise comparisons showed that relative TIR ROM was significantly larger in the lateral (P=0.04) and no-orthotic (P=0.007) in relation to the medial condition.

Discussion

The aim of the current investigation was to examine the effects of foot orthotic devices with a 5° medial and lateral wedge on kinetics and tibiocalcaneal kinematics the during the stance phase of running. This is, to the authors’ knowledge, the first investigation to concurrently examine the influence of different orthotic wedge configurations on the biomechanics of running. An investigation of this nature may, therefore, provide further insight into the potential prophylactic efficacy of wedged foot orthoses for the prevention of chronic running injuries.

The current study importantly confirmed that no significant differences in impact loading or axial tibial accelerations were evident as a function of the experimental orthotic conditions. This observation opposes those of Sinclair et al., Laughton et al. and Dixon, who demonstrated that foot orthoses significantly reduced the magnitude of axial impact loading during the stance phase of running [5,7,8]. However, the findings are in agreement with those noted by Butler et al,  who similarly observed that the magnitude of axial impact loading did not differ significantly whilst wearing rigid orthoses [6]. Although not all of the aforementioned investigations have published hardness ratings, at a shore A grade of 65 it is likely that the orthoses examined in the current explanation were more rigid than those utilized by Sinclair et al., Laughton et al. and Dixon [5,7,8]. It is proposed that the divergence between investigations relates to differences in hardness characteristics of the experimental orthoses. The magnitude of impact loading is governed by the rate of change in momentum of the decelerating limb as the foot strikes the ground [22]; as such, it appears that the orthoses examined in this analysis were not sufficiently compliant to provide any reduction in impact loading.

Of further importance to the current investigation is that the medial orthoses significantly reduced eversion and TIR parameters in relation to the lateral and no-orthotic conditions. It is likely that this observation relates to the mechanical properties of the medial wedge which is designed specifically to rotate the foot segment into a more inverted position. This finding has potential clinical significance as excessive rearfoot eversion and associated TIR parameters are implicated in the etiology of a number of overuse injuries such as tibial stress syndrome, plantar fasciitis, patellofemoral syndrome and iliotibial band syndrome [23-25]. This observation therefore suggests that medial orthoses may be important for the prophylactic attenuation of chronic running related to excessive eversion/ TIR.

The findings from the current study importantly show that whilst lateral orthoses are effective in attenuating pain symptoms [9] and reducing the magnitude of the external knee adduction moment [13-15] in patients with medial compartment tibiofemoral osteoarthritis, they may concurrently place runners at risk from chronic pathologies distinct from the medial aspect of the tibiofemoral joint. It appears based on the findings from the current investigation that caution should be exercised when prescribing lateral wedge orthoses without a thorough assessment of the runners’ individual characteristics.  

A limitation, in relation to the current investigation, is that only the acute effects of the wedged insoles were examined. Therefore, although the medial orthoses appear to prophylactically attenuate tibiocalcaneal risk factors linked to the etiology of injuries, it is currently unknown whether this will prevent or delay the initiation of injury symptoms. Furthermore, the duration over which the orthoses would need to be utilized in order to mediate a clinically meaningful change in patients is also not currently known. A longitudinal examination of medial/lateral orthoses in runners would therefore be of practical and clinical relevance in the future. A further potential limitation is that only male runners were examined as part of the current investigation. Females are known to exhibit distinct tibiocalcaneal kinematics when compared to male recreational runners, with females being associated with significantly greater eversion and TIR parameters compared to males [26]. Furthermore, females are renowned for being at increased risk from tibiofemoral joint degeneration in comparison to males [27], and experimental findings have shown that degeneration may also be more prominent at different anatomical aspects of the knee in females in relation to males [28]. This suggests that the requirements of females, in terms of wedged orthotic intervention, may differ from those of male runners, thus it would be prudent for future biomechanical investigations to repeat the current study using a female sample.

In conclusion, despite the fact that the biomechanical effects of wedged foot orthoses have been examined previously, current knowledge with regards to the effects of medial and lateral orthoses on the kinetics and tibiocalcaneal kinematics of running have yet to be explored. This study adds to the current literature in the field of biomechanics by giving a comprehensive comparative examination of kinetic and tibiocalcaneal kinematic parameters during the stance phase of running whilst wearing medial and lateral orthoses. The current investigation importantly showed that medial orthoses significantly attenuated eversion and TIR parameters in relation to the lateral and no-orthotic conditions. The findings from this study indicate therefore that medial orthoses may be effective in attenuating tibiocalcaneal kinematic risk factors linked to the etiology of chronic pathologies in runners.

References

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  2. van Gent, B.R., Siem, D.D., van Middelkoop, M., van Os, T.A., Bierma-Zeinstra, S.S., Koes, B.B. (2007). Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review. British Journal of Sports Medicine. 41, 469-480.
  3. McMillan, A., Payne, C. (2008). Effect of foot orthoses on lower extremity kinetics during running: a systematic literature review. Journal of Foot and Ankle Research. 13, 1-13.
  4. Mills, K., Blanch, P., Chapman, A. R., McPoil, T. G., Vicenzino, B. (2010). Foot orthoses and gait: a systematic review and meta-analysis of literature pertaining to potential mechanisms. British Journal of Sports Medicine, 44, 1035-1046.
  5. Sinclair, J., Isherwood, J., Taylor, P.J. (2014). Effects of foot orthoses on kinetics and tibiocalcaneal kinematics in recreational runners. Foot and Ankle Online Journal, 7, 3-11.
  6. Butler, R. J., Davis, I. M., Laughton, C. M., Hughes, M. (2003). Dual-function foot orthosis: effect on shock and control of rearfoot motion. Foot & ankle international, 24, 410-414.
  7. Laughton, C. A., Davis, I. M., Hamill, J. (2003). Effect of strike pattern and orthotic intervention on tibial shock during running. Journal of Applied Biomechanics, 19, 153-168.
  8. Dixon, S.J. (2007). Influence of a commercially available orthotic device on rearfoot eversion and vertical ground reaction force when running in military footwear. Military medicine, 172, 446-450.
  9. Parkes, M. J., Maricar, N., Lunt, M., LaValley, M. P., Jones, R. K., Segal, N. A., Felson, D. T. (2013). Lateral wedge insoles as a conservative treatment for pain in patients with medial knee osteoarthritis: a meta-analysis. JAMA, 310, 722-730.
  10. Reilly, K. A., Barker, K. L., Shamley, D. (2006). A systematic review of lateral wedge orthotics-how useful are they in the management of medial compartment osteoarthritis?. The Knee, 13, 177-183.
  11. Rafiaee, M., Karimi, M. T. (2012). The effects of various kinds of lateral wedge insoles on performance of individuals with knee joint osteoarthritis. International Journal of Preventive Medicine, 3, 693-698.
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  13. Kakihana, W., Torii, S., Akai, M., Nakazawa, K., Fukano, M., Naito, K. (2005). Effect of a lateral wedge on joint moments during gait in subjects with recurrent ankle sprain. American Journal of Physical Medicine & Rehabilitation, 84, 858-864.
  14. Butler, R. J., Marchesi, S., Royer, T., Davis, I. S. (2007). The effect of a subject‐specific amount of lateral wedge on knee mechanics in patients with medial knee osteoarthritis. Journal of Orthopaedic Research, 25, 1121-1127.
  15. Kakihana, W., Akai, M., Yamasaki, N., Takashima, T., Nakazawa, K. (2004). Changes of joint moments in the gait of normal subjects wearing laterally wedged insoles. American Journal of Physical Medicine & Rehabilitation, 83, 273-278.
  16. Boldt, A.R., Willson, J.D., Barrios, J.A., Kernozek, T.W. (2013). Effects of medially wedged foot orthoses on knee and hip joint running mechanics in females with and without patellofemoral pain syndrome. Journal of Applied Biomechanics. 29, 68-77.
  17. Sinclair, J., Vincent, H., Selfe, J., Atkins, S., Taylor, P.J., Richards, J. (2015). Effects of foot orthoses on patellofemoral load in recreational runners. Foot and Ankle Online Journal, 8, 5-12.
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  20. Sinclair, J., Taylor, P.J., Edmundson, C.J., Brooks, D., Hobbs, S.J. (2013). Influence of the helical and six available Cardan sequences on 3D ankle joint kinematic parameters. Sports Biomechanics, 11, 430-437.
  21. Eslami, M., Begon, M., Farahpour, N., Allard, P. (200). Forefoot–rearfoot coupling patterns and tibial internal rotation during stance phase of barefoot versus shod running. Clinical Biomechanics, 22, 74-80.
  22. Whittle, M.W. (1999). Generation and attenuation of transient impulsive forces beneath the foot: a review. Gait & posture, 10, 264-267.
  23. Viitasalo, J.T., Kvist, M. (1983). Some biomechanical aspects of the foot and ankle in athletes with and without shin splints. The American Journal of Sports Medicine, 11, 125-130.
  24. Lee, S.Y., Hertel, J., Lee, S.C. (2010). Rearfoot eversion has indirect effects on plantar fascia tension by changing the amount of arch collapse. The Foot, 20, 64-70.
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  27. Hame, S.L., Alexander, R.A. (2013). Knee osteoarthritis in women. Current Reviews in Musculoskeletal Medicine. 6, 182-187.
  28. Hanna, F.S., Teichtahl, A.J., Wluka, A.E., Wang, Y., Urquhart, D.M., English, D.R., Cicuttini, F.M. (2009). Women have increased rates of cartilage loss and progression of cartilage defects at the knee than men: a gender study of adults without clinical knee osteoarthritis. Menopause. 16, 666-670.

Fall 2017


Issue 10 (3), 2017


Foot anthropometrics in individuals with diabetes compared with the general Swedish population: Implications for shoe design
by Ulla Hellstrand Tang , Jacqueline Siegenthaler, Kerstin Hagberg, Jon Karlsson, Roy Tranberg


Osteochondromas of the subtalar joint: A case study
by Christopher Gaunder MD, Brandon McKinney DO, Joseph Alderete MD, Thomas Dowd MD


Divergent Lisfranc injury with dislocation of great toe interphalangeal joint: A rare case report
by Dr. Ganesh Singh Dharmshaktu, Dr. Binit Singh


Charcot foot management using MASS posture foot orthotics: A case study
by Edward S. Glaser DPM; David Fleming BS


Surgical treatment of a large plexiform neurofibroma of the lower extremity
by Jacob Jensen, David Shofler, Della Bennett


Staged surgical intervention in the treatment of septic ankle arthritis with autologous circular pillar fibula augmentation: A case report
by Sham J. Persaud DPM, MS; Colin Zdenek DPM; Alan R. Catanzariti DPM


Summer 2017


Issue 10 (2), 2017


Isolated, nondisplaced medial cuneiform fractures: Report of two cases
by Koun Yamauchi MD, Satoru Miyake MD, Chisato Kato MD, Takayuki Kato MD


Radiographic changes in coronal alignment of the ankle joint immediately after primary total knee arthroplasty for varus knee osteoarthritis
by Ichiro Tonogai, Daisuke Hamada, Koichi Sairyo


Trigger events for Charcot neuroarthropathy: A retrospective review
by Brent H. Bernstein DPM FACFAS, Payel Ghosh DPM, Colleen Law DPM, Danielle Seiler DPM, Thuyhien Vu DPM


The D-Foot, for prosthetists and orthotists, a new eHealth tool useful in useful in risk classification and foot assessment in diabetes
by Ulla Hellstrand Tang BSc, Roy Tranberg PhD, Roland Zügner BSc, Jon Karlsson MD PhD, Vera Lisovskaja PhD, Jacqueline Siegenthaler BSc, Kerstin Hagberg PhD


Effects of medial and lateral orthoses on Achilles tendon kinetics during running
by Gareth Shadwell, Jonathan Sinclair


Isolated, nondisplaced medial cuneiform fractures: Report of two cases

by Koun Yamauchi MD1*, Satoru Miyake MD1, Chisato Kato MD1, Takayuki Kato MD1

The Foot and Ankle Online Journal 10 (2): 1

Isolated, nondisplaced medial cuneiform fractures are difficult to diagnose using plain radiographs. Computed tomography (CT) or magnetic resonance imaging (MRI) are necessary to aid in diagnosis. This paper describes two patients with this fracture that were more difficult to suspect because the fractures occurred during running, which are extremely rare. Tenderness and swelling around the medial cuneiform was observed that led to suspicion of a fracture; this lead us to perform a CT scan or MRI for confirming the presence of the fracture. However, tenderness and swelling around the midfoot can be observed in a patient with a sprain without the fracture. Therefore, it is more important to note that isolated, nondisplaced medial cuneiform fracture can be induced by an indirect force such as that occurring while running.

Keywords isolated medial cuneiform fractures, non-displaced, during running, computed tomography, magnetic resonance imaging

ISSN 1941-6806
doi: 10.3827/faoj.2017.1002.0001

1 – Department of orthopedic surgery, Akita Hospital, Takara, Chiryu City, Aichi 472-0056, Japan.
*Corresponding author: Koun Yamauchi, koun_yamauchi@yahoo.co.jp


Here, we describe two consecutive patients with isolated, nondisplaced medial cuneiform fractures that occurred during running. Cuneiform fractures generally occurs along with other fractures of the midfoot, such as Lisfranc dislocation fractures, whereas the occurrence of isolated medial cuneiform fracture is rare. A total of only seven published case reports have been reported in the literature [1-5]. Nevertheless, an isolated, non-displaced fracture of the medial cuneiform may be easily suspected when the midfoot has been bruised by a direct, intense force, such as the impact of a traffic accident. However, it may be more difficult to suspect the fracture when being caused by indirect and acute force. Only one case report clearly describes the mechanism of isolated, nondisplaced medial cuneiform fracture being caused by indirect and acute force that occurred during dancing [4]. Therefore, the occurrence of isolated medial cuneiform fracture during running is extremely rare.

Case Report #1

A 25-year-old woman visited a hospital after hearing a cracking sound and feeling pain in her right midfoot during short-distance running at full speed in a park. Clinicians at the hospital diagnosed her injury as a sprain because they found no indications of fracture. Two days later, she visited our hospital with tenderness and swelling around the midfoot. However, radiograph of the midfoot showed no indications of a fracture (Figure 1), and we diagnosed her injury as a sprain.

Figure 1 Plain radiographs of the foot in first case. White arrows show cuneiform bone. (a) anterior–posterior image; (b) lateral–medial image; (c) oblique, lateral–medial image; and (d) oblique, medial–lateral image.

Five days later, she came for an examination; the tenderness and swelling around the midfoot persisted, although the spontaneous pain was gradually decreasing. We performed a computed tomography (CT) scan, which indicated an isolated, nondisplaced medial cuneiform fracture (Figure 2).

Figure 2 Computed tomography of the foot in the first patient. White arrows show fracture line. Dotted lines in axial image (a) show reference lines for coronal image (b) and sagittal image (c).

Her treatment included non weight-bearing (NWB) activity for two weeks without any immobilization. An arch support was applied on her right foot. Partial weight-bearing (PWB) activity was allowed from the fourth week after the injury, full weight-bearing (FWB) activity was allowed from the sixth week after the injury, and she was treated in rehabilitation from the fourth week to three months after the injury. At two months after injury, her hallux range of motion (ROM) recovered to the level of the contralateral side hallux ROM; however, swelling around the midfoot persisted but disappeared at three months after injury. We conducted a self-score, self-administered foot evaluation questionnaire (SAFE-Q) at two and three months after the injury [6]. The following were the scores at two and three months after injury, respectively: Pain scores: 54.1 and 76.4; activities of daily living (ADL) scores: 65.9 and 91.0; social functioning scores: 0.4 and 82.5; shoe-related scores: 41.7 and 91.7; and general health scores: 60 and 90.0 (Full score for each subscale was 100 points).

Case Report #2

A 35-year-old woman presented at our hospital with tenderness and swelling around the midfoot. She had felt sharp pain in her right midfoot as she dashed up an acute slope. Radiographs taken during first examination showed no indication of a fracture (Figure 3), but CT scan showed an isolated, nondisplaced medial cuneiform fracture (Figure 4). Furthermore, magnetic resonance imaging (MRI) showed an acute fracture of the medial cuneiform (Figure 5).

Figure 3 Plain radiographs of the foot in second patient. White arrows show cuneiform bone. (a) anterior–posterior image; (b) lateral–medial image; (c) oblique, lateral–medial image; and (d) oblique, medial–lateral image.

Figure 4 Computed tomography of the foot in the second patient. White arrows show fracture line. Dotted lines in axial image (a) show reference lines for coronal image (b) and sagittal image (c).

Figure 5 Magnetic resonance imaging (MRI) of the foot in the second patient. White arrows show fracture area in coronal images of T1-weighted image (a), T2-weighted image (b), and T2-weighted image with fat saturation sequence (c).

Her treatment included NWB activity for three weeks and immobilization with a soft-splint because of significant swelling. At three weeks after the injury, we started the same treatment strategy as that with the first patient. At two months after injury, her hallux ROM had recovered to the level of contralateral side hallux ROM, and swelling around the midfoot was no longer apparent. SAFE-Q scoring was conducted at 2, 3, and 8 months after injury. Following were the scores at 2, 3, and 8 months after injury, respectively: Pain scores: 76.7, 91.4, and 99.9; ADL scores: 75.0, 93.2, and 97.7; social functioning scores: 83.3, 82.4, and 100; shoe-related scores: 83.3, 58.3, and 91.7; and general health scores: 80, 90.0, and 100.

Discussion

Similar to earlier reports on diagnosis and treatment of an isolated, non-displaced medial cuneiform fracture [1-5], we were not able to diagnose the fracture in either of our patients based on the plain radiographs alone. All authors have reported that it was difficult to diagnose an isolated, non-displaced medial cuneiform fracture using plain radiographs and that CT and MRI were necessary to diagnose this fracture.

Observed tenderness and swelling around the medial cuneiform bone lead to suspicion of a fracture; this lead us to perform a CT scan or an MRI for confirming the presence of the fracture. An isolated, non-displaced fracture of the medial cuneiform may be easily suspected when the midfoot has been bruised by a direct, intense force, such as the impact of a traffic accident, whereas the stress fracture of this bone can be suspected when the feet of athletes are subjected to repetitive, physical loads. However, when the midfoot is subjected to indirect and acute one-time force, such as dancing or running, clinicians may not perform a CT scan or MRI because they generally do not suspect the occurrence of a fracture, thereby diagnosing the tenderness and swelling around the midfoot as a sprain and/or bruise. Therefore, our suspicion of the isolated, nondisplaced medial cuneiform fracture is noteworthy even when the patient’s midfoot has been subjected to indirect and acute one-time force during running. Although the bipartition of the medial cuneiform was not observed in both our patients, a clinician should suspect the presence of midfoot pain related to the bipartition of the medial cuneiform bone as a differential diagnosis. Steen et al [7] proposed that the bipartition of the medial cuneiform can be associated with midfoot pain following an acute injury.

As reported in the earlier reports, treatment for isolated, nondisplaced medial cuneiform fracture can be conservative [3, 5]. In both of our patients, CT scan taken at five weeks after injury exhibited bony union without complications, such as malunion or displacement. Although the patient’s hallux ROM showed recovery two months after injury, SAFE-Q scores remained unfavorable. In particular, SAFE-Q scores of the first patient were worse, which could have resulted from persistent swelling around her midfoot. At three months after injury, the SAFE-Q scores were better in both patients, except the shoe-related scores of the second patient. We were not able to ascertain any causes for the low shoe-related scores in the second patient. At eight months after injury, the SAFE-Q scores were almost full scores in the second patient, while the SAFE-Q scores were not conducted in the first patient.

Interestingly, CT scan exhibited a similar fracture type in both patients: dorsal and plantar bone fragment with avulsion fracture of the lateral–distal–plantar cortex. Because the fractures in both patients included joint surfaces (navicular–cuneiform joint and cuneiform–metatarsal joint), bone fragment displacement was contraindicated. Therefore, surgery using embedded screws may be an appropriate treatment option for fixation of dorsal and plantar bone fragments. Surgery, such as definitive fixation, is likely to maintain non-displacement until bony union is achieved. Definitive fixation is particularly appropriate for athletes because it enables early and successful recovery (because athletes are able to actively return to their respective sports sooner) compared to conservative treatment. We strongly suggest that more study is needed to assess the effect of surgical treatment options on recovery after isolated, nondisplaced medial cuneiform fracture.

Conclusion

Isolated medial cuneiform fracture can be induced by an indirect force while running and should be diagnosed by CT and MRI.

Acknowledgements

Ethical approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent:  Informed consent was obtained from all individual participants included in the study.

Funding declaration and Conflict of Interest:  This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. There are no conflicts of interest to declare.

Reference

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Spring 2017


Issue 10 (1), 2017


Small-vessel vasculitis: A review and case report
by Kinna A. Patel, DPM


Retained foreign body in the foot presenting as tenosynovitis of the flexor digitorum longus tendon
by Muhammad Haseeb, Muhammad Farooq Butt, Khurshid Ahmad Bhat


Clinical clearing of moderate and severe onychomycosis with the Nd:YAG 1064nm laser and post treatment prevention with tolnaftate
by Myron A. Bodman DPM, Marie Mantini Blazer DPM, Bryan D. Caldwell DPM, Rachel E. Johnson DPM


Raynaud’s-like symptoms induced by prescription medication
by Robert L. van Brederode, DPM, FACFAS


Temporary bridge plating of the medial column in Chopart and Lisfranc injuries
by Alaa Mansour DPM, Lawrence Fallat DPM, FACFAS


A unique presentation of recurrent cavus foot of an adolescent patient with Marfan syndrome: A case report
by Kaitlyn L. Ward DPM, Philip R. Yearian DPM, FACFAS


Letter to the Editor – Response
by Edward S Glaser and David Fleming