Midtarsal Joint Research Articles

How Do Hindfoot Fusions Affect Ankle Biomechanics: A Cadaver Model

While successful subtalar joint arthrodesis provides pain relief, resultant alterations in ankle biomechanics need to be considered, as this procedure may predispose the remaining hindfoot and tibiotalar joint to accelerated degenerative changes. However, the biomechanical consequences of isolated subtalar joint arthrodesis and additive fusions of the Chopart's joints on tibiotalar joint biomechanics remain poorly understood. We asked: What is the effect of isolated subtalar fusion and sequential Chopart's joint fusions of the talonavicular and calcaneocuboid joints on tibiotalar joint (1) mechanics and (2) kinematics during loading for neutral, inverted, and everted orientations of the foot? We evaluated the total force, contact area, and the magnitude and distribution of the contact stress on the articular surface of the talar dome, while simultaneously tracking the position of the talus relative to the tibia during loading in seven fresh-frozen cadaver feet. Each foot was loaded in the unfused, intact control condition followed by three randomized simulated hindfoot arthrodesis modalities: subtalar, double (subtalar and talonavicular), and triple (subtalar, talonavicular, and calcaneocuboid) arthrodesis. The intact and arthrodesis conditions were tested in three alignments using a metallic wedge insert: neutral (flat), 10° inverted, and 10° everted. Tibiotalar mechanics (total force and contact area) and kinematics (external rotation) differed owing to hindfoot arthrodeses. After subtalar arthrodesis, there were decreases in total force (445 ± 142 N, 95% CI, 340-550 N, versus 588 ± 118 N, 95% CI, 500-676 N; p < 0.001) and contact area (282 mm(2), 95% CI, 222-342 mm(2), versus 336 ± 96 mm(2), 95% CI, 265-407 mm(2); p < 0.026) detected during loading in the neutral position; these changes also were seen in the everted foot position. Hindfoot arthrodesis also was associated with increased external rotation of the tibiotalar joint during loading: subtalar arthrodesis in the neutral loading position (3.3° ± 1.6°; 95% CI, 2°-4.6°; p = 0.004) and everted loading position (4.8° ± 2.6°; 95% CI, 2.7°-6.8°; p = 0.043); double arthrodesis in neutral (4.4° ± 2°; 95% CI, 2.8°-6°; p = 0.003) and inverted positions (5.8° ± 2.6°; 95% CI, 3.7°-7.9°; p = 0.002), and triple arthrodesis in all loaded orientations including neutral (4.5° ± 1.8°; 95% CI, 3.1°-5.9°; p = 0.002), inverted (6.4° ± 3.5°; 95% CI, 3.6°-9.2°; p = 0.009), and everted (3.6° ± 2°; 95% CI, 2°-5.2°; p = 0.053) positions. Finally, after subtalar arthrodesis, additive fusions at Chopart's joints did not appear to result in additional observed differences in tibiotalar contact mechanics or kinematics with the number of specimens available. Using a cadaveric biomechanical model, we identified some predictable trends in ankle biomechanics during loading after hindfoot fusion. In our tested specimens, fusion of the subtalar joint appeared to exert a dominant influence over ankle loading. A loss or deficit in function of the subtalar joint may be sufficient to alter ankle loading. These findings warrant consideration in the treatment of the arthritic hindfoot and also toward defining biomechanical goals for ankle arthroplasty in the setting of concomitant hindfoot degeneration or arthrodesis.

Functional Outcomes After Gunshot Wounds to the Foot and Ankle.

The peer-reviewed, clinical data focusing on foot and ankle gunshot wounds are limited. The present study aimed to evaluate functional outcomes in a case series according to the area of injury, articular involvement, and the presence of infection. From January 2003 through February 2011 (8years), 37 patients treated at Sinai-Grace Hospital (Detroit, MI) for civilian gunshot wounds localized to the foot and/or ankle were reviewed. Of these, 27 (72.97%) met the inclusion criteria. All acute wounds were thoroughly irrigated in the emergency room (8 of 27, 29.63%) or operating room (19 of 27, 70.37%) within 1 hour of presentation. The injuries were categorized as either zone 1 or 2, if localized distally or proximally to the midtarsal joint, respectively. The Maryland Foot Score was recorded and compared based on the location, articular involvement, and infection status, using analysis of variance. The mean Maryland Foot Score in patients with zone 1 injuries was 89.3 (range 72 to 100) and in patients with zone 2 injures was 61.8 (range 13 to 97; p=.001). The mean Maryland Foot Score in patients with type A injuries was 93.1 (range 72 to 100) and in patients with type B injures was 69.2 (range 13 to 99; p=.001), regardless of location. Intraoperative cultures yielded Staphylococcus epidermidis (7 of 27, 25.93%) and Enterococcus cloacae (1 of 27, 3.7%). No cases of Pseudomonas aeruginosa were found, although 9 cases (33.33%) involved shoe penetration. One third of the cases (9 of 27) yielded intra-articular pain, of which 4 (14.82%) required joint arthrodesis.

Plantar-flexion of the ankle joint complex in terminal stance is initiated by subtalar plantar-flexion: A bi-planar fluoroscopy study

Gross motion of the ankle joint complex (AJC) is a summation of the ankle and subtalar joints. Although AJC kinematics have been widely used to evaluate the function of the AJC, the coordinated movements of the ankle and subtalar joints are not well understood. The purpose of this study was to accurately quantify the individual kinematics of the ankle and subtalar joints in the intact foot during ground walking by using a bi-planar fluoroscopic system. Bi-planar fluoroscopic images of the foot and ankle during walking and standing were acquired from 10 healthy subjects. The three-dimensional movements of the tibia, talus, and calcaneus were calculated with a three-dimensional/two-dimensional registration method. The skeletal kinematics were quantified from 9% to 86% of the full stance phase because of the limited camera speed of the X-ray system. At the beginning of terminal stance, plantar-flexion of the AJC was initiated in the subtalar joint on average at 75% ranging from 62% to 76% of the stance phase, and plantar-flexion of the ankle joint did not start until 86% of the stance phase. The earlier change to plantar-flexion in the AJC than the ankle joint due to the early plantar-flexion in the subtalar joint was observed in 8 of the 10 subjects. This phenomenon could be explained by the absence of direct muscle insertion on the talus. Preceding subtalar plantar-flexion could contribute to efficient and stable ankle plantar-flexion by locking the midtarsal joint, but this explanation needs further investigation.

Isolated complete dislocation of the tarsal navicular without fracture: A rare injury

Injuries to the midtarsal joints usually occur in various combinations such as fracture, fracture subluxation, and fracture dislocation. Isolated dislocations of the navicular bone without fracture are rare injuries. The few existing case reports describe the probable mechanism of injury and optimal treatment. We present a 64-year-old diabetic man whose tarsal navicular was completely dislocated without fracture following a traffic accident. The most probable mechanism of injury was an abduction–pronation injury causing a midtarsal dislocation, and on spontaneous reduction, the navicular was dislocated medially. This mechanism is similar to perilunate dislocation. Computed tomography of the involved foot was done to accurately define the full extent of the bony injury and magnetic resonance imaging was required to determine if there was a ligamentous injury and to assess the attachment of soft tissues to the displaced bone to help assess the risk of avascular necrosis. The patient was treated successfully with open reduction and primary talonavicular arthrodesis with Kirschner wires.

Lateral Swivel Dislocation of the Hindfoot : A Case Report and Literature Review

ABSTRACT Lateral swivel dislocation, a subtype pattern of dislocations occurring at mid tarsal joint is a rare type of injury. A medially or laterally directed force applied to the forefoot causes dislocation of the talonavicular joint but not subtalar joint. The calcaneum alongwith the remaining foot swivels on the intact interosseous talocalcaneal ligament. The present case report is a more rare lateral swivel type of dislocation of talonavicular joint in a 25-year-old male. The article also presents a comprehensive review of literature and management of such type of injuries of the hindfoot . How to cite this article Kapila R, Verka Ps, Garg Rs, Ahmed M. Lateral Swivel Dislocation of the Hindfoot: A Case Report and Literature Review. J Foot Ankle Surg (Asia-Pacific) 2015;2(1): 41-43.

Pantalar Arthrodesis: Surgical Technique and Review of Literature

ABSTRACT Surgical options for treatment of tibiotalar, subtalar, and trans verse tarsal joint arthritis are limited. Pantalar arthrodesis can produce a stable and braceable if not painless foot in the planti grade position. This article presents a review of etiology, clinical evaluation, procedural technique and outcomes reported in literature. Shi G, Gross CE, Huh J, Parekh SG. Pantalar Arthrodesis: Surgical Technique and Review of Literature. The Duke Orthop J 2015;5(1):4852.

Transcuneiform Crush Injury: A Case Report

Introduction: Transcuneiform fracture patterns without dislocations are uncommon. In a review of the literature, numerous case reports describe cuneiform fracture-dislocations involving either the transmetatarsal or midtarsal joint complexes due to direct trauma; however, an isolated transcuneiform fracture pattern without dislocation has not been reported. Methods: We present a rare injury of the foot: an isolated transcuneiform fracture without associated dislocation of the tarsometatarsal joint or midtarsal joint complex. Case: A 29 year old active duty Army male sustained direct blunt trauma to his foot when a 20 ton trailer fell onto it. His initial presentation prompted protected weight bearing after a clinical exam revealed soft tissue injury and tenderness to palpation about the dorsum of his midfoot. Due to persistent symptoms, he was referred to a musculoskeletal specialist. Radiographs and computed tomography (CT) images demonstrated a minimally displaced comminuted transcuneiform fracture involving the medial and intermediate cuneiforms without evidence of dislocation or subluxation. Treatment consisted of non-weight bearing cast immobilization with crutches for ten weeks before being transitioned into a weight bearing control ankle motion (CAM) boot. Radiographic evidence of healing was documented at 4 weeks by callus formation at the first metatarsal and medial cuneiform. The patient returned to low impact activity by 10 month follow-up without surgical intervention. Discussion and Conclusions: Blunt trauma to the midfoot can result in isolated or complex fracture patterns without the typical fracture-dislocation following high mechanism trauma. Appropriate clinical suspicion and careful physical examination can facilitate timely diagnosis and treatment. Minimally displaced transcuneifom fracture patterns without associated midfoot dislocation injuries can be treated nonoperatively with protected weight bearing, close radiographic and clinical follow up, and gradual advancement to activity with acceptable clinical outcomes.

Osteoartritis sub-astragalina posterior

La circunstancia de harber encontrado un caso de osteo-artritis subastragalina posterior, -lesión cuya rareza explica las pocas referencias anotadas en la literatura- y el hecho de las derivaciones clínicas y terapéuticas que comporta su diagnóstico, nos ha llevado a hacer una revisión de su conocimiento en el momento actual, dar cuenta de la feliz evolución del caso por nosotros anotado y, en fin, discutir ciertos aspectos fisiológicos y su relación con otros procesos afines. En especial, queremos señalar la posibilidad de que, con los recursos actuales, es posible controlar la evolución de estas infecciones en sólo la porción posterior de la articulación ya dicho, evitando así su difusión a la vertiente anterior y las articulaciones mediotarsianas.

CORR Insights®: Does the subtalar joint compensate for ankle malalignment in end-stage ankle arthritis?

Where Are We Now? It is well known that in clinical practice, stiffness of the ankle joint leads to hypermobility of an intact subtalar and chopart joints. The degree of deformity and stiffness compensation of the ankle joint depends on the constitutional laxity of the ligaments, asymmetric muscular activity (eg, spastic or paralytic paresis), the active correction of the hindfoot position to avoid pain through weight bearing, and the degree of the arthritis of the subtalar and chopart joints. Therefore, the degree of compensation of ankle joint malalignment is multifactorial. The question is whether a compensatory subtalar and chopart hypermobility leads to a decrease of pain and a better hindfoot function or causes pain and increases subtalar and chopart osteoarthritis? Where Do We Need To Go? Radiological studies can only measure the degree of compensation in weight bearing radiographs. The current study by Saltzman and colleagues shows a negative correlation between compensation of hindfoot deformity and osteoarthritis in the subtalar joint. A subtalar compensation of a varus deformity in the ankle joint appears more often and is more excessive, which can easily be explained by the plane of the dorsal facet of the subtalar joint, which predisposes for valgus deformity. A subtalar varus compensation of a valgus deformity of the ankle joint may be explained by an active contraction of the tibialis anterior and posterior muscles to reduce pain in the lateral tibiotalar joint. The subtalar valgus compensation is a passive process that may become irreversible in time because of a lack of spontaneous correction in the unbeared position. The varus compensation on the other hand, which is an active process and exhausting for the patient, is mostly reversible. Therefore, it is essential to correlate the radiological findings of the current study with the clinical appearance of hindfoot deformities. How Do We Get There? To get a better understanding on the compensation of ankle deformities and stiffness, prospective clinical radiological long-term followup studies are needed. These studies should address the clinical symptom at the time of the radiological examination, including localization of pain to pressure and translation, under weight bearing, passive and active ROM of the ankle, subtalar and chopart joints, areas of weight bearing at the sole, and optional pedobarography. Patients treated conservatively and operatively should be reinvestigated periodically to get prognostic data on different hindfoot deformities. These data would help determine the efficacy of operative and conservative treatment and the right time to change between both.

Severe midfoot fracture-dislocation treated with external biplanar mini-fixator and limited internal fixation

Objective To evaluate the clinical efficacy of external biplanar mini-fixator and limited internal fixation in treatment of severe midfoot fracture-dislocation.Methods Eight patients with severe midfoot fracture-dislocation were admitted from May 2009 to August 2012.They were 6 men and 2 women,28 to 57 years of age (average,35.4 years).According to the Gustilo classification,there were one type Ⅱand 7 cases of type Ⅲ.Two cases of midfoot fracture were complicated with dislocation of the transverse tarsal joint,4 with dislocation of the tarsometatarsal joint,and 2 with dislocation of both the transverse tarsal joint and the tarsometatarsal joint.The external biplanar mini-fixator was applied to stabilize and maintain lengths of the medial and lateral columns and normal geometry of the foot arch after reduction of the fracture-dislocation.K-wires were used if limited internal fixation was necessary.The external fixator was removed at 12 to 16 weeks postoperatively.The clinical treatment efficacy was assessed by the American Orthopaedic Foot and Ankle Society (AOFAS) midfoot scale and the visual analogue scale (VAS).Results The patients were followed up for an average of 13.4 months (from 10 to 24 months).Postoperative radiological films showed fine reduction of the fractures and dislocations.No reduction was lost after removal of external and internal fixations.They were able to walk independently and had good functional recovery of the injured feet without traumatic arthritis during the follow-up period.Their average AOFAS scores were 65.8 at 3 months after operation,71.3 at 6 months and 80.6 at 12 months; the average VAS scores were 7.5 at 3 months,4.3 at 6 months,and 1.2 at 12 months,respectively.Conclusion In treatment of severe midfoot fracture-dislocation,external biplanar mini-fixator combined with limited internal fixation can perfectly reconstruct and maintain the medial and lateral columns and normal geometry of the foot arch,preventing functional disability caused by foot malformation. Key words: Foot injuries; Fractures, bone; Dislocation; External fixators

Joint-preserving correction of Chopart joint malunions

Injuries to the mid-tarsal (Chopart) joint are frequently overlooked or misinterpreted and therefore, not adequately treated at initial presentation. Malunion results in a loss of essential joint function and a three-dimensional malalignment leading to considerable impairment of global foot function and a rapid development of painful posttraumatic arthritis. If no symptomatic arthritis is present, joint displacement or non-union may be subject to secondary anatomical reconstruction and internal fixation. Bone grafting becomes necessary in cases of non-union or partial avascular necrosis (AVN) of the navicular bone. In most cases joint destruction will have lead to manifest posttraumatic arthritis requiring fusion of the affected joint. Arthrodesis is always combined with axial realignment. Rebalancing of the medial and lateral foot columns is of utmost importance. We have treated 16 patients with joint-preserving correction of the Chopart joint: 6 of the navicular bone, 3 of the talar head, 3 of the anterior calcaneal process, 2 of the cuboid and 2 with combined malunions. Two female patients aged 50 and 67years developed AVN of the navicular bone and required talonavicular fusion and one patient with a nonunion of the anterior calcaneal process needed a second revision surgery to achieve union. The average American Orthopaedic Foot and Ankle Society (AOFAS) score of 12patients increased from 37 preoperatively to 77 at follow-up after an average of 2years. Joint-preserving corrections are generally possible for all four bony components of the Chopart joint in carefully selected cases of malunited fractures and fracture dislocations.

Subtle cavus foot: diagnosis and management.

The subtle cavovarus foot (SCF) is a mild malalignment caused by either primary hindfoot varus or a plantarflexed first ray, resulting in a typical constellation of symptoms because of altered foot mechanics. Key clinical signs are a peek-a-boo heel and a positive Coleman block test. The cavovarus position places lateral ankle soft-tissue structures, such as the anterior talofibular ligament and the peroneal tendons, on stretch during normal gait. This can lead to common conditions such as lateral ankle instability, peroneal tendon tears, and stress fractures of the lateral metatarsals and cuboid. The gait cycle is altered because a greater proportion of time is spent with the transverse tarsal joints locked due to the overall varus foot position. In contradistinction to physiologic valgus at heel strike, which maintains the transverse tarsal joints unlocked and affords approximately 50% force dissipation, the increased rigidity of the foot causes a maldistribution of forces that leads to accelerated wear of the midfoot joints and increased stresses along the plantar fascia and the Achilles tendon insertion. Successful nonsurgical management requires correction of the biomechanical anomaly; surgical management of a subtle cavovarus foot typically is part of a comprehensive plan for correcting the symptoms and the malalignment.

Children’s Orthopaedics

The August 2014 Children’s orthopaedics Roundup360 looks at: Conservative treatment still OK in paediatric clavicular fractures; Femoral anteversion not the usual suspect in patellar inversion; Shoulder dislocation best treated with an operation; Perthes’ disease results in poorer quality of adult life; Physiotherapy little benefit in supracondylar fractures; Congenital vertical talus addressed at the midtarsal joint; Single-sitting DDH surgery worth the effort; and cubitus valgus associated with simple elbow dislocation

AB1006 Evaluation of Clinical and Ultrasound Findings in Subtalar and Midfoot Disease in Rheumatoid Arthritis in Hong Kong: A Pilot Study

BackgroundApproximately 90% of Rheumatoid Arthritis (RA) patients report foot-related complaints within 10 years of disease onset. More than one-third of patients have significant disease in the feet. Athritis of the...

Brief communication: Cineradiographic analysis of the chimpanzee (Pan troglodytes) talonavicular and calcaneocuboid joints.

During terrestrial locomotion, chimpanzees exhibit dorsiflexion of the midfoot between midstance and toe-off of stance phase, a phenomenon that has been called the "midtarsal break." This motion is generally absent during human bipedalism, and in chimpanzees is associated with more mobile foot joints than in humans. However, the contribution of individual foot joints to overall foot mobility in chimpanzees is poorly understood, particularly on the medial side of the foot. The talonavicular (TN) and calcaneocuboid (CC) joints have both been suggested to contribute significantly to midfoot mobility and to the midtarsal break in chimpanzees. To evaluate the relative magnitude of motion that can occur at these joints, we tracked skeletal motion of the hindfoot and midfoot during passive plantarflexion and dorsiflexion manipulations using cineradiography. The sagittal plane range of motion was 38 ± 10° at the TN joint and 14 ± 8° at the CC joint. This finding indicates that the TN joint is more mobile than the CC joint during ankle plantarflexion-dorsiflexion. We suggest that the larger range of motion at the TN joint during dorsiflexion is associated with a rotation (inversion-eversion) across the transverse tarsal joint, which may occur in addition to sagittal plane motion.

Risk of osteoarthritis secondary to partial or total arthrodesis of the subtalar and midtarsal joints after a minimum follow-up of 10 years

IntroductionThe goal of this retrospective, multicentre study was to evaluate the long-term outcomes in patients who have undergone partial or total arthrodesis of the subtalar and midtarsal joints. HypothesisSecondary osteoarthritis of the adjacent joints can negatively affect the outcomes more than 10 years after these fusion procedures. Material and MethodsThe outcomes of 72 fusions (total: 22; partial: 50) performed between 1981 and 2002 were evaluated using the Maryland Foot Score (MFS), self-evaluation questionnaire and three weight-bearing X-ray views (Meary's with cerclage wire around heel, lateral and dorsoplantar). The average follow-up was 15±5 years (range 10–31). ResultsThere were two deep infections that resolved after lavage and antibiotics therapy. There were 21 early complications (10 complex regional pain syndrome, 7 delayed wound healing, 2 superficial infections, 2 venous thrombosis) that all resolved. There were five cases of non-union (6.9%) that healed after being re-operated. After five years, secondary osteoarthritis led to the fusion being extended to the tibotalar joint (1 case) and midtarsal joint (1 case). At the last follow-up, the average MFS was 71.5 (range 25–100). Patient deemed the result as either excellent (10%), very good (9%), good (55%), poor (19%) or bad (7%). Pain at the last follow-up was present in 84% of cases. The rear-foot was normally aligned in 45% of cases, varus aligned in 22% and valgus aligned in 33%. The MFS was significantly better in patients with normal alignment. Patients with neurological foot disorders had significantly more preoperative (80% cavovarus) and postoperative foot deformity (P<0.05). At the last follow-up, the rate of secondary osteoarthritis in the surrounding joints was elevated: 73% tibiotalar, 58.3% subtalar, 65.8% talonavicular, 53.5% calaneocuboid. The presence of osteoarthritis was not correlated with pain or lower MFS. However there was significantly more pain at last follow-up than at 12 months postoperative and two fusions were required in patients with secondary osteoarthritis. ConclusionAlthough partial or total arthrodesis of the subtalar and midtarsal joints is a reliable procedure, it induces secondary osteoarthritis. Even though it seems to be well tolerated more than 10 years after the initial procedure, this possibility must be discussed with young, active patients. Level of evidenceIV, retrospective study.

Intraarterial Injection of Indocyanine Green for Evaluation of Peripheral Blood Circulation in Patients with Peripheral Arterial Disease

To assess the peripheral blood flow of patients with peripheral arterial disease (PAD) by indocyanine green (ICG) arteriography (ICGA) with intraarterial injection of ICG and evaluate the efficacy of the ICGA tests. This study was undertaken from a retrospective review of patients with PAD who underwent ICGA tests during digital subtraction angiography (DSA) between November 2012 and June 2013. We defined some ICGA parameters as the magnitude of intensity of ICG, the time to maximum intensity, and the time from fluorescence onset to half the maximum intensity (T1/2). The ICGA parameters were evaluated in 2 regions, named regions of interest (ROIs). ROI 1 was part of the dorsum of the foot from the Chopart joint to the Lisfranc joint. ROI 2 was in the distal region of the first metatarsal bone and compared with the ankle-brachial pressure index (ABI), ankle pressure, toe-brachial pressure index, and toe pressure. A total of 22 limbs in 16 patients with PAD underwent ICGA tests during DSA. The T1/2 on ROI 2 was the most correlated with the ABI (ρ=-0.622, P=0.003). A value of T1/2 for ROI 2>10 sec was significantly correlated with an ABI value of <0.7 (sensitivity: 0.85, specificity: 1.0). By measuring the value of T1/2 in ROI 2, ICGA tests can be performed to assess the peripheral blood circulation during DSA. ICGA tests might help to promptly assess the peripheral blood flow during endovascular treatment procedures.

The use of the fastrak system to evaluate the independent movements of ankle, subtalar and midtarsal joints during walking

The use of the fastrak system to evaluate the independent movements of ankle, subtalar and midtarsal joints during walking

A Comparative Study between Taping and Medial Arch Support on EMG Activity of Selected Foot Muscles in Individuals with Flexible Flat Foot

Background & Objective: Loss of medial longitudinal arch or excessive pronation of the subtalar and midtarsal joints is associated with abnormal biomechanics and leads to overuse injuries of the lower limb. These injuries tend to occur gradually over a period of time as a result of soft tissue creep and hysterisis from repeated loading. The intrinsic and extrinsic foot muscles work out of phase and prolong their activity in order to stabilize the foot. Physiotherapy treatment involves the application of anti-pronation taping and temporary orthotics in order to alleviate patient's symptoms. Low Dye taping generates a supinating force and is designed to support the medial longitudinal arch. Temporary foot orthosis also has an anti-pronation effect and has been extensively used. Thus this study aimed to compare and analyze the EMG activity of Tibialis Anterior and Peroneus Longus with modified Low Dye taping as opposed to with medial arch support.

Fractures of the sustentaculum tali

Anatomical reconstruction of displaced sustentaculum tali fractures via a direct medial approach. Displaced fractures of the sustentaculum tali with incongruity or depression of the medial facet of the subtalar joint, entrapment of the flexor hallucis longus or flexor digitorum longus tendons, fracture line extending into the posterior facet of the subtalar joint. Infected or grossly contaminated soft tissue, severely restricted vascular supply to the foot, high perioperative risk. Direct medial approach over the sustentaculum tali, retraction of the tendons, joint exploration, fracture reduction using the medial facet and cortical outline as guidelines, fracture fixation with two small fragment screws from medial to lateral directed slightly plantarly and posteriorly. Fractures with depression of the medial facet as a whole can alternatively be reduced and fixed percutaneously. Lower leg splint for 5-7 days, partial weight-bearing with 20 kg for 6-8 weeks (until radiographic signs of consolidation) in the patient's own shoewear, early range of motion exercises of the ankle, subtalar and mid-tarsal joints. Over a course of 15 years, 31 patients were treated operatively for sustentacular fractures. In all, 27 patients (87%) had additional fractures to the same foot and ankle. Eighteen patients with a mean age of 41 years treated at our institution with screw fixation for a unilateral fracture of the sustentaculum tali could be followed for a mean of 80 months (range 15-151 months). No wound healing problems or infections were seen with the medial approach. At the time of follow-up, 15 sustentaculum tali fractures had an average Foot Function Index of 21.6 and an average AOFAS Ankle-Hindfoot Score of 83.6. Patients with isolated fractures of the sustentaculum tali had significantly better scores than those with additional injuries. In 1 patient, an additional lateral process fracture of the talus required subtalar fusion due to persistent pain. Care must be taken not to overlook these atypical calcaneal fractures and accompanying injuries to the mid-tarsal joint and the lateral talar process as seen in 45% and 23%, respectively, in the present series.