Definition
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Excision of the cuboid in total, which is then replaced with a metallic, patient-specific 3D-printed implant.
Indications
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Posttraumatic arthritis located at the cuboid and associated articulations.
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A shortened lateral column, typically from prior trauma, with compression cuboid fractures.
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Avascular necrosis of the cuboid.
Anatomy
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The cuboid has a pyramid morphology with a medial base and apex laterally. The cuboid is unique as it articulates with the metatarsals as well as directly with the calcaneus ( Figs. 17.1 and 17.2 ).
• Fig. 17.1
Lateral view of a total cuboid replacement model.
(Reprinted with permission from Paragon 28, Inc, Englewood, CO)
• Fig. 17.2
Anteroposterior view of a total cuboid replacement model.
(Reprinted with permission from Paragon 28, Inc, Englewood, CO)
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Multiple articulations with different osseous surfaces are present, including distal, proximal, and medial. There is significant ligamentous attachment including long and short plantar ligaments. ,
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The peroneal groove is located anterolaterally and the peroneal longus courses around towards its insertion at the plantar 1st metatarsal base.
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The cuboid is a biomechanical anchor and allows for adaptive accommodation provided from the lateral column. ,
Pathogenesis
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Loss of length to the lateral column can affect the foot’s shock absorption and mobile adaptation, which can increase stress to adjacent joints , ( Figs. 17.3 to 17.5 ).
• Fig. 17.3
Medial oblique and anteroposterior view of preoperative radiographs demonstrating a shortened lateral column and associated posttraumatic degenerative changes from a previous midfoot and cuboid injury.
• Fig. 17.4
Lateral view of preoperative radiographs demonstrating posttraumatic degenerative changes from a previous midfoot and cuboid injury.
• Fig. 17.5
Coronal CT scan of the foot demonstrating a compressed cuboid with multiple osseous cystic formations.
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Valgus stress causes compression of the cuboid.
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Direct crush injuries to the cuboid have been described after motor vehicle accidents, horseback riding, and direct loading of heavy weight. ,
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Cuboid fracture, or posttraumatic arthritis, is commonly indicative of a complex midfoot injury including involvement of the navicular, cuneiforms, and/or the Lisfranc joint complex. , ,
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Disturbance in lateral column length can lead to forefoot abduction, lateral subluxation of the tarsometatarsal joints, and pes planus.
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Compensatory biomechanics from altered native anatomy can cause a variety of foot deformities and include posttraumatic arthritis. , In the same manner, tendinopathy may result in secondary altered biomechanics of the peroneal groove.
Patient history and physical exam findings
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Patients complain of pain along the plantar and dorsal aspect of the lateral column, to the 4th or 5th metatarsal articulations, as well as articulation with the calcaneus.
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Pain may be exacerbated with propulsion in gait, with the increased demand causing stress along the lateral column.
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A previous history of trauma to the midfoot is common among patients with complaints of lateral column pain.
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Corticosteroid injections with/without fluoroscopic guidance can provide temporary relief; however, they do not eliminate symptoms.
Imaging and other diagnostic testing
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Radiographs often demonstrate osteophyte formation, which represent arthritic changes to the cuboid’s articulations.
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A contralateral radiograph can be useful to compare lengths of the lateral column.
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Advanced imaging, including CT scan, can assist in further analysis of arthritic changes, cyst formation, and changes in osseous morphology.
Nonoperative management
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Conservative treatment is warranted prior to consideration for surgical intervention, although oftentimes relief is minimal when posttraumatic arthritic changes are significant and advanced :
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Rest, ice, compression, and elevation (RICE)
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Activity modification
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Shoe modification
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Bracing
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Custom ankle foot orthoses (i.e., Arizona)
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Athletic ankle-stabilizing orthoses
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Shoe inserts (over the counter vs. custom)
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Oral or topical nonsteroidal antiinflammatories.
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Traditional surgical management
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Corrective osteotomy (i.e., opening wedge cuboid osteotomy).
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Lateral column lengthening ± calcaneal cuboid arthrodesis.
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Calcaneocuboid arthrodesis may affect adjacent joints and decrease the mean range of motion to the talonavicular joint (TNJ) by 33% and the subtalar joint by 8%. ,
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Fourth and 5th tarsometatarsal arthrodesis.
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Interpositional arthroplasty.
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Traditional surgical management often includes arthrodesis but elimination of motion in the highly mobile lateral column can be problematic. If the majority of the pathology is isolated to the cuboid and articulation to the 4th or 5th metatarsal, interpositional arthroplasty has traditionally provided relief. In the author’s opinion and experience, patients do well after an interpositional arthroplasty for about a year and then often symptoms begin to return. Opening wedge osteotomy or calcaneal lateral lengthening osteotomy could increase articulation pressures, resulting in increasing arthritic symptoms. In addition, osteotomies and/or arthrodesis include risks of high nonunion rates. Replacing the cuboid with a patient-specific implant restores the native length of the lateral column as well as allows motion at both the tarsometatarsal and calcaneocuboid joints. Preservation of motion provides more opportunity for decreased stress adjacent to the joint in comparison to arthrodesis. ,
3D-printed implant design specification and considerations
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A 3D-printed implant for cuboid pathology allows specific and precise determination of the degree of lateral column shortening.
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Obtain a CT scan of the contralateral foot to create an inverted variant for nominal anatomy of the affected cuboid.
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The implant material can vary depending on the surgeon’s preference. The implant seen throughout this chapter is made from titanium alloy (Ti6Al4V). Cobalt chromium (CoCr) is also readily available a common implant printing material.
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The implant is anchored into the lateral aspect of the lateral cuneiform via porous pegs.
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Additional fixation can be designed into the implant, including hole clearances for screw fixation. The design is patient specific to facilitate additional adjunctive procedures ( Fig. 17.6 ).
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