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Sustentacular-talar tarsal coalitions can be difficult to detect radiographically. The sustentacular-talar articulation is a part of the talocalcaneonavicular joint. Thus, arthrography of this joint, combined with tangential views of the sustentaculotalar articulation (Harris views), provides a new and simple method to detect or exclude talocalcaneal tarsal coalitions.
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We report four cases in which radiographic features of a fracture of the lateral malleolus and talar tilt of varying severity were associated with a displaced fracture of the calcaneum. In two cases, the initial diagnosis was of a primary ankle injury which led to inappropriate initial management. Gross fracture subluxation of the posterior subtalar joint had occurred in all four cases but could only be fully appreciated after CT examination of the hindfoot. Operative reduction and internal fixation of the calcaneal fracture led to spontaneous reduction of the talar displacement. The association of a swollen hindfoot, talar tilt and a flake fracture of the lateral malleolus must alert clinicians to this injury.
Rheumatoid arthritis frequently involves the foot and ankle, resulting in pain, deformity, and difficulty with ambulation. This article outlines clinical, radiographic, and gait evaluation in the management of foot and ankle problems in rheumatoid arthritis. Conservative nonsurgical management of foot deformities is presented including available shoewear and orthotic options. Surgical considerations including indications, biomechanic implications, and specific operative procedures are discussed.
Up to now there was no publication describing a combined instability of the calcaneocuboid and lateral ankle joint. A 38 years old teacher (a former gymnast) complained about increasing giving way symptoms and pain at the lateral foot and ankle. Because of this, he was unable to take part in sports activities. Clinical investigation revealed lateral ankle and calcaneocuboid joint instability. Surgical treatment was done using periosteal flap augmented capsular reefing for both joints, resulting in full ability in sport and profession four months later.
Injuries to the tarsometatarsal joint involving fracture dislocations are uncommon and are often referred to as Lisfranc lesions after the French field surgeon in the Napoleonic Wars. Despite the infrequency of this serious injury, they have the potential for chronic disability and require prompt, accurate diagnosis and precise anatomic reduction to minimize long term disability. A review of the literature shows that opinions differ as to the most appropriate method of treatment for these injuries, be it closed or open reduction, but most authors agree that it is imperative to achieve precise anatomic reduction.
Twenty-three patients with Lisfranc fracture dislocation of the foot were reviewed at an average of 19.4 months following injury. Results were assessed by a subjective questionnaire, physical examination, and radiographic analysis. There were 10 good (43.5%), 10 fair (43.5%), and 3 poor (13.0%) results. A subgroup of 11 patients underwent gait analysis in the pathokinesiology laboratory. No patient had a normal gait following a displaced Lisfrance fracture. Limp was thought to be due to a prolonged hindfoot period, and a delayed and shortened period of weight transfer through the midfoot to the forefoot as a result of pain inhibition. The best results both clinically and by gait analysis were achieved in those patients who had anatomic reductions.
Dislocation of the talonavicular joint is rare, caused by severe abduction or adduction of the forefoot. Proper reduction is necessary to avoid equinovarus deformity, ankylosis, or degenerative arthritis. A case of talonavicular dislocation with fracture of the head of the talus in a 52-year old woman is reported, with delayed treatment by open reduction using Kirschner wires and casting for 7 weeks. This patient is successfully employed as a waitress 2 years postinjury.
The goal of this project was to develop a computer simulation of normal human walking that would use as driving moments resultant joint moments from a gait analysis. The system description, initial conditions and driving moments were taken from an inverse dynamics analysis of a normal walking trial. A nine-segment three-dimensional (3-D) model, including a two-part foot, was used. Torsional, linear springs and dampers were used at the hip joints to keep the trunk vertical and at the knee and ankle joints to prevent nonphysiological motion. Dampers at other joints were required to ensure a smooth and realistic motion. The simulated human successfully completed one step (550 ms), including both single and double support phases. The model proved to be sensitive to changes in the spring stiffness values of the trunk controllers. Similar sensitivity was found with the springs used to prevent hyperextension of the knee at heel contact and of the metatarsal-phalangeal joint at push-off. In general, there was much less sensitivity to the damping coefficients. This simulation improves on previous efforts because it incorporates some features necessary in simulations designed to answer clinical science questions. Other control algorithms are required, however, to ensure that the model can be realistically adapted to different subjects.
The prevalence of osseous fragments in different limb joints was analysed in 3749 young Warmblood riding horses, which were pre-selected for sale at auction from 1991 to 1998 by the Association of Hanoverian Warmblood Breeders (Verband hannoverscher Warmblutzüchter e.V.) in Verden (Aller), Germany. The evaluation of these horses was based on a standardized radiological examination, including the distal interphalangeal (DIJ), the proximal interphalangeal (PIJ), the metacarpo- and metatarsophalangeal (MC/MTJ) and the tarsocrural joints (TCJ). In 32% of all horses at least one osseous fragment was found on these radiographs. TCJ were affected in 9.6% of the horses and MC/MTJ in 20.7%. The percentage of horses affected in the MTJ was significantly higher (13.7%) than that of horses affected in the MCJ (9.5%). The prevalences of osseous fragments were considerably lower in DIJ (4.5%) and PIJ (0.9%). Osseous fragments only occurred either in DIJ or PIJ or MC/MTJ or TCJ in 87% of the affected horses. Depending on the joint type, osseous fragments were found in analogous joints in the front and the hind limbs in up to 26% of the affected horses, whilst bilateral affection occurred in between 10% and 46% of the horses. Distribution of osseous fragments in the limb joints investigated here did not differ significantly between male and female horses. There was a significant increase in the percentage of horses with osseous fragments in MC/MTJ during the study period. The results of this study indicate the need to act against the high prevalences of osseous fragments in the limb joints of young Warmblood riding horses.
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PURPOSE: To evaluate the diagnostic capabilities of magnetic resonance (MR) imaging in the tarsometatarsal ([TMT] Lisfranc) joint with close anatomic correlation. MATERIALS AND METHODS: Six normal cadaveric feet were imaged by using T1-weighted spin-echo (oblique axial) and three-dimensional spoiled gradient-recalled acquisition in the steady state ([SPGR] coronal, sagittal) sequences. Subsequently, gadolinium-enhanced arthrography was performed in three specimens followed by T1-weighted spin-echo and SPGR MR imaging. Specimens were sectioned in all three planes followed by correlation of the MR imaging results with gross anatomic findings. RESULTS: In all specimens, the oblique axial and, less effectively, the coronal and sagittal planes allowed visualization of the Lisfranc ligament. Intermetatarsal ligaments were seen almost exclusively on the coronal images, and TMT ligaments on the sagittal images. Bone alignment could be assessed on the oblique axial images. CONCLUSION: MR imaging reliably depicts the anatomy of the TMT joint including ligamentous and osseous structures.
Using computer-assisted techniques, this study analyzes the mean contact area of the articular surface of the second tarsometatarsal joint. The articular contact area decreased proportionate to the displacement in both males and females, but it was consistently greater in males than in females for all simulated displacements. The reduction in the contact area was the highest with dorsolateral displacement compared with the lateral and dorsal displacements. Dorsolateral displacement of the second metatarsal of 3 mm led to 38.6% reduction in the contact area, compared with 33.1% and 20.2% reduction with lateral and dorsal displacements, respectively. This study shows that even minor degrees of displacement not apparent on plain radiographs lead to significant decrease in the contact area of the second tarsometatarsal joint. Careful evaluation of second tarsometatarsal injuries with computed tomography is recommended to detect minor degrees of displacement.
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This case report describes an isolated plantar lateral dislocation of the medial cuneiform. We were able to find only one other similar case reported in the literature. That case had a delayed diagnosis of 5 months and with an associated an avulsion fracture of the second metatarsal base. Dines et al. reported an isolated dorsomedial dislocation at the medial cuneonavicular joint. An irreducible dorsomedial dislocation with the anterior tibialis tendon being trapped between the medial cuneiform and the navicular has been reported. A distal and lateral dislocation of the medial cuneiform was reported in association with displacement of the second to fourth metatarsal and medial fractures of the navicular and cuneiform. The current report differs from previous cases. There was not an associated fracture; the direction of the dislocation was unique and could be reduced closed.
We describe three cases of low-energy injuries to the midfoot resulting in rupture of Lisfranc's ligament without tarsometatarsal injury. Examination of the feet revealed an obvious physical sign only on weightbearing, and all three patients were noted at surgery to have intercuneiform instability in association with a rupture of Lisfranc's ligament.
A case of isolated dorsal midtarsal (Chopart) dislocation resulting from blunt trauma is reported. The mechanism of injury, management, and long-term outcome are discussed. A 45-year-old inebriated man fell from a 4-m height and landed on his feet. He had immediate bilateral foot and back pain. Radiographs showed a burst fracture of the second lumbar vertebra, a left Pott's fracture, and an isolated dorsal dislocation of the right midtarsal (Chopart) joint. No neurovascular deficits or signs of compartment syndrome were noted. The image intensifier showed the unstable midtarsal joint with dorsal translation of the navicular and cuboid from the talus and calcaneum, respectively. Closed reduction of the midtarsal joint was performed with 2 transfixing 3.5-mm AO cortical screws. The right foot was immobilised in a short leg cast for 6 weeks; screws were removed 14 weeks later. At 76-month follow-up, the patient had returned to work as a construction worker, but still had right midfoot pain on prolonged walking or standing, because of persistent plantar opening up and dorsal ossification of the midtarsal joints and degenerative change at the talonavicular joint. With hindsight, open reduction may have led to a better outcome through repair of the plantar ligamentous structures, especially the plantar calcaneonavicular (spring) ligament.