JBJS | Article

The Journal of Bone & Joint Surgery, Volume 84, Issue 4

Scientific Article | April 01, 2002

Transcalcaneal Talonavicular Dislocation

William M. Ricci, MD; Carlo Bellabarba, MD; Roy Sanders, MD

Investigation performed at Tampa General Hospital, Tampa, Florida

William M. Ricci, MD
Department of Orthopaedic Surgery, Barnes-Jewish Hospital, Washington University School of Medicine, One Barnes Hospital Plaza, Suite 11300, St. Louis, MO 63110. E-mail address: ricciw@msnotes.wustl.edu

Carlo Bellabarba, MD
Department of Orthopaedics, University of Washington, 1959 N.E. Pacific Street, Box 356500, Seattle, WA 98195

Roy Sanders, MD
Florida Orthopaedic Institute, 4 Columbia Drive, Suite 710, Tampa, FL 33606

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

The Journal of Bone & Joint Surgery. 2002; 84:557-561

5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

text A A A

Abstract

Background: The combination of dorsal dislocation of the navicular from the talus and an associated comminuted fracture of the calcaneus (transcalcaneal talonavicular dislocation) is an unusual and severe injury. Six cases have been described previously. The purposes of this study were to report the prevalence of this injury and the variations in injury pattern and to characterize methods of treatment and patient outcomes.

Methods: Eight patients with nine cases of transcalcaneal talonavicular dislocation were treated by the senior author between January 1, 1990, and February 28, 1998. The comminuted fracture of the calcaneus was apparently caused by plantar flexion of the talus through the anterior portion of the calcaneus. There were five open Grade-III injuries and three associated lacerations of the posterior tibial artery. After initial provisional stabilization of the hindfoot and management of the soft tissues, all injuries were treated with delayed open reduction and internal fixation of the calcaneus and fusion of the subtalar joint. At the last follow-up examination, the outcomes were rated with the Maryland foot score, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot rating score, and the Creighton-Nebraska score for all patients who had not had an amputation.

Results: The duration of follow-up ranged from 1.1 to eight years. Chronic osteomyelitis developed in four patients, and three of them ultimately had an amputation. The Creighton-Nebraska scores for the remaining six feet ranged from 33 to 92 points, with only one having a good or excellent result. Five of the six patients had a limp, difficulty with shoe wear, limitation with regard to walking, and moderate pain.

Conclusions: Transcalcaneal talonavicular dislocation is a severe injury that often leads to osteomyelitis and amputation. Patients who do not lose the leg as a result of uncontrolled infection should be counseled to expect severe functional limitations and/or chronic pain.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | References

The calcaneus is the most commonly fractured tarsal bone. Ten percent of calcaneal fractures are associated with fractures of the spine, up to 20% are associated with other extremity fractures, and the fracture is bilateral in up to 9% of cases ^1,2 . Less than 2% of calcaneal fractures are open. The most common cause of an intra-articular fracture of the calcaneus is a fall from a height ² . Fractures and fracture-dislocations of and around the talus are often high-energy injuries that are frequently associated with open wounds ³ . The combination of dorsal dislocation of the navicular from the talus and a comminuted fracture of the calcaneus (transcalcaneal talonavicular dislocation) is an unusual and severe injury. To our knowledge, a total of six cases have been described4-6 and a series describing treatment methods and results of treatment of this injury has never been reported. The purposes of our study were to characterize this injury pattern by reporting its prevalence, describe associated injury patterns, review treatment methods, and evaluate patient outcomes.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 1:: The characteristic injury pattern is plantar dislocation of the talus from the navicular with an associated comminuted fracture of the calcaneus. a (Case 1), b (Case 3), c (Case 4), d (Case 6), e (Case 7), and f (Case 8) are lateral radiographs of the foot and ankle made after injury.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 2:: Case 7. a: Lateral radiograph made at the time of injury. b: Clinical photograph showing a Grade-IIIA wound8. c: Debrided bone, including the majority of the posterior facet of the calcaneus. d: Initial stabilization of the subtalar and talonavicular joints with Kirschner wires and antibiotic-impregnated cement to fill the void in the calcaneus. e and f: Lateral and anteroposterior radiographs of the foot made at 3.2 years postoperatively.

View Larger

TABLE I: Patient Data

Case	Side	Age (yr)	Mechanism of Injury	Other Fractures
1	L	33	Fall	L5 burst, L1-L5 transverse processes, sacrum, bilat. femur, L tibia, R calcaneus, L 1-5 metatarsals
2	L	28	Motor-veh. acc.	L2 burst, R transcalcaneal talonavicular dislocation, L 2-5 metatarsals, R medial cuneiform
	R	28	Motor-veh. acc.	L2 burst, L transcalcaneal talonavicular dislocation, L 2-5 metatarsals, R medial cuneiform
3	L	34	Parachute jump	L4 burst, bilat. femur
4	L	20	Motor-veh. acc.	L femur, L patella, R pilon, R calcaneus
5	R	36	Motor-veh. acc.	R acetabulum, bilat. femur, R tibial plateau, L humerus, L calcaneus
6	L	29	Motor-veh. acc.	L femoral neck and shaft, R fracture-dislocation of 1st metatarsophalangeal joint
7	R	25	All-terrain-veh. acc.	L4 burst, R femur, R olecranon
8	L	37	Parachute jump	Pelvis, L femur

Add to My JBJS

TABLE I: Patient Data

Case	Side	Age (yr)	Mechanism of Injury	Other Fractures
1	L	33	Fall	L5 burst, L1-L5 transverse processes, sacrum, bilat. femur, L tibia, R calcaneus, L 1-5 metatarsals
2	L	28	Motor-veh. acc.	L2 burst, R transcalcaneal talonavicular dislocation, L 2-5 metatarsals, R medial cuneiform
	R	28	Motor-veh. acc.	L2 burst, L transcalcaneal talonavicular dislocation, L 2-5 metatarsals, R medial cuneiform
3	L	34	Parachute jump	L4 burst, bilat. femur
4	L	20	Motor-veh. acc.	L femur, L patella, R pilon, R calcaneus
5	R	36	Motor-veh. acc.	R acetabulum, bilat. femur, R tibial plateau, L humerus, L calcaneus
6	L	29	Motor-veh. acc.	L femoral neck and shaft, R fracture-dislocation of 1st metatarsophalangeal joint
7	R	25	All-terrain-veh. acc.	L4 burst, R femur, R olecranon
8	L	37	Parachute jump	Pelvis, L femur

View Larger

TABLE II: Injury Patterns and Treatment

*TN = talonavicular, ST = subtalar, CC = calcaneocuboid, TT = tibiotalar, PTA = posterior tibial artery, PTT = posterior tibial tendon, and FDC = flexor digitorum communis tendon.

Case	Associated Foot and Ankle Injuries*	Initial Stabilization*	No. of Ops.	Type of Wound ^8,9	Fused Joints*
1	None	Percut. stab., TN joint	8	IIIA	ST, TN, CC at 5 wk
2L	None	Ext. fixat., talus to medial cuneiform	3	Closed	ST and CC at 2 wk
2R	TT dislocation, talar fracture	Ext. fixat., tibia to midfoot	4	Closed	ST at 6 wk
3	TT dislocation, navicular fracture, PTA laceration	Percut. stab., TN, ST, TT joints	7	IIIA	ST, TN, CC at 2 wk
4	TT dislocation	Percut. stab., TN and TT joints; ext. fixat., tibia to midfoot	9	Closed	ST at 35 wk
5	Navicular fracture	Ext. fixat., tibia to midfoot	7	IIIB	ST, TN, CC at 13 wk
6	TT dislocation; PTA, PTT, FDC lacerations	Percut. stab., TN joint	5	IIIA	ST at 1 wk
7	PTA laceration	Percut. stab., TN and ST joints	6	IIIA	ST, TN, CC at 5 wk
8	None	None	2	Closed	ST at 3 weeks

Add to My JBJS

TABLE II: Injury Patterns and Treatment

*TN = talonavicular, ST = subtalar, CC = calcaneocuboid, TT = tibiotalar, PTA = posterior tibial artery, PTT = posterior tibial tendon, and FDC = flexor digitorum communis tendon.

Case	Associated Foot and Ankle Injuries*	Initial Stabilization*	No. of Ops.	Type of Wound ^8,9	Fused Joints*
1	None	Percut. stab., TN joint	8	IIIA	ST, TN, CC at 5 wk
2L	None	Ext. fixat., talus to medial cuneiform	3	Closed	ST and CC at 2 wk
2R	TT dislocation, talar fracture	Ext. fixat., tibia to midfoot	4	Closed	ST at 6 wk
3	TT dislocation, navicular fracture, PTA laceration	Percut. stab., TN, ST, TT joints	7	IIIA	ST, TN, CC at 2 wk
4	TT dislocation	Percut. stab., TN and TT joints; ext. fixat., tibia to midfoot	9	Closed	ST at 35 wk
5	Navicular fracture	Ext. fixat., tibia to midfoot	7	IIIB	ST, TN, CC at 13 wk
6	TT dislocation; PTA, PTT, FDC lacerations	Percut. stab., TN joint	5	IIIA	ST at 1 wk
7	PTA laceration	Percut. stab., TN and ST joints	6	IIIA	ST, TN, CC at 5 wk
8	None	None	2	Closed	ST at 3 weeks

View Larger

TABLE III: Results

*MD = Maryland foot score ⁷ , AOFAS = American Orthopaedic Foot and Ankle Society ankle-hindfoot rating score ¹⁰ , C-N = Creighton-Nebraska score ¹¹ .

Case	Complications	Scores* (points)
MD	AOFAS	C-N
1	Osteomyelitis of calcaneus, below-the-knee amputation at 11 wk
2L	Surgical wound infection	54	41	33
2R	Osteomyelitis of calcaneus, below-the-knee amputation at 13 wk
3	Osteomyelitis of talus, talectomy at 43 wk	75	52	52
4	Heel pressure necrosis, malunion of calcaneus	71	65	48
5	None	92	85	92
6	Nonunion of subtalar fusion, revision of subtalar fusion at 203 wk	65	51	50
7	Traumatic wound necrosis	78	69	70
8	Osteomyelitis of calcaneus, Syme amputation at 57 wk

Add to My JBJS

TABLE III: Results

*MD = Maryland foot score ⁷ , AOFAS = American Orthopaedic Foot and Ankle Society ankle-hindfoot rating score ¹⁰ , C-N = Creighton-Nebraska score ¹¹ .

Case	Complications	Scores* (points)
MD	AOFAS	C-N
1	Osteomyelitis of calcaneus, below-the-knee amputation at 11 wk
2L	Surgical wound infection	54	41	33
2R	Osteomyelitis of calcaneus, below-the-knee amputation at 13 wk
3	Osteomyelitis of talus, talectomy at 43 wk	75	52	52
4	Heel pressure necrosis, malunion of calcaneus	71	65	48
5	None	92	85	92
6	Nonunion of subtalar fusion, revision of subtalar fusion at 203 wk	65	51	50
7	Traumatic wound necrosis	78	69	70
8	Osteomyelitis of calcaneus, Syme amputation at 57 wk

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Patients

Four hundred and fifteen displaced intra-articular calcaneal fractures were treated by the senior author (R.S.) between January 1, 1990, and February 28, 1998. We retrospectively identified nine cases (in eight patients) of dorsal dislocation of the talonavicular joint associated with a fracture of the calcaneus. There were seven men and one woman, with ages ranging from twenty to thirty-seven years. Each patient had sustained a high-energy injury to the foot, and all of the calcaneal fractures were severely comminuted Type-IV injuries according to the system of Sanders et al.7. The plantar flexed head of the talus appeared to cause a fracture of the anterior process of the calcaneus ( Fig. 1 ) and often exited through the medial plantar skin of the foot. The injury mechanisms are presented in Table I .

Fractures and Associated Injuries

There were four closed and five open injuries. The open wounds were all located medially, and according to the system of Gustilo and Anderson8,9 four open fractures were Grade IIIA and one was Grade IIIB ( Table II ). Three open injuries were associated with laceration of the posterior tibial artery, and one of them was associated with laceration of the posterior tibial and flexor digitorum communis tendons as well.

Management

( Fig. 2 )

Initial management included stabilization of the hindfoot with external fixation and/or percutaneous pin fixation across the injured, unstable joints ( Table II ). All patients with an open fracture underwent serial irrigation and dï¿½bridement of devitalized soft tissue and bone with or without the placement of an antibiotic-impregnated cement spacer. All open wounds were closed within one week after injury with either delayed primary wound closure (four cases) or with split-thickness skin-grafting (one case). When soft-tissue swelling had resolved enough to allow wrinkling of the skin, all injuries were treated with delayed open reduction and internal fixation of the calcaneus and fusion of the subtalar joint through a lateral surgical approach. Transverse tarsal joints that were unstable or associated with a comminuted intra-articular fracture were also fused. Four feet underwent talonavicular and calcaneocuboid fusion (triple arthrodesis), and one required calcaneocuboid fusion ( Table II ). The laceration of the posterior tibial tendon was treated eight days after injury with transfer of the flexor hallucis longus to the posterior tibial tendon. The lacerated flexor digitorum communis tendon was not repaired.

Outcome Measures

Outcomes were assessed with the Maryland foot score ⁷ , the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot rating score10, and the Creighton-Nebraska score11 at the last follow-up examination.

Results

Introduction | Materials and Methods | Results | Discussion | References

Injury Pattern

All patients had dorsal dislocation of the navicular from the talus with a comminuted Type-IV fracture of the calcaneus according to the system of Sanders et al. 7. The head of the talus appeared to have crushed the anterior process of the calcaneus. Four limbs had no adjacent fractures or dislocations, four limbs had an associated tibiotalar dislocation, two had an associated navicular fracture, and one had an associated talar fracture ( Table II ).

Outcome

The duration of follow-up ranged from 1.1 to eight years. Six limbs in six patients did not require amputation as the result of the injury. At the last follow-up examinations of these patients, at 1.5 to eight years postoperatively, the Maryland foot scores ranged from 54 to 92 points, with two fair results, three good results, and one excellent result. The AOFAS ankle-hindfoot scores ranged from 41 to 85 points, and the Creighton-Nebraska scores ranged from 33 to 92 points, with four poor results, one fair result, and one excellent result ( Table III ). Five of the six patients had a limp, difficulty with shoe wear, limitation with regard to walking, and moderate pain.

Three patients ultimately had an amputation as a result of uncontrolled osteomyelitis ( Table III ). Two below-the-knee amputations and one Syme amputation were performed. One of these patients (Case 1) had had a Grade-IIIA open wound that was initially treated with multiple operative dï¿½bridements. A triple arthrodesis was performed five weeks after the injury. Polymicrobial osteomyelitis of the calcaneus developed, and a below-the-knee amputation was performed eleven weeks after the injury. The second patient who had an amputation (Case 8) had a closed injury. Open reduction and internal fixation of the calcaneus and a subtalar fusion was performed three weeks after the injury. Chronic osteomyelitis of the calcaneus developed and was treated with multiple courses of intravenous antibiotics. A Syme amputation was ultimately performed fifty-seven weeks after the original injury. The third patient (Case 2, right) also had a closed injury. Open reduction and internal fixation of the calcaneus and subtalar fusion was performed six weeks after the injury. These procedures were also complicated by persistent osteomyelitis of the calcaneus. A below-the-knee amputation was performed thirteen weeks after the original injury.

Wound and Infectious Complications

Necrosis of a traumatic wound developed in a patient (Case 7) who had an open Grade-IIIA injury associated with laceration of the posterior tibial artery. This problem was successfully treated with multiple operative irrigations and dï¿½bridements, free muscle flaps, and split-thickness skin grafts. In another patient (Case 4), pressure necrosis developed over a displaced calcaneal tuberosity fragment; a free fascial flap and skin grafts were required for coverage.

Superficial infection developed in the surgical wound of one patient (Case 2, left) who had a closed injury. Open reduction and internal fixation of the calcaneus and fusions of the subtalar and calcaneocuboid joints had been performed two weeks after injury. The wound infection was successfully treated with operative dï¿½bridements and intravenous antibiotics.

Osteomyelitis was the most common complication, developing in four of the nine limbs. Three of these infections led to amputation, as described above. The fourth patient with osteomyelitis (Case 3) had an open Grade-IIIA injury. This injury was initially treated with multiple dï¿½bridements, placement of antibiotic beads, and percutaneous Kirschner-wire fixation of the subtalar, talonavicular, and tibiotalar joints. Seventeen days after injury, the patient underwent open reduction and internal fixation of the calcaneus and fusion of the subtalar, talonavicular, and calcaneocuboid joints. This procedure was complicated by osteomyelitis of the talus, which ultimately required talectomy.

Other Complications

There was one failed subtalar fusion that required revision. Two patients required removal of painful hardware. One patient required exostectomy because of a malunited fracture of the calcaneus.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

Association of dorsal dislocation of the navicular from the talus with fracture of the calcaneus is an uncommon but severe injury. In 1952, Coltart4 reported on 228 talar injuries, including five cases of "severe comminution of the calcaneum with a fracture through the neck of the talus. The body of the talus is inverted and embedded in the calcaneum." These injuries were "usually compound and infected," and three of the five patients required a below-the-knee amputation. No further discussion of treatment or results was presented. In 1976, Kleiger6 schematically described plantar dislocation of the talus at the talonavicular joint with calcaneal fracture in his discussion of talar injury mechanisms. He postulated that the "calcaneus is shattered and the talus is pushed through the calcaneal fragments by the tibia to produce plantar talar dislocation." No cases were reported in his article. In 1993, Ebraheim et al.5 reported two cases of complex fracture-dislocation of the calcaneus. In one of their cases, the talus was dislocated and plantar flexed and the calcaneus was dislocated laterally and highly comminuted. This patient was treated with open reduction and internal fixation of the calcaneus with multiple Kirschner wires through a lateral incision. The talus was reduced and the talonavicular and calcaneocuboid joints were pinned. At fourteen months, the patient was reported to have had an "excellent" range of motion of the ankle, 40% subtalar motion compared with that on the contralateral side, no ankle instability, and no avascular necrosis.

Two percent of the calcaneal fractures treated by the senior one of us were associated with transcalcaneal talonavicular dislocation. The hallmark of this injury pattern was plantar dislocation of the talus from the navicular associated with a severely comminuted calcaneal fracture. The head of the talus appeared to have crushed the anterior process of the calcaneus. Variations in injury pattern included adjacent fracture of the tibial plafond, talus, or navicular and/or dislocation of the tibiotalar joint.

The high prevalence of open injuries and of associated long-bone and spine fractures as well as the generally poor outcomes in our patients reflect the extreme energy of this injury. This finding is consistent with Coltart's observation that these injuries were commonly the result of the explosion of land mines4. Three of our patients ultimately required amputation because of osteomyelitis. This high number of amputations is also consistent with the report by Coltart. Only one of our patients had an uncomplicated course, and this was the only patient who had a good or excellent functional outcome according to both the Maryland and the Creighton-Nebraska score.

A limitation of this study is the small sample size (nine injuries), which reflects the unusual nature of this injury pattern. To our knowledge, only six similar cases have been reported in the literature and there are no other reports reviewing treatment methods and outcomes. The small number of cases makes it difficult to determine prognostic factors. However, the presence of osteomyelitis appears to be associated with an exceptionally poor outcome. Four of our patients had osteomyelitis (three of the calcaneus and one of the talus). Three of these patients ultimately required amputation, and the fourth required talectomy.

The importance of this injury lies in its severity. Initial management should focus on provisional stabilization of the hindfoot with external fixation spanning the injured joints and/or percutaneous pin fixation across the injured joints and management of the soft-tissue injury. Definitive surgery should be delayed until the soft-tissue envelope is sufficiently healed and free of infection. Patients with this injury should be counseled to expect severe functional limitations and/or chronic pain or even amputation.

References

Introduction | Materials and Methods | Results | Discussion | References

Giannestras N, Sammarco GJ. Fractures and dislocations in the foot. In: Rockwood CA Jr, Green DP, editors. Fractures. Vol 2. Philadelphia: JB Lippincott; 1975. p 1400-89.

DeLee JC. Fractures and dislocations of the foot. In: Mann RA, Coughlin MJ, editors. Surgery of the foot and ankle. 6th ed, vol 2. St. Louis: Mosby; 1993. p 1465-703.

Marsh JL, Saltzman CL, Iverson M,Shapiro DS. Major open injuries of the talus. J Orthop Trauma,1995;9: 371-6.. 9371 1995 [PubMed]

Coltart WD. "Aviator's Astragalus.". J Bone Joint Surg Br,1952;34: 545-66.. 34545 1952 [PubMed]

Ebraheim NA, Savolaine ER, Paley K,Jackson WT. Comminuted fracture of the calcaneus associated with subluxation of the talus. Foot Ankle, 1993;14: 380-4.. 14380 1993 [PubMed]

Kleiger B. Injuries of the talus and its joints. Clin Orthop,1976;121: 243-62.. 121243 1976 [PubMed]

Sanders R, Fortin P, DiPasquale T,Walling A. Operative treatment in 120 displaced intraarticular calcaneal fractures. Results using a prognostic computed tomography scan classification. Clin Orthop,1993;290: 87-95.. 29087 1993 [PubMed]

Gustilo RB,Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: a retrospective and prospective analysis. J Bone Joint Surg Am,1976;58: 453-8.. 58453 1976 [PubMed]

Gustilo RB, Mendoza RM,Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma,1984;24: 742-6.. 24742 1984 [PubMed]

Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS,Sanders M. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int,1994;15: 349-53.. 15349 1994 [PubMed]

Crosby LA,Fitzgibbons TC. Open reduction and internal fixation of type II intra-articular calcaneus fractures. Foot Ankle Int,1996;17: 253-8.. 17253 1996 [PubMed]

View Large | Download Slide(.ppt)
Add to My JBJS

View Larger

TABLE I: Patient Data

Case	Side	Age (yr)	Mechanism of Injury	Other Fractures
1	L	33	Fall	L5 burst, L1-L5 transverse processes, sacrum, bilat. femur, L tibia, R calcaneus, L 1-5 metatarsals
2	L	28	Motor-veh. acc.	L2 burst, R transcalcaneal talonavicular dislocation, L 2-5 metatarsals, R medial cuneiform
	R	28	Motor-veh. acc.	L2 burst, L transcalcaneal talonavicular dislocation, L 2-5 metatarsals, R medial cuneiform
3	L	34	Parachute jump	L4 burst, bilat. femur
4	L	20	Motor-veh. acc.	L femur, L patella, R pilon, R calcaneus
5	R	36	Motor-veh. acc.	R acetabulum, bilat. femur, R tibial plateau, L humerus, L calcaneus
6	L	29	Motor-veh. acc.	L femoral neck and shaft, R fracture-dislocation of 1st metatarsophalangeal joint
7	R	25	All-terrain-veh. acc.	L4 burst, R femur, R olecranon
8	L	37	Parachute jump	Pelvis, L femur

Add to My JBJS

TABLE I: Patient Data

Case	Side	Age (yr)	Mechanism of Injury	Other Fractures
1	L	33	Fall	L5 burst, L1-L5 transverse processes, sacrum, bilat. femur, L tibia, R calcaneus, L 1-5 metatarsals
2	L	28	Motor-veh. acc.	L2 burst, R transcalcaneal talonavicular dislocation, L 2-5 metatarsals, R medial cuneiform
	R	28	Motor-veh. acc.	L2 burst, L transcalcaneal talonavicular dislocation, L 2-5 metatarsals, R medial cuneiform
3	L	34	Parachute jump	L4 burst, bilat. femur
4	L	20	Motor-veh. acc.	L femur, L patella, R pilon, R calcaneus
5	R	36	Motor-veh. acc.	R acetabulum, bilat. femur, R tibial plateau, L humerus, L calcaneus
6	L	29	Motor-veh. acc.	L femoral neck and shaft, R fracture-dislocation of 1st metatarsophalangeal joint
7	R	25	All-terrain-veh. acc.	L4 burst, R femur, R olecranon
8	L	37	Parachute jump	Pelvis, L femur

View Larger

TABLE II: Injury Patterns and Treatment

*TN = talonavicular, ST = subtalar, CC = calcaneocuboid, TT = tibiotalar, PTA = posterior tibial artery, PTT = posterior tibial tendon, and FDC = flexor digitorum communis tendon.

Case	Associated Foot and Ankle Injuries*	Initial Stabilization*	No. of Ops.	Type of Wound ^8,9	Fused Joints*
1	None	Percut. stab., TN joint	8	IIIA	ST, TN, CC at 5 wk
2L	None	Ext. fixat., talus to medial cuneiform	3	Closed	ST and CC at 2 wk
2R	TT dislocation, talar fracture	Ext. fixat., tibia to midfoot	4	Closed	ST at 6 wk
3	TT dislocation, navicular fracture, PTA laceration	Percut. stab., TN, ST, TT joints	7	IIIA	ST, TN, CC at 2 wk
4	TT dislocation	Percut. stab., TN and TT joints; ext. fixat., tibia to midfoot	9	Closed	ST at 35 wk
5	Navicular fracture	Ext. fixat., tibia to midfoot	7	IIIB	ST, TN, CC at 13 wk
6	TT dislocation; PTA, PTT, FDC lacerations	Percut. stab., TN joint	5	IIIA	ST at 1 wk
7	PTA laceration	Percut. stab., TN and ST joints	6	IIIA	ST, TN, CC at 5 wk
8	None	None	2	Closed	ST at 3 weeks

Add to My JBJS

TABLE II: Injury Patterns and Treatment

*TN = talonavicular, ST = subtalar, CC = calcaneocuboid, TT = tibiotalar, PTA = posterior tibial artery, PTT = posterior tibial tendon, and FDC = flexor digitorum communis tendon.

Case	Associated Foot and Ankle Injuries*	Initial Stabilization*	No. of Ops.	Type of Wound ^8,9	Fused Joints*
1	None	Percut. stab., TN joint	8	IIIA	ST, TN, CC at 5 wk
2L	None	Ext. fixat., talus to medial cuneiform	3	Closed	ST and CC at 2 wk
2R	TT dislocation, talar fracture	Ext. fixat., tibia to midfoot	4	Closed	ST at 6 wk
3	TT dislocation, navicular fracture, PTA laceration	Percut. stab., TN, ST, TT joints	7	IIIA	ST, TN, CC at 2 wk
4	TT dislocation	Percut. stab., TN and TT joints; ext. fixat., tibia to midfoot	9	Closed	ST at 35 wk
5	Navicular fracture	Ext. fixat., tibia to midfoot	7	IIIB	ST, TN, CC at 13 wk
6	TT dislocation; PTA, PTT, FDC lacerations	Percut. stab., TN joint	5	IIIA	ST at 1 wk
7	PTA laceration	Percut. stab., TN and ST joints	6	IIIA	ST, TN, CC at 5 wk
8	None	None	2	Closed	ST at 3 weeks

View Larger

TABLE III: Results

*MD = Maryland foot score ⁷ , AOFAS = American Orthopaedic Foot and Ankle Society ankle-hindfoot rating score ¹⁰ , C-N = Creighton-Nebraska score ¹¹ .

Case	Complications	Scores* (points)
MD	AOFAS	C-N
1	Osteomyelitis of calcaneus, below-the-knee amputation at 11 wk
2L	Surgical wound infection	54	41	33
2R	Osteomyelitis of calcaneus, below-the-knee amputation at 13 wk
3	Osteomyelitis of talus, talectomy at 43 wk	75	52	52
4	Heel pressure necrosis, malunion of calcaneus	71	65	48
5	None	92	85	92
6	Nonunion of subtalar fusion, revision of subtalar fusion at 203 wk	65	51	50
7	Traumatic wound necrosis	78	69	70
8	Osteomyelitis of calcaneus, Syme amputation at 57 wk

Add to My JBJS

TABLE III: Results

*MD = Maryland foot score ⁷ , AOFAS = American Orthopaedic Foot and Ankle Society ankle-hindfoot rating score ¹⁰ , C-N = Creighton-Nebraska score ¹¹ .

Case	Complications	Scores* (points)
MD	AOFAS	C-N
1	Osteomyelitis of calcaneus, below-the-knee amputation at 11 wk
2L	Surgical wound infection	54	41	33
2R	Osteomyelitis of calcaneus, below-the-knee amputation at 13 wk
3	Osteomyelitis of talus, talectomy at 43 wk	75	52	52
4	Heel pressure necrosis, malunion of calcaneus	71	65	48
5	None	92	85	92
6	Nonunion of subtalar fusion, revision of subtalar fusion at 203 wk	65	51	50
7	Traumatic wound necrosis	78	69	70
8	Osteomyelitis of calcaneus, Syme amputation at 57 wk