Jay Lieberman DPM, FACFAS, Director of Podiatric Medical Education, Northwest Medical Center Cherison Cuffy Chief Resident Foot and Ankle Surgery, Northwest Medical Center Guest Case Study: Medial Column Fusion The patient is a 25 year old male who presented to the office 72 hours status post injury to his right foot. He apparently sustained a bone contusion after inadvertently kicking the wall of a swimming pool. He was evaluated in the emergency department at Northwest Medical Center. Standard radiographs were taken which revealed severe degenerative joint changes of the talonavicular and navicular cuneiform joints. There was no gross evidence of fracture or dislocation and the patient was placed in a posterior splint and referred to the foot and ankle physician on call for further evaluation. The patient relayed that he “suffers a lot” with his right foot even prior to the injury. He experiences a tremendous amount of aching pain at the end of the work day localized to his right foot. The symptoms have been present for years and he also noted stiffness in his hands upon arising in the morning. The patient has a medical history of Rheumatoid Arthritis (RA) and has been treated with Prednisone, Methotrexate, Humira, Enbrel and multiple nonsteroidal agents which have not relieved his symptoms.

Physical examination revealed a decreased medial longitudinal arch with moderate edema to the dorsal midfoot without erythema. His neurovascular status was intact.  No gross dermatological abnormalities were seen. His musculoskeletal evaluation revealed tenderness particularly to the first tarsometatarsal joint and navicular cuneiform joints. There was decreased passive range of motion noted to the subtalar joint and midfoot.

Standard radiographs demonstrated severe degenerative joint changes of the subtalar joint posterior facet, talonavicular, calcaneocuboid, navicular cuneiform, and first metatarsal cuneiform joints. There were also cystic changes about the fifth metatarsal head. The metatarsophalangeal joints appeared spared of degenerative changes.  Radiographs were taken of the contralateral foot, which did not show any evidence of arthritic changes.

(contra lateral foot)

The patient was offered conservative versus surgical options for treating his pain. This case was rather interesting due to the severe joint changes seen unilaterally in a patient with a history of RA. The overriding thought in this particular case was that the degenerative changes that occurred in the right foot are a result of the talocalcaneal coalition. In the rheumatoid foot, one would usually see symmetric joint changes initially demonstrated in the metatarsophalangeal joints. Triple arthrodesis is an option usually reserved for mature patients with radiographic evidence of a tarsal coalition and arthritic changes.  However, in this case, we thought a medial column arthrodesis would be a sensible surgical procedure that would address the joints which were particularly painful and hopefully give this patient some relief by stabilizing the longitudinal arch.  The patient agreed to surgery after explanation of the risks, benefits, complications, alternatives, details of the procedure and standard postoperative course.

The patient was brought to the operating room after routine pre-operative work-up and medical clearance. The patient was placed in the supine position and a pneumatic thigh tourniquet placed on the right lower extremity. The goal of the surgery was to fuse the first metatarsal cuneiform joint, navicular cuneiform joints, and the talonavicular joint. A dorsomedial incision was utilized, extending from the talonavicular joint to the first metatarsal cuneiform joint. Dissection was carried down to joint capsule, with care to retract and preserve neurovascular structures. Venous tributaries were cauterized and ligated as necessary. Fluoroscopy was utilized throughout the procedure to identify the joints of interest due to the extensive arthritic changes. Periosteal and capsular incision was made midline and reflected to expose the joint surfaces. Spurring had to be resected and osteophytes excised with rongeur and osteotomes to obtain adequate visualization. Normal osseous anatomy was distorted by the severe periarticular adaptive changes.  The use of Integra’s Hintermann retractors assisted in joint distraction for increased exposure. The articular cartilage of the joints were resected in standard fashion and joint surfaces prepared with subchondral drilling and feathering techniques.

Pre-operative surgical planning was to use multiple screws and compression staples to achieve the intended fusion of these joints. An intra-operative decision was made to employ a technique of fixation previously described for patients with Charcot neuroarthropathy. The idea was to utilize a large dual threaded cannulated intraosseus screw spanning the first metatarsal joint to the talonavicular joint. This would hopefully provide compression and intrinsic stability to the medial column.  Steinman pins have also been used as an alternative to stabilize the medial column. This concept of fixation lends itself to that of intramedullary nail fixation as used in osteosynthesis of tibial diaphyseal fractures or more closely compared to retrograde nail fixation in achieving tibiotalocalcaneal arthrodesis.

The incision was extended distally to the medial aspect of the first metatarsophalangeal joint. Dissection was carried down to and through the capsule to expose the joint.

Click on the images below for larger view.

The talonavicular joint and first metatarsal joint was placed in the desired position with the use of fluoroscopy and loading the foot with a sterile pan to simulate weight bearing. A guide wire for the 7.5mm cannulated screw was driven from the first metatarsal articulation into the talus under fluoroscopic guidance. Medial and lateral fluoroscopic views were used to assess central placement of the guide wire in the first metatarsal.

The appropriate cannulated drill was then passed over the guide wire in preparation for screw placement. Screw length was determined by placing it against the medial aspect of the foot with fluoroscopy.  A screw length of 120mm was determined to be adequate for interosseous compression.  The screw was placed across the medial column with the proximal threads engaging the body of the talus and the distal threads within the diaphysis of the first metatarsal. Adequate apposition and compression was attained between the joint surfaces which was observed grossly and confirmed fluoroscopically.

Trel-XC bone putty was placed about the joint surfaces and into the medullary canal of the first metatarsal.  The guide wire was then removed and a routine layered closure performed.

Other forms of fixation could have been used in this particular case along with other surgical procedures in addressing this patient’s complaint.  The choice to place the screw entering the articular surface of the first metatarsophalangeal joint could be questioned due to the destructive nature of the intramedullary screw placement and with prior radiographs demonstrating a non-arthritic joint. A joint sparing technique would be to drive the guide wire from the posterior aspect of the talus distally to the first metatarsal. A 7.5mm screw was used because it was thought to be large enough to capture the endosteum of the first metatarsal without compromising the integrity of the cortex. This size screw would also be large enough to capture the talus and achieve interosseous compression and medial column stability. The talocalcaneal coalition was not addressed surgically, but the incomplete ankylosis of the subtalar joint was thought to obviate surgical resection and arthrodesis at this time.  It is possible that if his symptoms continue, further surgical intervention may be warranted to include subtalar joint and calcaneocuboid joint arthrodesis.

At this juncture the patient has had the sutures removed and wound checked. The incision is well coapted without evidence of infection and he has been placed in a non weight bearing neutral ankle below knee cast.  The patient complained of first metatarsophalangeal joint pain the first week postoperatively, but these symptoms have resolved with adequate range of motion without pain.

"The residents and attendings from Northwest Medical Center would like to thank our regional Integra rep, Edward Amo,  for providing us with all the products needed for a positive outcome  in this case.  We have had great success using Integras two prong and four prong compression staples.   Because of the irregularity of the eroded joint spaces and the need for bone grafting, we felt more direct compression would be the best approach.  Jay Lieberman, DPM, FACFAS"

Integra’s Hintermann retractors: 

Integra’s Hintermann retractors		Integra’s 7.5mm x 120mm Quix screws (dual threaded cannulated intraosseous screws)
Trel-XC bone putty
Compression Staples

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