Midfoot

Lisfranc Injuries

1.Who was Dr. Jacques Lisfranc de St. Martin? (1790-1847) He was a French surgeon that served under napoleon’s Army. He is buried in Paris, France near the catacombs.
2.Who often gets Lisfranc injuries? population?  Age of mid-30s, Men 2x more often than women. Occurs 1:55,000 people/ year ( Rosenberg 1995)
3.Where is the Lisfranc joint located at? tarsometatarso joint (TMTJ)
4.What is the shape of the metatarsal bases of the 1st base? of the 2nd base? 1st base is trapezoid shape, 2nd base is triangle wedge shape. The 2nd base creates a keystone such as seen in a Roman arch to hold up the midfoot arch.
5.Which is stronger, the dorsal, interosseous or plantar ligaments of the midfoot? Plantar ligaments.
6.Where does the Lisfranc Ligament attach to? From the dorsal lateral aspect of the medial cuneiform – to the dorsal medial aspect of the 2nd metatarsal base
7.What tendon can get stuck in the LIsfranc joint and prevent closed reduction? The Tibialis Anterior tendon (AT) can become wedge and block reduction
8.What is the mechanism of action (MOA) for Lisfranc injuries? Plantarflexing with rotational forces or Directly dropping something onto midfoot.
9.What are signs & Symptoms of Lisfranc injuries?
  1. Midfoot pain and swelling
  2. Ecchymosis (purple midarch)
  3. Open fracture or deformity
  4. Unable to tolerate weight-bearing (WB)
10.What are radiographic findings in Lisfranc Injuries? Lateral view

  • Dorsal dislocation of TMTJ or “step off” dislocation

AP view

  • Increase space between 1st and 2nd metatarsal base
  • “Fleck sign” or osseous fragment between 1st and 2nd base
  • Medial aspect of 2nd base is not congruent with medial aspect of 2nd cuneiform

MO view

  • Medial aspect of 4th met base is not congruent with medial aspect of medial cuneiform
11.What classification system used? Quenu and Kuss, (1909), Hardcastle (1982), Myerson
12.If there are bloody blisters would you operate? No! High risk of infection, instead wait until swelling and re-epithelialization occurs. Dress with Bulky Jones splint
13.What is in a Bulky Jones splint?
  •  Stockinette and Webril
  • 2 layers of cotton padding
  • 6-inch ace wrap
14.Common complications with Lisfranc injuries?  Compartment syndrome
15.Five P’s of compartment syndrome?
  1.  pain
  2. pallor
  3. pulselessness
  4. paresthesias
  5. paralysis
16.How do you check compartment syndrome? Wicks catheter or the Intra-compartmental pressure monitor
17.How do you surgically treat Lisfranc injuries? ORIF vs Arthrodesis. Bigg argument in our profession, be able to defend either answer!
18.How would do your surgical cuts? Two longitudinal incisions. The first between 1st and 2nd metatarsal, the second between 3rd and 4th metatarsals
19.What screws would you use in the medial column?   3.5 or 4.0  cortical screw
20. What screws would you use in the lateral column? No screws! It is hypermobile and never fused, used K-wires instead and later remove.
21. What is the Post-operative treatment?
  • Remove sutures in 2-3 weeks
  • NWB in cast for 6 weeks
  • Remove wires at 6 weeks
  • CAM boot for additional 4-5 weeks
  • (optional) remove hardware at 6 months
22. Complications post surgical Malunion, Non-union, Compartment syndrome, avascularity, and ARTHRITIS.

Navicular

1.What tendon attaches to the navicular bone? Posterior tibialis tendon (PT)
2.Where is the watershed area in the navicular? the central watershed area in the middle 1/3
3.What is the navicular’s blood supply?  PT artery supplies medially & plantarly (1/3). DP artery supplies laterally & dorsally (1/3)
4.Types of fractures seen at the navicular?
  1. Avulsion fractures
  2. Stress fractures
  3. Body fractures
5.Where are avulsion fractures commonly seen? 1st most common – Dorsally from talonavicular ligament tear after twisting or eversion. 2nd most common avulsion fracture from PT tendon.
6.When do you treat an avulsion fracture? If >2mm displaced or 10 degrees rotated, treat surgically. If minimally displaced then NWB 4-6 weeks.
7. When do you get a navicular body fracture? from a direct axial load (i.e. fall from height)
8.Classification for navicular fractures?
  1. Watson-Jones classification
  2. Sangeorzan classification
  3. Saxena classification
9.Sangeorzan Classification? Type 1 – transverse coronal plane
Type 2 – a sagittal fracture (most common)
Type 3 – comminution with lateral displacement
10.Watson-Jones? Type I: Avulsion by PT tendon
Type II: dorsal lip fracture
Type IIIa: Transverse body, non-displaced
Type IIIb: Transverse body & displaced
Type IV: Stress
11.Sexena classification? Need a coronal view of CT scan. Based on A, B, C (C being most medial)
12.When do you get navicular stress fractures?  in high intense athletes (sprint or jumping)
13.How do you treat stress fractures? 4-6 weeks NWB
14.What are the differential diagnoses?  PT Tendonitis, accessory navicular, spring ligament tear, Koehler’s disease, Neuritis
15.What bone would you definitely not expect to see in a 3-year-old child?  Navicular
16.What ossicle increases the risk of a Talo-navicular coalition?  Os tibialis externum

Cuboid

1.T or F: Cuboid fractures are pretty common fractures seen in the foot? False, they are pretty rare
2.What is the function of the cuboid? stabilizes the lateral column, acts as a lever for Peroneus Longus tendon.
3.What type of fractures are seen in the cuboid?
  1.  avulsion fractures (most common)
  2. compression fractures
4.What causes avulsion fractures? on the lateral aspect of the cuboid from attachment to calcaneocuboid ligament
5.When do you see compression fractures? aka, a “nutcracker” fractures is seen when the forefoot abducts from a Lisfranc type injury
6.What is the blood supply to the cuboid? medial and lateral plantar arteries
7.What tendon attaches to the cuboid?  the tibialis posterior (PT)
8.What is cuboid syndrome? The cuboid is subluxed downward causing pain.
9.When do you see increased calcaneocuboid angle on xray? flatfoot deformity
10.C-C joint stability: what increases stability and stabilizes cuboid?  Locking the midtarsal joint/MTJ pronation → talus dorsiflexion and abduction, calcaneal inversion

Pes Cavus

1.What does it mean to have a high arch? Sagittal plane deformity – arch fails to flatten out with WB
2.The 4 points when approaching a cavus foot?
  1. Etiology
    • progressive? stable?
  2. Plane of deformity
  3. Forefoot vs Rearfoot driven
  4.  Flexible vs Rigid
    • any OA
3.What are 5 etiologies for the cause of pes cavus?
  1. Charcot-Marie Tooth
  2. Polio
  3. Cerebral palsy
  4. Friedreich ataxia
  5. Spinal cord lesion
4.What biomechanics abnormalities are seen in Pes Cavus?
  • Equinus
  • hindfoot varus
  • forefoot adduction
  • plantarflex 1st ray
  • extensor substitution
  • claw toes/ hallux malleus
  • high stepping gait
5.Where is the apex of the deformity?
  • Metatarsus cavus – Apex at Lisfranc’sJoint
  • Lesser tarsus cavus – Apex in lesser tarsus
  • Forefoot cavus – Apex at Chopart’s Joint
  • Combined cavus- Combination of the others
6.How do you check flexible vs rigid cavus foot? perform the Coleman block test
7.Describe the test? Place 1″ block under the lateral foot
eliminates the contribution of the plantarflexed 1st ray and forefoot pronation to the hindfoot deformity.Flexible hindfoot will correct to neutral or valgus when block placed under lateral aspect of the foot. Rigid hindfoot will not correct. Rigid hindfoot deformities require corrective hindfoot osteotomy
8.What other diagnostic tests would you order? Radiograph, CT, Muscle biopsy to rule out Charcot Marie Tooth
9.What are some radiographic findings in a lateral view?
  • Increased calc inclination (>21°)
  • Decreased talar declination
  • Bullet hole sign
  • Posterior break in cyma line
  • Decreased Hibbs angle
  • Altered Meary’s angle
  • Increased met declination angle
  • Dorsal gapping of joints
10.What are some radiographic findings in an AP view?
  • Adduction at Lisfranc’s, lesser tarsus or Chopart’s
  • Talo-1st met angle, metadductus angle, Engle’s angle
  • Increased TN coverage
  • Reduced Kite’s angle
11.What are some conservative treatments?
  1. Stretching
  2. Accommodative shoe gear
  3. Orthotics FFO/AFO

These options are good for slow progressing flexible flatfoot

12.What are some soft tissue surgical options? Soft Tissue

  • Steindler stripping
  • Tendon Achilles Lengthening (TAL)
  • Peroneal tendon release/transfer
  • Jones suspension
  • Hibbs suspension
  • Heyman procedure
  • STATT
  • PL/PT Transfer
  • Peroneal Anastamosis
  • Tarsal tunnel release
13.What are some osseous surgical options? Osseous

  • Forefoot osteotomy
  • Cole osteotomy
  • Japas osteotomy
  • Jahss osteotomy
  • Dwyer osteotomy
  • Duvries Arthrodesis
  • Calcaneal Z or scarf osteotomy
  • LDCO
  • Arthrodesis – double, triple, STJ, medial column
14.How would you treat progressive stable?  If progressive, needs fusion
15.How would you treat rigid vs flexible? Rigid – perform osseous procedure.

Flexible – soft tissue procedure or tendon transfer

16.How would you treat based on the plane of deformity? Sagittal – Cole or PL tendon transfer

Frontal – do a tendon transfer

17.What are some complications from a Cavus foot type?
  • Ankle instability
  • 5th met base fracture
  • plantar fasciitis
  • Sesamoiditis
18.What causes Charcot-Marie-Tooth? A heterogenous disorder with a deficit in proteins of the myelin sheath.

  • Most commonly peripheral myelin protein 22 (PMP-22)
  • Most commonly CMT-1A (80%)
19.What effects does this nerve damage cause? Causes progressive muscular deformity and imbalance.
Especially intrinsics, peroneus brevis and anterior tibialis (anterior and lateral compartments)
20.Describe the associative findings in a Charcot-Marie-tooth (CMT) type foot?
  • Anterior Tibialis
  • Peroneus Brevis
  • Intrinsic muscles
21.The remaining normal antagonistic muscles remain, what can be seen when they overpower the weak agonists?
  •  Peroneus Longus – plantaflexes 1st ray
  • EHL/EDL – Claw toe
  • Gastroc-Soleus – Equinus
22.Which muscle is atrophic in CMT?  Peroneal longus and brevis

Pes Planus

1.When do we operate on a flat foot? The goal of flatfoot surgery is to stabilize the subtalar and midtarsal joint to create a functional gait. Things to consider:

  • Pain
  • progression (worsening)
  • deformity
2.What is the difference between flexible vs rigid flatfoot? Flexible flatfoot is seen in non-weight-bearing with a preservation of the medial arch; may be asymptomatic.

Rigid flatfoot is stiff and flattened on and off weight-bearing

3.What can influence the severity of the flatfoot with findings above the ankle?
  • obesity
  • ankle valgus
  • tibia varum
  • genu valgum
  • neuromuscular disorder
  • family genetics
  • ligamentous laxity
4.What are physical (clinical) findings in a flat foot?
  1. low arch
  2. rearfoot eversion
  3. medial talar head prominence
  4. “too many toes” sign or abducted forefoot
  5. calluses
5.Should you check ankle dorsiflexion and plantarflexion for flatfoot? Yes! Equinus plays a big role in forefoot and midfoot loading adding to the pathology of flatfoot
6.How do you check for Equinus?  Silfverskiold test
7.Describe test: check dorsiflexion with both knee flexion and knee extension

  • if tight only with knee extension, then gastrocnemius is tight
  • if tight also with knee flexion, then soleus is also tight
8.What are the differential diagnosis for Adult flatfoot?
  1. congenital flatfoot
  2. PTTD
  3. tarsal coalition
  4. charcot
  5. neuromuscular disorder
9.What clinical tests can you perform to determine rigid vs flexible?
  • Hubscher maneuver
  • double heel-rise test
  • single heel raise test
10.What does the double heel raise show? In a severe flatfoot, if a patient is unable to perform a double heel raise, the patient shows lack of rearfoot supinatory varus flexibility – indicating rigid.
11.What is PTTD? Posterior Tibial Tendon Dysfunction. The patient had somewhat of an arch when young but has slowly collapsed over time due to the PT tendon becoming weak or lengthening through tears.
12.What is the biomechanics that leads to a progressive flatfoot? the talus plantarflexes and adducts -> subtalar joint pronates -> the midtarsal joint unlocks ->increse in transverse plane motion -> contracted Achilles adds to symptoms = leads to collapse medial arch
13.What are some Xray findings in a flat foot?
  • decrease the calcaneal inclination angle
  • increase talar declination angle
  • increase talar head uncovering
  • increased talocalcaneal angle (Kite’s angle)
  • anterior break in cyma line
  • increased calcaneocuboid angle
14.What are some conservative treatment options? FFO/AFO, Immobilize in CAM boot, arch support pads, steroid injection
15.What are some soft tissue procedures?
  • tenosynovectomy
  • tendon transfers
  • gastroc recession
  • TAL
16.What are osseous procedures in the frontal plane?
  •  arthroereisis procedures
  • calcaneal osteotomies
  • Dwyer
  • silver
17.What are osseous procedures in Transverse Plane?
  • Evans
  • CCJ distraction arthrodesis
  • Kidner
18.What are the procedures in the Sagittal Plane?
  •  Cotton
  • Miller
  • Young
  • Lowman
19.What is the surgical procedure for a Kidner?
  1. Incision made parallel to the border of the tendon. extend from medial malleolus to medial cuneiform
  2. Accessory navicular is excised
  3. Tendon is sutured to medial surface of the navicular
20.What are the differential Diagnosis for a pediatric with flatfoot?
  • Flexible flatfoot
  • Rigid flatfoot
    • Congenital Vertical Talus
    • Tarsal Coalition
    • Peroneal spasticity
  • Skewfoot
21.A 7-year-old boy presents with pain in both feet. He falls a lot and is worried about his flat foot. Xray reveals no coalition and flatfoot radiographic findings. What surgery do you recommend? Arthroeresis
22.What are the types of arthroeresis?
  • Self-locking
  • axis-altering
  • impact-blocking
23.What are the contraindications for STJ arthroeresis? Skewfoot, rigid flatfoot, severe frontal deformity.
24.Describe the STJ arthroeresis procedure:  Arthroeresis; from Greek work ereisis- to “propp up”

  1.  1-3cm incision with relaxed skin tension lines over sinus tarsi. Start 1cm inferior and 1.5cm anterior to lateral malleolus
  2. incise retinaculum
  3. insert the guidewire into sinus tarsi
  4. trial implant
  5. check for excessive subtalar pronation and evaluate the position
  6. evaluate on Xray
  7. choose final implant
25.If a 13-year-old with flatfoot shows signs of clumsiness and frequent falling, and upon further investigation, he has difficulty arising from the floor, what do you need to rule out as a diagnosis? Becker or Duchenne muscular dystrophy
26.What is CVT? Congenital Vertical Talus, the talus is sitting “up and down” in a vertical position creating a rocker-bottom deformity. Also called congenital convex pes valgus!
27.How do you treat CVT? initial is conservative: 6 weeks of serial casting by closed reduction. The idea is to pull the navicular distally and relocate the head of the talus. Afterward, you can pin it percutaneous and then continue casting to correct the equinus.
28.What if serial casing doesn’t work on CVT? Take to surgery, open reduction internal fixation (ORIF). Remember to use smooth K wires!
29.In a 5-year-old what skin incision would give best visual in a tiny foot? Cincinnati incision
30.What is tarsal coalition? a union between two bones in the tarsal area
31.What are the most common tarsal coalitions? from most common to least?
  1. talocalcaneal
    • middle facet (most common)
    • anterior facet
    • posterior facet
  2. calcaneonavicular
  3. Talonavicular
  4. calcaneocuboid (least common)
32.What Xray view is optimal to see a tarsal coalition? The 45 oblique view is best. Can also be seen in lateral view. Harris-Beath for middle facet fusion.
33.What radiographic findings are seen in a tarsal coalition?
  1.  Halo sign or “C” sign
  2. Anteater sign
  3. rounding of the sustentaculum tali
  4. talocalcaneal joint space narrowing
34.What is the classification for tarsal coalition?  Downey Classification (1991)
35.What is the surgical treatment for tarsal coalition? resection of the fused bone or arthrodesis
36.What is skewfoot? forefoot adduction and heel valgus or z shaped foot

Classifications