As mentioned earlier, one of the main indications for calcaneocuboid fusion is correction of flat foot deformity. Logel and colleagues ² described lengthening of lateral column by calcaneocuboid distraction arthrodesis and tendon transfer on 10 fresh frozen cadaver lower extremity specimens. Because lengthening of the lateral column increases the pressure on the lateral column, creating forefoot varus, these investigators added first metatarsocuneiform arthrodesis, reducing the pressure on the lateral column and elevating the medial arch of the foot and all the radiographic parameters, with noticeable improvement.

Another prospective study by van der Krans and colleagues ⁸ applied calcaneocuboid distraction arthrodesis, posterior tibial tendon augmentation, and percutaneous Achilles tendon lengthening to 20 patients (20 feet) with adult acquired flexible flatfoot. The mean age was 55 (30–66) years and the group comprised 16 women and 4 men. Arthrodesis of the first cuneiform-metatarsal joint was performed in 8 patients and naviculocuneiform arthrodesis was performed in 2 patients to correct the forefoot supination and hallux valgus. The foot function index and American Orthopedic Foot and Ankle Society (AOFAS) Clinical Rating Index hindfoot score were obtained preoperatively and postoperatively. Patients were followed over 25 months. The results were complete pain relief and increase in daily activity in 17 patients. The satisfaction rate ranged from good to excellent in 15 patients. Pain at the distraction site was noted in 3 patients only. Significant improvement was observed on radiographic parameters in dorsoplantar and lateral talometatarsal angle in addition to ground-navicular distance. The technique was performed with 0.8-cm to 1.0-cm distractions and an iliac crest graft was used. Fixation was achieved with a cervical H-plate from Synthes (Synthes Inc., West Chester, PA, USA) with 2 distal and 2 proximal cortical screws. Postoperatively, all patients were immobilized with a non–weight-bearing cast for 4 weeks followed by a weight-bearing cast for another 4 weeks. Next, a cam walker was used for the last 4 weeks. Orthotics were prescribed at 5 months. On radiographic studies, union was noticed in 16 feet within 3 months and in 1 foot within 4 months and 1 foot in 5 months. Nonunion was noticed in 2 feet only. Three patients complained of paresthesia or anesthesia in the sural nerve area.

Another study by Kitaoka ³ viewed the role of calcaneocuboid distraction arthrodesis in posterior tibial tendon dysfunction and flatfoot. In the early stages, a soft tissue procedure was used. For example, flexor digitorum longus tendon transfer might benefit the patient. In late stages of the disorder associated with rigid deformity and hindfoot arthritis, arthrodesis plays a main role.

The last scenario is when a patient is in the late stages but stiffness is not associated; those patients benefit from calcaneocuboid distraction arthrodesis. Anderson and Davis ³ reported the results of calcaneocuboid distraction arthrodesis in patients with acquired flat foot associated with posterior tibial dysfunction. One of 13 patients developed nonunion, and most patients reported improvement in foot alignment and symptoms.

Calcaneocuboid distraction arthrodesis may be associated with limitations and complications. The main limitation is that calcaneocuboid distraction arthrodesis includes using a bone graft, which might be large enough to prolong the healing process.²

Three main complications are associated with calcaneocuboid distraction arthrodesis: nonunion, malunion, and stress fracture of the lateral column.^1,^3,^8,¹⁶ In a study performed by Thomas and colleagues, 17 feet were used. Two nonunion, 3 delayed unions, 3 graft stress fractures, and 1 fifth metatarsal stress fracture were reported.³ Another study by Chi and colleagues of 12 feet with isolated calcaneocuboid distraction arthrodesis reported 2 nonunions.³ However, these investigators also reported study arthrodesis, resulting in 8 nonunions.³

Posttraumatic calcaneocuboid fusion is a broad subject. Many studies have been performed on calcaneal trauma and the percentage of calcaneocuboid joint involvement. Studies have shown that the calcaneocuboid joint is involved in 33% to 76% of calcaneal fractures. In a study of 553 calcaneal fractures prepared by Zwipp and colleagues, 59.7% were associated with calcaneocuboid joint involvement.⁵ Clinically, patients with calcaneocuboid joint involvement have the same level of pain as patients without calcaneocuboid joint involvement according to Ebraheim and colleagues.⁵ However, walking on a rough surface causes a problem. Also subtalar joint involvement is difficult to rule out clinically. Generally, severe trauma is mostly associated with calcaneocuboid joint involvement.

Other conditions that might affect the calcaneocuboid joint and result in fusion include ^1,^3,⁸:

1. Forefoot or midfoot adductus, which applies more mechanical pressure to lateral columns.

2. Pronation deformity, which might be associated with hypermobile calcaneocuboid joint or unstable midtarsal joint.

3. Cuboid syndrome or subluxation of the calcaneocuboid joint, which might be caused by many factors such as firing of the peroneal tendon in external or internal rotation and results in more stress applied to the calcaneocuboid joint and subluxation at the end. On the other hand, cuboid syndrome is an inflammation of the calcaneocuboid joint caused by mild malposition of that joint. Isolated subluxation or dislocation of the calcaneocuboid joint without fracture is not common.

4. Direct injury to the ligaments of calcaneocuboid joint might occur and is usually associated with supination mechanism.

5. Biomechanical disorder or idiopathic lateral column pain, when no cause can be found to explain the calcaneocuboid joint pain. In this case, gait analysis with complete biomechanical examination of the foot is important. Furthermore, orthotics might be considered as a milestone for treatment.

6. Lateral band release of the plantar fascia caused by severe dissection during plantar fasciotomy procedure usually results in applying more pressure to the calcaneocuboid joint and manifests as lateral column pain.

Noninvasive treatment of calcaneocuboid joint disorder

Before considering surgical intervention for lateral column and calcaneocuboid joint disease, conservative modalities of treatment are highly recommended. These modalities include padding of the cuboid to offload the pressure on the calcaneocuboid joint.¹ In addition, custom-molded orthotics plays an important role similar to cuboid padding. Repositioning the calcaneocuboid joint in normal alignment, the maneuver to realign the joint is called black snake heel whip.¹ This maneuver is performed by having the patient standing flexing the knee in the affected limb to 90°. The physician stands behind the patient and holds the forefoot of the patient with their fingers and positions their thumbs over each other on the medial plantar aspect of the cuboid bone. Next, the physician manipulates the foot like a whip in a fast movement to reposition the cuboid laterally and dorsally. A pop noise indicates that the calcaneocuboid joint has been repositioned. Low-dye strapping is then used to keep the alignment intact.

Prolotherapy ¹ is one of the methods to treat chronic calcaneocuboid subluxation by strengthening the capsule and ligaments of the joint. It is an injection of dextrose, anesthetic, and phenol. The mechanism is to inject through the joint capsule, which results in sclerosis and increases the blood supply. A pseudoarthrosis develops and subluxation improves.

Calcaneocuboid Arthrodesis

Fusion of the calcaneocuboid joint can be considered after all noninvasive methods of treatment have failed. Usually, triple arthrodesis is indicated when a patient has midtarsal or subtalar joint pain associated with calcaneocuboid joint arthrosis.¹

Although isolated calcaneocuboid joint arthrodesis is believed to end with degenerative arthritic changes in the surrounding joints, much success has been reported by performing isolated calcaneocuboid joint fusion. Thomas and colleagues performed 5 isolated fourth and fifth metatarsal base cuboid fusions and 15 isolated calcaneocuboid fusions.¹ As a result, some patients who had distal fusion developed pain at the calcaneocuboid joint. However, patients who had calcaneocuboid joint fusion did not report any pain. The distal joints adjust and function better, considering that the main motion in the lateral column comes from the fourth and fifth metatarsal cuboid joint more than the calcaneocuboid joint. Also Achilles lengthening should be considered when performing lateral column fusion to avoid posterior equines. It is helpful to use an injection in the distal or proximal joints to locate the source of the pain in the lateral column.^1,⁸

Abduction of the foot might develop after calcaneocuboid fusion, but usually patients function normally without the talonavicular joint being affected.¹

Surgical technique

The patient is placed on the operating table in a supine position. A blanket is placed under the ipsilateral hip for support.^7,^8,^15,¹⁷ A pneumatic thigh tourniquet is applied for hemostasis and inflated to 350 mm Hg for the duration of the case. Next, the foot and ankle are scrubbed, draped, and prepared in the usual aseptic manner. A longitudinal linear skin incision is made along the lateral aspect of the foot over the calcaneocuboid joint starting from the tip of the fibula and extending to the base of the fourth metatarsal. Care is taken to retract the sural nerve with any branches. Then, the deep fascia is dissected to expose the extensor digitorum brevis and peroneal tendon sheath. The extensor digitorum brevis is dissected from its origin after opening the capsule and the muscle is retracted distal to the calcaneocuboid joint. Then the peroneal tendon sheath is split longitudinally and reflected plantarly.

Usually, a freer elevator is used to maintain retraction of all soft tissue structures and to be inserted within the calcaneocuboid joint. The location of the joint is confirmed using fluoroscopy. After the calcaneocuboid joint is exposed, a sagittal saw or sharp osteotome or curette is used to remove the articular cartilage from the proximal surface of the cuboid and the distal surface of the calcaneus. Care should be taken to maintain the saddle shape of the cuboid-calcaneal joint. If a sagittal saw is used, the blade should be placed parallel to the transverse and sagittal planes. After removing a 1-mm to 1.5-mm layer of subchondral bone, the arthrodesis site is exposed with proper bone-to-bone apposition and cancellous bone surfaces. A key elevator can be used to reflect the periosteum and to expose the calcaneocuboid joint. It is important to confirm that the joint capsule is dissected completely to have better exposure of the joint.

Before starting the internal fixation, a small drill of 1.6-mm wire is used to fenestrate bone surfaces both at the cuboid and at the calcaneus. A laminar spreader can be inserted in the joint to get better exposure for fenestration and deep drilling to increase vascularity during the healing process.

Several methods can be followed to perform internal fixation of the calcaneocuboid joint. Using 4.0-mm cannulated screws is 1 method that can be used for fixation. Usually, 1 screw is inserted proximally to distally from the anterior process of the calcaneus, extending in an oblique direction to the cuboid, and the other screw is inserted in the opposite direction distally to proximally and crossing the first screw.

The second method of fixation is power staples. This method is usually applied to soft bone and patients with rheumatoid arthritis. Attention should be directed to the arrangement of staples around the joint to obtain the proper stabilization.

The third method of fixation is plate fixation. More stability to the fusion site can be applied by using plate fixation. Usually, an H-plate with locking screws is used to provide interfragmentary compression. The plate is placed dorsolaterally overlying the calcaneocuboid joint and the 3.5-mm distal lateral screws are inserted using the proper technique followed by the 3.5-mm distal medial screw. Care should be taken to ensure that the screws remained within the cuboid under fluoroscopy. The 2 3.5-mm proximal screws are then inserted within the plate. Care should be taken to ensure that the calcaneal screws do not enter the subtalar joint under fluoroscopy. The surgical site is then flushed with copious amounts of sterile saline and a bone graft is inserted to fill the minimal void within the calcaneocuboid joint. The arthrodesis site should be inspected before closing the wound. The extensor digitorum brevis and peroneal tendon sheath can be repaired to the underlying periosteum by using absorbable suture. Also an absorbable suture, such as 2.0 and 3.0 vicryl, can be used for capsule and subcutaneous closure. Skin can be closed with nonabsorbable suture such as 4.0 prolene. During closure, care should be taken not to disturb the sural nerve, particularly when suturing the subcutaneous layers. Injection of 0.5% bupivacaine postoperatively is recommended to maintain postoperative pain relief. A sterile dressing is applied to the incision site. Afterward, compression dressing with a below-knee posterior fiberglass splint is placed.

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