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BACKGROUND: Isolated subtalar and talonavicular joint arthrodeses have been associated with adjacent joint arthritis and altered hindfoot kinematics during simplified loading scenarios. However, the effect on kinematics during dynamic activity is unknown. This study assessed changes in subtalar and talonavicular kinematics after isolated talonavicular (TNiso) and subtalar (STiso) arthrodesis, respectively, during stance simulations. METHODS: Fourteen midtibia specimens received either a TNiso or STiso arthrodesis, with 7 randomized to each group. A 6-degree-of-freedom robot sequentially simulated the stance phase for the intact and arthrodesis conditions. Bootstrapped bias-corrected 95% CIs of the talonavicular and subtalar joint kinematics were calculated and compared between conditions. RESULTS: The TNiso decreased subtalar inversion, adduction, and plantarflexion in late stance (P < .05). The subtalar range of motion in the sagittal and coronal planes decreased by 40% (P = .009) and 46% (P = .002), respectively. No significant changes in talonavicular joint kinematics were observed after isolated subtalar arthrodesis; however, the range of motion was reduced by 61% (P = .007) and 50% (P = .003) in the coronal and axial planes, respectively. CONCLUSION: In this model for arthrodesis, changes in subtalar kinematics and motion restriction were observed after isolated talonavicular arthrodesis, and motion restriction was observed after isolated subtalar arthrodesis. Surprisingly, talonavicular kinematics did not appear to change after isolated subtalar arthrodesis. CLINICAL RELEVANCE: Both joint fusions substantially decrease the motion of the reciprocal adjacent joint. Surgeons should be aware that the collateral costs with talonavicular fusion appear higher, and it has a significant effect on subtalar kinematics during the toe-off phase of gait.

Assuntos

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The modified Lapidus procedure (MLP), which consists of fusion between the first metatarsal (M1) and medial cuneiform, has been widely performed with satisfactory clinical outcomes, but it has a variable nonunion rate ranging between 4% and 10% and loss of correction in up to 5.8% of the cases. Excessive motion around the site of tarsometatarsal arthrodesis, specially at the intercuneiform joint, is probably the reason. The original Lapidus procedure (OLP), which includes fusion of the M1 to second metatarsal (M2), may be beneficial in preventing nonunion and recurrence. The objective of this study was to describe intraoperative technical tips in the OLP to improve M1 to M2 fusion, which may prevent complications. Since the Lapidus procedure continues to gain popularity, it is the authors opinion that the OLP requires special attention because it is a more technically demanding surgery compared to the MLP.Level of Evidence: Level V: Expert opinion.

Assuntos

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Utilization of the talonavicular joint (TN) arthrodesis as an isolated procedure or in combination with hindfoot arthrodesis has been described in the literature for treatment of numerous hindfoot conditions. When used in isolation or with concomitant hindfoot arthrodesis, the TN joint has demonstrated nonunion rates reported as high as 37% in the literature. Despite previous research, there remains a lack of agreement upon the ideal fixation technique for TN joint arthrodesis with and without concomitant subtalar joint arthrodesis. The purpose of this study was to retrospectively compare the radiographic and clinical results of TN joint arthrodesis as part of double arthrodesis procedure utilizing 4 separate fixation constructs in the treatment of advanced hindfoot malalignment in stage III adult-acquired flatfoot deformity. We retrospectively reviewed 105 patients who underwent TN joint arthrodesis as part of double arthrodesis procedure utilizing 4 separate fixation constructs. Our results demonstrated a nonunion rate of 16.2%, with 17 nonunions identified within our patient population. One (2.4%) nonunion was observed in the 3-screw cohort, 7 (33.3%) nonunions were observed in the 2-screw cohort, 4 (16.0%) nonunions were observed in the 2-screw plus plate cohort, and 5 (29.4%) nonunions were observed in the 1-screw plus plate cohort. The difference in nonunion rate between the 4 cohorts was statistically significant. Based on these results, we conclude that the use of a 3-screw construct for TN joint arthrodesis as part of double arthrodesis procedure demonstrates a statistically significant reduction in nonunion rate and should be considered a superior fixation construct for this procedure.

Assuntos

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Arthrodesis of the first metatarsal-medial cuneiform articulation is a reliable and effective surgery for correction of hallux abducto valgus deformity. However, one potential relative contraindication to the procedure is the extended period of non-weightbearing immobilization that is typically associated with the postoperative course. The objective of this investigation was to perform a systematic review of the incidence of nonunion after early weightbearing in patients who underwent arthrodesis of the first metatarsal-medial cuneiform articulation for correction of a hallux abducto valgus deformity. We performed a review of electronic databases with the inclusion criteria of retrospective case series, retrospective clinical cohort analyses, and prospective clinical trials with 15 or more participants; a mean follow-up period ≥12 months; a postoperative early weightbearing protocol (defined as ≤2 weeks); a clear description of the fixation construct; and a reported incidence rate of nonunion. Eight studies met our inclusion criteria, with a total of 443 arthrodeses analyzed. Of these, 16 (3.61%) were described as developing a nonunion. This would likely be considered an acceptable rate of nonunion when considering this procedure and might indicate that the Lapidus procedure does not always require an extended period of postoperative non-weightbearing immobilization.

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Arthrodiastasis of the calcaneocuboid joint after medial double arthrodesis has been described, but the extent remains unreported. We present our comparative findings after medial double and Lapidus fusion on the effects of the calcaneocuboid joint. Adults undergoing medial column fusion with internal fixation and a minimal clinical and radiographic follow-up period of 3 months were included. Subjects were excluded for Charcot deformity, previous arthrodesis surgery, and history of calcaneocuboid joint trauma or surgery. Although 52 patients were identified, 32 (mean age 56.69 ± 12.56 years; 11 males) met the study criteria (15 medial double and 17 Lapidus procedures). The height of the calcaneocuboid joint on the lateral radiograph and width of the calcaneocuboid joint on the anteroposterior radiograph were measured postoperatively and fixed, given the overlap often noted preoperatively in flatfoot deformities. The joint depth was measured at 3 points and averaged both preoperatively and postoperatively on lateral and anteroposterior radiographs. The volume of the calcaneocuboid joint (mm(3)) was the primary endpoint. Medial column fusion elicited a statistically significant mean increase of 32% in calcaneocuboid joint diastasis (p < .001). The percent change in diastasis volume was statistically different between the medial double (61.90% ± 40.59%) and the Lapidus (5.71% ± 14.84%, p < .001) fusion procedures. These results confirmed our hypothesis that arthrodesis of the more proximal medial column joints would produce greater lateral column arthrodiastasis. Adding to the published data, medial double arthrodesis increased the volume of the calcaneocuboid joint by 62%.

Assuntos

Assuntos

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OBJECTIVE: The objectives of this present case study are to report a rare combination of a displaced talar neck fracture with a compression fracture of the calcaneocuboid joint in a 5-year-old child and to describe its radiological features, surgical treatment and clinical outcome. A 5-year-old male boy was injured in a car accident in which his left foot underwent one of the tires. On arrival at the hospital, a displaced talar neck fracture associated both with a cuboid fracture and compression of the articular surface of the cuboid at the calcaneocuboid join was identified. Fractures were fixed surgically. Leg was protected with a below-knee plaster split immobilization and non-weight-bearing for 5 weeks. After that period, the patient initiated a rehabilitation protocol with active and passive motion exercises. DISCUSSION: Fractures and fracture dislocations at the mid-tarsal joint have an important impact on the global foot function because malunion can result in post-traumatic arthritis and three-dimensional deformities of the foot. If a cuboid compression fracture is not reduced properly, it can result in the shortening of the lateral column with the development of an abduction, pronation and flat foot deformity. A talar neck fracture, if unreduced, can result in medial column displacement and rotational dislocation of the talar head, leading to a subluxation in the talonavicular joint with severe restriction of foot function. With early surgical treatment and open reduction and internal fixation, our patient recovered from the accident without having symptoms of pain, avascular necrosis, postoperative foot deformities or neurovascular deficits. CONCLUSIONS: The combination of a displaced talar neck fracture with a compression fracture of the calcaneocuboid joint in children usually requires correct diagnoses and early treatment with anatomic reduction and internal fixation to prevent severe post-traumatic deformities. LEVEL OF EVIDENCE: V.

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Background: Trauma to the canine foot may result in injury to soft tissue or bone or both. Foot injury often results in fractures and joint instability because of disruption to carpal or tarsal ligaments. Several fixation methods have been described for stabilizing tarsometatarsal arthrodesis. The aim of this paper is to report the case of a unilateral tarsometatarsal arthrodesis with use of circular skeletal fixator on the left pelvic limb of a dog. Case: A 5-year-old intact male dog weighting 25 kg was referred to the veterinary hospital with a left tarsal degloving injury. The previous history revealed that the dog had been bitten by another dog seven days prior to the referral. On physical exam it had swelling and severe pain on the left foot, crepitus of the intertarsal/tarsometatarsal region, instability, bone exposure and myiasis larvae on the wound. The dog was non-weight-bearing on the affected limb. No other abnormalities were found. Radiographs revealed it to be an open fracture of the left tarsal distal line with tarsometatarsal luxation. Adherent dressings were changed for seven days to minimize the contamination before surgery. The dog was treated by open reduction and internal fixation using a circular skeletal fixator. After general anesthesia was induced, a lateral approach to the tarsometatarsal joint was made. The tarsometatarsal joint then was exposed. Articular cartilage was removed with a pneumatic burr. Manual reduction was performed. There were placed two rings proximal to the fracture and one distal with Kirschner wires were angled 45° between them through the bone. One of them was a semi-ring in the shape of a horseshoe. The 1,5 mm Kirschner wires were tensioned by a dynamometer loaded at 30 kg. For wound closure a free skin graft from the thorax was used. Articular anchylosis was reached in three months but the implant removal was posterior to that time due to the owner's choice. Discussion: Traumatic injury is the most important cause for fracture and instability of the tarsometatarsal joint and was the cause of injury for this case. Partial arthrodesis is considered the treatment of choice for tarsal instabilities with ligament disruption. Implant problems following union can complicate arthrodeses stabilized with internal fixation, and they may require a second surgery for implant removal. In this case the size of the rings conformed well to the proximal tarsus, and allowed sufficient space for wire placement in the metatarsal bones and did not interfere with ambulation. The dog recovered good limb function soon after the surgery and articular anchylosis was reached within three months as expected. In a study three of ten dogs undergoing tarsometatarsal arthrodesis due to continued lameness after bony union, using a laterally applied plate required a second surgery for implant removal. Implant failure is a common complication of tarsocrural and tarsometatarsal arthrodeses stabilized with bone screws, Steinmann pins or plate fi xation. Tarsometatarsal partial arthrodesis with use of circular skeletal fixator is a proper option for contaminated wounds without enough skin for closure. The limiting factor is the surgeon experience for this choice of fixation, material availability and the owner's commitment with the treatment.

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We conducted an ambispective cohort study of 83 patients with a diagnosis of Lisfranc fracture dislocation from 1993 to 2008. The lesions were classified into two groups: pure dislocations and fracture dislocations of the Lisfranc joint using the Hardcastle-Reschamer classification. The results included the following data: sociodemographic and epidemiologic variables, lesion-related variables, clinical parameters, and the following clinical and functional assessment scales: Baltimore Painful Foot Score, Creighton-Nebraska Health Foundation, American Orthopaedic Foot and Ankle Society (AOFAS), and Hannover Scoring System. Sixty-three patients were treated surgically. Closed reduction and minimally invasive fixation with Kirschner nails were performed in 53 patients (63.9%), and open reduction with a dorsal approach and fixation with Kirschner nails in 10 cases (15.2%). In 46 cases de medial column was fixed, in 61 cases the intermediate column, and in 42 the lateral column. Sixty-six (79.5%) of the patients had complications including both acute and late ones. Regardless of the technique used, the purpose of treatment was the anatomical reduction of the involved joints. Based on our experience, we think that the use of Kirschner nails is effective, as it provides enough stiffness and stability. In general terms, this injury is not as disabling as it had been considered in the literature. Patients consider their discomfort as tolerable and compatible with the demands of their activities of daily living and they may perform their work considering the time limitations.

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Pelvic limb deformities are common in many avian species. Three young birds, including a six-week-old Cockatoo and two three-month-old goslings, were presented with tarsal joint deformities. They were treated with an experimental prototype of a hinged linear external fixator, placed in a transarticular fashion, in order to maintain joint function during treatment. All birds had close to normal leg function at six to ten weeks postoperatively. These results suggest that the hinged external fixator may be a viable treatment option for tarsal joint deformities in young birds.

Assuntos