Yale Williams DO¹, Kyle Barner DO¹, Ben Koerner DO¹, Angela Walker DO¹, Aaditya Pateal MS-2², Mihir Patel MS-2², Kevin Valdes MS-2^2
1Department of Orthopaedic Surgery, HCA Research Medical Center, Kansas City, MO
²College of Osteopathic Medicine, Kansas City University, Kansas City, MO

Abstract

Introduction
This case report presents a patient who suffered a left talonavicular plantar dislocation, comminuted cuboid fracture-dislocation, along with a rare navicular-cuneiform fracture involving medial column instability following a workplace accident. The navicular-cuneiform joint plays a crucial role in stabilizing the medial longitudinal column and transverse arch of the foot. Treatment options for similar midfoot injuries include external fixation, Kirschner wires, open reduction and internal fixation (ORIF), or arthrodesis. While the medical literature offers protocols for midfoot injuries, especially Lisfranc injuries, there is limited information and protocols on more proximal medial column dislocation with medial column instability. To address this complex case, the medical team used a provisional technique involving Kirschner wires for anatomic reduction followed by subsequent arthrodesis of the medial column. This approach aimed to provide the necessary stability for the medial column to heal and endure biomechanical demands. Prior research revealed unknown documented instances of this specific injury with subsequent anatomic reduction and arthrodesis with a medial column nail, rendering it a unique solution for addressing such complex midfoot injuries. 

Methods
The patient was originally seen as a trauma patient. Closed reduction of his left foot was attempted, but unable to be attained due to significant disruption in the soft tissue and bony architecture of the midfoot. Therefore, a mini open technique was used to obtain anatomic reduction of the medial midfoot structures. Provisional reduction was obtained with K-wires to allow for soft-tissue swelling to subside. The subsequent procedure was definitive which involved a midline axial incision on the medial aspect of the foot, exposing the medial column and preparing joint surfaces, while a second incision exposed the intermediate and lateral naviculocuneiform joints and the second and third tarsometatarsal joints. Arthrodesis was obtained across talonavicular, navicular-cuneiform, and cuneiform-1st metatarsal via a medial column nail. Additionally, arthrodesis from the second metatarsal to the talus and third metatarsal to the talus was performed. 

Results
The surgical approach involving Kirschner wires for initial anatomic reduction followed by arthrodesis yielded successful outcomes in addressing the complex midfoot injury. Radiographic assessment post-surgery confirmed proper alignment and stabilization of the medial column. Specifically, the talonavicular joint, navicular-cuneiform joint, and the first metatarsal-cuneiform joint exhibited fusion. This unique technique tailored to the specific injury pattern resulted in improved stability and biomechanical support for the patient’s medial column.

Discussion
This case study presents a rare complex condition of left plantar talonavicular dislocation, navicular-cuneiform fracture-dislocation with significant medial column instability. The patient suffered a crushing injury, resulting in severe soft tissue displacement and potential neurovascular damage. Understanding the functional columns of the foot (medial and lateral) guided the choice between open reduction internal fixation (ORIF) and primary arthrodesis. High-energy crushing injuries in the midfoot require stable provisional reduction to avoid complications. The optimal management strategy for midfoot fracture-dislocations remains controversial. Available evidence suggests favorable outcomes with primary arthrodesis in specific cases, while others report successful results with ORIF. While the management of traumatic midfoot injuries lacks a consensus, timely and accurate diagnosis, along with anatomical reduction and stable fixation, are crucial to prevent functional impairment and complications such as arthritis, avascular necrosis, or midfoot collapse. This case represents a rare unstable, medial column injury treated with provisional fixation and subsequent arthrodesis.

Keywords: midfoot dislocation, navicular-cuneiform joint, plantar talonavicular dislocation, comminuted cuboid fracture-dislocation, medial column instability, proximal medial column dislocation, arthrodesis, Kirschner Wire

Introduction 
The navicular-cuneiform joint comprises the navicular bone articulating distally with three cuneiform bones (medial, intermediate, lateral) (5). Within this joint lies a common synovial capsule, allowing for minimal motion (5). Its primary function is to stabilize the medial longitudinal column and transverse arch (5). Navicular-cuneiform fractures are rare midfoot injuries typically associated with high-energy traumatic incidents (5). Treatment necessitates immobilization and anatomic reduction through surgery to achieve stability and minimize further soft tissue damage (5). One surgical approach to attaining stability involves arthrodesis, wherein adjacent bones are fused.

In cases of high-energy crushing injuries to the midfoot, treatment options include external fixation or Kirschner wires, and less commonly, open reduction and internal fixation (ORIF) or arthrodesis (2). While external fixation and Kirschner wires are useful for anatomic reduction, they may not offer the long-term stability necessary for midfoot injuries to heal adequately (2). Conversely, there is some literature describing ORIF and arthrodesis as treatment options, with arthrodesis demonstrating better long-term outcomes for midfoot injuries (3). In a prospective study detailed by Ly et. al, arthrodesis demonstrated better long-term outcomes in terms of stability and arthritis development compared to ORIF of the midfoot. Arthrodesis provides superior stabilization of the midfoot and long-term rigidity contributing to improved overall outcomes.

This case describes a patient who sustained multiple injuries, including a left plantar talonavicular dislocation, navicular-cuneiform dislocation, comminuted cuboid fracture-dislocation, after falling off a lift at work. Although procedures detailing protocol after midfoot injuries are described in the medical literature, there is very little describing more proximal medial column injuries with associated medial column instability. This case highlights the challenges associated with managing proximal medial column fracture dislocations with medial column instability, which remains a relatively understudied aspect of midfoot injuries. The use of a Kirschner wire for anatomic reduction, followed by arthrodesis of the first metatarsal to talus, left second ray arthrodesis from second metatarsal to talus, and left third ray arthrodesis from third metatarsal to talus, with a PDGF allograft, was utilized with the aim of providing the necessary stability for the medial column to heal and sustain biomechanical demands. 

The technique described in this case involving the utilization of Kirschner wires for anatomic reduction followed by medial column and midfoot arthrodesis to address a talo-navicular dislocation and navicular-cuneiform disruption with medial column instability appears to be unprecedented in the existing medical literature. Extensive research and literature review conducted before this case report failed to identify any documented instances of this specific treatment approach being employed for such a complex midfoot injury. The novelty of this technique lies in its application to this unique case.

Case Presentation  
A 39- year-old male presented to the Emergency Department on 12/28/2022 with multiple injuries after falling off a 30-foot lift at work and landing on his left side. Patient complained of left foot, low back, and left elbow pain. 

The physical examination demonstrated the patient was neurovascularly intact to all extremities, left foot was in severe plantarflexion, and an open fracture of the left forearm. 

Plain x-ray films and computed tomography (CT) examinations revealed a left open Monteggia fracture, left diaphyseal fibula fracture, left comminuted cuboid fracture, a plantar talonavicular dislocation, and L1-L3 compression fractures. The patient was taken to the OR. A closed reduction of the talonavicular joint was attempted and unable to be obtained due to the 100% plantar displacement of the navicular. We therefore decided to proceed with open reduction. The medial column of the left foot was realigned and two Kirschner wires were placed from the first metatarsal into the medial cuneiform, across the navicular and into the talus. Additionally, another K-wire was placed from the medial cuneiform into the base of the second metatarsal to stabilize the Lisfranc joint. These procedures achieved adequate realignment and stabilization of the midfoot. Post-operatively, patient was maintained in a bulky dressing and short AO splint. The soft tissue appeared swollen postoperatively, but eventually the swelling subsided for definitive fixation.

On 1/20/2023, the patient underwent further intervention. Utilizing the K-wires as guidance, a left midfoot arthrodesis from first metatarsal to talus, left second ray arthrodesis from second metatarsal to talus, and left third ray arthrodesis from third metatarsal to talus were performed, with a PDGF allograft augmentation across the TMT joint and intermediate navicular cuneiform joint. The patient was placed into a well padded short AO splint postoperatively and would be non weight bearing for a minimum of 12 weeks.

Operative Technique 
On 1/20/23, The procedure began with exsanguination of the left lower extremity and inflation of the tourniquet. A midline axial incision was made on the medial aspect of the foot, extending from the talus to the first metatarsal base. Care was taken to protect the anterior and posterior tibial tendons throughout the procedure. The medial column was exposed, and various joint surfaces, including the talonavicular, naviculocuneiform, and first tarsometatarsal joints, were prepared by removing cartilage and subchondral plate. Joint surfaces were fenestrated, and the underlying medullary bone was exposed.

A second incision was made between the second and third rays, and dissection was carried out to expose the intermediate and lateral naviculocuneiform joints, the lateral aspect of the talonavicular joint, and the second and third tarsometatarsal (TMT) joints. Joint preparation was performed using osteotomes and a sagittal saw, followed by fenestration of the joint surfaces. After appropriate preparation and mobilization, PDGF allograft was placed across all joint surfaces. The talonavicular joint was provisionally pinned, and the medial column was reduced, followed by the placement of a medial column nail. A dorsal incision was made over the first metatarsophalangeal (MTP) joint, and a K-wire was inserted retrogradely for the nail. The nail was assembled, inserted to the appropriate depth, and confirmed with X-rays. A distal interlock screw and compression mechanism were utilized to stabilize the medial column. The medial column nail was specifically chosen for this type of fixation as it required minimum soft tissue dissection to place and would be effective at stabilizing the medial column instability. 

A Weber clamp was used to reduce the second and third TMT joints and intermediate/lateral naviculocuneiform joints. K-wires were placed across the respective joints, and 4.0 mm cannulated screws were inserted. Due to a break in the second metatarsal, additional graft material was used, and excess K-wires were removed. The final X-rays confirmed appropriate joint reductions, hardware placement, and compression. The wounds were irrigated, and the deep tissues were closed with sutures. The subcutaneous tissues were closed, and the skin was sutured. An ankle block was administered for pain management, and the wounds were dressed, followed by the application of a posterior plaster splint. The lateral column was not fused to refrain from inhibiting mobility needed for proper walking mechanics on uneven ground.

Discussion
Our patient presented with a complex condition involving a plantar talonavicular dislocation, navicular-cuneiform fracture-dislocation, accompanied by significant instability in the medial column. Fracture-dislocations in the midfoot are rare, accounting for only 0.1% to 0.4% of all fractures and dislocations (11). Typically, these injuries occur due to axial load or twisting forces applied to a plantar flexed foot. However, this particular case was unique due to the occurrence of a crushing injury, resulting in severe soft tissue displacement and potential neurovascular damage.

Understanding the function of these essential and nonessential joints is crucial in guiding the choice between open reduction internal fixation (ORIF) and primary arthrodesis. The medial column provides stability, while the lateral column allows for mobility (12). It should also be noted that studies comparing the two methods have reported varying outcomes. For instance, a prospective randomized trial by Ly et al. demonstrated that primary arthrodesis resulted in lower rates of revision surgery and higher postoperative activity levels compared to ORIF (3).

While literature on traumatic midfoot injuries is limited, available case reports suggest favorable results with ORIF in specific fracture-dislocation cases (3,4). It should also be noted that in cases where there are fracture-dislocations involving the naviculocuneiform joint and complex fracture dislocations of the talonavicular joint, primary arthrodesis may better help with the stabilization and functional outcome (3,5,9).

In instances where high-energy crushing injuries occur in the midfoot, substantial instability often requires the implementation of external fixation or Kirschner wires to effectively address the problem (4,5,6,7,8,10). Failing to establish a stable provisional reduction can result in additional complications: soft tissue damage which can cause further complications and diminish foot viability (5). 

The importance of the medial and lateral columns in foot stability is highlighted by cases involving isolated navicular dislocations accompanied by lateral column injuries (4,5,10). Disruption of bony and ligamentous structures in both columns is often observed, emphasizing their interconnectedness (8).

[Figures 1-4]: 4 images of the left foot of the patient in the Emergency Department. 2 views demonstrate a midfoot fracture dislocation with plantar displacement of the navicular.  

[Figures 5-6]: K-wires were used for proper alignment and immobilization of the fractured location.  Any excess k-wire was cut off.

[Figures 7-8]: Post-surgical radiographs demonstrate a well-reduced medial column with a medial column arthrodesis nail. There are also screws across the second and third TMT joints, as well as the intermediate and lateral naviculocuneiform joints.

Conclusion
In conclusion, this case study highlights the complexity and challenges associated with midfoot fracture-dislocations. Due to there being a general lack of consensus on treatment for traumatic midfoot injuries, it is worth noting that further research is needed to better understand the optimal management strategies for midfoot fracture-dislocations. This includes larger-scale studies with long-term follow-up to compare outcomes, considering factors such as injury force, extent of ligamentous or bony damage, and integrity of adjacent neurovascular and soft tissue structures (9). Prompt diagnosis, timely anatomical reduction, and stable fixation are essential to overall improved outcomes.

Figure 1 | Figure 2 | Figure 3 | Figure 4 | Figure 5 | Figure 6 | Figure 7 | Figure 8

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