Orthopedics

Feature Article 

Calcaneocuboid Joint Arthritis of the Midfoot Precedes Tibiotalar Joint Arthritis

Anthony Dugarte, MD, CSCS; Sahil Bharwani, BA; HoJun Yoo, BA; Alexander Vondra Boiwka, MD, MS; Charles C. Yu, MD; Navkirat S. Bajwa, MD; Jason O. Toy, MD; Jonathan E. Tang, MD; Uri Ahn, MD; Nicholas Ahn, MD

Abstract

Surgical models have best shown the relationship between ankle and mid-foot osteoarthritis, although findings regarding the calcaneocuboid joint have varied. To the authors' knowledge, no studies have evaluated the relationship between degenerative changes across the tibiotalar and calcaneocuboid joints. The goal of this study was to determine whether such a relationship exists and which joint degenerates first. A single examiner evaluated 694 tibiotalar and calcaneocuboid joints to determine the presence of osteoarthritis. Multiple linear regression analysis was conducted with a standard P value cutoff (P<.05) and 95% confidence interval. The average incidence of tibiotalar and calcaneocuboid osteoarthritis in specimens older than 40 years was compared with the incidence in those 40 years and younger. A positive correlation between tibiotalar and calcaneocuboid osteoarthritis was noted. African-American subjects were less likely than white subjects to have tibiotalar osteoarthritis. The finding of right and left tibiotalar and calcaneocuboid osteoarthritis in subjects 40 years and younger showed that midfoot arthritis was significantly more common than arthritis of the ankle. The prevalence of calcaneocuboid osteoarthritis remains stable after 40 years of age, and the prevalence of tibiotalar osteoarthritis approaches that of calcaneocuboid osteoarthritis. Calcaneocuboid osteoarthritis precedes tibiotalar osteoarthritis. Altered biomechanics involved in calcaneocuboid osteoarthritis are transferred to the tibiotalar joint, leading to tibiotalar osteoarthritis as the subject ages. Early education, surveillance, physical therapy, shoe adjustment, and orthotics may help to reduce the forces across the midfoot and prevent ankle arthritis in the long term. [Orthopedics. 2016; 39(6):e1112–e1116.]

Abstract

Surgical models have best shown the relationship between ankle and mid-foot osteoarthritis, although findings regarding the calcaneocuboid joint have varied. To the authors' knowledge, no studies have evaluated the relationship between degenerative changes across the tibiotalar and calcaneocuboid joints. The goal of this study was to determine whether such a relationship exists and which joint degenerates first. A single examiner evaluated 694 tibiotalar and calcaneocuboid joints to determine the presence of osteoarthritis. Multiple linear regression analysis was conducted with a standard P value cutoff (P<.05) and 95% confidence interval. The average incidence of tibiotalar and calcaneocuboid osteoarthritis in specimens older than 40 years was compared with the incidence in those 40 years and younger. A positive correlation between tibiotalar and calcaneocuboid osteoarthritis was noted. African-American subjects were less likely than white subjects to have tibiotalar osteoarthritis. The finding of right and left tibiotalar and calcaneocuboid osteoarthritis in subjects 40 years and younger showed that midfoot arthritis was significantly more common than arthritis of the ankle. The prevalence of calcaneocuboid osteoarthritis remains stable after 40 years of age, and the prevalence of tibiotalar osteoarthritis approaches that of calcaneocuboid osteoarthritis. Calcaneocuboid osteoarthritis precedes tibiotalar osteoarthritis. Altered biomechanics involved in calcaneocuboid osteoarthritis are transferred to the tibiotalar joint, leading to tibiotalar osteoarthritis as the subject ages. Early education, surveillance, physical therapy, shoe adjustment, and orthotics may help to reduce the forces across the midfoot and prevent ankle arthritis in the long term. [Orthopedics. 2016; 39(6):e1112–e1116.]

The foot is a complex structure that provides a rigid support for standing, walking, and running, regardless of the terrain.1 During gait, interplay between the joints of the foot and the ankle is synchronous. Disruption of the biomechanics in a single joint may lead to dysfunction throughout the structure.1 Thus, understanding the functional anatomy of the foot and ankle joints is a prerequisite to the study of dysfunction. Knowledge of how pathology changes normal function can help in the provision of optimal treatment. This study examined the relationship between tibiotalar joint osteoarthritis and calcaneocuboidal osteoarthritis (ie, ankle and midfoot osteoarthritis).

Many studies have attempted to describe the relationship between ankle (tibiotalar) and midfoot (calcaneocuboid) osteoarthritis with surgical models. Some studies noted an increased prevalence of arthritis of the ipsilateral hindfoot or midfoot after ankle arthrodesis.2–7 This is believed to be the result of altered biomechanics that transform forces exerted on the hindfoot and midfoot, as previously described.3,4 Schuh et al6 performed gait analysis studies in support of this idea and concluded that compensatory increases in motion occurred in the talonavicular, calcaneocuboid, and subtalar joints after ankle arthrodesis.

To further support this theory, Jung et al8 simulated tibiotalar arthrodesis in 12 cadaveric specimens. After arthrodesis, each specimen was cyclically loaded with a hydraulic test frame. A substantial increase in pressure in the talonavicular and calcaneocuboid joints at dorsiflexion levels, consistent with the late stance phase of the gait cycle, was noted in each case. The authors concluded that this response may be the cause of secondary tarsal joint degeneration in late ankle arthrodesis. A substantial increase in pressure in the talonavicular and calcaneocuboid joints (both of which are included in the Chopart joint) at dorsiflexion levels, consistent with the late stance phase of the gait cycle, was noted in each case.

In contrast, Sheridan et al9 noted that although midfoot and hindfoot osteoarthritis seems to be universal in patients with ankle osteoarthritis, several long-term studies of ankle arthrodesis did not assess pre-existing osteoarthritis of the midfoot and hindfoot. These investigators questioned whether this was a direct consequence of arthrodesis.

Suckel et al10 noted an increase in force and peak pressure on the talonavicular joint but a decrease in force on the calcaneocuboid joint after tibiotalar arthrodesis. However, this study included just 8 specimens. In another study, Suckel et al11 followed 15 patients with isolated ankle osteoarthritis who had undergone tibiotalar arthrodesis. Radiographs showed that subtalar and talonavicular degeneration was more likely than calcaneocuboid degeneration after arthrodesis. Further, they used cadaveric foot models to simulate foot strike. The native trial showed a continuous increase in load transmission in both parts of the Chopart joint. After simulation of arthrodesis, load transmission in the talonavicular joint increased significantly in the second half of the foot, whereas the calcaneocuboid joint showed decreased transmission of load.11

As described earlier, surgical models have best shown the relationship between ankle and midfoot osteoarthritis. The literature on these effects on the talonavicular joint seems to be congruent, but findings on the calcaneocuboid joint vary. To the authors' knowledge, no studies have evaluated the relationship between degenerative processes across the tibiotalar and calcaneocuboid joints. The goals of this study were to determine whether there is a relationship between tibiotalar and calcaneocuboid degeneration and to identify which joint appears to degenerate first.

Materials and Methods

This study was conducted with 694 specimens from The Hamann-Todd Osteological Collection at Cleveland's Natural History Museum. This collection contains more than 3300 treated and dried specimens obtained from bodies collected from the county morgue and city hospitals from 1893 to 1938. This study did not require institutional review board approval because the specimens had no identifiable private information.

A single examiner evaluated 694 tibiotalar and calcaneocuboid (Figure 1) joints with a modification of the Kellgren-Lawrence classification for knee osteoarthritis to determine the presence of osteoarthritis in each specimen (Table 1).12 This scale was based on methods suggested by Kettler and Wilke13 and validated by Eubanks et al,14 who used changes in the bony end plates and facet arthrosis to grade disk degeneration at the L5-S1 interspace. A grade of 0 to 4 was assigned to each tibiotalar and calcaneocuboid joint evaluated, based on modifications of the corresponding criteria: grade 0, normal facet joints or vertebral end plates; grade 1, mild arthrosis with osteophytic reaction involving up to 50% of the facet joint or vertebral end plates; grade 2, moderate arthrosis with osteophytic reaction involving 50% to 100% of the facet joint or vertebral end plates; grade 3, severe arthrosis with an osteophytic reaction involving 100% of the facet joints or vertebral end plates with hypertrophic osteophytes bridging the joint space; and grade 4, complete ankylosis.


Grade 4 right calcaneocuboid osteoarthritis. The articular surface of a right calcaneous joint articulation with its corresponding cuboid (left). The corresponding articular surface of a right cuboid (right). Together, these articulations form the right calcaneocuboid joint.

Figure 1:

Grade 4 right calcaneocuboid osteoarthritis. The articular surface of a right calcaneous joint articulation with its corresponding cuboid (left). The corresponding articular surface of a right cuboid (right). Together, these articulations form the right calcaneocuboid joint.


Kellgren-Lawrence Classification of Knee Osteoarthritis

Table 1:

Kellgren-Lawrence Classification of Knee Osteoarthritis

Statistical analysis of the compiled data was performed with Statgraphics Centurion XVI software (Statpoint Technologies, Inc, Warrentown, Virginia). Multiple linear regression analysis was conducted, with correction for confounding factors (age, sex, and race), with a standard P value cutoff (P<.05) and 95% confidence interval to determine statistical significance. Finally, the average incidence of tibiotalar and calcaneocuboid osteoarthritis in specimens older than 40 years at death vs 40 years and younger at death was compared.

Results

Multiple regression analysis showed a positive correlation between right and left tibiotalar osteoarthritis as well as right and left calcaneocuboid osteoarthritis, with correction for age, sex, and race (Figures 23). A positive correlation was seen between right tibiotalar and calcaneocuboid osteoarthritis, with a slope of .175 and a P value approaching 0 (Table 2). Similarly, left tibiotalar and calcaneocuboid osteoarthritis showed a positive correlation, with a slope of .145 and a P value approaching 0 (Table 3).


Linear regression of right tibiotalar (R TT) vs right calcaneocuboid (R CC) osteoarthritis, corrected for age, sex, and race.

Figure 2:

Linear regression of right tibiotalar (R TT) vs right calcaneocuboid (R CC) osteoarthritis, corrected for age, sex, and race.


Linear regression of left tibiotalar (L TT) vs left calcaneocuboid (L CC) osteoarthritis, corrected for age, sex, and race.

Figure 3:

Linear regression of left tibiotalar (L TT) vs left calcaneocuboid (L CC) osteoarthritis, corrected for age, sex, and race.


Linear Regression Statistics for Right Calcaneocuboid Joint vs Right Tibiotalar Joint Corrected for Age, Sex, and Race

Table 2:

Linear Regression Statistics for Right Calcaneocuboid Joint vs Right Tibiotalar Joint Corrected for Age, Sex, and Race


Linear Regression Statistics for Left Calcaneocuboid Joint vs Left Tibiotalar Joint Corrected for Age, Sex, and Race

Table 3:

Linear Regression Statistics for Left Calcaneocuboid Joint vs Left Tibiotalar Joint Corrected for Age, Sex, and Race

Multivariate analysis of right and left tibiotalar and calcaneocuboid osteoarthritis in specimens 40 years and younger showed a higher prevalence of midfoot arthritis compared with ankle arthritis in this age group. Analysis of the group older than 40 years showed that the prevalence of calcaneocuboid osteoarthritis is relatively stable after age 40 years and that the prevalence of tibiotalar osteoarthritis approaches that of calcaneocuboid osteoarthritis in this age group (Table 4).


Average Osteoarthritis Grades for Tibiotalar and Calcaneocuboid Joints by Age and Side

Table 4:

Average Osteoarthritis Grades for Tibiotalar and Calcaneocuboid Joints by Age and Side

Discussion

The association between ankle arthrodesis and subsequent midfoot arthritis has been shown with a surgical model.2–7 However, no studies have described an association between degenerative changes across the tibiotalar and calcaneocuboid joints. The authors hypothesized that if there is a correlation between midfoot (calcaneocuboid) osteoarthritis and ankle (tibiotalar) osteoarthritis, midfoot osteoarthritis precedes ankle osteoarthritis. To explore this hypothesis, the authors performed a retrospective cadaveric study. This type of analysis has benefits and limitations that are inherent to the study design. These studies are inexpensive to execute and can be performed quickly. However, specimen availability can greatly limit sample size, and it is impossible to obtain any subjective information. A prospective cohort in which patients can be followed with imaging, physical examination, surveys, and autopsy is the optimal study design, but these studies take many years to conduct and can be expensive.

The authors expected to find a strong correlation between tibiotalar and calcaneocuboid osteoarthritis, and a large volume of evidence corroborates the relationship between degenerative processes and age. Nonetheless, after correction for age, sex, and race as confounding factors, statistical analysis showed a strong correlation between midfoot and ankle arthritis (Figures 23). This finding suggests that there may be more to this particular process than standard age-related degenerative models. In addition, African-American subjects showed significantly less tibiotalar osteoarthritis than white subjects.

Further examination of the data showed that subjects 40 years and younger at death had a significantly higher prevalence of right and left calcaneocuboid osteoarthritis compared with right and left tibiotalar osteoarthritis, which was minimal in this age group. This suggests that in the genesis of midfoot and ankle osteoarthritis, midfoot osteoarthritis occurs first. This finding is corroborated by the higher prevalence of right and left tibiotalar osteoarthritis compared with right and left calcaneocuboid osteoarthritis in subjects older than 40 years. Further, the prevalence of calcaneocuboid osteoarthritis was stable compared with the findings in subjects 40 years and younger. These findings show that midfoot (calcaneocuboid) osteoarthritis precedes ankle (tibiotalar) osteoarthritis. Finally, the altered biomechanics involved in calcaneocuboid osteoarthritis (most prevalent in subjects 40 years and younger) are transferred to the tibiotalar joint, leading to tibiotalar osteoarthritis (most prevalent in subjects older than 40 years) as the subject ages.

Many of the current findings on ankle and foot pathology are based on studies that analyzed stance because it is a weight-bearing phase that makes up 60% of the gait cycle.15 Chondrocyte metabolism depends heavily on the local mechanical environment. Normal tissue loading maintains joint health, whereas alterations in loading patterns during the stance phase can result in inappropriate tissue stress patterns, changes in chondrocyte metabolism, and ultimately variations of the joint space that manifest as osteoarthritis.16 Periarticular or direct trauma can disrupt the mechanical loading distribution of the cartilage and lead to a degenerative remodeling process.16 Biomechanical changes can be subtle as well.

The authors propose a model in which the midfoot assumes most of the force applied across the foot and ankle at younger ages, in essence, sparing the ankle joint. If these forces alter midfoot biomechanics, then osteoarthritis develops. Once osteoarthritis reaches a significant level, the forces are transferred to the ankle, where degenerative changes occur. The transfer of forces to the ankle provides protection to the midfoot, preventing further degeneration.

Conclusion

Thus far, the relationship between midfoot and ankle osteoarthritis has been best expressed through surgical models depicting alterations in joint biomechanics. This study used degeneration around the calcaneocuboid and tibiotalar joints to evaluate this relationship and determine which joint degenerates first. The authors found a positive correlation between ankle and midfoot osteoarthritis. The study also showed that at younger ages the midfoot assumes a larger share of the force applied across the foot and ankle, leading to earlier degeneration compared with the ankle. Over time, ankle osteoarthritis becomes more prevalent and midfoot osteoarthritis stabilizes.

The authors believe that this study can provide further insight into the natural history of the degenerative changes that occur in the midfoot and ankle and thereby ultimately aid in preventing painful arthropathy. Patients who are at increased risk for altered midfoot biomechanics (eg, midfoot injury, midfoot surgery, aberrations in arch height, loss of midfoot stability during gait17) may benefit from early education and increased surveillance and physical therapy. Shoe adjustment, orthotics, and measures to reduce the force across the midfoot may reduce the incidence of ankle arthritis in the long term.

References

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  2. Coester LM, Saltzman CL, Leupold J, Pontarelli W. Long-term results following ankle arthrodesis for post-traumatic arthritis. J Bone Joint Surg Am. 2001; 83(2):219–228.
  3. Fuchs S, Sandmann C, Skwara A, Chylarecki C. Quality of life 20 years after arthrodesis of the ankle: a study of adjacent joints. J Bone Joint Surg Br. 2003; 85(7):994–998. doi:10.1302/0301-620X.85B7.13984 [CrossRef]
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  9. Sheridan BD, Robinson DE, Hubble MJ, Winson IG. Ankle arthrodesis and its relationship to ipsilateral arthritis of the hind-and mid-foot. J Bone Joint Surg Br. 2006; 88(2):206–207. doi:10.1302/0301-620X.88B2.17065 [CrossRef]
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Kellgren-Lawrence Classification of Knee Osteoarthritis

ClassificationDescription
Grade 0No discernible wear or osteophytes
Grade 11-mm osteophyte(s) and/or <25% joint surface wear
Grade 21- to 2-mm osteophyte(s) and/or 25%–50% joint surface wear
Grade 32- to 3-mm osteophyte(s) and/or >50% joint surface wear
Grade 4Multiple large osteophytes and/or definite bony end deformity

Linear Regression Statistics for Right Calcaneocuboid Joint vs Right Tibiotalar Joint Corrected for Age, Sex, and Race

ParameterEstimateErrorStatisticPLower LimitUpper LimitSum of SquaresdfMean SquareF-RatioP
Constant0.3560040.1375272.5886.00960.0864550.625553
Right calcaneocuboid0.1750570.0336485.2025800.1091080.24100623.3978123.397828.690
Age0.0071510.0023553.03634.00240.0025350.01176817.428117.42821.370
Sex0.0191560.0918120.208643.8347−0.160790.1991040.2879610.287960.35.5523
Race0.204830.0771352.65547.00790.0536480.3560125.7502815.750287.05.0079
Model46.864411.71614.370
Residual561.8566890.815467
Total (corrected)608.72693

Linear Regression Statistics for Left Calcaneocuboid Joint vs Left Tibiotalar Joint Corrected for Age, Sex, and Race

ParameterEstimateErrorStatisticPLower LimitUpper LimitSum of SquaresdfMean SquareF-RatioP
Constant0.0672710.1409840.477155.6332−0.209050.343596
Left calcaneocuboid0.1451440.0345614.199600.0774050.21288313.3488113.348816.22.0001
Age0.0134290.0023625.6859900.00880.01805843.8747143.874753.320
Sex0.1394590.0916641.52143.1282−0.04020.3191172.7897512.789753.39.0656
Race0.1554920.0773952.00909.04450.0038010.3071833.3216213.321624.04.0445
Model63.3349415.8337
Residual559.5796800.82291
Total (corrected)622.914684

Average Osteoarthritis Grades for Tibiotalar and Calcaneocuboid Joints by Age and Side

AgeRight Tibiotalar JointRight Calcaneocuboid JointLeft Tibiotalar JointLeft Calcaneocuboid Joint
≤40 y.9321.637.8881.826
>40 y1.2281.7531.3041.722
Authors

The authors are from Case Western Reserve University School of Medicine (AD, JET) and Case Western Reserve University (SB, HY), Cleveland, Ohio; the Department of Orthopaedics and Sports Medicine (AVB), University at Buffalo, Buffalo, New York; the Department of Orthopedic Surgery (CCY), Henry Ford Hospital—Wayne State University, Detroit, Michigan; the Department of Orthopedics (NSB), University of South Alabama College of Medicine, Mobile, Alabama; the Department of Orthopedic Surgery (JOT), Yale University, New Haven, Connecticut; New Hampshire NeuroSpine Institute (UA), Bedford, New Hampshire; and University Hospitals (NA), Cleveland, Ohio.

Dr Dugarte, Mr Bharwani, Mr Yoo, Dr Boiwka, Dr Yu, Dr Bajwa, Dr Toy, and Dr Tang have no relevant financial relationships to disclose. Dr U Ahn has received payments for the development of instrumentation and surgical tools from, has patents with, and receives royalties from Alphatec, Spine 360, and K1. Dr N Ahn has received grants from Stryker and Ulrich.

The authors thank University Hospitals and Case Western Reserve University for providing office space and medical and academic resources; and Lyman Jellema, curator of The Cleveland Museum of Natural History's Hamman-Todd Osteological Collection, for providing the specimens, a work space, and assistance with proper setup for measurements.

Correspondence should be addressed to: Anthony Dugarte, MD, CSCS, 389 E 270th St, Euclid, OH 44132 ( dugarte.anthony@gmail.com).

Received: August 14, 2015
Accepted: June 20, 2016
Posted Online: August 30, 2016

10.3928/01477447-20160819-04

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