Diagnosis and Treatment of Peritalar Injuries in the Acute Trauma Setting: A Review of the Literature

The bony and ligamentous structure of the foot is a complex kinematic interaction, designed to transmit force and motion in an energy-efficient and stable manner. Visible deformity of the foot or atypical patterns of swelling should raise significant concern for foot trauma. In some instances, disruption of either bony structure or supporting ligaments is identified years after injury due to chronic pain in the hindfoot or midfoot. This article will focus on injuries relating to the peritalar complex, the bony articulation between the tibia, talus, calcaneus, and navicular bones, supplemented with multiple ligamentous structures. Attention will be given to the five most common peritalar injuries to illustrate the nature of each and briefly describe methods for achieving the correct diagnosis in the context of acute trauma. This includes subtalar dislocations, chopart joint injuries, talar fractures, navicular fractures, and occult calcaneal fractures.

The Receptive and Propulsive Behavior of Human Foot Joints During Running With Different Striking Strategies

Foot structure and kinematics have long been considered as risk factors for foot and lower-limb running injuries. The authors aimed at investigating foot joint kinetics to unravel their receptive and propulsive characteristics while running barefoot, both with rearfoot and with midfoot striking strategies. Power absorption and generation occurring at different joints of the foot in 6 asymptomatic adults were calculated using both a 3-segment and a 4-segment kinetic model. An inverse dynamic approach was used to quantify mechanical power. Major power absorption and generation characteristics were observed at the ankle joint complex as well as at the Chopart joint in both the rearfoot and the midfoot striking strategies. The power at the Lisfranc joint, quantified by the 4-segment kinetic model, was predominantly generated in both strategies, and at the toes, it was absorbed. The overall results show a large variability in the receptive and propulsive characteristics among the analyzed joints in both striking strategies. The present study may provide novel insight for clinical decision making to address foot and lower-limb injuries and to guide athletes in the adoption of different striking strategies during running.

Combined Subtalar and Naviculocuneiform Fusion for Treating Adult Acquired Flatfoot Deformity With Medial Arch Collapse at the Level of the Naviculocuneiform Joint

Background: A challenge in treating acquired flatfoot deformities is the collapse of the medial arch at the level of the naviculocuneiform (NC) joint. Triple fusions, being a treatment option, may lead to problems such as increased foot stiffness. We thus established a method that combines subtalar (ST) fusion with NC fusion while preserving the Chopart joint. We analyzed the radiographic correction, fusion rate, and patient satisfaction with this procedure. Methods: 34 feet in 31 patients (female, 23; male, 8; age 67 [45-81] years) were treated with a ST and NC joint fusion. In 15 cases, a medial sliding-osteotomy was additionally necessary to fully correct hindfoot valgus. The following radiographic parameters were measured on weightbearing radiographs preoperatively and at 2 years: talo–first metatarsal angle, talocalcaneal angle, calcaneal pitch, talonavicular coverage angle and calcaneal offset. Fusion was radiologically confirmed. Results: All parameters, except the calcaneal pitch, showed a significant improvement. Fusion was observed after 1 year in all but 2 cases (94.1%). One nonunion each occurred at the ST and NC joint without needing any subsequent treatment. One patient developed avascular necrosis of the lateral talus with need for total ankle replacement after 1 year. All patients were satisfied with the obtained results. Conclusion: Our data suggest that a combined fusion of the ST and NC joint was effective and safe when treating adult acquired flatfoot with collapse of the medial arch at the level of the NC joint. Although the talonavicular joint was not fused, its subluxation was significantly reduced. Level of Evidence: Level IV, case series.

Incidence and Characteristics of Midfoot Injuries

Background: The epidemiology of midfoot injuries is poorly known. It has been estimated that the incidence of Lisfranc injuries (intra-articular injury in the tarsometatarsal joint) is 1/55 000 person-years and the incidence of Chopart injuries (intra-articular injury in the talonavicular and calcaneocuboidal joint) 4/100 000 person-years. The purpose of our study was to assess the computed tomography (CT) imaging–based incidence (per 100 000 person-years) and trauma mechanisms of midfoot injuries. Methods: All CT studies performed due to acute injury of the foot and ankle region between January 1, 2012, and December 31, 2016, at Tampere University Hospital were reviewed. Patients presenting with an injury in the midfoot region in the CT scan were included in this study, and their records were retrospectively evaluated to assess patient characteristics. Results: During the 5-year study period, 953 foot and ankle CT scans were obtained because of an acute injury of the foot and ankle. Altogether, 464 foot injuries were found. Of these, 307 affected the midfoot area: 233 (75.9%) the Lisfranc joint area, 56 (18.2%) the Chopart joint area, and 18 (5.9%) were combined injuries or miscellaneous injuries in the midfoot. The incidence of all midfoot injuries was 12.1/100 000 person-years. The incidence of Lisfranc injuries was 9.2/100 000 person-years. The incidence of Chopart injuries was 2.2/100 000 person-years. Conclusions: The incidence of Lisfranc injuries was higher and the incidence of Chopart injuries lower than previously estimated. More than two-thirds of the midfoot injuries in this study were nondisplaced (<2 mm displacement in fracture or joint) and were caused by low-energy trauma. Level of Evidence: Level III, epidemiologic study.

Subtalar and Naviculocuneiform Fusion in Treating Adult Acquired Flatfoot Deformity with Medial Arch Collapse at the Level of the Naviculocuneiform Joint

Category: Midfoot/Forefoot Introduction/Purpose: A conflicting problem in treating acquired flatfoot deformities is the break-down of the arch at the naviculocuneiform (NC) joints. After having encountered problems with extended triple fusion, in particular increased stiffness of the foot, we established a rational to combine subtalar (ST) fusion with NC I-III fusion while preserving the talonavicular (TN) and calcaneo-cuboidal (CC) joint. Our hypothesis was that the break-down of the arch at the NC joint can be specifically addressed while sparing the Chopart Joint (TN and CC joint). This, in turn, will allow the patient to accommodate better to the ground while walking. The aim of the study was to analyze the radiographic correction and fusion rate, and to determine patient’s satisfaction with this procedure. Methods: Between 2009 and 2015, a consecutive series of 34 feet in 31 patients (female, 23; male, 8; age 67 [45-81] years) were treated by combining a fusion of the subtalar joint with a NC fusion. Both joints were exposed through a medial approach. Two 7.5mm-screws were used for ST fusion, and two 5.5mm-screws were used for NC fusion. In addition an anatomically contoured plate was used as a medio-plantar tension bending support of the NC joint. In 15 patients, an additional medial sliding-osteotomy was done to fully correct valgus misalignment of the hindfoot. The following measures were taken on standard weight-bearing radiographs including hindfoot alignment view preoperatively and at 2 years: the talus-first metatarsal angle, the talocalcaneal angle, the calcaneal pitch, the talonavicular coverage angle, the talus-first metatarsal angle, and calcaneal offset. Bony fusion was confirmed on plain radiographs. If no trabeculation was visible, a CT scan was performed. Results: All radiographic parameters, except the calcaneal pitch, showed a statistically significant improvement (Table 1). Solid fusion at the arthrodesis site was observed between 8 and 12 weeks in all but 2 cases (94.1%). One nonunion occurred at the ST joint and one at the NC joint. No interventions were necessary as both cases were asymptomatic. One patient developed an avascular necrosis of the lateral talus with need for a total ankle replacement after one year. All patients were satisfied with the results of this procedure and stated that they would undergo the surgery again. All patients were able to wear normal shoes without insoles. Conclusion: Our results show that a combined fusion of the subtalar and NC joint is an effective and safe technique in treating the adult acquired flatfoot with collapse of the medial arch at the level of the NC joint. The deformity was corrected in all three planes. Even though the TN joint was not fused, its subluxation was significantly reduced. Although our radiographic results are promising, a clinical follow-up study is necessary to quantify the clinical benefit of this procedure.