Young Male With Midfoot Dislocation and Medial Column Instability Treated With Arthrodesis Using a Midfoot Nail

Introduction This case report presents a patient who suffered a left talonavicular plantar dislocation, comminuted cuboid fracture-dislocation, along with a rare navicular-cuneiform fracture involving medial column instability following a workplace accident. The navicular-cuneiform joint plays a crucial role in stabilizing the medial longitudinal column and transverse arch of the foot. Treatment options for similar midfoot injuries include external fixation, Kirschner wires, open reduction and internal fixation (ORIF), or arthrodesis. While the medical literature offers protocols for midfoot injuries, especially Lisfranc injuries, there is limited information and protocols on more proximal medial column dislocation with medial column instability. To address this complex case, the medical team used a provisional technique involving Kirschner wires for anatomic reduction followed by subsequent arthrodesis of the medial column. This approach aimed to provide the necessary stability for the medial column to heal and endure biomechanical demands. Prior research revealed unknown documented instances of this specific injury with subsequent anatomic reduction and arthrodesis with a medial column nail, rendering it a unique solution for addressing such complex midfoot injuries. Methods The patient was originally seen as a trauma patient. Closed reduction of his left foot was attempted, but unable to be attained due to significant disruption in the soft tissue and bony architecture of the midfoot. Therefore, a mini open technique was used to obtain anatomic reduction of the medial midfoot structures. Provisional reduction was obtained with K-wires to allow for soft-tissue swelling to subside. The subsequent procedure was definitive which involved a midline axial incision on the medial aspect of the foot, exposing the medial column and preparing joint surfaces, while a second incision exposed the intermediate and lateral naviculocuneiform joints and the second and third tarsometatarsal joints. Arthrodesis was obtained across talonavicular, navicular-cuneiform, and cuneiform-1st metatarsal via a medial column nail. Additionally, arthrodesis from the second metatarsal to the talus and third metatarsal to the talus was performed. Results The surgical approach involving Kirschner wires for initial anatomic reduction followed by arthrodesis yielded successful outcomes in addressing the complex midfoot injury. Radiographic assessment post-surgery confirmed proper alignment and stabilization of the medial column. Specifically, the talonavicular joint, navicular-cuneiform joint, and the first metatarsal-cuneiform joint exhibited fusion. This unique technique tailored to the specific injury pattern resulted in improved stability and biomechanical support for the patient's medial column. Discussion This case study presents a rare complex condition of left plantar talonavicular dislocation, navicular-cuneiform fracture-dislocation with significant medial column instability. The patient suffered a crushing injury, resulting in severe soft tissue displacement and potential neurovascular damage. Understanding the functional columns of the foot (medial and lateral) guided the choice between open reduction internal fixation (ORIF) and primary arthrodesis. High-energy crushing injuries in the midfoot require stable provisional reduction to avoid complications. The optimal management strategy for midfoot fracture-dislocations remains controversial. Available evidence suggests favorable outcomes with primary arthrodesis in specific cases, while others report successful results with ORIF. While the management of traumatic midfoot injuries lacks a consensus, timely and accurate diagnosis, along with anatomical reduction and stable fixation, are crucial to prevent functional impairment and complications such as arthritis, avascular necrosis, or midfoot collapse. This case represents a rare unstable, medial column injury treated with provisional fixation and subsequent arthrodesis.