Talonavicular Joint Research Articles

Talar Head Coverage Correction in the Absence of Lateral Column Lengthening: A Prospective Study with Calcaneal Osteotomy and First Ray Procedures

Category: Hindfoot; Midfoot/Forefoot; Other Introduction/Purpose: Peritalar subluxation (PTS) is a crucial feature of Progressive Collapsing Foot Deformity (PCFD). Surrounding structures assume distinct behaviors, contributing to different disease deformities (classes). One of its most traditional aspects is the midfoot abduction (class B), usually noted by a lateral deviation of distal structures at the talonavicular joint. This finding commonly leads surgeons to perform a lateral column lengthening osteotomy for abduction correction, a complex surgery with potential complications. The first ray's ability to reestablish the tripod and restore the hindfoot by derotating structures under the talus was previously theorized. This study aimed to test the capability of the Lapidus and the Cotton procedures in conjunction with a calcaneus displacement osteotomy (MDCO) to improve midfoot abduction in the setting of a collapsed foot. Methods: In this IRB-approved, prospective cohort study, we analyzed patients undergoing medial column instability surgery and evaluated preoperatively with a weight-bearing CT (WBCT). We included individuals receiving a Lapidus bone block procedure or a Cotton for PCFD or Hallux Valgus (HV). Patients having a lateral column lengthening procedure of any type were excluded. Talonavicular coverage angle (TNCA) was measured as a marker of midfoot abduction. Medial arch collapse and forefoot varus were evaluated by the sagittal talus-first metatarsal angle (TFMA), and the forefoot arch angle (FFA) was measured. Associated procedures and the correction amount (displacement or wedge size) were recorded. Normality was estimated by the Shapiro- Wilk test and comparison among timelines by the one-way ANOVA. A multivariate regression analysis was executed to evaluate which of the measurements influenced abduction improvement. Statistical significance was considered for p-values of less than 0.05. Results: A total of 20 patients (age: 43.85 [19-72], BMI 30.98 [SD: 5.95]) were included, 11 PCFD (55%) and 9 HV (45%) with a mean follow-up of 7.5 months (3-12). Bone block Lapidus was performed in most subjects (90%), and the median wedge used was 9mm (5-12mm). MDCO occurred in 55% of patients. All measured variables had improvement with surgery (TNCA: 23.74 to 10.66, p<0.0001; FFA: 6.27 to 12.67, p<0.0001; TFMA: 11.73 to 4.22, p=0.0003). A correlation was found between TNCA improvement and FFA improvement (rs=0.46, p=0.0407), but not among TNCA improvement and TFMA improvement (rs=0.43, p=0.06). The size of the wedge did not strongly influence the TNCA correction (R2=0.016, p=0.0036), an improvement moderately explained by the MDCO amount (R2=0.186, p<0.0001). Conclusion: This study demonstrated correction of midfoot abduction, translated by the TNCA, in the absence of lateral column lengthening procedures. When evaluating patients submitted to first ray procedures (bone block Lapidus and Cotton) in conjunction with MDCO, an enhancement on the talar head coverage was noted. Variables associated with arch height and forefoot varus (FFA and TFMA) were correlated with the TNCA improvement. Nevertheless, only the MDCO displacement amount and not the size of the used allograft wedge could explain changes in TNCA. The provided data might support surgeons when planning treatment in the PCFD scenario.

Behavior of the Subtalar Joint after Arthroereisis in Adult Acquired Flatfoot, Evaluation with WBCT

Category: Hindfoot Introduction/Purpose: Flatfoot is a common deformity in adult and pediatric populations, with a 5% incidence. It corresponds to a complex three-dimensional pathology characterized by peritalar subluxation (PTS) of the hindfoot, with a dynamic behavior during weight-bearing. This is how weight-bearing computed tomography (WBCT) has become a fundamental tool for optimizing staging in flatfoot deformities. The indication for arthroereisis is a symptomatic flexible flat foot or hindfoot valgus in the pediatric or adolescent population in most publications. There are no studies that evaluate the behavior of the subtalar joint and degree of three-dimensional correction achieved in adult patients who underwent arthroereisis for symtomatic flexible flatfoot. Methods: After obtaining IRB approval, our prospectively collected surgical database was queried for patients undergoing arthroereisis for symptomatic flexible flatfoot. Patients were included if they had preoperative weight-bearing CT (WBCT). Patients were excluded if they had less than four months postoperative, had revision surgery, or declined to participate. Nine patients (15 feet) met the inclusion/exclusion criteria. All patients were brought back to the clinic for weight-bearing CT scan and to sign informed consent for the specific needs of this study. All measurements were performed by one of the authors in two time-frames (alignment of the hindfoot and talonavicular joint), separated for one month each. Results: Median age of 39 years. 14 feet showed a significant correction of the evaluated parameters. The preoperative median Talonavicular Coverage angle and Posterior and Middle Facet Subluxation of the subtalar joint were 33°, 19° and 39° respectively in preoperative WBCT, and 18°, 10° and 27° respectively in postoperative WBCT. The t test showed p < 0.01 for the change between preoperative and postoperative angles. The incidence of sinus tarsi pain was 20%, 2 patients required removal of the implant, 1 of them bilateral, without loss of correction in control with WBCT at the final follow-up (6 months after extraction). Conclusion: The application of subtalar arthroereisis is a minimally invasive alternative and effective therapy for adult acquired flatfoot, which achieves an adequate three-dimensional correction observed with WBCT after surgery. No loss of correction was observed in patients who required implant removal.

Does a 1st Metatarsophalangeal Fusion in a Patient with Pes Planus Improve the Pes Planus Deformity? A Retrospective Case Series

Category: Midfoot/Forefoot; Bunion Introduction/Purpose: A pes planus deformity is a pathology relating to the loss of normality of the complex interaction of the bones and joints of the foot resulting in a flattening of the medial longitudinal arch with or without abduction of the midfoot. The distal aspect of the medial longitudinal arch can be a feature of the deformity. The fusion of the 1st metatarsophalangeal joint (MTPJ) is a common operation. In patients with concomitant pes planus deformity, it is unknown if reducing and stabilising the distal aspect of the medial ray through a 1st MTPJ fusion can subsequently improve the pes planus deformity. We sought to analyse the pes planus deformity pre and post 1st MTPJ fusion with the null hypothesis that there was no difference. Methods: We identified patients who had undergone 1st MTPJ fusion using our electronic database from January 2011 to October 2021. To meet the inclusion criteria, cases required pre- and post-operative weightbearing plain radiographs, with a Meary's angle of >4 degrees on pre-operative imaging. Routine pes planus measurements were undertaken by 2 independent observers. Pre- and post-operative measurements were tested for significant change using Wilcoxon Signed Rank Test or Paired T-Test depending on the normality testing of the data. Routine demographic data was also collected. Data was analysed using IBM SPSS v.27. Results: Following radiographic analysis, 25 feet fitted the inclusion criteria. The mean patient age was 63 years. There was no pre-operative correlation between Meary's angle and the hallux valgus angle (Kendall's tau p=.441). Pre-operatively, Meary's line broke at the talo-navicular and navicular-cuneiform joints in 12 cases each; the remaining case broke at the tarsal-metatarsal joint. A statistically significant improvement between the pre- and post-operative measurements was identified in Meary's angle, calcaneal pitch angle, talo-navicular coverage angle, intermetatarsal angle and talo-navicular angle (see table). Significant changes were also noted in the medial cuneiform height (mean increase of 2.74mm; p=.022). A post-operative Meary's angle of <4°was only achieved in 4/25 (16%) of cases. Of the remaining 21 cases, the point at which Meary's line broke moved proximally one joint in 4 and distally one joint in 3 cases; it remained at the same joint in 14 cases. Conclusion: Our results suggest that 1st MTPJ fusion improves axial alignment of the foot as well as reducing Meary's angle by a statistically significant amount, although diagnostic criteria for pes planus remained in most cases.

2022 J. Leonard Goldner Award Winner: Passive Eversion Assessment for Progressive Collapsing Foot Deformity after Lateral Column Lengthening: A Cadaveric Biomechanical Study

Category: Hindfoot; Midfoot/Forefoot; Other Introduction/Purpose: Lateral column lengthening (LCL) is an established procedure for progressive collapsing foot deformity (PCFD) patients. While functional improvements are often reported after LCL, increased post-surgical lateral foot pain, attributed to decreased subtalar joint motion, remains a concern. The optimal wedge size is determined intraoperatively by measuring passive eversion of the hindfoot to ensure adequate eversion motion and radiographic correction. However, it is unknown whether a subjective assessment of passive eversion is associated with objective postoperative measurements of foot stiffness, such as plantar pressure. Our goal was to quantify the relationship between eversion during a passive assessment and plantar pressures during simulations of level walking. We hypothesized that a strong relationship exists between the location of plantar pressure and the eversion measured with passive manipulation. Methods: A deformity was created in ten mid-tibia cadaveric specimens (four female, age range: 35-72) by transecting the spring ligament and medial talonavicular joint capsule followed by cyclic loading. A six degrees-of-freedom robotic gait simulator was used to simulate the stance phase of level walking. Joint kinematics and plantar pressure data were collected during each simulation. A passive assessment of hindfoot eversion was then conducted manually by a fellowship-trained orthopaedic surgeon and recorded by the motion capture system. Five conditions were tested: intact, PCFD, and three LCL wedge conditions (4, 6, 8mm). Outcome measures for each condition included the lateral-to-medial forefoot plantar pressure ratio during walking simulations and the peak subtalar eversion measured during the assessment. A linear mixed effects model was used to determine the association between the plantar pressure and LCL wedge thickness. Pearson correlation coefficients were calculated to determine the relationship between subtalar eversion and plantar pressure. Results: There was a significant relationship between the size of LCL wedge and the forefoot lateral-to-medial average pressure ratio (p<0.001). Every 2mm increase in LCL wedge size resulted in a 0.20 +- 0.03 increase in the LM ratio, indicating a significant lateral shift in plantar pressure with each increase in wedge size. The 4mm wedge was most effective in restoring plantar pressure and eversion to intact (Figure 1). The peak subtalar eversion measured during the assessment decreased with an increase in the size of the LCL wedge. A strong correlation (r(38)=0.51, p<0.01) was found between the LM ratio and the peak subtalar eversion. This indicates that a decrease in the eversion measured during passive assessment is strongly associated with a lateral shift in plantar pressure. Conclusion: This study demonstrates that reduced eversion following LCL is associated with increased lateral plantar pressure which is consistent with stiffness and lateral plantar pain that is a well-known complication of this surgery. Passive eversion measurement is likely to help predict functional performance. The 4mm wedge best restored outcomes to normal, whereas larger wedges resulted in increased lateral loading and decreased eversion. A change in correction of 2mm made a significant difference in loss of eversion motion and minimizing the amount of lengthening is strongly recommended.

Significance of the anatomical relationship between the flexor digitorum longus and sustentaculum tali for reconsideration of the talocalcaneonavicular joint stability mechanism

The talocalcaneonavicular joint (TCN-j) is supported by the spring ligament, which has recently been revealed to be part of the joint capsule complex, along with the tendinous sheath of the tibialis posterior and flexor digitorum longus (FDL). Nonetheless, the FDL’s role in TCN-j stability has received limited attention. This study aimed to elucidate the positional relationships between the FDL and sustentaculum tali, which comprises the TCN-j. We hypothesized that the FDL runs medial to the sustentaculum tali, and its course significantly changes from the sitting to the standing position. Six ankles from six body donors were investigated, and seven ankles from seven volunteers were assessed using ultrasonography. The FDL was three-dimensionally located inferomedial to the sustentaculum tali. The FDL tendinous sheath was attached to the sustentaculum tali or connected by the tibialis posterior via the tendinous sheath. Based on the in vivo ultrasound image, the FDL location relative to the sustentaculum tali was maintained; however, the curvature of the FDL course was significantly more prominent in standing than in sitting. The FDL force against the bending moment may prevent the excessive eversion of the foot and aid the conventional spring ligament’s contribution to TCN-j stability for maintaining the longitudinal arch.

Effects Of Low-Dye Taping On Plantar Fascia Strain And Kinematics In Individuals With Plantar Fasciitis

Plantar fasciitis is thought to be caused by excessive strain of the plantar fascia, which may occur due to altered foot kinematics displayed by individuals with plantar fasciitis. The low-Dye taping method has been found to be effective at reducing pain and increasing function in individuals with plantar fasciitis, although the exact mechanisms for these changes are unclear. PURPOSE: To determine the effects of low-Dye taping on plantar fascia strain and foot kinematics in individuals with plantar fasciitis. METHODS: Fifteen adults with plantar fasciitis completed the repeated measures study. Each participant walked barefoot at a self-selected speed while untaped and while their pathological foot was taped with the low-Dye taping method. A six-segment musculoskeletal model of the foot was used to provide estimates of plantar fascia and other foot ligament strains. Statistical Parametric Mapping (SPM) was used to compare plantar fascia strain, and post hoc SPM analyses of several foot joint kinematics were conducted to explain the differences in plantar fascia strain. Finally, strains of several foot ligaments were investigated using SPM procedures. RESULTS: Significantly greater plantar fascia strain was found during the untaped condition between 67-79% of stance phase (p = 0.001), which does not include the time in which peak strain occurred. The low-Dye taping method also reduced dorsiflexion of the talonavicular joint from 52-86% of stance phase (p < 0.001), which represents a reduction in arch collapse. In addition, significant strain reductions in the taped condition were noted in the superior and inferior slips of the spring ligament from 14-87% (p < 0.001) and 16-87% (p < 0.001) of stance phase, respectively, as well as in the 2nd, 3rd, and 4th slips of the long plantar ligament from 56-86% (p < 0.001), 59-86% (p < 0.001), and 68-81% (p < 0.001) of stance phase, respectively. CONCLUSIONS: Our findings suggest that if low-Dye taping is effective for individuals with plantar fasciitis, it is not by reducing peak plantar fascia strain, but instead by reducing cumulative strain across the entire stance phase. This reduction in strain during stance phase occurs due to the reduction in arch collapse. Furthermore, several other ligaments are significantly affected by the low-Dye taping method.

Early Outcomes of Combined Total Ankle Total Talus Replacement Using a 3D-Printed Talus Component With Hindfoot Arthrodesis.

Late-stage talar avascular necrosis (AVN) results in devascularization of the talus with osteonecrosis and subchondral collapse. A combined total ankle and total talus replacement (TATTR) with hindfoot arthrodesis may be utilized for end-stage talar AVN with tibiotalar and hindfoot joint arthritis. The purpose of this study is to evaluate the short-term outcomes of combined TATTR with hindfoot arthrodesis. Patients who underwent a combined TATTR or TTR with a hindfoot arthrodesis (subtalar with or without talonavicular arthrodesis) from 2016 to 2020 were retrospectively reviewed. Patient demographics, comorbidities, and surgical data were collected. Outcomes included the Visual Analog Scale (VAS) scores, range of motion, radiographic parameters, union rates, and complications. A total of 18 patients were reviewed. Nine patients were included with an average of 19.4 months follow-up. Significant postoperative improvements were observed in VAS scores (P < .001), ankle plantarflexion (P = .04), talocalcaneal height (P = .03), and tibiotalar alignment (P = .02). All patients achieved a successful union of their subtalar and talonavicular joints arthrodesis. There was one reoperation for a persistent varus ankle deformity. This is the first study to evaluate the clinical outcomes, radiographic outcomes, and union rate in combined TATTR with hindfoot arthrodesis. The early results demonstrated significant clinical improvement with 100% hindfoot union rate and no prosthetic failure.Level of Evidence: IV.

Minimally Invasive Method in Treatment of Idiopathic Congenital Vertical Talus: Recurrence is Uncommon.

Historically, treatment for congenital vertical talus (CVT) has included open reduction of the talonavicular joint and extensive soft tissue release. In 2006, a new minimally invasive method consisting of serial manipulation and casting followed by percutaneous fixation of the talonavicular joint and percutaneous Achilles tenotomy was introduced. Although the early results of this new technique are promising, more research is needed to verify that the talonavicular correction is maintained with time. We conducted a retrospective chart review of all patients with idiopathic CVT who underwent minimally invasive correction by a single surgeon at a tertiary care institution. Radiographic evaluation of the preoperative, immediate postoperative, 1 year postoperative and latest follow-up appointments were performed. Complications and clinical outcomes were recorded. Radiographic recurrence of the deformity was defined as lateral talar axis-first metatarsal base angle >30 degrees. Statistical analysis was performed on the maintenance of radiographic correction and factors associated with recurrence. Forty seven feet in 35 patients were included in the study with average follow-up of 45 months. The average preoperative lateral talar axis-first metatarsal base angle was 74±18 compared with 12±8 after initial surgical intervention. In addition, radiographic correction of all other measured angles was achieved in every child following the initial surgery. Radiographic recurrence of talonavicular deformity was seen in 4 feet (9%). No cases of recurrence required a second corrective surgery during the follow-up period. There was a significant association between patient age at the time of treatment and recurrence of talonavicular deformity with patients older than 12 months being more likely to experience recurrence ( P =0.041). In this large series, we found that correction of talonavicular deformity can be achieved and maintained in a large majority of children with idiopathic CVT who undergo treatment with this minimally invasive technique and recurrences are uncommon. Treatment with this technique should be initiated as soon as a diagnosis of CVT is confirmed and the patient is medically stable to decrease the likelihood of experiencing recurrence of talonavicular deformity. Level III.

Extensile anteromedial approach for modified pantalar arthrodesis

The aim of this paper is to present a case report of an alternative surgical approach for the anteromedial incision for a modified pantalar arthrodesis. After recent literature supporting an anteromedial approach for a total ankle replacement (TAR), with the incision extending from the ankle joint to the talonavicular joint [1], the decision was made by the principal investigator to use this approach for a modified pantalar arthrodesis. This surgical principle is based on the understanding that the safest incision placement generally lies between angiosomes [2]. This approach splits the angiosome between the anteromedial blood supply from the posterior tibial artery and the anterior and lateral blood supply from the dorsalis pedis artery. Currently, no data regarding incision complications can be found with this approach with respect to a modified pantalar arthrodesis.

Comparison of Direct Versus Image Based Foot Posture Index in School Going Children

Introduction: The Foot Posture Index-6 (FPI-6) is a simple quantification tool to assess static foot alignment in children. Palpation of the foot is required for assessment of one of the six criteria that comprise the FPI-6; the remaining five criteria may be evaluated using still-frame photographs. Using only the image-based criteria may allow evaluation of foot posture without going in person for physical checkup. The purpose of the current study was to compare this image based criteria of FPI with direct observation FPI in school going children. Methods/Procedure: 38 participants were assessed from different schools of Ahmedabad for the study. Children were evaluated for FPI and scoring of five criteria were done. Three photos with a camera of the medial longitudinal arch, posterior ankle and the talonavicular joint approximately 45° from the posterior calcaneus for both right and left feet were taken. Then assessment of the five image-based criteria of the FPI-6 for both feet were done and scoring was done. Results: As this is a comparison of two methods, Bland Altman analysis has been performed and bias is almost negligible (mean bias for Lt. FPI – 0.16 and for Rt. FPI 0.03) so both methods are equivalent. Conclusion: Image based FPI evaluation can be done with caution to assess foot posture evaluation in school going children which can be very useful in current pandemic situation. Keywords: Image based Foot Posture Index, Foot Posture Index, School Going Children

Anatomical and biomechanical evaluation of the lateral calcaneo-cuboid and bifurcate ligaments

BackgroundThis study aims to analyze the ligaments of the dorso-lateral calcaneo-cuboid joint and to assess the biomechanical relevance of the bifurcate ligament. Methods16 specimens were analyzed for their ligamentous anatomy of the dorso-lateral calcaneo-cuboid joint and side-alternating assigned to two groups with varying ligamentous dissection order. The Chopart joint was stressed in plantar, medial, and lateral direction measuring the displacement by an 3D motion tracker for every dissection step. Results37.5% of specimens had all ligaments (lateral calcaneo-cuboid, dorsal calcaneo-cuboid, bifurcate calcaneo-cuboid, bifurcate calcaneo-navicular), 37.5% were lacking bifurcate´s calcaneo-cuboid-portion, and 25% presented without dorsal calcaneo-cuboid. Biomechanical testing revealed no significant displacement within the calcaneo-cuboid or talo-navicular joint for any stressed state except for axial compression with dissected dorsal talo-navicular joint capsule in Group 2. ConclusionBroad morphological variability and missing significant displacement regardless of its integrity, make the bifurcate ligament appear of limited biomechanical relevance.

Closed isolated anterolateral calcaneal dislocation: a case report

BackgroundComplete isolated calcaneal dislocation, defined as dislocation of talocalcaneal and calcaneocuboid joints with intact talonavicular joint without significant fracture, is an exceedingly rare injury.Case presentationA 49-year-old man, after a motor vehicle collision, presented with a closed isolated anterolateral dislocation of the calcaneus associated with fracture of the sustentaculum tali, cuboid, lateral process of the talus, and avulsion fracture of superior peroneal retinaculum. Urgent successful closed reduction was immediately performed in the emergency room under sedation. Two days later, through sinus tarsi approach extended proximally to posterior of the lateral malleolus and distally to the calcaneocuboid joint, peroneal tendons were reduced in the retromalleolar groove and avulsion fracture of the superior peroneal retinaculum was reduced and fixed by a suture anchor. A chondral lesion (6 × 8 mm) was seen in the posterior facet of the calcaneus for that chondroplasty and microfracture were performed. Also, small bony fragments from the cuboid were excised. The reduced calcaneocuboid joint was fixed by two Kirschner wires. In the second stage, 10 days later, through medial approach to the talocalcaneal joint, multiple free bony fragments were excised. Then sustentaculum tali was reduced and fixed using a lag screw. Postoperatively, a non-weight bearing short leg cast was applied for six weeks. The patient had permission to start partial weight bearing 6 weeks after removal of K-wires. Finally, at the 10th postoperative week, he had full weight-bearing without any aid instrument. He was able to return to his regular activities about 6 months after the injury. At 34 months, the American Orthopaedic Foot and Ankle Society ankle-hindfoot scale was 92 from 100. The foot function index percentile was 7% and the visual analogue score for pain was 1.9. The last radiographs revealed normal configuration of talocalcaneal, calcaneocuboid, and talonavicular joints with a little joint space narrowing in posterior part of the subtalar joint.ConclusionPatients with isolated anterolateral calcaneal dislocations, even with multiple associated fractures, can have acceptable outcomes, if it is urgently diagnosed and properly managed.

The Effect of Progressive Lateral Column Lengthening in a Novel Stage II-B Flatfoot Cadaveric Model Evaluated Using Software-Guided Radiographic Measurements of Foot Alignment.

This work used software-guided radiographic measurement to assess the effects of progressive lateral column lengthening (LCL) on restoring alignment in a novel cadaveric model of stage II-B flatfoot deformity. A stage II-B flatfoot was created in 8 cadaveric specimens by transecting the spring ligament complex, anterior deltoid, and interosseous talocalcaneal and cervical ligaments. Weightbearing computed tomographic (WBCT) scans were performed with specimens under 450 N of compressive load in the intact, flat, and 6-, 8-, and 10-mm lateral column-lengthening conditions. Custom software-guided radiographic measurements of the lateral talo-first metatarsal (Meary) angle, anteroposterior talo-first metatarsal angle, naviculocuneiform overlap, and 2 new measures (plantar fascia [PF] distance and angle) were recorded on digitally reconstructed radiographs. Four anonymized analysts performed measurements twice. Intra- and interobserver agreement was assessed using intraclass correlation coefficients (ICCs). Six-millimeter LCL restored alignment closest to the intact foot in this new cadaveric model, whereas 10-mm lengthening tended toward overcorrection. The PF line displaced laterally in the flatfoot condition, and LCL restored the PF line to a location beneath the talonavicular joint. Interobserver agreement was excellent for PF distance (ICC = 0.99) and naviculocuboid overlap (ICC = 0.91), good for Meary angle (ICC = 0.81) and PF angle (ICC = 0.69), and acceptable for the talonavicular coverage angle (ICC = 0.65). In this stage II-B cadaveric flatfoot model, cervical ligament transection was essential to create deformity after the medial hindfoot ligaments were transected. Software-guided radiographic measurement proved reliable; standardized implementation should improve comparability between studies of flatfoot deformity. The novel PF distance performed most consistently (ICC = 0.99) and warrants further study. With this model, we found that a 6-mm LCL restored alignment closest to the intact foot, whereas 10-mm lengthening tended toward overcorrection. Future joint-sparing flatfoot corrections may consider using a relatively small LCL combined with other bony and/or anatomic ligament/tendon reconstructions.

Where is the primate transverse tarsal joint? Chopart vs. Lisfranc

The concept of the transverse tarsal joint is typically associated with accommodative twists of the foot, and with a midfoot flexion known as the midtarsal break. The specific joints associated for these motions are often assumed, but are rarely validated. The two most common candidates are “Chopart’s Joint,” which separates the cuboid and navicular from the calcaneus and talus, and “Lisfranc’s Joint,” formed by a combination of all the tarsometatarsal joints. Both of these joints were initially identified as sites for surgical amputations and were not based on any presumed function. This study investigates the utility of these composite joints as sites of foot motion for humans and for some non‐human primates.Data were drawn from 3D kinematic evaluations of the cadaveric feet of 12 humans, 11 chimpanzees, and 11 baboons. Data were collected in response to an anterior‐posterior and medial‐lateral driving motion of the leg over the foot. Data were derived from rigid cluster tracking of individual foot bones during an anterior‐posterior motion of the leg, typically associated with dorsiflexion‐plantarflexion, and a medial‐lateral leg motion, associated with inversion‐eversion and/or supination‐pronation. Data were analyzed using the Functional Alignment procedure to derive the orientation of axes of rotation for the involved joints.Results show that the axis orientation of Chopart’s Joint is not a good compromise between the very different motions of the talonavicular and calcaneocuboid joints in any primate. This observation applies to results drawn from both anterior‐posterior and medial‐lateral driving motions. The rotational axis of Lisfranc’s Joint in the different primates is also quite divergent from the individual tarsometatarsal joint axes when responding to the anterior‐posterior driving action, but the axis is more parallel to those of the tarsometatarsal joints during the medial‐lateral driving action. However, it should be noted that the joint axes of the individual tarsometatarsal joints are almost identical, while the Lisfranc’s Joint axis stands apart.These results show that the individual joint actions are more complicated than their composite forms expressed as Chopart’s or Lisfranc’s joints. The concept of single “transverse tarsal” joint may not be functionally justified, within the human animal or as a basis for comparison of humans and non‐human primates. Researchers should reassess how well these traditional joint concepts apply to their specific questions of foot biomechanics.The author conveys his respect and gratitude to the persons whose remains are associated with this project.

Comminuted navicular fracture treated with an internal fixation plate – Technical Tip

Fractures of the navicular are relatively uncommon lesions. Comminuted fractures of the navicular body may be associated with focal bone collapse and loss of integrity of the medial column of the midfoot with gross instability, leading to deformities and potential early osteoarthritis. The treatment is challenging due to the difficulties to maintain the length and stability of the midfoot medial column and restoring the anatomy without damaging the vascular supply. Here we present an option for the surgical treatment of comminuted fractures of the navicular using a low-profile locking plate with the “bridge” principle as a temporary internal fixator. The technique consists of restoring the navicular anatomy by fixing the larger fragments with screws and applying indirect reduction of minor fragments. The bone length is maintained by a bridge-plating system with screws inserted into the talus and the medial cuneiform, crossing the talonavicular and naviculocuneiform joints. Implants are removed after fracture healing. Level of Evidence: V; Therapeutic Study; Expert Opinion.

Treatment of severe planovalgus foot deformity in a child

Planovalgus foot deformity is one of the most common orthopedic conditions detected in childhood. According to the literature, it is present in 70% of children under 11 years with various degree of severity. Without timely correction, the common complications of this deformity are: arthrosis of the talonavicular joint, valgus deformity of the knee joints, impaired posture and functional scoliosis, pain syndrome, impaired function of the lower extremities, which is an indication for surgical treatment of this pathology.&#x0D; The article presents a clinical case report of surgical treatment of a patient with severe planovalgus foot deformity. The main stages of surgical correction were tendon-muscle plasty, subtalar arthroeresis and Cotton osteotomy (wedging osteotomy of the medial sphenoid bone).&#x0D; Relying on the results of surgical treatment of the patient, we conclude that the use of the combination of methods is valid for the treatment of patients with severe planovalgus foot deformity.

Diagnostic yield of exome sequencing in congenital vertical talus

BackgroundCongenital vertical talus (CVT), also known as “rocker-bottom foot”, is a rare foot deformity associated with a dislocation of the talonavicular joint. Although genetic causes of CVT have been described in single isolated and syndromic families, whole-exome sequencing (WES) of large cohorts have not yet been reported. MethodsIn this study, 62 probands with CVT were evaluated for likely causative single nucleotide variants (SNVs) and copy number variants (CNVs) using WES. Segregation of variants within families was determined by Sanger sequencing. ResultsIn this cohort, CVT occurred as an isolated anomaly in 75.8% (47/62) and was familial in 19.3% (12/62) of cases. Analysis of WES data led to the identification of likely causative variants in known disease genes in 30.6% (19/62) of all CVT probands. More than one proband had likely causative SNVs in TSHZ1, GDF5, and LMX1B. Only two probands had likely causative CNVs: a chromosome 12q13.13 deletion of the 5’ HOXC gene cluster, and a chromosome 18q22.3q23 deletion involving TSHZ1. Familial CVT was strongly predictive of identifying a molecular diagnosis [75% (9/12) of familial cases compared to 20% (10/50) of non-familial cases (Chi-square test, P-value = 0.0002)]. There was no difference in the solved rate based on isolated or syndromic presentation, unilateral or bilateral affectation, or sex. ConclusionsCVT is genetically heterogeneous and more often caused by SNVs than CNVs. There is a high yield of WES in familial CVT cases (∼75%). Additional research is needed to identify the causes of sporadic CVT, which had much lower solved rates.

Cadaveric Gait Simulation of the Effect of Subtalar Arthrodesis on Total Ankle Replacement Kinematics.

Patients undergoing total ankle replacement (TAR) often have symptomatic adjacent joint arthritis and deformity. Subtalar arthrodesis can effectively address a degenerative and/or malaligned hindfoot, but there is concern that it places abnormal stresses on the TAR and adjacent joints of the foot, potentially leading to early TAR failure. This study hypothesized that ankle and talonavicular joint kinematics would be altered after subtalar arthrodesis in the setting of TAR. Thirteen mid-tibia cadaveric specimens with neutral alignment were tested in a robotic gait simulator. To simulate gait, each specimen was secured to a static mounting fixture about a 6-degree of freedom robotic platform, and a force plate moves relative to the stationary specimen based on standardized gait parameters. Specimens were tested sequentially in TAR and TAR with subtalar arthrodesis (TAR-STfuse). Kinematics and range of motion of the ankle and talonavicular joint were compared between TAR and TAR-STfuse. There were significant differences in kinematics and range of motion between TAR and TAR-STfuse groups. At the ankle joint, TAR-STfuse had less internal rotation in early-mid stance (P < .05), with decreased range of motion in the sagittal (-2.7 degrees, P = .008) and axial (-1.8 degrees, P = .002) planes in early stance, and increased range of motion in the coronal plane in middle (+1.2 degrees, P < .001) and late (+2.5 degrees, P = .012) stance. At the talonavicular joint, there were significant differences in axial and coronal kinematics in early and late stance (P < .05). Subtalar arthrodesis resulted in significantly decreased talonavicular range of motion in all planes in early and late stance (P < .003). In ankles implanted with the TAR design used in this study, kinematics of the ankle and talonavicular joint were found to be altered after subtalar arthrodesis. Aberrant motion may reflect altered contact mechanics at the prosthesis and increased stress at the bone-implant interface, and affect the progression of adjacent joint arthritis in the talonavicular joint. These findings may provide a correlate to clinical studies that have cited hindfoot arthrodesis as a risk factor for TAR failure.

A case report of lateral subtalar dislocation

Introduction: Subtalar or peritalar dislocation is defined as simultaneous dislocation of talocalcaneal and talonavicular joint. Most injuries are caused by moderate to high energy trauma including motor vehicle accidents and falls from height. This case is operated for lateral subtalar dislocation treated with open reduction.Case: A 35 year old male patient came to Emergency Department of C U Shah Medical College And Hospital, Surendranagar with complaints of pain and tenderness over left ankle after history of road traffic accident between patient and bike. On clinical examination, it revealed tenderness and eversion deformity of the foot. Dorsalis pedis and Posterior Tibial pulses were intact. Sensation in the foot was preserved.Conclusion: Subtalar dislocations are rare but serious injuries of the talus this injury is usually due to high energy trauma. Early diagnosis and urgent reduction are the prerequisites for a satisfactory functional outcome. The prognosis is generally good, although long-term monitoring is required to combat the appearance of subtalar arthrosis.

Non-union of the Navicular with Associated Talonavicular and Calcaneocuboid Joint Degenerative Arthritis and Its Management: A Case Report

Non-union of the Navicular with Associated Talonavicular and Calcaneocuboid Joint Degenerative Arthritis and Its Management: A Case Report