Outcomes of Selective Arthrodesis Based on Joints Affected in 33 Feet With Müller-Weiss Disease

No consensus exists regarding operative treatment of Müller-Weiss disease (MWD). Its only classification is based solely on Méary's angle and serves neither as guide to management nor prognosis. We report on 33 feet that underwent surgery following failed conservative management. Treatment was directed towards joint(s) involved, as determined by clinical examination, plain radiography and SPECT-CT. Thus, surgery consisted of isolated talonavicular in 6 feet, triple in 8, subtalar and talonavicular in 7, talonaviculocuneiform in 4, talonaviculocuneiform with interpositional tricortical iliac crest graft in 6 and pantalar arthrodesis in 2. PROMIS scores for pain interference and depression decreased significantly (p < .001) with significant accompanying increase in physical function (p = .003). Union occurred in 31 of 33 feet (94%) with complete resolution of pain at an average follow-up of 84 months. Of the 2 nonunions, 1 had fracture through the lateral navicular, and the other marked sclerosis and avascularity of the lateral navicular. We describe our pathways for selecting arthrodesis based on the joints affected. Isolated talonavicular arthrodesis was performed in early stages of MWD, which begins at the talonavicular articulation. When disease extended to both sides of the navicular, we performed talonaviculocuneiform arthrodesis. When considering isolated talonavicular, double medial or triple arthrodesis, there should be adequate cancellous bone stock remaining in the lateral part of the navicular, as determined on medial oblique radiographs and CT scan. In case of inadequate bone stock or fracture through the lateral navicular, talonaviculocuneiform arthrodesis with interpositional iliac crest bone graft is recommended.

Tarsal coalition in adults

Adult tarsal coalition consists in abnormal union of two or more tarsal bones. Reported incidence ranges between 1 and 13%. It is generally a congenital condition, due to dominant autosomal chromosome disorder, but with some acquired forms following trauma or inflammatory pathology. Poorly specific clinical signs and the difficulty of screening on conventional X-ray may lead to diagnostic failure. The present review of tarsal coalition addresses the following questions: how to define tarsal coalition? How to diagnose it? How to treat it? And what results can be expected? There are 3 types of tarsal coalition, according to the type of tissue between the united bones: bony in pure synostosis, cartilaginous in synchondrosis, and fibrous in syndesmosis. Location varies; the most frequent forms are talocalcaneal (TC) and calcaneonavicular (CN), accounting for more than 90% of cases. Cuneonavicular, intercuneal and cuboideonavicular locations are much rarer, at less than 10%. Tarsal coalition is classically painful, often with valgus spastic flatfoot in young adults. The pain is caused by the biomechanical disturbance induced by the bone, cartilage or fibrous bridges which partially or completely hinder hindfoot and/or midfoot motion. Conventional imaging, with weight-bearing X-ray and CT, is standard practice. Weight-bearing CT is increasingly the gold standard, displaying abnormalities in 3 dimensions. Functional imaging on MRI and tomoscintigraphy assess direct and indirect joint impact at the affected and neighboring joint lines. Non-operative treatment can be proposed, with orthoses, rehabilitation and/or injections. But surgery is the most frequent option: either resection of the bony, cartilaginous or fibrous constructs to restore optimally normal anatomy, or arthrodesis in the affected joint line or the entire joint. Surgery can be open, arthroscopic or percutaneous, depending on the severity of the biomechanical impact on the affected and neighboring joints. Resecting the abnormality is the standard practice in all locations if it affects less than 50% of the talocalcaneal joint line and there is no osteoarthritis to impair the functional outcome. Otherwise, fusion is required. Level of evidence: V; expert opinion.

The Role of the Transverse Arch in Progressive Collapsing Foot Deformity

BACKGROUND

The transverse arch (TA) has recently been shown to significantly increase the intrinsic stiffness of the midfoot when coupled with the medial longitudinal arch (MLA). Progressive collapsing foot deformity (PCFD) is a complex deformity that ultimately results in a loss of stiffness and collapse of the MLA. The role of the TA has not been investigated in patients diagnosed with this disorder using weightbearing CT (WBCT). Therefore, this study aims to answer the following questions: (1) Is the curvature of the TA decreased in PCFD? (2) Where within the midfoot does TA curvature flattening happen in PCFD?

METHODS

A retrospective review of weightbearing CT images was conducted for 32 PCFD and 32 control feet. The TA curvature was assessed both indirectly using previously described methods and directly using a novel measurement termed the transverse arch plantar (TAP) angle that assesses the angle formed between the first, second, and fifth metatarsals in the coronal plane. Location of TA collapse was also assessed in the coronal plane.

RESULTS

The TAP angle was significantly higher in PCFD (mean 115.2 degrees, SD 10.7) than in the control group (mean 100.8 degrees, SD 7.9) (P < .001). No difference was found using the calculated normalized TA curvature between PCFD (mean 17.1, SD 4.8) and controls (mean 18.3, SD 4.0) (P = .266). Location of collapse along the TA in PCFD was most significant at the second metatarsal and medial cuneiform.

CONCLUSION

The TA is more collapsed in PCFD compared to controls. This collapse was most substantial between the plantar medial cuneiform and the plantar second metatarsal. This may represent a location of uncoupling of the TA and MLA.

LEVEL OF EVIDENCE

Level III, retrospective case control.

Osteochondrosis in the central and third tarsal bones of young horses

Recently, the central and third tarsal bones of 23 equine fetuses and foals were examined using micro-computed tomography. Radiological changes, including incomplete ossification and focal ossification defects interpreted as osteochondrosis, were detected in 16 of 23 cases. The geometry of the osteochondrosis defects suggested they were the result of vascular failure, but this requires histological confirmation. The study aim was to examine central and third tarsal bones from the 16 cases and to describe the tissues present, cartilage canals, and lesions, including suspected osteochondrosis lesions. Cases included 9 males and 7 females from 0 to 150 days of age, comprising 11 Icelandic horses, 2 standardbred horses, 2 warmblood riding horses, and 1 coldblooded trotting horse. Until 4 days of age, all aspects of the bones were covered by growth cartilage, but from 105 days, the dorsal and plantar aspects were covered by fibrous tissue undergoing intramembranous ossification. Cartilage canal vessels gradually decreased but were present in most cases up to 122 days and were absent in the next available case at 150 days. Radiological osteochondrosis defects were confirmed in histological sections from 3 cases and consisted of necrotic vessels surrounded by ischemic chondronecrosis (articular osteochondrosis) and areas of retained, morphologically viable hypertrophic chondrocytes (physeal osteochondrosis). The central and third tarsal bones formed by both endochondral and intramembranous ossification. The blood supply to the growth cartilage of the central and third tarsal bones regressed between 122 and 150 days of age. Radiological osteochondrosis defects represented vascular failure, with chondrocyte necrosis and retention, or a combination of articular and physeal osteochondrosis.

Morphology variations with medial cuneiform in hallux valgus

The hypermobility of the first tarsometatarsal joint has been identified as a key factor in the development of hallux valgus. Previous research found a link between the tarsometatarsal joint obliquity and the hallux valgus angle. Nevertheless, most studies relied on radiographs that lack 3D evidence. This study used 3D analysis to investigate the morphological differences in the medial cuneiform between hallux valgus and normal feet. In this study, twenty-three hallux valgus feet and twenty-three normal feet were scanned with computed tomography and 3D models of medial cuneiforms were reconstructed. Medial cuneonavicular and the first tarsometatarsal joint surfaces of the medial cuneiform were manually extracted. To obtain the obliquity angle of the medial cuneiform and curvature of the medial cuneonavicular joint, the joint surfaces were approximated to planes and spheres. Furthermore, the orientations of two joint surfaces were accessed through a novel positioning method. No significant difference was found in the cuneiform obliquity between hallux valgus and normal feet. Hallux valgus and normal groups did not differ significantly in any of the medial cuneiform joint orientations. The medial cuneiform in hallux valgus had a larger curvature diameter of the medial cuneonavicular joint (P = 0.029), indicating a flatter surface. The results demonstrated that the generally supported atavism (i.e., tarsometatarsal joint obliquity) does not exist in the hallux valgus feet. A flatter medial cuneonavicular joint surface was found in hallux valgus feet. This study contributes to the comprehensive understanding of the etiological factors with hallux valgus.

Computed tomography and fluoroscopy versus radiographic guidance for internal fixation of simulated dorsomedial-plantarolateral central tarsal bone fractures in nonracehorses

OBJECTIVE

The aim of this study was to assess screw placement in simulated dorsomedial-plantarolateral central tarsal bone (CTB) fractures using two imaging guidance techniques - computed tomography (CT) with fluoroscopy compared to digital radiography alone (DR).

STUDY DESIGN

Experimental study.

SAMPLE POPULATION

Equine cadaver hindlimbs (n = 10 pairs).

METHODS

One tarsus per pair was randomly assigned to have a 4.5 mm cortical screw placed across the CTB using CT and fluoroscopy (CT/F group) or digital radiography alone (DR group). Postoperative CT was performed on all limbs. Variables related to marker placement, procedure time, and screw positioning were recorded and compared using a paired t-test for dependent means (p < .05).

RESULTS

Time for marker placement was longer for the CT/F group (p = .001), with no difference in total procedure time (p = .12). CT/F was not superior to radiography alone (p > .05) for parameters related to screw positioning. Based on the 95% CI, there was greater range in relative screw length using radiography (76.5%-91.2%) versus CT/F (78.4%-84.0%).

CONCLUSION

Internal fixation of CTB fractures can be successfully performed using either technique for imaging guidance. CT and fluoroscopy did not result in faster or more accurate screw placement compared to radiographs alone, except in determining screw length.

CLINICAL SIGNIFICANCE

Mild adjustments in fluoroscopic or radiographic angle appeared to be a point of variability in the perception of screw placement. While CT is recommended for improved understanding of fracture configuration and surgical planning, radiographic guidance may be a suitable alternative for internal fixation of dorsomedial-plantarolateral fractures.

Radiologic foot alignment and clinical outcome after percutaneous drilling for symptomatic accessory navicular in skeletally immature children

Various surgical treatments are available for a symptomatic AN, including percutaneous drilling (PD). PD is reportedly effective for ANs in skeletally immature children. However, no reports have described the foot alignment after PD in skeletally immature children. This study was performed to compare the radiographic parameters between the preoperative period and the final follow-up after PD for symptomatic ANs in skeletally immature children. From October 2013 to December 2020, PD was performed on 13 feet in 10 skeletally immature children. The patients comprised 5 boys and 5 girls with a mean age at surgery of 11.9 years. The mean follow-up period was 14.8 months. We measured 5 radiographic findings preoperatively and at the final follow-up: calcaneal pitch angle (CPA), talocalcaneal angle (TCA), talonavicular coverage angle (TNCA), anteroposterior talo-first metatarsal angle (ATMA), and lateral talo-first metatarsal angle (LTMA). Ten feet were assessed as excellent, 1 as fair, and 2 as poor. Ten unions (76.9%) were achieved among the 13 feet. The mean CPA improved from 16.4 ± 4.1 degrees preoperatively to 18.2 ± 3.4 degrees at the final follow-up, the TCA improved from 43.0 ± 3.7 to 45.2 ± 4.4 degrees, and the TNCA improved from 19.9 ± 4.4 to 15.4 ± 5.0 degrees (P < .05). The ATMA and LTMA were not significantly different between the preoperative period and final follow-up. We found that PD for symptomatic ANs in skeletally immature children was effective treatment, and some radiographic parameters showed significant differences between the preoperative period and final follow-up.

A modified method for reconstruction of posterior tibial tendon after resection of juvenile painful type II accessory navicular

BACKGROUND

The surgical treatment of accessory navicular (AN) is divided into simple resection of AN and Kidner surgery used to reconstruct posterior tibial tendon (PTT) after AN resection. However, both of these procedures have certain disadvantages. Herein, we proposed a modified method to reconstruct PTT and compared the short-term clinical effect of our method with the modified Kidner procedure.

METHODS

We collected data from 23 adolescent children with painful type II AN treated in our department between January 2015 and June 2020. The American Orthopedic Foot and Ankle Society Ankle-Hind foot (AOFAS-AH) Scores, the Meary Angle, and Pitch Angle of the lateral weight-bearing plain radiographs status were recorded before and after the operation to evaluate the treatment outcomes.

RESULTS

In the modified Kidner surgery (MK) group, the median AOFAS-AH increased from 61 (59-68) to 87 (83-91) (P < 0.05); the Pitch angle of the lateral weight-bearing plain radiographs increased from 13.0 (8-18) to 17.4 (14-22), and the Meary angle decreased from 18.3 (14-24) to 14.2 (8-20) (P < 0.05). In the PTT preservation folded suture (FS) group, the median AOFAS-AH increased from 61 (59-68) to 87 (85-91) (P < 0.05); the Pitch angle of the lateral weight-bearing plain radiographs increased from 12.3 (7-18) to 18.4 (15-26), and the Meary angle decreased from 17.8 (13-23) to 5.7 (3-8) (P < 0.05). There was no significant difference in AOFAS-AH postoperative scores between the FS group and MK group; however, the improvement on Pitch and Meary angle of the lateral weight-bearing plain radiographs was significantly better in the FS group than in MK group (P < 0.05).

CONCLUSIONS

For painful type II AN in juvenile patients, the insertion-preserving folding suture procedure had similar short-term results on AOFAS-AH scores but greater improvement in the Meary angle and the Pitch Angle than the modified Kidner method.

LEVEL OF EVIDENCE

III.

Intra-articular Osteoid Osteoma of the Intermediate Cuneiform Bone Causing Articular Degeneration: A Rare Case and Literature Review

Osteoid osteoma of the cuneiform bone is an exceedingly rare and easily missed cause of foot pain. The uncharacteristic and nonspecific radiographs of such intra-articular osteoid osteoma further increase difficulty in making the diagnosis. To date, there has been no description of intra-articular osteoid osteoma of the intermediate cuneiform bone causing articular degeneration in any published literatures. We present a case of intra-articular osteoid osteoma of the intermediate cuneiform bone causing articular degeneration, who underwent curettage, allograft bone graft, and navicular-cuneiform arthrodesis. The patient presented with radiographic bone union, full motor function recovery and pain-free at the 22-month follow-up. This report adds to the existing literature. Intra-articular osteoid osteoma of the intermediate cuneiform bone causing articular degeneration is an exceedingly rare and easily missed cause of foot pain. It proves a complicated and challenging task to identify intra-articular osteoid osteoma. Clinicians should be particularly careful not to exclude the possibility of arthritis and, thus, vigilant when choosing the surgical option.

Tarsal Navicular Bone Stress Injuries: A Multicenter Case Series Investigating Clinical Presentation, Diagnostic Approach, Treatment, and Return to Sport in Adolescent Athletes

BACKGROUND

Tarsal navicular bone stress injuries (BSIs) are considered "high risk" because of prolonged healing times and higher rates of nonunion in adult populations but, to our knowledge, have not been comprehensively examined in adolescent athletes.

PURPOSE

To describe the characteristics of tarsal navicular BSIs in adolescents.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective analysis of patients aged 10 to 19 years with a radiographically diagnosed tarsal navicular BSI was performed at 8 academic centers over a 9-year study period. Age, sex, body mass index (BMI), primary sport, physical examination findings, imaging, treatment, surgical technique, return-to-sport time, and complications were analyzed.

RESULTS

Among 110 patients (mean age, 14.7 ± 2.7 years; 65% female), common primary sports were cross-country/track and field (29/92 [32%]) and gymnastics/dance (25/92 [27%]). Grade 4 BSIs were identified in 44% (48/110) of patients, with fracture lines present on radiography or magnetic resonance imaging. Nonoperative treatment (mean age, 14.4 ± 2.6 years), consisting of protected weightbearing and either a protective boot (69/88 [78%]) or a cast (19/88 [22%]), was trialed in all patients and was successful in 94 patients (85%). Operative treatment (mean age, 17.1 ± 1.4 years) was ultimately pursued for 16 patients (15%). Patients who required surgery had a higher BMI and a higher percentage of fracture lines present on imaging (nonoperative: 36/94 [38%]; operative: 14/16 [88%]). The median time to return to weightbearing, running, and full sport was significantly longer in duration for the operative group than the nonoperative group (P <.05). Complications associated with surgery included 1 case each of delayed union, nonunion, and painful implants, the latter of which required secondary surgery.

CONCLUSION

Adolescent tarsal navicular BSIs were identified most commonly in female patients in leanness sports. Adolescents who required surgery were more likely to be older, have higher BMIs, and have grade 4 BSIs, and they returned to sport within a median of 5 months after single- or double-screw fixation with a low risk of postoperative complications. A better understanding of the presenting signs and symptoms and appropriate diagnostic imaging of navicular BSIs may lead to an earlier diagnosis and improved outcomes.

The painful lateral column of the foot: from back to front

The purpose of this article is to focus attention on the abnormalities which the radiologist may encounter in patients presenting with lateral ankle or foot pain outside of the context of acute trauma. These include anterolateral impingement, subfibular impingement, subtalar instability and tarsal sinus syndrome, tarsal coalition, sural neuromas, peroneal tendon abnormalities, calcaneocuboid instability and occult cuboid fractures, and painful accessory ossicles. The expected and unexpected findings on radiographs, CT, US, and MRI are discussed.

[Application value of imaging examination in the diagnosis of Muller-Weiss disease]

OBJECTIVE

To analyze radiological characteristics of Muller-Weiss disease, evaluate the clinical value of the imaging examination in diagnosis of Muller-Weiss disease.

METHODS

The imaging data of 26 patients with Muller-Weiss disease were collected from September 2015 to August 2020, including 7 males and 19 females, aged 43 to 68 years old with an average of (52.7±4.6) years old. In the X-ray examination observed the shape and position of the navicular bone. The talar-first metatarsal angle(TFM) was measured on the weight-bearing anteroposterior radiograph. The arch angle and angle between mid-axis of talus and mid-axis of the first metatarsal(Meary angle) were measured on the weight-bearing lateral radiographs. The morphology, density, adjacent joint space and position of the navicular bone were evaluated by computed tomography(CT), and magnetic resonance imaging(MRI) was used to observe the shape, signal, cartilage and surrounding soft tissue changes of the navicular bone.

RESULTS

Among 26 patients, 21 cases were unilateral and 5 cases were bilateral;X-ray examination showed that the lateral part of navicular bone of foot was compressed and flattened, showing"comma like"or"drop like", navicular moved to the medial side, partial fragmentation of bone, peripheral articular hyperplasia, uneven density and narrowing of relationship gap. According to Meary angle and deformity degree of the affected foot on the lateral X-ray of the load-bearing foot, Maceira staging was performed. There were 0 cases in stageⅠ, 2 cases in stage Ⅱ, 11 cases in stage Ⅲ, 9 cases in stage Ⅳand 4 cases in stage Ⅴ. CT examination showed bone fragmentation, medial displacement of navicular bone and formation of the talocalcaneal joint. MRI examination showed the irregular shape and uneven signal of navicular bone, narrowing of joint space, talocalcaneal joint surface hyperplasia and cartilage destruction, tarsal joint effusion and swelling of surrounding soft tissue.

CONCLUSION

Muller-Weiss disease has specific imaging manifestation, and an accurate diagnosis can be made based on the patient's age, gender, and clinincal history. Preoperative imaging examination can stage the disease, help clinicians to formulate better surgical plans, and postoperative imaging examination can better evaluate the surgical effect.

[Tuberculous osteomyelitis in the lateral cuneiform bone causing prolonged pain]

Tuberculous osteomyelitis is an uncommon infection. In this case report, a 29-year-old Greenlandic male with increasing pain, swelling and discolouring of his left foot for four months was admitted to the hospital. He had no systemic symptoms. A CT scan of the foot showed a pathological fracture of the lateral cuneiform bone, and a chest X-ray revealed apical infiltrates indicating tuberculosis. Cultivation of bronchoalveolar lavage fluid was positive for Mycobacterium tuberculosis which confirmed the diagnosis of tuberculosis in the lungs and bone. The patient was treated with immobilization of the foot and antitubercular drugs for 12 months.

Operative Outcomes for Accessory Navicular in Adolescents

The purpose of this study is to report the operative outcomes in a consecutive series of adolescent patients with symptomatic accessory navicular (AN). A retrospective review was conducted. Patient characteristics, operative techniques, and outcomes were recorded. Radiographs were used to identify the type of AN, skeletal maturity, and presence of concurrent pes planus. Twenty-two patients and 24 feet were studied. All 22 patients had an excision of the AN, and 19 patients had an additional reefing of the tibialis posterior tendon. At final follow up, 22 cases reported no pain, one had minimal pain, and one reported no change in pain. Symptomatic AN is more common in females. Surgery technique was not correlated with postoperative pain. Surgery eliminated pain in 91% of patients and can be safely performed in athletes with high rate of return to their previous athletic performance. (Journal of Surgical Orthopaedic Advances 31(1):053-055, 2022).

The Bipartite Medial Cuneiform

This report discusses an unusual case of a 23-year-old woman with a painful bipartite medial cuneiform and severe arthritic and cystic changes at the partition with no history of trauma. Magnetic resonance imaging confirmed a large cyst with subchondral erosions at the dorsal and plantar segments with significant bone marrow edema. Definitive treatment consisted of arthrodesis on the dorsal to plantar segments using one lag screw, demineralized bone matrix grafting, and a bone stimulator.

Resection of Tarsal Coalition in 27 Children with 2 Years Follow-Up - Patient-Reported Outcomes Using the Validated Oxford Ankle Foot Questionnaire

BACKGROUND

Patient Reported Outcome Measures (PROM) after resection of tarsal coalitions are sparse. This cross-sectional study evaluates the outcome after resection of tarsal coalitions in children using the validated Oxford Foot and Ankle Questionnaire (OxAFQ).

METHODS

Tarsal coalition patients between 5-16 years of age from Aarhus University Hospital (Denmark) and The Royal London Hospital (United Kingdom) were included. The patients were identified using patient and theatre register. All patients and proxies filled in the PROM: OxAFQ-C and OxAFQ-proxy respectively. The scores were calculated within each domain and reported as means (95% confidence intervals). Talocalcaneal coalitions were compared to calcaneonavicular coalition with regard to OxAFQ score and re-operation rate.

RESULTS

27 patients and their proxies returned 54 questionnaires in total regarding 36 feet. Mean time from surgery to filling of the questionnaire was 25 (21-30) months. The relative mean OxAFQ score was higher in the School and Play and Emotional domain than the Physical domain, p = 0.007. The OxAFQ scores and re-operation rates were similar for both coalitions, p=0.63.

CONCLUSION

The OxAFQ PROM showed more encouraging results in playing or emotional health status than the physical health status. The outcome for both types of coalitions is similar.Level of Evidence: IV.

Accessory Ossicles in the Region of the Foot and Ankle: An Epidemiologic Survey in a Jordanian Population

Background and Objectives: The incidence of accessory bones in the region of foot and ankle is quite variable between studies and are often confused with avulsion fractures in trauma patients with musculoskeletal injuries. The aim of this study was to assess the incidence of accessory ossicles of the foot and ankle according to gender, side and coexistence, and to determine how frequently accessory ossicles were misdiagnosed as avulsion fractures. Materials and Methods: Oblique and/or lateral foot radiographs of 1000 adult patients referred from emergency departments to foot and ankle clinic were retrospectively reviewed for the presence of accessory ossicles. The Kappa statistic was used in order to assess the validity of radiographic interpretation for the presence of these bones. Results: Accessory ossicles were detected in 40.2% of the radiographs. The incidence rates for the accessory ossicles in order of frequency were: Os trigonum (15.4%), accessory navicular (13.7%), os peroneum (11.5%), os vesalianum (1.1%), os supranaviculare (0.7%), os subfibulare (0.6%), os talotibiale (0.4%), os calcaneus secundarius (0.3%), os supratalare (0.3%), os infranaviculare (0.3%), os intermetatarseum (0.2%), and os subtibiale (0.1%). Coexistence of two or three ossicles in the same foot was observed in 4.4% of the cases, mostly coexistence with os peroneum (2.9%), followed by accessory navicular (1.6%). 2.7% of accessory ossicles were initially misdiagnosed as avulsion fractures at emergency departments. Interrater agreement over identification of different accessory ossicles was found to be reasonably reliable, with a Kappa greater than 0.80 for all assessed bones. Conclusions: In clinical practice, a thorough knowledge of normal anatomical variants is essential to facilitate appropriate diagnosis and treatment and can help to prevent diagnostic errors.

Radiographic characteristics and outcomes of simple resection for naviculo-medial cuneiform coalition in adults

BACKGROUND

This study aimed to report the outcomes of coalition resection in adults with naviculo-medial cuneiform (NC) coalition.

METHODS

Seventeen adults (20 feet) who underwent NC coalition resection were identified. The location and morphology of coalitions and five angular parameters, including medial arch sag angle (MASA), were assessed on weightbearing radiographs. Pre- and postoperative visual analogue scale and foot function index were evaluated for clinical outcomes.

RESULTS

Most feet (19 out of 20) had a coalition at the plantar-medial aspect, and there was no radiographic evidence of residual NC joint space compromise. There was no radiographic evidence of medial arch sag (MASA, p = 0.749) or recurrence at the final follow-up (21.7 months, range 12 to 48). Clinical scores improved significantly in all patients.

CONCLUSIONS

Resection of NC coalition in adults can be successful and provides an option to arthrodesis when conservative treatments have failed.

Symptomatic Os Navicular on 99mTc-MDP SPECT/CT

Os navicular bone is an accessory bone of the foot, which is mainly found on the medial side of the proximal navicular bone. Os navicular bone may be symptomatic and cause medial foot pain. We report a case of a 42-year-old athlete male having right foot pain diagnosed with os navicular syndrome on 99mTc-MDP bone scintigraphy SPECT/CT. We emphasize on the use of SPECT/CT in not only allocating the ossicle anatomically, but also for the purpose of evaluating an active source of pain in a region of multiple complex small bones.

Tarsometatarsal stabilization after metatarsal bone amputation for treatment of an aneurysmal bone cyst in a cat

CASE DESCRIPTION

A 5-year-old 4.0-kg (8.8-lb) castrated male domestic shorthair cat was referred because of grade 4/5 left hind limb lameness and swelling in the region of the second metatarsal bone of that limb.

CLINICAL FINDINGS

Computed tomography revealed an expansile osteolytic lesion of the second metatarsal bone associated with a periosteal reaction on the third metatarsal bone. There was no evidence of metastases.

TREATMENT AND OUTCOME

Amputation of the second and third metatarsal bones was performed but resulted in medial instability of the remaining metatarsal bones. The instability was treated by placing a loop of 2-0 monofilament, nonabsorbable suture from a screw placed in the distal row of the tarsal bones to a tunnel in the proximal metaphysis of the fourth metatarsal bone. Clinical reevaluation of the cat 7, 15, 30, 60, 90, and 210 days after surgery and radiographic reevaluation 90 and 210 days after surgery showed complete recovery of the cat. The implants were removed at the time of the 7-month reevaluation. Clinical evaluation 18 months after implant removal showed the treated joint to be stable.

CLINICAL RELEVANCE

The surgical stabilization technique described here provided medial stability of the tarsometatarsal joint after amputation of the second and third metatarsal bones. This method may be an alternative to arthrodesis while maintaining articular function in cats.

Severe Talonavicular Osteoarthritis After a Neglected Navicular Stress Fracture: A Case Report

CASE

A 17-year-old high school rugby player complained of right midfoot pain for 18 months. Radiographs showed severe osteoarthritic changes in the right talonavicular joint. A navicular fracture, talonavicular joint narrowing, a talar head cyst, and proximal navicular fragmentation were detected on computed tomography (CT). The patient underwent removal of the osteochondral fragments and fracture reduction and returned to rugby 8 months postoperatively. CT showed a remodeling of the talonavicular joint 2 years postoperatively.

CONCLUSION

In a young athlete, reconstruction of the talonavicular joint should be attempted before joint fusion, even if the joint shows signs of secondary osteoarthritis.

Isolated Medial Cuneiform Fractures: A Systematic Search and Qualitative Analysis of Case Studies

BACKGROUND

Isolated medial cuneiform fracture is a rare but diagnostically challenging condition. Diagnostic delay in these cases may lead to delays in ideal treatment approaches and prolonged symptoms. An understanding of clinical presentation is needed to expedite diagnosis, facilitate decision making, and guide treatment approach.

METHODS

Case studies/series were searched in four databases until September 2019. Included studies had participants with a history of traumatic closed medial cuneiform fracture. Studies were excluded if the medial cuneiform fractures were open fractures, associated with multitrauma, or associated with dislocation/Lisfranc injury. Three blinded reviewers assessed the methodological quality of the studies, and a qualitative synthesis was performed.

RESULTS

Ten studies comprising 15 patients were identified. Mean ± SD patient age was 38.0 ± 12.8 years, with 86.7% of reported participants being men. The overall methodological quality was moderate to high, and reporting of the patient selection criteria was poor overall. The most commonly reported clinical symptoms were localized tenderness (60.0%) and edema (53.3%). Direct blow was the most common inciting trauma (46.2%), followed by axial load (30.8%) and avulsion injuries (23.1%). Baseline radiographs were occult in 72.7% of patients; magnetic resonance imaging and computed tomography were the most common diagnostic modalities. Mean ± SD diagnostic delay was 64.7 ± 89.6 days. Conservative management was pursued in 54.5% of patients, with reported resolution of symptoms in 3 to 6 months. Surgical intervention occurred in 45.5% of patients and resulted in functional restoration in 3 to 6 months in all but one patient.

CONCLUSIONS

Initial radiographs for isolated medial cuneiform fractures are frequently occult. Due to expedience and relatively low cost, radiographs are still a viable first-line imaging modality. If clinical concern remains, magnetic resonance imaging may be pursued to minimize diagnostic delay. Conservative management is a viable treatment method, with expected return to full function in 3 to 6 months.

Two stage surgical treatment of cuboid osteomyelitis. A case report and review of the literature

Isolated osteomyelitis of the cuboid bone is an extremely rare condition. A 32 year old man was evaluated for a painful and swollen right foot after a penetrating trauma and the presence of a sinus in the lateral aspect the midfoot. MRI findings were consistent with the presence of cuboid osteomyelitis. The patient underwent a two stage procedure which included partial excision of the cuboid bone, the use of a cemented spacer for lateral column length preservation, followed by arthrodesis of the calcaneocuboid joint with a tricortical autologous bone graft harvested from the ilium and preservation of the cuboid-metatarsal joints. At 4 years follow up, the patient is asymptomatic. Diagnosis of isolated cuboid osteomyelitis requires high clinical suspicion and a two stage procedure is an effective approach for symptomatic patients who do not respond to conservative treatment. LEVEL OF CLINICAL EVIDENCE: IV.

Staged Surgical Management of Open Navicular Fracture Secondary to a Gunshot Injury

The management guidelines of gunshot wound (GSW) injuries to the lower extremities have primarily been described more recently in the literature. A navicular fracture with adjacent joint involvement is presented from a GSW with initial external fixation management to prevent loss of anatomical alignment and successful staged definitive treatment with internal fixation. Based on previous experiences with rearfoot joint involvement from GSW injuries, we were able to direct definitive treatment with arthrodesis of violated joints. After a 1-year follow-up, the patient has returned to normal activities without any limitations. This case report demonstrates a stepwise approach to management of an open navicular fracture secondary to a GSW.

Comparison of outcomes of arthrodesis and reconstruction (advancement), posterior tibial tendon with excision of accessory tarsal navicular bone (Kidner procedure) in type 2 accessory navicula

BACKGROUND

The therapeutic outcome of the local arthrodesis surgery for type 2 accessory navicula (AN) is rarely reported. This study aimed to compare the clinical outcomes between Kidner and arthrodesis procedures for type 2 AN.

METHODS

Sixteen patients (20 feet) with symptomatic type 2 AN receiving surgical treatment in our hospital between November 2013 and December 2015 were retrospectively included. Ten patients (13 feet) underwent the Kidner surgery (Kidner group) and 6 patients received local arthrodesis procedure (arthrodesis group). Radiographic indices before/after surgery were compared between the two groups. Patient's satisfaction with surgery outcome was evaluated by patient self-assessment questionnaire.

RESULTS

The calcaneal pitch angle was significantly increased after surgery in both groups (bothp<0.01), while the talocalcaneal coverage angle and lateral talo-first metatarsal angle were not significantly changed after surgery. There was no significant difference regarding the postoperative changes in the three radiographic indices between the two groups. In the arthrodesis group, 3 patients (4 feet) had an excellent outcome, 2 patients (2 feet) a good outcome, and 1 patient (1 foot) had a fair outcome. In the Kidner group, 6 patients (8 feet), 2 patients (3 feet), 1 patient (1 foot) and 1 patient (1 foot) had excellent, good, fair, and poor treatment outcomes, respectively. The rate of good-to-excellent outcomes was comparable between the arthrodesis group and Kidner group (83% vs. 80%, p=0.696).

CONCLUSION

Our results suggested that both the Kidner surgery and arthrodesis surgery were an effective treatment for symptomatic type 2 AN.

Radiological findings of fibrocartilaginous coalition of the third tarsometatarsal joint: a retrospective cross-sectional study with computed tomography and magnetic resonance imaging

BACKGROUND

Fibrocartilaginous coalition of the third tarsometatarsal joint has been indicated as an extremely rare form of tarsal coalition in the radiological literature, and most articles concerned with tarsal coalition do not mention involvement of this joint. Only two reports written in the English language that approach this subject were found, an orthopedic report and an anthropological report.

PURPOSE

To evaluate the prevalence of this finding and discuss and illustrate the radiological characteristics of this coalition.

MATERIAL AND METHODS

A retrospective analysis of 614 computed tomography or magnetic resonance imaging scans of the ankle and/or foot, acquired at a health service within a period of three months, was performed to assess the prevalence of this coalition.

RESULTS

Of the examinations characterized as valid for analysis for the purposes of the study, 17 cases compatible with fibrocartilaginous coalition of the third tarsometatarsal joint were found, thus indicating an involvement of approximately 2.97% of the examined feet.

CONCLUSION

Our radiological findings are typical, and the prevalence found in this study was statistically significant, being similar to that described in the anthropological report (3.2%-6.8%).

[Stress fracture in the first and second cuneiform bone in a 23-year-old female]

This is a case report of a healthy 23-year-old female who developed a stress fracture in the first and second cuneiform bone from training towards physical testing at the police school. Stress fractures in these bones are rare and can therefore be overlooked. This case report highlights that patients without preceding trauma, where suspicion of a fracture is maintained despite negative X-ray findings, should be evaluated for a stress fracture with more advanced imaging such as CT or MRI although the anatomic location is unusual.

Total Loss of the Intermediate Cuneiform by Posttraumatic Avascular Necrosis: A Case Report

We report a unique case of the total loss of the intermediate cuneiform by posttraumatic avascular necrosis resulting from a left foot open fracture and dislocation of the navicular bone and medial and intermediate cuneiforms at the Chopart and Lisfranc joints in a 64-year-old woman. The injury was managed with open reduction and internal fixation with Kirschner wires and cannulated screws. During postoperative follow-up, we observed avascular necrosis of the intermediate cuneiform and the total loss of the bone. An extensive English literature search revealed only one case report published on this topic. Thus, we provide this case study to help guide clinical decision making in the future.

A Case Report of Bilateral Navicular Osteonecrosis Successfully Treated With Medial Femoral Condyle Vascularized Autografts: A Case Report

CASE

A 17-year-old boy with a history of chronic bilateral navicular osteonecrosis with fragmentation was treated with 6-month staged bilateral open reduction and internal fixation of tarsal navicular with debridement of the necrotic bone and ipsilateral medial femoral condyle vascularized bone grafting.

CONCLUSION

The patient progressed to full painless weight-bearing on each extremity by 4 months postoperatively with osseous union of both chronic fracture sites and incorporation of vascularized bone grafts. Patient-Reported Outcomes Measurement Information System (PROMIS) scores were improved from preoperative levels at 6 months from each operation. This patient's atypical presentation of a rare disease was successfully treated with the utilization of vascularized bone grafting to salvage the tarsal navicular and preserve the talonavicular joint, enabling return of function and avoidance of early arthrodesis procedure.

The occurrence of tarsal injuries in male mice of C57BL/6N substrains in multiple international mouse facilities

Dislocation in hindlimb tarsals are being observed at a low, but persistent frequency in group-housed adult male mice from C57BL/6N substrains. Clinical signs included a sudden onset of mild to severe unilateral or bilateral tarsal abduction, swelling, abnormal hindlimb morphology and lameness. Contraction of digits and gait abnormalities were noted in multiple cases. Radiographical and histological examination revealed caudal dislocation of the calcaneus and partial dislocation of the calcaneoquartal (calcaneus-tarsal bone IV) joint. The detection, frequency, and cause of this pathology in five large mouse production and phenotyping centres (MRC Harwell, UK; The Jackson Laboratory, USA; The Centre for Phenogenomics, Canada; German Mouse Clinic, Germany; Baylor College of Medicine, USA) are discussed.

Giant Cell Tumor of Tendon Sheath with Tarsal Bones and Intertarsal Joint Invasion: A Case Report

The giant cell tumor of tendon sheath (GCTTS) is a benign lesion most commonly attached to the tendons and bones of the fingers, hands, and wrists. The involvement of GCTTS to the foot is uncommon. The GCTTS invading tarsal bones and intertarsal joints is not described yet, and the appropriate diagnosis and treatment remain unclear. We report a case of GCTTS with the involvement of tarsal bones and intertarsal joint. Computed tomography scan and magnetic resonance imaging were used to further diagnose and evaluate the quality and range of tumor. The patient was treated with surgical excision of the tumor without application of bone graft. After adequate clearance of the tumor, the patient returned to an asymptomatic walk in 3 months. No malfunction, fracture, or tumor recurrence was found in 2-years follow-up. This report includes clinical, radiologic, histologic diagnostic, and surgical challenges in an unexpected lesion and a review of the literature.

External Fixation Diastasis Management of Kohler's Disease in a 14-Year-Old Boy: A Case Report

A case presentation of an adolescent with tarsal navicular avascular necrosis is presented. External fixation with tarsal navicular diastasis is a simple, straightforward management option to allow osseous regrowth and bone healing. In this case, the external fixator was well tolerated and the patient demonstrated a quick return to function without pain or discomfort. The external fixation technique with tarsal navicular diastasis is an uncommon but effective means of reversing the tarsal navicular avascular process and avoiding an open technique such as arthrodesis.

Measurement of talar morphology in northeast Chinese population based on three-dimensional computed tomography

Morphological data of talus are important for the design of talar prostheses. The talar morphology of Chinese population has been rarely reported. This study adopted a three-dimensional (3D) measurement approach to provide accurate data for the anatomical morphology of talus in Northeast Chinese population and compared it with that of foreigners.One hundred forty-six healthy subjects form Northeast China underwent computed tomography (CT) arthrography. 3D digital talar model was reconstructed and thirteen morphological parameters were measured through Mimics and Magics software. Length and breadth indexes of total talus, trochlea, medial and lateral malleolus articular surface were mainly selected. Statistical analysis was conducted by independent-samples and paired-samples t test through SPSS software.All the indexes were normally distributed. No significant difference between left and right talus was identified in either males or females (P > .05). Most of the indexes showed significant sexual differences except the radian of lateral malleolus articular surface and the posterior breadth of trochlea (P < .05). The talar anatomy of Chinese subjects is different from the published data in other populations.The promising approach adopted in this study addresses some inconvenience with previous conventional methods on cadaver specimens. The geometric parameters of talus in Chinese population differ from those in other populations. The talar measurements and morphology analysis in this study suggest that population characteristics should be taken into account. This study will provide references for the design of talar prostheses in Chinese population.

Closed Distal Dislocation of the Intermediate Cuneiform in a Complex Lisfranc Fracture-Dislocation: A Case Report

CASE

A 21-year-old, active duty male sustained an irreducible, complex Lisfranc fracture-dislocation with distal extrusion of his intermediate cuneiform. He was treated in a staged manner with external fixator placement, followed by an extended midfoot fusion with autograft bone. At 19 months, he could perform all activities of daily living independently with minimal pain using an Intrepid Dynamic Exoskeletal Orthosis.

CONCLUSIONS

Complex Lisfranc injuries are severe and often result in chronic pain and disability after operative management. To our knowledge, this is the only case report describing a Lisfranc fracture-dislocation with a distally extruded intermediate cuneiform treated with a fusion.

A case of erosive polyarthropathy from Medieval northern Italy (12th-13th centuries)

OBJECTIVE

To evaluate and differentially diagnose erosive skeletal lesions located on multiple joints of an individual archaeologically recovered in 2017.

MATERIALS

Skeletal remains of a well-preserved skeleton dating to the 12th-13th centuries from the medieval church of San Biagio in Cittiglio (Varese, northern Italy).

METHODS

Macroscopic and radiographic imaging.

RESULTS

Erosive marginal symmetrical lesions are present on the metatarsophalangeal, metacarpophalangeal and interphalangeal joints of an adult male, aged 55-75 years. Osteolytic changes, in the form of pocket erosions, surface resorptions and pseudocyst formations, are also macroscopically observed on some carpal and tarsal bones and on several large peripheral joints.

CONCLUSIONS

A careful differential diagnosis of the lesions and their macroscopic and radiological appearance is suggestive of a case of rheumatoid arthritis-like polyarthropathy.

SIGNIFICANCE

This case contributes to the debate regarding the antiquity of erosive polyarthropathies, providing additional evidence for the existence of these diseases in the Old World prior to the European discovery of the Americas.

LIMITATIONS

Small sample size limits discussion of the scope of the disease in antiquity.

SUGGESTIONS FOR FURTHER RESEARCH

This case highlights the need for further macroscopic, radiographic, and biomolecular studies of pre-modern European skeletal samples to investigate the hypothesized pre-existence of these pathological conditions in Europe prior to 1492.

Fractures and dislocations of the lisfranc tarso-metatarsal articulation: outcome related to timing and choice of treatment

A Lisfranc injury is when one or more of the metatarsals are displaced from the tarsus. The term is more commonly used to describe an injury to the midfoot, centred on the 2nd tarso-metatarsal joint. These fractures are sometimes easily overlooked, especially if they are part of a polytrauma. They are often difficult to diagnose and treat, but if they go undetected and are not properly treated, they can cause long-term or chronic disability. Our team reviewed a group of 71 patients with a Lisfranc fracture dislocation. The lesions were classified according to Meyerson classification. All the patients were re-evaluated 3 years after their surgeries by clinical examination, Ankle-Hindfoot Scale AOFAS questionnaire, X-rays and baropodometric analysis. This review outlines the treatment outcome of this injury, taking into consideration the timing of diagnosis.

Tarsal coalition in paediatric patients

Tarsal coalition is due to failure of segmentation between two or more foot bones during embryological development at a site where the joint cleft fails to develop. Depending on the nature of the tissue connecting the bones, the abnormality is a syndesmosis, synchondrosis, or synostosis. Although the coalition exists at birth, synostosis usually develops only late during growth. Talo-calcaneal and calcaneo-navicular coalitions account for over 90% of all cases of tarsal coalition. The joint at the site of the coalition is stiff. Pain during physical activity is the main symptom, although recurrent ankle sprain is another possible presenting manifestation. During the physical examination, range-of-motion limitation at the hindfoot or midfoot should be sought, as well as varus or valgus malalignment of the hindfoot. Either pes planus or pes cavus may be seen. Calcaneo-navicular coalition may be visible on the standard radiograph, whereas talo-calcaneal coalition is best visualised by computed tomography or magnetic resonance imaging. As growth proceeds, the coalition becomes ossified and range-of-motion diminishes. Onset of the pain is often in the second decade of life or later. In patients with symptomatic tarsal coalition, the initial management should always consist in non-operative treatment for at least 6 months. A consensus exists that surgery should be offered when non-operative treatment fails. Open resection of the coalition is the treatment of choice, although endoscopic resection is also an option. Sound evidence exists that resection of the coalition can produce favourable outcomes even in the long-term. Fusion should be reserved for failure of resection, extensive coalitions, multiple coalitions, and patients with advanced osteoarthritis.

The relationship of MRI findings and clinical features in symptomatic and asymptomatic os naviculare

AIM

To investigate the relationship between magnetic resonance imaging (MRI) findings and clinical features in patients with os naviculare.

MATERIALS AND METHODS

All patients with a foot or ankle MRI study showing an os naviculare were identified from a specialist orthopaedic hospital between 2014 and 2017. A total of 110 patients with 133 os naviculare were included. The MRI features were recorded, as well as the presence or absence of medial foot pain and/or tenderness over the navicular tuberosity. Fisher's exact test was used for categorical data and unpaired t-tests for continuous data. Specificity and sensitivity were calculated for MRI features.

RESULTS

There were 80 female and 30 male patients with a mean age of 46±1.7 years at time of MRI (range 11-90.6 years). There was a significant correlation between os naviculare oedema (p=0.008) and navicular tuberosity oedema (p=0.001) with a history of medial foot pain. There were significant associations between mean age (p=0.003), type of os naviculare (p=0.004), os naviculare oedema (p<0.001), navicular tuberosity oedema (p=0.001), and soft tissue oedema (p=0.01) with examination findings of tenderness over the navicular tubercle. Oedema of the os naviculare, navicular tuberosity, or soft tissues were found to have a high specificity but low sensitivity for medial foot pain and tenderness.

CONCLUSION

When present, certain MRI findings indicate that an os naviculare is likely to be a cause of patient symptoms, but when absent they do not exclude the possibility of it causing symptoms.

Effectiveness of Nonoperative Treatment of the Symptomatic Accessory Navicular in Pediatric Patients

BACKGROUND

Initial management of symptomatic accessory navicular in pediatric patients is nonoperative. However, efficacy of nonoperative treatment has not been studied or established. If nonoperative treatment is frequently unsuccessful or does not give lasting pain relief, surgery could be offered as first line treatment. This study retrospectively reviewed outcomes of pediatric patients treated nonoperatively for symptomatic accessory naviculae in an effort to provide clinicians success rates for their discussion of treatment options with patients and their families.

METHODS

A retrospective analysis of pediatric patients diagnosed and treated nonoperatively for a symptomatic accessory navicular bone at Cincinnati Children's Hospital Medical Center between dates August 1^st, 2006 and August 24^th, 2016 was performed. Outcome measures consisted of complete pain relief, partial relief without operative intervention, or need for operative intervention. Radiographic imaging for each patient was also used to identify the type of accessory navicular and presence of concurrent pes planus.

RESULTS

A total of 169 patients were included, with 226 symptomatic accessory naviculae. Average age at diagnosis was 11.8 years, with majority females (78%). Type 2 accessory naviculae were most frequent (72.7%), with Type 1 and Type 3 in 9.7% and 17.4%, respectively. Average number of nonoperative trials was 2.1, with 28% experiencing complete pain relief, 30% requiring surgical intervention, and 41% that experienced partial pain relief and did not require surgical intervention, and were recommended as needed (PRN) follow-up based on clinical improvement. Of those that achieved complete pain relief, the average length of non-operative treatment was 8.0 months.

CONCLUSIONS

The results of this study can be used by clinicians to frame discussions surrounding treatment options for symptomatic accessory navicular bones with both patients and their families.Level of Evidence: III.

Pathology and management of flexible flat foot in children

We describe the pathology and treatment of flexible flat foot in children. The flexible flat foot is seen in the overly flexible foot and usually involves hypermobility of the subtalar joint. It typically occurs in childhood and may continue to adulthood. The arch develops spontaneously during the first decade of life in most children and comes within the normal range observed in adult feet. We prescribed orthoses for the treatment of flexible flat foot patients. Lateral weight-bearing radiographs and ultrasonography were helpful for the evaluation of the flat foot. Bleck recommended the UCBL shoe insert in cases of flexible flat foot if the standing or lateral rentgenogram demonstrates a talar plantar flexion angle (TPF) of 45° or greater. Bordelon suggested that cases of flexible flat foot should be treated if the standing or lateral roentgenogram demonstrates a Meary's talo-1st metatarsal angle (T1-MTA) of -15°or greater. However, the radiograph of a young child's foot poses some difficulties in making an accurate evaluation, because of the radiolucent cartilage zone. In this situation, a sagittal image obtained by ultrasonography has proved to be a powerful aid to evaluate the type of the flat foot. We classified the flat foot into three types: talo-navicular sag (T-N sag), naviculo-cuneiform sag (NC sag) and talo-navicular and naviculo-cuneiform sag (Mixed sag) following the criteria of Tachdjian. We recommended the NC sag and Mixed sag groups to be treated by using orthoses, while we kept a status of watchful waiting for the T-N sag group. However, we should consider the increasing complaints of children and their parents during the orthotic treatment. A through discussion between the parents of patients and the pediatric orthopedic doctors is necessary before orthotic treatment is started.

Maximum standardized uptake value of foot SPECT/CT using Tc-99m HDP in patients with accessory navicular bone as a predictor of surgical treatment

Quantitative bone SPECT/CT (single-photon emission computed tomography/computed tomography) using Tc-99m hydroxymethylene diphosphonate is emerging as a useful imaging modality for skeletal diseases. Accessory navicular bone (ANB) has been evaluated by bone scintigraphy only qualitatively and semiquantitatively. However, a truly objective quantitative assessment of ANB is lacking. Here, we measured the maximum standardized uptake value (SUVmax) of the ANB and investigated its usefulness as an imaging biomarker for ANB.Consecutive quantitative bone SPECT/CT studies that had been performed on the foot were retrospectively analyzed. One hundred five patients (male:female = 44:61; median age = 32.0 [range, 11-81] years old; 31 negative controls without ANB and 74 patients with ANB [7 unilateral and 67 bilateral]) and their 210 feet were investigated. The ANBs were classified into types I, II, III (Geist classification), and 0 (contralateral navicular of unilateral ANB). Type II ANBs were subclassified into II-1 (with bony abnormality) or II-0 (without bony abnormality). The treatment modality was observation, conservative treatment, or surgical removal. The associations between the SUVmax and clinical findings, including surgery, were investigated.Patients with type II-1 ANB had the highest SUVmax among all ANB types (P < .001). The SUVmax of symptomatic ANB was greater than that for asymptomatic ANB (P < .001), and the SUVmax for the surgically resected ANB group was also significantly higher than that for the observation only or conservative treatment group (P < .001). Subtype II-1 had a significantly higher SUVmax compared with subtype II-0 (P < .001). Logistic regression analyses in type II ANB showed that young age (P = .020) and SUVmax (P = .031) were significant predictors for surgery. Receiver operating characteristic curve and survival analyses revealed an optimal SUVmax cutoff of 5.27 g/mL for predicting final surgical treatment.SUVmax derived from quantitative bone SPECT/CT was strongly associated with symptom, surgical treatment, and a known high-risk type of ANB. Risk stratification for final surgical treatment of ANB can be achieved using the SUVmax from quantitative bone SPECT/CT.

Accessory navicular syndrome as a cause of foot pain during stroke rehabilitation

Although usually asymptomatic, an accessory navicular bone can lead to medial foot pain, especially in younger people engaged in high impact sports. In many such cases, the tendon of posterior tibialis (which inverts and plantarflexes the foot) inserts onto the accessory bone resulting in greater strain on the tendon. In the present case, pain due to an accessory navicular bone first developed during stroke rehabilitation in a 69-year-old man. The relative overactivity of posterior tibialis in strokes involving the leg and overuse due to active rehabilitation were likely contributors. An accessory navicular syndrome should be considered as a cause of medial foot pain in patients following a stroke. As in our case, conservative management with rest, ice and elevation is usually successful.

Lisfranc injury: assessment and management in emergency departments

Injuries to the tarsometatarsal joint complex, also referred to as a Lisfranc injury, are relatively uncommon presentations to emergency departments (EDs), however accurate diagnosis is vital to prevent the risk of long-term disability. Advanced nurse practitioners (ANPs) must use a broad range of clinical skills to manage patients' injuries effectively. A high level of suspicion, recognition of the clinical manifestations of Lisfranc injury and appropriate radiographic images are required to formulate a correct diagnosis. This article describes Lisfranc injuries, revises the anatomy of the midfoot, and discusses diagnosis and management. It includes a case study to illustrate assessment and management of a patient who presented to an ED with a Lisfranc injury following a fall from a height and considers the diagnostic decisions and management options available to ANPs.

Radiological assessment of congenital talipes equinovarus (clubfoot): Is it worthwhile?

The lack in consensus with regard to qualitative use of standard radiographs and their predictive value in evaluating congenital talipes equinovarus among infants continues to be apparent in clinical practice. Since standard radiographs continue to play a role in the assessment of clubfoot it is essential to ensure that the values measured are reliable and reproducible keeping in mind acceptable tolerances for clinical application. This study was undertaken to assess the inter-observer and the intra-observer reliability in estimation of talocalcaneal and talo-first metatarsal angles on standard radiographs done according to Simon's method. The study was conducted by consecutively selecting eleven children with unilateral idiopathic congenital clubfoot who presented to our tertiary care hospital with a paediatric orthopaedic service unit. Only those with unilateral idiopathic clubfoot with persistent deformity at the age of 3 months were included. The data obtained from three observers on two separate occasions was analysed by the method proposed by Bland and Altman to assess intra and inter observer variability in the measurements. The results of the present study suggest a significant difference between the measurements on two occasions by the same observer. The difference was constant and the level of experience of the observer had no significance. Also, there was a marked inter observer variability as evident from the calculation of limit of agreement. Therefore, radiological assessment of the type and degree of malalignment in these cases is insufficient as it does not possess the accuracy required in evaluation and further management.

Contribution of Medial Cuneiform Osteotomy to Correction of Longitudinal Arch Collapse in Stage IIb Adult-Acquired Flatfoot Deformity

Background Residual forefoot supination after correcting the hindfoot in stage IIb adult-acquired flatfoot deformity can be addressed with a dorsal opening wedge medial cuneiform (Cotton) osteotomy. The amount of correction is generally judged clinically, and there currently are no preoperative guides that can predict the size of graft needed. The aim of this study was to evaluate the correlation between patient and operative factors and the correction achieved with the Cotton osteotomy.

METHODS

Seventy-nine feet in 74 patients undergoing Cotton osteotomy as part of flatfoot reconstruction were reviewed retrospectively. Preoperative and minimum 40-week postoperative lateral foot weightbearing radiographs were compared to assess correction of longitudinal arch collapse as measured by 13 radiographic parameters, with particular emphasis on the cuneiform articular angle (CAA). Additional demographic and intraoperative variables analyzed for association with radiographic change included age, gender, body mass index, amounts and graft types of Cotton osteotomy and lateral column lengthening, and amount of medializing calcaneal osteotomy. A multivariate linear regression model was developed for each variable found to be significant in univariate analysis.

RESULTS

The Cotton osteotomy graft size was significantly associated with changes in the CAA ( P < .001), calcaneal pitch ( P = .03), lateral talonavicular Cobb angle ( P = .03), and lateral naviculomedial cuneiform Cobb angle ( P = .03). The Cotton graft size was the only factor found to significantly predict a change in the CAA in the final linear regression model ( P < .001, R² = 0.27), with each millimeter of Cotton corresponding to a 2.1-degree decrease of the CAA.

CONCLUSION

Correction of longitudinal arch collapse, as measured by the CAA, was primarily influenced by the size of the graft used for the Cotton osteotomy in a linear fashion. The preoperative CAA may help surgeons titrate the proper amount of graft placed intraoperatively.

LEVEL OF EVIDENCE

Level IV, Retrospective Case Series.

Short T2 imaging using a 3D double adiabatic inversion recovery prepared ultrashort echo time cones (3D DIR-UTE-Cones) sequence

PURPOSE

To investigate high contrast imaging of short T2 tissues with a three-dimensional double adiabatic inversion recovery prepared ultrashort echo time Cones (3D DIR-UTE-Cones) sequence.

METHODS

The sequence used two sequential adiabatic inversion pulses to suppress signals from long T2 tissues, followed by multispoke UTE acquisition to detect signals from short T2 tissues. The two adiabatic inversion pulses are identical with a center frequency located at the water peak, but the spectral width is broad enough to cover both water and fat frequencies. The feasibility of this technique was demonstrated through numerical simulation and phantom studies. Finally, DIR-UTE-Cones was applied to three healthy volunteers to image cortical bone, patellar tendon, and Achilles tendon. T2* was also measured via single-component exponential fitting.

RESULTS

Numerical simulation suggests that the DIR technique provides perfect nulling of muscle and fat as well as efficient suppression of other long T2 tissues with T1 values between fat and water or those above water. Excellent image contrast can be achieved with DIR-UTE-Cones for the short T2 tissues, with fitted T2* values of 0.28-0.38 ms for cortical bone, 0.56 ± 0.07 ms for the patella tendon, and 0.45 ± 0.06 ms for the Achilles tendon, respectively.

CONCLUSION

The 3D DIR-UTE-Cones sequence provides robust suppression of long T2 tissues and allows selective imaging as well as T2* measurement of short T2 tissues such as cortical bone, patellar tendon, and the Achilles tendon. Magn Reson Med 79:2555-2563, 2018. © 2017 International Society for Magnetic Resonance in Medicine.

Kohler disease: Imaging King Tut's foot in 21st century

Kohler disease refers to childhood onset avascular necrosis of the navicular bone. Hybrid SPECT-CT bone scintigraphy offers both functional and anatomic details in a single acquisition if radiography is non-diagnostic in a limping child. We present the case of a 7 year-old child with persistent post-traumatic left foot pain. Tc99m MDP bone SPECT-CT scan demonstrated characteristic anatomic features of left navicular avascular necrosis.