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What is Talotarsal Joint Dislocation?

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Talotarsal displacement is a pathologic condition that will not "fix" itself. This condition leads to excessive strain on the structures within the foot and ankle as well as to the knees, hips and back while standing, walking, or running. There are clear clinical and radiographic signs that are used to diagnose this disease as well as to show improvement after treatment. Unfortunately, this disease is usually ignored or over-looked while the focus of attention is aimed at the secondary symptoms rather than to the realignment of what lead to the development of those secondary symptoms.

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What is Talotarsal Joint Dislocation?

  1. 1. Primer onTalotarsal Joint Dislocation
  2. 2. IntroductionWhen it comes to the meaning of a word, there can be many opinions and assumptions.At the end of the day, however, it’s about what can be proven.Assumptions are not always based on fact but a on a perceived belief.
  3. 3. What is a Word? A “word” is the unit of language that functions asa principal carrier of meaning.
  4. 4. Dislocation“the displacement of any part, more especiallyof a bone” Dorlands Medical Dictionary
  5. 5. DislocationTypes of dislocation: closed, open, complete, incomplete, traumatic, congenital, compound, simple, complicated, fracture, habitual/recurrent, partial, pathologic, subluxation, luxation.
  6. 6. Dislocation“A dislocation is a separation of two boneswhere they meet at a joint. A dislocated bone isno longer in its normal position, which mayresult in damage to ligaments, nerves, and bloodvessels.” Medline PlusNote: there is no modifier on “separation,” i.e. it does notstate incomplete/partial or complete/total separation.
  7. 7. Historical Use of Dislocation
  8. 8. A Practical Treatise on Fractures & Dislocations – Frank Hasting Hamilton, 1863“ A dislocation is the displacement of one bone fromanother at its placed of natural articulation.”“Dislocations may be divided into accidental ortraumatic, spontaneous or pathologic, andcongenital.”“A complete dislocation is one in which no portionsof the articular surfaces remain in contact. A partialdislocation is one in which the articular surfaces arenot completely removed from each other.” Page 30
  9. 9. Fractures and Dislocation – Thomas Pickering Pick, 1885“The word “dislocation” etymologically means‘displacement’ (Lat. dis, a preposition, denotingseparation, and locus, a place), but in surgery itis for the most part applied to that condition of ajoint in which the two articular surfaces areeither partially or completely displaced from oneanother, and no longer occupy their normalposition.” page 308
  10. 10. Fractures and Dislocation – Thomas Pickering Pick, 1885“Dislocations, or displacements of the articular surfacesof a joint, are divided into three classes as regards theircause. (1) Traumatic, where the displacement has beenproduced by violence. (2) Spontaneous orpathological, resulting from gradual destructive changesin the joint and surrounding tissues, so that the bones nolonger remain in apposition, but are displaced bymuscular contraction or the weight of the limb or trunk.(3) Congenital, arising from some congenital defect in thejoint.” page 308
  11. 11. Fractures and Dislocation – Thomas Pickering Pick, 1885“Dislocations may be complete or partial: completewhen the two articular surfaces which enter into theformation of a joint are completely separated fromeach other, so as to be no longer in contact; andpartial when the two articular surfaces aredisplaced as regards their normal relation to eachother, but are not completely separated, so thatsome portion of the one articular surface stillremains in contact with some part of the other.” page 309
  12. 12. Fractures and Dislocation – Thomas Pickering Pick, 1885“The effects of a dislocation upon the structuresentering into the formation of a joint, or in itsimmediate neighborhood, are always ofimportance and frequently serious. Thebones, ligaments, muscles, vessels, andnerves, may all suffer.” Page 313
  13. 13. Fractures and Dislocation – Thomas Pickering Pick, 1885“When the diagnosis of dislocation has beenestablished, the first indication is to effectreduction as speedily as possible.” Page 322
  14. 14. A Practical Treaties on Fractures andDislocations – Lewis Atterbury Stimson, 1899“A Dislocation is a permanent, abnormal, totalor partial displacement from each other of thearticular portions of the bones entering into theformation of a joint.” Page 393
  15. 15. A Practical Treaties on Fractures andDislocations – Lewis Atterbury Stimson, 1899“When the articular surfaces are so far displacedthat they no longer touch each other, or thatthey touch only by their edges, the dislocation issaid to be complete; if the displacement is less, itis called incomplete dislocation or subluxation.” Page 393
  16. 16. Surgery: Bones; Joints; Fractures;Dislocations, Orthopedics;… Keen & Costa, 1907“A dislocation is a displacement from each otherof the articular ends of the bones which enterinto the formation of a joint.”“Dislocations may be divided into complete andincomplete, according to the degree ofdisplacement.” page 377
  17. 17. Textbook of Disorders and Injuries of the Musculoskeletal System – Robert B. Salter, 1970“Displacement of a joint. When the normalreciprocal relationship between the two jointsurfaces is lost, the joint is said to be displaced.The joint may be completely displaced or it maybe partially displaced. In either case the joint isunstable and is associated with deformity.” Page 27
  18. 18. Foot and Ankle Trauma – Barry Scurran, 1989“Dislocation represents (disease) not to osseousjoint structures or to the tendons that movethem but to the soft tissues that bind them.” Page 271
  19. 19. Foot and Ankle Trauma – Barry Scurran, 1989“The capsular and ligamentous soft tissuesparadoxically provide the strength for jointstability and yet permit the freedom for jointmotion. When the end range of motion for ajoint is reached, the joint soft tissues limitfurther excursion.” Page 271
  20. 20. Foot and Ankle Trauma – Barry Scurran, 1989“Limitation of joint motion is further aided byjoint biomechanics, osseous contours, and activemuscular agonist and antagonist function.” Page 271
  21. 21. Foot and Ankle Trauma – Barry Scurran, 1989“…dislocations are radiographically evident bythe incongruity of the osseous components.Postreduction radiographs or spontaneouslyreduce dislocation may appear “normal”because no osseous compromise or fracture hasoccurred.” Page 271
  22. 22. Dislocation• is a disease process• is not normal• needs to be treated/fixed• failure to fix leads to other pathologic conditions• Doesn’t matter if it’s a partial or full
  23. 23. Clinical Signs of Talotarsal Joint Dislocation Aligned TTJ Dislocated TTJBalanced/aligned hindfoot. Imbalanced/malaligned hindfoot.Articular facets are Articular facets are NOT in constant congruent contact. in constant congruent contact.Minimal strain on the supporting Excessive strain on the supporting soft tissues- ligaments/tendons. soft tissues- ligaments/tendons.Hindfoot is in neutral/slightly Hindfoot is in a hyperpronated pronated position. position.
  24. 24. Radiographic Evidence ofTalotarsal Joint Dislocation
  25. 25. Radiographic Evidence of Talotarsal Joint Dislocation Normal TaloTarsal Joint TaloTarsal Joint Dislocation/Displacement “Open” sinus tarsi Partial to full obliteration of the sinus tarsiClinical significance: this is the easiest sign to show displacement. This immediatelyindicates that the talus is, at minimum, partially dislocated on the tarsal mechanism. Thejoints/articular facets are no longer in constant congruent contact.
  26. 26. Radiographic Evidence of Talotarsal Joint Dislocation Normal TaloTarsal Joint TaloTarsal Joint Dislocation/DisplacementNormal Talar Declination Angle Abnormal Talar Declination Angle Normal = < 21 degrees Abnormal = > 21 degreesClinical significance: an increased talar declination angle indicates a sagittal planedeformity. This creates an imbalance to the leg, pelvis and back. Also, it is directlyresponsible for increased strain on the medial column of the foot. This deformity occursabove the bottom of the foot.
  27. 27. Radiographic Evidence of Talotarsal Joint Dislocation Normal TaloTarsal Joint TaloTarsal Joint Dislocation/Displacement Normal navicular height Navicular drop due to the dislocationClinical significance: navicular drop directly leads to excessive strain to the supportingstructures of the medial column of the foot such as the spring ligament, medial band of theplantar fascia and especially the posterior tibial tendon. It can also lead to disorders of thefirst ray/hallux.
  28. 28. Radiographic Evidence of Talotarsal Joint Dislocation Normal TaloTarsal Joint TaloTarsal Joint Dislocation/Displacement Normal cyma line Anterior plantar angulated cymaClinical significance: the anterior displacement of the talus forces the navicular forward.This pushes the medial cuneiform forward, which in turn pushes the first metatarsal headinto the base of the proximal phalanx (hallux), leading to limited joint motion. This alsounlocks the midtarsal joint leading to an excessively long period of pronation.
  29. 29. Radiographic Evidence of Talotarsal Joint Dislocation Normal TaloTarsal Joint TaloTarsal Joint Dislocation/Displacement Notice that the calcaneal inclination angle (CIA) is the same.Clinical significance: a lower than normal CIA indicates a “flat foot” (pes planovalgus). It ispossible to have a talotarsal dislocation without a “flat foot”.
  30. 30. Several Examples of RadiographicEvidence of Talotarsal Joint Dislocation Normal Talotarsal Joint Abnormal Talotarsal Joints
  31. 31. Normal Talar Second Metatarsal Angle Indicator of transverse plane talotarsal alignment.
  32. 32. Talar Second Metatarsal Angle • The bisection of the talus compared to the forefoot or the bisection of the 2nd metatarsal. • The outer/upper angular range of normal is < 16 degrees. • > 16 degrees is considered pathologic indicating a medially displaced talus on the tarsal mechanism.
  33. 33. Radiographic Evidence ofNormal Talotarsal Joint Alignment • Aligned talotarsal joint. • Talar second metatarsal angle in the perfectly aligned talotarsal joint is 3-5 degrees. Anything lower than 16 degrees is considered to be normal.
  34. 34. Pathologic Talar Second Metatarsal AngleNormal Abnormal
  35. 35. Partially Dislocated Talotarsal Joint Anterior/Middle Facets. Posterior Facets
  36. 36. Radiographic Evidence ofTalotarsal Joint Dislocation • Talar Second Metatarsal Angle (T2MA) > 16. • Significant transverse plane deformity. • This shows an anteriomedial talotarsal joint displacement.
  37. 37. Radiographic Evidence of Talotarsal Joint Dislocation Weightbearing image Weightbearing image with talotarsal joint in alignment/ exhibiting talotarsal joint displacement/ neutral stance position relaxed stance position.Clinical significance: This comparison of normal to abnormal shows a flexible dislocation ofthe talus on the tarsal mechanism. This is a recurrent dislocation. Excessive abnormal stainis placed on the medial column of the foot when weightbearing. Also, there are excessiveforces acting on the knee and possibly the hip.
  38. 38. Radiographic Evidence ofTalotarsal Joint Dislocation • Relaxed stance weightbearing radiograph. • T2MA > 16. • Talotarsal joint displacement.
  39. 39. Radiographic Evidence ofTalotarsal Joint Dislocation • Relaxed stance weightbearing radiograph. • T2MA > 16. • Talotarsal joint displacement.
  40. 40. Radiographic Evidence ofTalotarsal Joint Dislocation • Relaxed stance weightbearing radiograph. • T2MA > 16. • Talotarsal joint displacement.
  41. 41. Extra-osseous Talotarsal Stabilization with internal fixationClinical significance: Talotarsal joint is realigned, articular facets remain in constantcongruent contact. Internal fixation device allows normal/natural talotarsal motion withoutblocking/limiting motion. Restoration of the pathologic pre-existing deformities. Bothsagittal and frontal plane correction exhibited.
  42. 42. Extra-osseous Talotarsal Stabilization with internal fixation.Clinical significance: Talotarsal joint is realigned, articular facets remain in constantcongruent contact. Internal fixation device allows normal/natural talotarsal motion withoutblocking/limiting motion. Restoration of the pathologic pre-existing deformity showingtransverse plane correction with normalization of the talar second metatarsal angle.
  43. 43. Extra-osseous Talotarsal Stabilization with internal fixation does not fix pes planovalgus/flatfeet.Clinical significance: The calcaneal inclination angle is still pathologic while the talotarsaljoint has been restored.
  44. 44. Extra-osseous Talotarsal Stabilization Type I Arthroereisis and Type II Non-Arthroereisis. Type I Arthroereisis Type II Non-ArthroereisisClinical significance: Type I device is placed into the sinus tarsi so that the tip touches the bisection of the talus/lateral ½ ofthe sinus tarsi and functions to block or limit motion of the lateral process of the talus. Type II device is placed much deeperalong with the natural oblique orientation of the sinus tarsi and functions with the natural motion of the talotarsal joint asopposed to the natural motion. Journal of Foot and Ankle Surgery Volume 51, Issue 5 , Pages 613-619, September 2012
  45. 45. Thank you for your time.We hope this has helped to shed some light on this subject.
  46. 46. To learn more please visit: www. HyProCure.com

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