Midfoot Injuries Research Articles

The missed chapter on midfoot: Chopart injuries.

Midtarsal injuries are often missed at initial presentation which may lead to long-term complications. Nonetheless, radiographs (XR) are used as a primary imaging method. The place of cone beam computer tomography (CBCT) remains unclear in the management of midfoot injuries. The aim of this study was to update imaging findings on traumatic ankle and foot injuries (TAAFI) with CBCT and to assess the sensitivity, specificity and accuracy of XR compared to CBCT for midfoot injuries detections. All CBCT studies performed due to (TAAFI) that had previous XR were collected for a period of 5years. They were retrospectively anonymized and analyzed by a radiologist. A second blinded study of XR was made by a second radiologist as a control. A total of 754 cases were included. Lisfranc and Chopart injuries were detected in 153 (20.2%) and 154 (20.4%) patients, respectively. Lisfranc and Chopart's lesions combined together were seen in 33 cases (10.7%). A blinded retrospective analysis of XR compared to CBCT shows a sensitivity of 64.9% (56.8-72.4%; 95% CI), a specificity of 95.0% (92.9-96.6%; 95% CI) and an accuracy of 88.9% (86.4-91.0%; 95% CI) for Chopart's injuries. Regarding Lisfranc, the sensitivity was 62.1% (53.9-69.8%; 95% CI), specificity 99.0% (97.8-99.6%; 95% CI) and accuracy 91.5% (89.3-93.4%; 95% CI). This cohort study highlights the missed injuries of Chopart on XR and the low association with Lisfranc avulsions. The use of CBCT helps in detecting and assessing midfoot injury.

LATERAL COLUMN MIDFOOT INJURY: DO THEY ALL NEED FIXATION?

BackgroundResearch on midfoot injuries have primarily concentrated on the central column and the Lisfranc ligament without amassing evidence on lateral column injuries. Lateral column injuries have historically been treated with Kirschner wire fixation when encountered.ObjectiveOur aim in this study was to analyse lateral column injuries to the midfoot, their method of treatment and the radiological lateral column outcomes. Our nul hypothesis being that fixation is required to obtain and maintain lateral column alignment.MethodsData was retrospectively collected from four centres on surgically treated midfoot fracture dislocations between 2011 and 2021. Radiographs were analysed using departmental PACS. All statistics was performed using SPSS 26.ResultsA total of 235 cases were diagnosed as having a lateral column injury out of the 409 cases included. On cross tabulation, there was a significant association with having a central column injury (234/235, p<.001) and 70% of cases (166/235) also had an additional medial column injury. Of the 235 lateral column injuries, data was available regarding fixation radiographic alignment on 222 cases. There were 44 cases which underwent Kirschner wire fixation, 23 plate fixations and 3 screw fixations. Lateral column alignment loss was seen in 2.84% (4/141) of those which didn't undergo fixation, 13.64% (6/44) which underwent K wires, and 0 % in those fixed by screws or K wires.ConclusionLateral column injury occurs in over half of midfoot fractures in this study. It rarely occurs alone and is most commonly related to three column injuries. Nevertheless, following stabilisation of the central column, additional fixation of injuries to the lateral column do not appear beneficial. The use of a bridge plate to fix the central column appears protective and purely ligamentous injury was a higher risk than an injury that included the bone.

Reappraisal of the Use of X-Rays in Acute Ankle and Midfoot Injuries. A Prospective Evaluation of the Ottawa Ankle Rules (OAR) in a Single Tertiary Trauma Centre

INTRODUCTION: Acute ankle and foot injuries commonly present to the emergency departments, often resulting in routine radiography referrals, despite the fact that less than 15% of cases exhibit clinically significant fractures. The OAR has been designed to reduce the number of unnecessary radiographs ordered for these patients. We evaluated the OAR for predicting ankle and midfoot fractures in a cohort of patients treated in a single tertiary trauma centre. MATERIALS AND METHOD: A prospective study was conducted in the emergency department and orthopaedic clinics of a tertiary trauma centre. 73 patients aged 18 years and older were recruited during a 12-month study period. Radiographs were performed for all patients after clinical evaluation findings were recorded. The main outcomes measured were sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratios (positive and negative) of the OAR. RESULTS: 41 patients had ankle injuries, 21 around the midfoot, and 11 within both areas. In detecting ankle fractures, OAR had a sensitivity of 100%, a specificity of 73.68%, and a negative predictive value of 100% compared to the detection of midfoot fractures (100%, 84.61%, and 100%, respectively). The OAR had the potential of reducing radiographs by 42.47%. CONCLUSION: OAR is an accurate and highly sensitive tool to detect ankle and midfoot fractures. The implementation would lead to a significant reduction in the request for radiographs without missing any clinically significant fractures, thus, reducing costs, radiation exposures, and waiting times.

A Rare Midfoot Injury Case Report: Complete Dislocation of the Navicular With Dislocation of the Cuboid

Injuries of the midfoot are rare and they usually occur as a result of high-energy trauma. The navicular and cuboid, bones that belong to the midfoot, are fundamental structures in stabilizing the medial and lateral columns of the foot respectively, so they require an adequate treatment. We present a 26-year-old man with a complete tarsal navicular bone dislocation without associated navicular fracture, and a complete cuboid dislocation after sustaining a 4 meters fall, it was also accompanied by fracture of the lateral cuneiform and the base of the fourth metatarsal. The patient was treated successfully with open reduction and fixation with screw and Kirschner wires. At 18 months follow-up, we considered the patient’s outcome was good obtaining 90 (90/100) points in American Orthopedic Foot and Ankle Society Midfoot Score. Level of Evidence: Diagnostic Level V.

Lisfranc injuries in athletes: a review

Lisfranc injuries remain one of the most potentially debilitating foot injuries, often resulting in long-term chronic pain, arthritis and a delayed return to work. About 20% of injuries sustained by athletes are in the foot, with midfoot injuries being the second most common type. About 3.5% of severe injuries in this category are career ending. Male athletes have a higher incidence of severe injuries, twice more likely needing surgery and three times more likely to end their career early. Female athletes have a high incidence of stress injuries due to the known ‘female athletic triad’ contributing to it. Low-energy injuries are often treated non-operatively. Severe injuries need operative management as well as metalwork removal in most cases later. The importance of early recognition, correct classification, whether to manage non-operatively and the postoperative rehabilitation are the key components of a chance to a good recovery and possible return to sports in athletes. As the diagnosis is similar for both athletes and non-athletes, this review will summarize the relatively little evidence on the epidemiology, management and outcomes for Lisfranc injuries in athletes.

The Accuracy of 3D Measurements in Weightbearing Computed Tomography to Diagnose Lisfranc Instability

Category: Midfoot/Forefoot; Other Introduction/Purpose: Up to one-third of Lisfranc injuries are missed on initial evaluation, resulting in significant morbidity. Prompt diagnosis of Lisfranc injuries is, therefore, critical in optimizing outcomes, and yet there remains a lack of consensus on diagnostic criteria to identify Lisfranc instability using anatomic measurements. Prior studies have underscored the utility of weight-bearing computed tomography (WBCT) in diagnosing Lisfranc instability, which allows for bilateral three-dimensional (3D) evaluation under physiologic load. The aim of this study was to quantify appropriate cutoff values using 3D anatomic measurements of Lisfranc instability under physiologic load and as compared to the uninjured extremity. Methods: A total of 234 adult patients with bilateral WBCT scans of the foot were included: 43 patients with Lisfranc instability & 191 patients without a history of midfoot injuries. Lisfranc instability was confirmed intraoperatively or by clinical evaluation by the surgeon. Patients with prior midfoot surgery, Charcot arthropathy, severe midfoot arthropathy, or significantly displaced fracture of the cuneiforms or 1st, 2nd, or 3rd metatarsal bases were excluded. Lisfranc joint measurements were conducted bilaterally, including C1-M2 diastasis, C1-M2 area and 3D WBCT volume. Patient demographics were collected. Descriptive statistics were calculated for quantitative variables. Percent difference as compared to the contralateral side was calculated for volume, area, and diastasis. Mann Whitney U tests were utilized to determine differences in measurements between patients in the Lisfranc cohort and patients in the uninjured cohort (p-value < 0.05). Diagnostic cutoffs for Lisfranc instability were determined with minimum distance to the corner analysis on ROC curves. Results: The distribution of patients with Lisfranc instability was 58% female with an average age of 38.5±17.6 years. Of the Lisfranc injuries, 36% were purely ligamentous, 18% demonstrated an avulsion injury, and 43% involved a metatarsal base fracture. In the Lisfranc cohort, the median percent difference between injured and uninjured feet was 28.2% (IQR: 20.9%) for volume, 36.3% (IQR: 31.1%) for C1-M2 area, and 40.0% (IQR: 23.3%) for C1-M2 diastasis. Mann-Whitney testing was significant for percent difference between left and right feet for Lisfranc patients versus patients with an uninjured midfoot (p < 0.001). The area under the curve and associated diagnostic cutoffs for Lisfranc instability, were 0.81 and 18% for volume, 0.84 and 20% for area, and 0.91 and 28% for diastasis (Figure 1). Conclusion: Diastasis (1D), area (2D), and volume (3D) measurements are effective measurements to diagnose Lisfranc instability on WBCT. With current diagnostic algorithms, however, 1D measurements afford superior diagnostic sensitivity as compared to 2D and 3D measurements when using WBCT, suggesting Lisfranc instability may be best appreciated in the axial plane. Additional studies are necessary to expand the sample population to assess for corroboration with the current results, especially for subtle Lisfranc instability.

3D Weightbearing CT for the Diagnosis of Lisfranc Instability: An Update

Category: Midfoot/Forefoot; Other Introduction/Purpose: Lisfranc instability is often a challenging injury to diagnose, with up to one-third being missed on initial evaluation. Lisfranc instability is assessed by widening of the space between the second metatarsal base and the medial cuneiform. This space is visualized on X-Ray; however, in subtle Lisfranc instability cases computed tomography (CT) imaging is often obtained. Given the 1D nature of diastasis measurement, X-ray should be an adequate means of evaluating this widening, yet clinical practice suggests weightbearing CT (WBCT) is more sensitive. This suggests the 3D location of the diastasis measurement is crucial. This study aimed to first compare weight-bearing X-ray and WBCT diastasis and area measurements of the Lisfranc complex, and second to compare WBCT diastasis measurements at various locations in the coronal plane. Methods: A total of 90 patients with both weight-bearing foot X-ray and bilateral foot WBCT were included: 37 patients had confirmed Lisfranc instability, and 53 patients had no history of midfoot injury. Lisfranc instability was confirmed intraoperatively or by clinical examination performed by the surgeon. For all 90 patients, the interosseous diastasis and area between the medial cortex of the second metatarsal and the lateral cortex of the medial cuneiform were measured on both weightbearing X-ray and axial slices of WBCT. For a subset of patients (12 in each cohort) the diastasis between second metatarsal and medial cuneiform was measured at 4 distinct axial locations using coronal slices of the WBCT (Figure 1). Results: A Wilcoxon test comparison of diastasis and area measurements on weightbearing X-ray and axial slices of WBCT revealed a significant difference in the weightbearing X-ray and WBCT measurements (p < 0.001) for both the control and Lisfranc cohorts. A comparison of weightbearing X-ray diastasis to dorsal, interosseous, and plantar diastasis measurements on coronal slices using Kruskal Willis analysis for the control cohort revealed a significant difference in all three measurements (Figure 1, p-values listed). Kruskal Willis analysis of the Lisfranc cohort demonstrated a significant difference between the X-ray diastasis and the plantar WBCT diastasis (p=0.01), but no difference from interosseous (p=0.08) or dorsal (p=0.33) diastases. A comparison of the axial WBCT diastasis measurements compared to the three coronal diastasis measurements revealed no difference in either cohort. Conclusion: Our results showed that for assessing the Lisfranc joint in subtle cases and healthy individuals, WBCT remains the most accurate imaging tool. However, in patients with confirmed Lisfranc instability, X-ray measurements are more reliable if the instability is at the dorsal and interosseous levels and not the plantar level. Hence, to assess the Lisfranc joint at different levels, WBCT has superiority over X-ray. Additionally, the axial diastasis of the Lisfranc joint on WBCT seems similar to coronal diastasis rendering both views reliable for measurements.

Talonavicular Dislocations: A Bad Actor Made Worse Without Sufficient Fixation

Category: Trauma; Midfoot/Forefoot Introduction/Purpose: The talonavicular joint (TNJ) is critical to midfoot architecture, and traumatic disruptions of this joint threaten the midfoot arch. We sought to better elucidate injuries to the TNJ and understand if transient methods of stabilization after TN dislocations (TNDs), such as closed/open reduction with or without percutaneous pinning resulted in different radiographic and clinical outcomes when compared to more permanent methods such as bridge plating or primary arthrodesis of the TNJ. Methods: We retrospectively identified skeletally mature patients from one tertiary level 1 trauma center treated for midfoot injuries between 2002-2022. Patients with isolated or concomitant TNDs were included. Demographics, treatment, radiographic outcomes, and patient reported outcomes (PROs) were recorded. Patients who underwent temporary fixation methods (closed/open reduction and trans-articular pinning with k-wire removal at 6-8 weeks) were compared to those with permanent fixation (bridge plating or primary arthrodesis). Primary outcome was reoperation, including fusions and amputations. Secondary outcomes were radiographic arch measurements (Meary’s angle [MA], calcaneal inclination angle [CIA]) and PROMIS measures of physical function, pain interference, and anxiety. Sixty-two patients and 66 feet were included (Table 1). Average follow up was 2 years. Results: TNDs manifested as both pure dislocations (18) and in conjunction with associated injuries: chopart dislocations (5), talar head/body fractures (23), navicular fractures (35), and subtalar dislocations (25). Twelve were a part of Hawkins IV talar neck fracture dislocations (18%). Forty-two patients were treated with temporary fixation (64%). Injuries treated with transient fixation had higher mean change in MA from immediately postop to final follow-up (-7.9° v -1.1°, p=0.006). They also exhibited significantly different MA and CIA values at final follow-up (7.8° v -1.4°; 17.3° v 21.3°, p< 0.03). Nearly two thirds required reoperation; 32% underwent fusion and 7% required amputation. Fixation method had no significant association with PROMIS scores, but those with temporary fixation methods trended toward lower final PF scores (34.9 v 41.1, p=0.11). Conclusion: TNDs are generally the result of high energy mechanisms, often occurring in combination with other significant mid/hindfoot injuries. Reduction and fixation method of these injuries should be carefully considered to avoid potential ramifications of loss of normal arch and midfoot sag.

Don't Miss Me: Midfoot Sprains, A Point-of-Care Review.

Athletes practicing high-contact sports are exposed to an increased risk of midfoot injuries, namely midtarsal sprains. The complexity of reaching an accurate diagnosis is clearly depicted in the reported incidence of midtarsal sprains, ranging from 5% to 33% of ankle inversion injuries. Because the focus of the treating physician and physical therapist is on lateral stabilizing structures, midtarsal sprains are missed at initial evaluation in up to 41% of patients, with delayed treatment as a result.Detecting acute midtarsal sprains requires a high degree of clinical awareness. Radiologists must become familiar with the characteristic imaging findings of normal and pathologic midfoot anatomy to avoid adverse outcomes such as pain and instability. In this article we describe Chopart joint anatomy, mechanisms of midtarsal sprains, clinical importance, and key imaging findings with a focus on magnetic resonance imaging. A team effort is essential to provide optimal care for the injured athlete.

“E-sign” in imaging: Debunking congenital bipartite from isolated medial cuneiform fracture

Bipartite medial cuneiform is a rare congenital normal variant at the Lisfranc joint that is a potential trap for isolated medial cuneiform fracture or midfoot injury

Pattern of Injury in Polytrauma Compared to Single Limb Related Midfoot Fractures

Category: Trauma; Midfoot/Forefoot Introduction/Purpose: Midfoot fractures in polytrauma patients are often an under appreciated injury relative to their other major injuries sustained. In this study, our aim was to explore the mechanisms and patterns of injury in a polytrauma related midfoot fractures as compared to single limb injuries. Methods: Setting: Multicentre observational study Methods: Data was retrospectively collected from three centres on surgically treated midfoot fracture dislocations between 2011 and 2021. Radiographs were analysed using departmental PACS. All statistics was performed using SPSS 26. Results: A total of 212 cases were included in the study. Almost all polytrauma cases had occurred as the result of a fall from height or road traffic collision (RTC) (19/20). In single limb injuries, 32% (61/192) had also occurred as the result of fall from height or RTC. The most common mechanism for single limb midfoot fracture was a trip (79/192). Crush injuries only occurred in the single limb injury group in our cohort (n=21). Regarding patterns of injury, there was no significant difference in prevalence of medial column injury (p=.260), or central column injury (p=.704). There were significantly more lateral column injuries in the polytrauma group (75% vs 44%, p=.008), and the polytrauma group was exclusively fracture related compared to 17% of single limb injury having purely ligamentous injury (p=.047). Conclusion: Polytrauma related midfoot injuries have a higher prevalence of lateral column injury than the single limb injuries. Single limb injuries can however, have an equally significant force involved as polytrauma patients with over 50% occurring as the result of high velocity injury. A high index of suspicion should be maintained for midfoot injuries in high velocity mechanisms, regardless of other injuries sustained.

Lateral Column Midfoot Injury: Do They All Need Fixation?

Category: Trauma; Midfoot/Forefoot Introduction/Purpose: Research on midfoot injuries have primarily concentrated on the central column and the Lisfranc ligament without amassing evidence on lateral column injuries. Lateral column injuries have historically been treated with Kirschner wire fixation when encountered. Our aim in this study was to analyse lateral column injuries to the midfoot and their treatment. Methods: Setting: Multicentre observational study Methods: Data was retrospectively collected from three centres on surgically treated midfoot fracture dislocations between 2011 and 2021. Radiographs were analysed using departmental PACS. All statistics was performed using SPSS 26. Results: A total of 113 cases were diagnosed as having a lateral column injury out of the 242 cases included. On cross tabulation, there was a significant association with having a central column injury (112/113, p<.001) and 70% of cases also had an additional medial column injury. Of the 113 lateral column injuries which underwent fixation of the central column, only 13 had undergone Kirschner wire fixation of the lateral column. There were no reported loss of lateral column alignment in either the temporary fixation or no fixation groups in this study. Conclusion: Lateral column injury occurs in almost half of midfoot fractures in this study. It rarely occurs alone and is most commonly related to three column injuries. Nevertheless, following stabilisation of the central column, injuries to the lateral column are unlikely to require any further stabilisation with no reported loss of alignment in our study without lateral column fixation.

The Occurrence Parallelism of the 1st and 2nd Ray in Mid Foot Fracture Dislocations. A Review of 234 Cases

Category: Trauma Introduction/Purpose: The parallel nature of the 1st and 2nd metatarsal has been reported in Lisfranc type injuries to the midfoot, reportedly the result of the lateral and dorsal subluxation of the 2nd metatarsal base. In this study, our aim was to explore the prevalence of parallelism in midfoot injuries and the associated features. Methods: Setting: Multicentre observational study Methods: Data was retrospectively collected from three centres on surgically treated midfoot fracture dislocations between 2011 and 2021. Radiographs were analysed using departmental PACS. Parallelism was defined as a 1/2 intermetatarsal angle of less than 6. All statistics was performed using SPSS 26. Results: A total of 234 cases were included in the study. All 234 had undergone non-weightbearing (NWB) radiographs, with 80 patients who had also undergone (WB) weightbearing radiographs. The prevalence of parallelism was 21.3% (17/80) in the WB radiographs and 20.1% (47/234) in the NWB radiographs. The average IMA in the non-parallel group was 9.45 (95% CI 9.12,9.77) and 4.18 (95% CI 3.78, 4.57) in the parallel group. Concomitant lateral column injury was the only factor with a significant association with parallelism (p=.015). Other factors such as bone or ligamentous injury (p=.657), medial column injury (p=.085) and central column injury (p=.323) did not have a significant association. Conclusion: Parallelism in midfoot fracture dislocations occurs in approximately 20% of cases. If present, a high index of suspicion to the presence of a lateral column injury should be maintained due to its significant association.

Tarsometatarsal Joint Preparation using a Modified Dorsal Approach vs Standard Approach: A Cadaver Study

Category: Midfoot/Forefoot Introduction/Purpose: Lisfranc injuries are a relatively common midfoot injury involving the tarsometatarsal (TMT) joint. Surgical fixation typically involves open reduction with internal fixation or primary arthrodesis of the joint(s). The standard surgical approach to the TMT joint involves two dorsal incisions however, a recent study has suggested the use of a modified single dorsal incision approach. The goal of this paper is to compare the total surface area of the joint that can be prepared for primary arthrodesis of the TMT using the standard vs modified single dorsal approach. Methods: Ten fresh frozen below-the-knee cadaver specimens were randomly assigned to receive either the standard or modified dorsal single incision operative approach to the TMT joint. Prior to initiating the study, specimens were inspected with fluoroscopic radiographs for preexisting pathology or prior surgical intervention. The joint surface was visualized and then underwent articular preparation as for a joint fusion. After adequate joint preparation, the TMT joint was disarticulated and the surface was photographed for image analysis. Using ImageJ, articular joint surface preparation areas were measured by two blinded reviewers. to assess the joint surface preparation and this was compared by surgical approach. Results: After ImageJ and Mann-Whitney U statistical analysis, there was no significant difference in the amount of joint prepared when comparing the standard versus modified dorsal approach for the first three TMT joints (p= 0.548, p=0.310, p= 0.548). The percentage of joint preparation utilizing the standard dorsal approach versus the modified dorsal approach for TMT joints one through three are as follows (percentages utilized are listed as the median value with its correlating range): First TMT- 67.6% (range 26%) by the standard approach versus 71.7% (range 9%) by the modified dorsal approach, second TMT- 67.9% (range 24%) versus 65.7% (range 12%), and third TMT- 65.9% (range 42%) versus 59.6% (range 24%). Table 1 summarizes our results between each operative approach. Conclusion: With our findings, we demonstrate that a modified single dorsal approach to the Lisfranc joint provided comparable joint preparation for primary arthrodesis as the standard dual incision approach. However, the modified dorsal approach may be beneficial in that it avoids creating a skin bridge which has potential for necrosis with the standard two incision approach. The authors believe the comparable joint preparation combined with its potential to alleviate soft tissue complications make the modified dorsal approach a viable surgical approach for a TMT arthrodesis.

Defining Operative Indications in Lisfranc Injuries

Category: Trauma; Midfoot/Forefoot Introduction/Purpose: Injuries to the midfoot, especially subtle, primarily ligamentous ones, have historically been under- recognized. The literature surrounding midfoot injuries has also evolved as understanding has improved. Earlier studies focused on non-subtle midfoot dislocations and fracture dislocations, injuries in which the need for operative intervention was perhaps obvious. However, in more subtle injuries, there is some lack of clarity amongst orthopaedic surgeons as to what constitutes an operative indication. The purpose of this study was to perform a literature review of Lisfranc injuries to answer the simple question of what the operative indication was in the given study. Methods: A literature search [MEDLINE (PubMed), EMBASE, Google Scholar, and Cochrane databases] was performed to identify studies on Lisfranc injuries. Given that the purpose was to assess surgical indications for Lisfranc injuries, all studies that included a surgical indication for Lisfranc injuries, including case reports and review articles, were included. Studies that were not relevant to that question (i.e. biomechanical studies, anatomic studies, etc.) were excluded. PRISMA guidelines were followed where applicable, although since this study did not involve the synthesis of outcome data, some aspects were not relevant. Studies were classified as having no operative indication, a vague operative indication, or an explicit operative indication. A vague operative indication is one that referenced displacement or instability without explicitly defining those terms, i.e. displacement between which bones (M1-M2, C1-M2, or otherwise) and to what degree (any displacement, >1mm, >2mm, or otherwise) with or without stress exam. Results: 737 studies were identified with the search term 'Lisfranc injury.' After review of the titles, 389 were felt to be potentially relevant to the question at hand. The papers were then reviewed to establish whether the indication for surgery was explicitly stated. We were unable to access 31 of these studies, and a further 51 were felt not to be relevant, leaving 307 studies that were assessed. 63.2% of these studies (194/307) did not give any specific indication for surgery. While 113 studies did give an indication for surgery, 59.3% of these studies (67/113) gave only a vague indication for surgery. Only 15.0% of studies assessed (46/307) had a clear, explicit operative indication. Conclusion: It is a basic tenet of any surgical discipline that one must understand what does and does not require surgery. The answering of this question perhaps becomes more difficult when the pathology is subtle and difficult to define. However, establishing clear guidelines is a necessity in this setting. There appears to be a relative lack of clear and explicit operative indications in the literature with respect to Lisfranc injuries. Surgeons and authors should be clear and consistent about which injuries require surgery; as we move forward, better outcome data will allow us to refine our indications.

Reconstruction of large midfoot bone loss using titanium spinal mesh cage with bone graft: A case report

High energy trauma injuries in the lower extremity represent unique challenges to surgeons and often involve complex, limb threatening wounds with extensive soft tissue and bone loss. In this case report, we present a case of a 20 year old male who was presented to us with a history of 8 months old high impetus road traffic trauma which resulted in multiple open fracture of the midfoot with ipsilateral closed tibial - fibular shaft and medial malleolar fracture. Open midfoot injury with severe bone loss included complete loss of navicular, all three cuneiforms, base of 1st and 2nd metatarsals. For reconstructing this severe midfoot defect, we have utilized a titanium mesh cage which is routinely used in spinal surgeries. This innovative technique and orthoplastic approach has given the patient a stable plantigrade foot with a near normal midfoot biomechanics and ultimately, restoration of this patient's quality of life.

Reliability of ‘Ottawa Ankle Rules’ in Acute Ankle and Midfoot Injuries

INTRODUCTIONThe Ottawa ankle rules (OARs) are clinical decision guidelines used to identify whether patients with ankle injuries need to undergo radiography. The OARs have been proven that their application reduces unnecessary radiography. MATERIAL & METHODSThis prospective study was conducted at Sumeru City Hospital, Lalitpur in the Department of Emergency and Outpatient Department of Orthopaedics. Thirty-six patients were included in the study. Twenty-five patients were in ankle group and 11 patients were in midfoot group. All patients were sent for X-rays after evaluating them according to OARs. RESULTS Among 36 cases, 8 clinically significant fractures were found. Sensitivity of OARs for detecting fractures was 100 % for both ankle and midfoot group. Specificity of OARs for detecting fractures were 47.36 % for ankle group and 66.67 % for midfoot group. Negative predictive value of OARs was 100 %. CONCLUSIONOARs are very accurate and highly sensitive tools for detecting fractures in acute ankle and midfoot injuries. Implementation of these rules would lead to significant reduction in the number of radiographs and thereby reduce the cost of the treatment, radiation exposure and waiting time of patients at hospital.

The First Tarsometatarsal Joint in Lisfranc Injuries.

Lisfranc injuries are among the most debilitating injuries to the foot. Characterization of first tarsometatarsal (TMT) joint involvement in Lisfranc injuries is limited. Multiple studies have indicated that this joint is damaged in a variety of Lisfranc injury patterns, but there is sparse information regarding how often and in what form. A retrospective review was performed of operative Lisfranc fractures from 2010 to 2020 with patients identified by Combined Procedural Terminology codes. Hardcastle and Myerson Lisfranc injury classifications and computed tomography and radiograph characterizations of the first TMT joint were evaluated by 3 foot and ankle fellowship-trained orthopaedic surgeons. Radiographic characteristics were collected. Light's kappa coefficient evaluated interrater reliability for injury classification. Injury mechanism and Lisfranc classification effects on the first TMT joint were further assessed using inferential statistics. Of 71 patients with a Lisfranc injury of which 37 (52%) were high energy, 61 (86%) showed radiographic evidence of first TMT joint injury. A fragment was present in the TMT articular surface in 33 (47%) with median size = 8.7 mm and medial capsular avulsion in n = 25 (35%). Forty-eight patients (68%) had medial/lateral TMT joint incongruence ≥2 mm (median overhang = 4 mm), 21 (30%) had dorsal/plantar incongruence (median overhang = 6 mm). Angulation of TMT articular surfaces ≥5 degrees on the transverse/anteroposterior plane occurred in n = 32 (45%) and in n = 12 (17%) on the sagittal/lateral plane, which significantly differed between classifications (P = .020). The overwhelming majority of Lisfranc midfoot injuries seen at our tertiary referral center had imaging evidence of damage to the first TMT joint (86%), and the incidence may be higher. The most common patterns of first TMT joint involvement we found were joint incongruity, articular surface fractures, angulation of the articular surfaces, and medial capsular ligament avulsion fractures. A better understanding of injuries to the first TMT joint can help orthopaedic surgeons with diagnosis.

Can Weightbearing Cone-beam CT Reliably Differentiate Between Stable and Unstable Syndesmotic Ankle Injuries? A Systematic Review and Meta-analysis.

Ankle injuries are common presentations to the emergency department and may lead to syndesmotic instability. These have a high socioeconomic burden due to prolonged rehabilitation, chronic pain, and posttraumatic arthritis. Early diagnosis is essential to minimize these complications, and the assessment of instability in the clinical setting is often limited by pain and clinician experience. Cross-sectional imaging of the distal syndesmosis accurately evaluates the syndesmosis through abnormal bony relationships, which in the presence of instability, worsens during physiological loading. Cone-beam CT (CBCT) has gained popularity in the diagnosis of these injuries because it enables syndesmotic assessment under weightbearing conditions, it mitigates the high radiation dose, and it is time-efficient. The purposes of this systematic review were: (1) to establish normal values for weightbearing CBCT of the syndesmosis in uninjured ankles and ascertain interobserver reliability and (2) to identify the impact of weightbearing on the syndesmosis in patients with occult ankle injuries and assess the effect of patient demographics on these metrics. This systematic review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and registered in PROSPERO (ID CRD42021248623). MEDLINE, PubMed, Embase, and Emcare databases were searched for studies assessing for syndesmotic instability, of which 307 studies were screened and 11 studies with 559 ankles in 408 uninjured patients and 151 patients with syndesmotic instability were included. All patients 18 years of age or older presenting with unilateral ankle injuries who underwent weightbearing CBCT for the diagnosis of an occult fracture or syndesmotic instability compared with the uninjured contralateral side were included. A control group of uninjured ankles was identified during weightbearing CBCT performed for other indications such as forefoot or midfoot injuries. Methodological assessment of the studies was performed using the Risk of Bias In Non-randomized Studies (ROBINS-1) tool and most included studies had a low risk of bias. Thus, a random-effects restricted maximum likelihood ratio model was used. In the uninjured ankle, the mean area of the tibiofibular syndesmosis was 112.5 ± 7.1 mm 2 , which increased to 157.5 ± 9.6 mm 2 after injury when compared with uninjured ankles with a standardized mean difference of 29.5 (95% confidence interval 19.5 to 39.5; p < 0.01), and an excellent interobserver agreement (κ = 1.0 [95% CI 0.9 to 1.0]). However, syndesmosis volume decreased with age (β = -0.76; p = 0.04), and therefore, has a negative association with increasing age. Our study has shown that the syndesmotic area is the most reliable parameter in the assessment of syndesmotic injuries because it increases in the presence of instability during weightbearing status. It is a composite measurement that could potentially allow clinicians to use weightbearing CBCT as an adjunct when there is a clinical suspicion of syndesmotic instability. Thus, weightbearing CBCT has the potential of being diagnostic of syndesmotic instability and should be evaluated against current radiological modalities to evaluate its accuracy. Level IV, prognostic study.

Coronal Hindfoot Alignment in Midfoot Charcot Neuroarthropathy

Coronal plane hindfoot malalignment produces abnormal compensatory forces within the midfoot and forefoot. The primary aim of this study is to compare radiographic hindfoot alignment in patients with a midfoot Charcot event, and identify patterns associated with breakdown. A retrospective review of 43 patients (48 limbs) with midfoot Charcot neuroarthropathy were compared between the coronal hindfoot alignments and Charcot joint involvement. Coronal hindfoot alignment was classified as neutral (n = 15), valgus (n = 16), and varus (n = 17) utilizing the Saltzman hindfoot alignment radiograph. Charcot joint breakdown was classified as isolated tarsometatarsal joint (n = 8), combination of tarsometatarsal and naviculocuneiform joints (n = 22), and midtarsal joints including talonavicular and calcaneocuboid joints (n = 18). Patients exhibiting varus hindfoot alignment had 5.8 times greater risk of breakdown at the tarsometatarsal and naviculocuneiform joints (odds ratio 5.8, 95% confidence interval 1.7-22.9, p < .01). Hindfoot varus induces external rotation of the talus, resulting in compensation through the naviculocuneiform and tarsometatarsal joint, which correlates with our findings of a 6-fold increase in naviculocuneiform and tarsometatarsal joint collapse. Patients exhibiting valgus hindfoot alignment had 27 times greater risk of breakdown at the midtarsal joint (odds ratio 27.0; 95% confidence interval 5.6-207.0, p < .01). Hindfoot valgus induces internal rotation of the talonavicular joint, which correlates with our findings of a 27-fold increase in midtarsal joint breakdown. Varus and valgus hindfoot alignment are associated with different midfoot injury patterns, which may have implications in surgical management and allow for focused surveillance in neuropathic patients presenting with early-stage clinical findings consistent with Charcot neuroarthropathy.