At his first postoperative appointment, he was found to have a large area of near full-thickness skin slough about his dorsal foot wound. The decision was made to place him into an ankle spanning external fixator and remove his provisional K-wires to allow for soft tissue healing with supervised wound care of his dorsal soft tissue envelope. A specialized wound care team managed his wound with non-adherent dressings and weekly hyperbaric therapy. Given the severity of his soft tissue and osseous injuries, subsequent treatment options included limb salvage versus amputation. Fortunately, he went on to heal his dorsal skin 11 weeks from the time of injury and his external fixator was removed to allow for epithelialization of his pin sites. A repeat CT scan was obtained which showed avascular necrosis of his intermediate cuneiform (Fig. 6). Three weeks after his soft tissue envelope and pin sites were adequately healed, we elected to proceed with a limb salvage procedure.
He then underwent an extended midfoot fusion spanning the naviculocuneiform and tarsometatarsal joints. We excised his necrotic intermediate cuneiform and harvested a size-matched piece of autologous tricortical iliac crest graft to recreate his intermediate cuneiform (Fig. 7). We fused his naviculocuneiform joint with a medial plate extending to the first and second metatarsal bases and subsequently fused across his second and third tarsometatarsal joints. He was kept nonweightbearing in a cast for 12 weeks and then transitioned to a controlled ankle movement boot. At 3 months post-operatively, his hardware remained intact with evidence of fusion and his wounds - healed uneventfully (Fig. 8). He was then referred for fabrication of an Intrepid Dynamic Exoskeletal Orthosis (IDEO) and started on a return-to-walk program. At 7 months, radiographs demonstrated bony fusion of his midfoot (Fig. 9). At 9 months, he was able to successfully complete an Army Physical Fitness Test (APFT) 2-mile walk with 1/10 pain on the visual analog scale and he was able to complete all activities of daily living (ADLs) independently.
At his most recent follow-up, 19 months post-fusion, he experiences minimal discomfort with ambulation while wearing his IDEO. His Foot and Ankle Ability Measure ADL subscale score was calculated based on his responses while not wearing his IDEO. He scored a 75/100 indicating preserved ability to perform most ADLs without difficulty, with the exception of certain recreational activities. When he wears his IDEO, his overall pain and function is improved. He is able to complete his ADLs independently without the IDEO and utilizes his IDEO for higher level activities.
Fracture-dislocation injuries to the tarsometatarsal joints with cuneiform involvement typically result from high-energy or crush mechanisms. These injuries are rare, with only case reports described in the literature22-25. Additionally, fracture-dislocations of the cuneiforms are rare injuries described in the literature with the intermediate cuneiform being the most commonly injured of the 326. This is due to weaker cuneonavicular, intercuneiform, and metatarsocuneiform ligamentous connections, favoring dorsal dislocations10,11,27,28.
Several case reports describe a variety of methods in managing both dorsal and plantar fracture-dislocations of the intermediate cuneiform with open reduction and capsular closure11, which include K-wire fixation6,7,9,12, Steinmann pins13,21, screws8,10,14, or naviculocuneiform fusion14, with acceptable clinical outcomes. In our patient, closed reduction was impossible given the distally extruded intermediate cuneiform. The delayed presentation and substantial soft tissue injury warranted urgent open reduction and K-wire fixation to provisionally reduce the complex fracture-dislocation. Because of severe injury to the overlying soft tissue envelope, we had discussions regarding limb salvage versus amputation with the patient. After external fixator placement and soft tissue recovery, we were able to perform an extended midfoot fusion with autologous bone grafting.
High energy, complex lower extremity injuries have been increasingly more common during Operation Enduring Freedom and Operation Iraqi Freedom29, and their rehabilitation after amputation or limb salvage has been a topic of extensive research as of late30-32. His military occupational specialty is one of the most physically demanding; however, with the application of an IDEO33-35 and institution of a return-to-walk program, he was able to complete the APFT 2-mile walk with minimal pain and he can perform ADL's independently after successfully salvaging his limb.
Complex Lisfranc fracture-dislocations and cuneiform fracture-dislocations are exceedingly rare injuries that can be managed a variety of ways. All the reports in the literature, to our knowledge, describe dorsal and plantar cuneiform fracture-dislocations. In this case, we provide the first known case report to our knowledge of a midfoot fracture-dislocation with distal dislocation of the intermediate cuneiform, treated with an extended midfoot fusion and rehabilitated with an IDEO back to an independent lifestyle.
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