Case 1. A sixty-eight-year-old farmer, while working in the fields,
stepped into a hole, resulting in inversion and plantar flexion
of the left foot. He was able to bear weight after the accident,
and he continued working. That evening, he noticed increasing pain
and swelling, and the next day he was diagnosed as having an ankle
sprain and was treated with ibuprofen and exercise. He continued
to work over the ensuing few months but had persistent pain in the
lateral aspect of the left foot. Four months after the initial injury,
because of persistent pain, he saw an orthopaedic surgeon, who obtained
radiographs, diagnosed a complete cuboid dislocation, and referred him
to us.
Physical examination at that time showed a well-perfused foot with
palpable dorsalis pedis and posterior tibial pulses. The skin was
intact, and only mild swelling was present. An indentation was noted
at the lateral aspect of the midfoot. Tenderness was present over
the calcaneocuboid joint. Motor and sensory examinations were unremarkable.
Ankle motion consisted of 20° of dorsiflexion and 50° of plantar
flexion, and subtalar motion consisted of 5° of inversion and 5°
of eversion. The patient had an antalgic gait. Plain radiographs
and a computed tomographic scan revealed the cuboid to be completely
dislocated distal to the lateral metatarsal bases (Figs. 1-A and 1-B). The fourth and
fifth metatarsals had migrated proximally. No fractures were evident.
The patient was taken to the operating room, where, after induction
of general anesthesia, an attempt at closed reduction by inverting
the foot while placing a dorsally directed force on the cuboid failed.
An incision was then made dorsolaterally from the calcaneocuboid
joint to the base of the fourth metatarsal (Fig. 1-C). With use
of two interosseous pins, the lateral column of the foot was distracted,
restoring the normal alignment of the fourth and fifth metatarsals,
but the cuboid still could not be reduced. Upon further exploration,
we found that the peroneus longus was interposed between the base
of the fifth metatarsal and the cuboid. Once the peroneus longus
tendon was freed from this position, the cuboid was reducible, but
it tended to subluxate plantarward. Therefore, two 3.5-mm screws
were placed retrograde across the calcaneocuboid joint and one screw
was placed across the cuboid-fifth metatarsal joint. Direct visualization
and intraoperative radiographs in both the anteroposterior and lateral
planes showed anatomic reduction of the cuboid.
The patient was managed with a short leg cast and non-weight-bearing
for eight weeks. He then progressed to partial weight-bearing with
use of a short leg plaster cast for four weeks, followed by use
of a removable walking boot for an additional four weeks. At the
end of that time, the hardware was removed. He then progressed to
full weight-bearing and returned to his regular activities as a
farmer. Six months after the operation, metatarsalgia developed
under the fourth metatarsal head; it was treated successfully with
a custom-made orthotic device.
Three years after the delayed operative reduction and fixation, the
patient was continuing at his previous level of activity as a farmer,
with no limitations. The metatarsalgia continued to be well controlled
with a metatarsal pad. Radiographs showed no degenerative or avascular
changes in the foot (Figs. 1-D and 1-E).
Case 2. A thirty-seven-year-old man presented to his local doctor
two and a half weeks after sustaining an inversion plantar-flexion
injury to the right foot while playing basketball. The patient had
pain in the lateral aspect of the foot since the time of the injury.
He had, however, returned to work as a carpenter. Because of the
persistent pain, three weeks after the injury he was referred to
a local orthopaedic surgeon, who made radiographs, diagnosed a complete
cuboid dislocation, and referred the patient to us.
On physical examination, the patient had tenderness along the lateral
and plantar aspects of the right foot. An indentation was noted
at the lateral aspect of the midfoot. Swelling was moderate, but
the skin was intact. Plain radiographs (Figs. 2-A and 2-B) and computed tomography
scans showed an inferomedial dislocation of the cuboid without fracture.
Since the patient had relatively little pain with the injury, a
fasting blood-glucose level was determined and a thorough neurological
examination was performed to rule out neuropathy. This workup revealed
negative findings.
The patient underwent open reduction with use of a dorsolateral
incision extending from the calcaneocuboid joint to the base of
the fourth metatarsal. As in Case 1, we could not reduce the dislocation.
Further exploration revealed that the peroneus longus tendon was
blocking the reduction (Fig. 2-C). After the tendon was swept distally
and plantarward around the cuboid back into its groove, the reduction
was easily achieved but was found to be very unstable. The cuboid
was stabilized with four 0.062-in (0.157-cm) Kirschner wires. The first
two wires were placed in retrograde fashion across the calcaneocuboid
joint. A third wire was placed through the cuboid into the lateral
cuneiform. A final wire was placed from distal to proximal, fixing
the cuboid to the fifth metatarsal. Direct visualization and operative
radiographs showed anatomic reduction of the cuboid.
The patient was managed with a short leg cast and non-weight-bearing
for eight weeks, at which time the wires were removed. He then progressed
to full weight-bearing over a two-week period. At ten weeks, he
had returned to his previous level of activity with no limitations.
At the one-year follow-up evaluation, the patient reported that he
was functioning without limitations with regard to the foot. Subtalar
motion, which was the same bilaterally, consisted of 5° of inversion
and 5° of eversion.