Rosenbaum AJ

Fractures of the cuboid bone are uncommon, with an annual incidence of approximately 1.8 per 100,000.¹ This is largely attributed to the inherent stability provided by its anatomy and position in the foot’s lateral column, where it functions as a link between the lateral column and transverse plantar arch.² Regarding its anatomy, the cuboid is a pyramidal-shaped bone with 6 bony surfaces that provide tremendous stability—3 of these are articular, 3 nonarticular.

Although the cuboid bone is susceptible to low-energy avulsion injuries, injuries that occur in the setting of high-energy trauma are most concerning, as they often occur concurrently with other midfoot fractures and dislocations. These less common crush injuries are associated with comminution, articular disruption, and shortening of the lateral column.^3-5 Avulsion injuries occur via a twisting mechanism, while the more complex nutcracker fracture evolves via longitudinal compression of the lateral column, with the foot in a position of forced plantarflexion.⁶ Other comminuted fractures occur from direct impact on the lateral aspect of the foot.

Management of cuboid fractures varies according to etiology, fracture displacement, and articular involvement. Conservative management is reserved solely for stable, nondisplaced fractures.⁷ Unstable fracture-dislocations and those with associated lateral column shortening necessitate operative treatment, which attempts to restore anatomy, stability, and length of the foot’s lateral column.^7-9 However, with the exception of open injuries, fractures tenting the skin, and injuries with concomitant compartment syndrome, the high-energy nature of cuboid fractures often precludes early surgical intervention, as the foot’s soft-tissue envelope is too compromised. For this reason, operative intervention is often performed on a delayed basis only after recovery of the soft tissue.

In this case report and literature review, we describe a reconstructive shelf arthroplasty of the fifth tarsometatarsal (TMT) joint as a primary intervention for crush-type cuboid fractures with associated joint subsidence and lateral column shortening. The shelf arthroplasty, which was first credited to Konig in 1891, has historically been described as a remodeling operation using bone graft wedges for the treatment of nonconcentric acetabular dysplasia.¹⁰ Although bone grafting is recognized as an effective means of addressing osseous voids in the setting of comminuted cuboid fractures, its specific application in the form of a shelf arthroplasty has not been described.¹¹ The patient provided written informed consent for print and electronic publication of this case report.

Case Report

An otherwise healthy 45-year-old woman presented to our institution’s emergency department (ED) complaining of right foot pain after a motor vehicle accident. She was the restrained driver in a head-on collision. Primary survey revealed a swollen, ecchymotic, and tender right foot. Radiographs demonstrated fractures of her first, second, third, and fourth metatarsals, and a comminuted cuboid fracture with lateral column shortening and disruption of the fifth TMT joint (Figure 1).

Due to swelling, initial management consisted of soft-tissue management through the use of a well-padded splint. As this was her only injury, she was instructed to remain non-weight-bearing, ambulate with crutches, and return to our outpatient office for close follow-up. The need for delayed surgical intervention of her multiple foot injuries, due to her compromised soft-tissue envelope, was discussed prior to discharge.

Surgical intervention was performed 15 days after the injury, when the soft-tissue swelling had dissipated. The surgical plan included fixation of the multiple metatarsal fractures and lateral column reconstruction and stabilization. With regard to the lateral column, we obtained patient consent for several possible procedures, including fifth TMT joint closed reduction and percutaneous pinning, open reduction and internal fixation (ORIF), and TMT joint reconstruction with iliac crest bone graft (ICBG).

The metatarsals were addressed first via a dorsomedial incision, using a 5-hole 2.7-mm Limited Contact Dynamic Compression Plate (Synthes) to stabilize the first metatarsal and 2.0-mm Kirschner wires (K-wires) to maintain the length and alignment of the second, third, and fourth metatarsals (Figure 2). Closed reduction and percutaneous pinning of the fifth metatarsal was then attempted but abandoned because of persistent instability and subsidence of the cuboid in the proximal and plantar direction. ORIF was then attempted through a dorsolateral incision extending from just distal to the sinus tarsi to the base of the fourth metatarsal. However, the lateral cuboid was too comminuted to accommodate any fixation and prevent fifth TMT joint subluxation and lateral column shortening.

Autograft reconstruction of the lateral column was therefore performed, using radiographs of the patient’s uninjured, contralateral foot as a template for our lateral column shelf arthroplasty (Figure 3). Based on this template, the length and alignment of the lateral column were provisionally maintained with two 2.0-mm K-wires placed between the fifth metatarsal and intact cuboid (Figure 4). Tricortical ICBG was then harvested through an anterior approach to the iliac crest and contoured accordingly to fill the osseous void. To facilitate graft incorporation, comminuted fragments of cuboid bone were removed, with the remaining bone decorticated. The graft was then fixed to the remaining cuboid with two 4.0-mm partially threaded cannulated screws (Synthes; Figures 2, 4). This construct restored the length of the lateral column and effectively buttressed the fifth TMT joint, preventing subsidence and dislocation of the TMT joint.

After a 2-day postoperative course in the hospital, the patient was discharged. She remained non-weight-bearing in a splint with Robert Jones cotton bandage. At her 2-week postoperative visit, all hardware was intact and there was no evidence of infection. Her sutures were removed and she was placed in a new splint. At the patient’s 5-week postoperative visit, all K-wires were removed. At this time she remained non-weight-bearing but was transitioned into a controlled ankle movement (CAM) boot and was allowed to begin active and passive ankle exercises. At her 10-week follow-up, radiographs revealed appropriate interval healing and callus formation. The patient began weight-bearing as tolerated in the CAM boot at that time. At 12 weeks, she was transitioned into a hard-soled shoe for comfort and was allowed to ambulate in the footwear of her choice as tolerated. Her activity levels were slowly advanced, and, at her 12-month follow-up, the patient had returned to playing tennis in her recreational league with no residual sequelae (Figure 5).

Discussion

Although rare, cuboid fractures are critical to identify and can result in significant disability, as they are frequently associated with additional foot trauma, as demonstrated in this case.^1-4When isolated cuboid fractures are present, further imaging must be performed, including additional radiographic views and computed tomography, to search for other injuries, such as TMT joint complex disruption.

Only those cuboid fractures that are low-energy, stable, or nondisplaced can be effectively managed conservatively.¹²In the presence of instability, articular incongruity, or lateral column shortening, operative intervention is warranted. Arthritic degeneration, pain, and deformity result from residual incongruity at the calcaneocuboid or TMT joints, or when lateral column length is not restored.^4-6,13 The latter leads to forefoot abduction and lateral subluxation of the lesser metatarsals, with ensuing posttraumatic pes planus or planovalgus deformity, which often necessitates secondary reconstructive procedures or arthrodesis.^14,15 Stable reduction and restoration of lateral column length can be challenging, particularly in the setting of comminution and bone loss. Common methods of treatment involve lifting the dorsolateral cortex of the cuboid and buttressing the impacted articular surface with bone graft or bone graft substitutes. Fixation can be achieved with K-wires, small fragment plates and screws, and distraction external fixation.¹¹ The latter is a particularly beneficial technique, as it can be used independent of or in conjunction with ORIF.

In a study by Weber and Locher,¹¹ the short-term to midterm results of cuboid ORIF were assessed in 12 patients. Results were found to be good with respect to restoration of length, joint reconstruction, and overall return to function.¹¹ Admittedly, these authors at times employed a similar but conceptually different approach to our patient. In their 7 patients with severe comminution and lateral column shortening, corticocancellous ICBG was used. However, Weber and Locher¹¹did not describe this as a shelf arthroplasty, but instead as an adjunct to primary ORIF.

In our case, the tricortical ICBG shelf arthroplasty was used as it is in the hip, as a salvage procedure. Although little is known about outcomes following shelf arthroplasty for lateral column reconstruction in the foot, a 50% failure rate has been observed in the hip.¹⁶ As such, our preference was to perform an anatomic ORIF of the cuboid and lateral column, with the shelf arthroplasty only indicated if we were unable to achieve this. We believe that the need for tricortical ICBG in the treatment of cuboid fractures is indicative of a more severe injury and that it is a less optimal and more technically demanding intervention compared with primary ORIF. Furthermore, in other studies devoted to the treatment of cuboid fractures, patients requiring reconstruction with structural graft are not included in primary ORIF cohorts.¹⁷

As in the hip, suboptimal outcomes may occur when shelf arthroplasty is performed in the foot. There are additional considerations unique to the foot that surgeons must also contemplate when considering shelf arthroplasty. As demonstrated in the literature for adult-acquired flatfoot deformity, lateral column reconstruction is challenging and controversial and is associated with overload, pain, and the need to remove prominent hardware.¹⁸ These complications may also occur after shelf arthroplasty for cuboid fractures.

The work by Weber and Locher¹¹ did not elucidate such considerations, and outcomes of ORIF and ICBG reconstruction were not compared. This is a limitation of their study, as differences in functional outcomes between the 2 procedures remain unknown. Given the degree of comminution that precludes ORIF and necessitates a graft reconstruction, we believe that the description of the shelf arthroplasty as a salvage procedure more accurately reflects the severity of injury. This may have implications regarding outcomes and patient expectations that the orthopedic surgeon must address. Future studies must further evaluate the outcomes of this technique, independent of and in comparison with ORIF.

Conclusion

In this case, we describe shelf arthroplasty for cuboid fractures. It is a reconstructive salvage procedure that is indicated when ORIF cannot be achieved. This useful approach to a complex injury must remain in the armamentarium of orthopedic surgeons. As we have demonstrated, it can effectively restore a damaged lateral column, providing length and, in our case, enabling the patient to return to her pre-injury level of activity.

Fractures of the cuboid bone are uncommon, with an annual incidence of approximately 1.8 per 100,000.¹ This is largely attributed to the inherent stability provided by its anatomy and position in the foot’s lateral column, where it functions as a link between the lateral column and transverse plantar arch.² Regarding its anatomy, the cuboid is a pyramidal-shaped bone with 6 bony surfaces that provide tremendous stability—3 of these are articular, 3 nonarticular.

Although the cuboid bone is susceptible to low-energy avulsion injuries, injuries that occur in the setting of high-energy trauma are most concerning, as they often occur concurrently with other midfoot fractures and dislocations. These less common crush injuries are associated with comminution, articular disruption, and shortening of the lateral column.^3-5 Avulsion injuries occur via a twisting mechanism, while the more complex nutcracker fracture evolves via longitudinal compression of the lateral column, with the foot in a position of forced plantarflexion.⁶ Other comminuted fractures occur from direct impact on the lateral aspect of the foot.

Management of cuboid fractures varies according to etiology, fracture displacement, and articular involvement. Conservative management is reserved solely for stable, nondisplaced fractures.⁷ Unstable fracture-dislocations and those with associated lateral column shortening necessitate operative treatment, which attempts to restore anatomy, stability, and length of the foot’s lateral column.^7-9 However, with the exception of open injuries, fractures tenting the skin, and injuries with concomitant compartment syndrome, the high-energy nature of cuboid fractures often precludes early surgical intervention, as the foot’s soft-tissue envelope is too compromised. For this reason, operative intervention is often performed on a delayed basis only after recovery of the soft tissue.

In this case report and literature review, we describe a reconstructive shelf arthroplasty of the fifth tarsometatarsal (TMT) joint as a primary intervention for crush-type cuboid fractures with associated joint subsidence and lateral column shortening. The shelf arthroplasty, which was first credited to Konig in 1891, has historically been described as a remodeling operation using bone graft wedges for the treatment of nonconcentric acetabular dysplasia.¹⁰ Although bone grafting is recognized as an effective means of addressing osseous voids in the setting of comminuted cuboid fractures, its specific application in the form of a shelf arthroplasty has not been described.¹¹ The patient provided written informed consent for print and electronic publication of this case report.

Case Report

An otherwise healthy 45-year-old woman presented to our institution’s emergency department (ED) complaining of right foot pain after a motor vehicle accident. She was the restrained driver in a head-on collision. Primary survey revealed a swollen, ecchymotic, and tender right foot. Radiographs demonstrated fractures of her first, second, third, and fourth metatarsals, and a comminuted cuboid fracture with lateral column shortening and disruption of the fifth TMT joint (Figure 1).

Due to swelling, initial management consisted of soft-tissue management through the use of a well-padded splint. As this was her only injury, she was instructed to remain non-weight-bearing, ambulate with crutches, and return to our outpatient office for close follow-up. The need for delayed surgical intervention of her multiple foot injuries, due to her compromised soft-tissue envelope, was discussed prior to discharge.

Surgical intervention was performed 15 days after the injury, when the soft-tissue swelling had dissipated. The surgical plan included fixation of the multiple metatarsal fractures and lateral column reconstruction and stabilization. With regard to the lateral column, we obtained patient consent for several possible procedures, including fifth TMT joint closed reduction and percutaneous pinning, open reduction and internal fixation (ORIF), and TMT joint reconstruction with iliac crest bone graft (ICBG).

The metatarsals were addressed first via a dorsomedial incision, using a 5-hole 2.7-mm Limited Contact Dynamic Compression Plate (Synthes) to stabilize the first metatarsal and 2.0-mm Kirschner wires (K-wires) to maintain the length and alignment of the second, third, and fourth metatarsals (Figure 2). Closed reduction and percutaneous pinning of the fifth metatarsal was then attempted but abandoned because of persistent instability and subsidence of the cuboid in the proximal and plantar direction. ORIF was then attempted through a dorsolateral incision extending from just distal to the sinus tarsi to the base of the fourth metatarsal. However, the lateral cuboid was too comminuted to accommodate any fixation and prevent fifth TMT joint subluxation and lateral column shortening.

Autograft reconstruction of the lateral column was therefore performed, using radiographs of the patient’s uninjured, contralateral foot as a template for our lateral column shelf arthroplasty (Figure 3). Based on this template, the length and alignment of the lateral column were provisionally maintained with two 2.0-mm K-wires placed between the fifth metatarsal and intact cuboid (Figure 4). Tricortical ICBG was then harvested through an anterior approach to the iliac crest and contoured accordingly to fill the osseous void. To facilitate graft incorporation, comminuted fragments of cuboid bone were removed, with the remaining bone decorticated. The graft was then fixed to the remaining cuboid with two 4.0-mm partially threaded cannulated screws (Synthes; Figures 2, 4). This construct restored the length of the lateral column and effectively buttressed the fifth TMT joint, preventing subsidence and dislocation of the TMT joint.

After a 2-day postoperative course in the hospital, the patient was discharged. She remained non-weight-bearing in a splint with Robert Jones cotton bandage. At her 2-week postoperative visit, all hardware was intact and there was no evidence of infection. Her sutures were removed and she was placed in a new splint. At the patient’s 5-week postoperative visit, all K-wires were removed. At this time she remained non-weight-bearing but was transitioned into a controlled ankle movement (CAM) boot and was allowed to begin active and passive ankle exercises. At her 10-week follow-up, radiographs revealed appropriate interval healing and callus formation. The patient began weight-bearing as tolerated in the CAM boot at that time. At 12 weeks, she was transitioned into a hard-soled shoe for comfort and was allowed to ambulate in the footwear of her choice as tolerated. Her activity levels were slowly advanced, and, at her 12-month follow-up, the patient had returned to playing tennis in her recreational league with no residual sequelae (Figure 5).

Discussion

Although rare, cuboid fractures are critical to identify and can result in significant disability, as they are frequently associated with additional foot trauma, as demonstrated in this case.^1-4When isolated cuboid fractures are present, further imaging must be performed, including additional radiographic views and computed tomography, to search for other injuries, such as TMT joint complex disruption.

Only those cuboid fractures that are low-energy, stable, or nondisplaced can be effectively managed conservatively.¹²In the presence of instability, articular incongruity, or lateral column shortening, operative intervention is warranted. Arthritic degeneration, pain, and deformity result from residual incongruity at the calcaneocuboid or TMT joints, or when lateral column length is not restored.^4-6,13 The latter leads to forefoot abduction and lateral subluxation of the lesser metatarsals, with ensuing posttraumatic pes planus or planovalgus deformity, which often necessitates secondary reconstructive procedures or arthrodesis.^14,15 Stable reduction and restoration of lateral column length can be challenging, particularly in the setting of comminution and bone loss. Common methods of treatment involve lifting the dorsolateral cortex of the cuboid and buttressing the impacted articular surface with bone graft or bone graft substitutes. Fixation can be achieved with K-wires, small fragment plates and screws, and distraction external fixation.¹¹ The latter is a particularly beneficial technique, as it can be used independent of or in conjunction with ORIF.

In a study by Weber and Locher,¹¹ the short-term to midterm results of cuboid ORIF were assessed in 12 patients. Results were found to be good with respect to restoration of length, joint reconstruction, and overall return to function.¹¹ Admittedly, these authors at times employed a similar but conceptually different approach to our patient. In their 7 patients with severe comminution and lateral column shortening, corticocancellous ICBG was used. However, Weber and Locher¹¹did not describe this as a shelf arthroplasty, but instead as an adjunct to primary ORIF.

In our case, the tricortical ICBG shelf arthroplasty was used as it is in the hip, as a salvage procedure. Although little is known about outcomes following shelf arthroplasty for lateral column reconstruction in the foot, a 50% failure rate has been observed in the hip.¹⁶ As such, our preference was to perform an anatomic ORIF of the cuboid and lateral column, with the shelf arthroplasty only indicated if we were unable to achieve this. We believe that the need for tricortical ICBG in the treatment of cuboid fractures is indicative of a more severe injury and that it is a less optimal and more technically demanding intervention compared with primary ORIF. Furthermore, in other studies devoted to the treatment of cuboid fractures, patients requiring reconstruction with structural graft are not included in primary ORIF cohorts.¹⁷

As in the hip, suboptimal outcomes may occur when shelf arthroplasty is performed in the foot. There are additional considerations unique to the foot that surgeons must also contemplate when considering shelf arthroplasty. As demonstrated in the literature for adult-acquired flatfoot deformity, lateral column reconstruction is challenging and controversial and is associated with overload, pain, and the need to remove prominent hardware.¹⁸ These complications may also occur after shelf arthroplasty for cuboid fractures.

The work by Weber and Locher¹¹ did not elucidate such considerations, and outcomes of ORIF and ICBG reconstruction were not compared. This is a limitation of their study, as differences in functional outcomes between the 2 procedures remain unknown. Given the degree of comminution that precludes ORIF and necessitates a graft reconstruction, we believe that the description of the shelf arthroplasty as a salvage procedure more accurately reflects the severity of injury. This may have implications regarding outcomes and patient expectations that the orthopedic surgeon must address. Future studies must further evaluate the outcomes of this technique, independent of and in comparison with ORIF.

Conclusion

In this case, we describe shelf arthroplasty for cuboid fractures. It is a reconstructive salvage procedure that is indicated when ORIF cannot be achieved. This useful approach to a complex injury must remain in the armamentarium of orthopedic surgeons. As we have demonstrated, it can effectively restore a damaged lateral column, providing length and, in our case, enabling the patient to return to her pre-injury level of activity.

Fractures of the cuboid bone are uncommon, with an annual incidence of approximately 1.8 per 100,000.¹ This is largely attributed to the inherent stability provided by its anatomy and position in the foot’s lateral column, where it functions as a link between the lateral column and transverse plantar arch.² Regarding its anatomy, the cuboid is a pyramidal-shaped bone with 6 bony surfaces that provide tremendous stability—3 of these are articular, 3 nonarticular.

Although the cuboid bone is susceptible to low-energy avulsion injuries, injuries that occur in the setting of high-energy trauma are most concerning, as they often occur concurrently with other midfoot fractures and dislocations. These less common crush injuries are associated with comminution, articular disruption, and shortening of the lateral column.^3-5 Avulsion injuries occur via a twisting mechanism, while the more complex nutcracker fracture evolves via longitudinal compression of the lateral column, with the foot in a position of forced plantarflexion.⁶ Other comminuted fractures occur from direct impact on the lateral aspect of the foot.

Management of cuboid fractures varies according to etiology, fracture displacement, and articular involvement. Conservative management is reserved solely for stable, nondisplaced fractures.⁷ Unstable fracture-dislocations and those with associated lateral column shortening necessitate operative treatment, which attempts to restore anatomy, stability, and length of the foot’s lateral column.^7-9 However, with the exception of open injuries, fractures tenting the skin, and injuries with concomitant compartment syndrome, the high-energy nature of cuboid fractures often precludes early surgical intervention, as the foot’s soft-tissue envelope is too compromised. For this reason, operative intervention is often performed on a delayed basis only after recovery of the soft tissue.

In this case report and literature review, we describe a reconstructive shelf arthroplasty of the fifth tarsometatarsal (TMT) joint as a primary intervention for crush-type cuboid fractures with associated joint subsidence and lateral column shortening. The shelf arthroplasty, which was first credited to Konig in 1891, has historically been described as a remodeling operation using bone graft wedges for the treatment of nonconcentric acetabular dysplasia.¹⁰ Although bone grafting is recognized as an effective means of addressing osseous voids in the setting of comminuted cuboid fractures, its specific application in the form of a shelf arthroplasty has not been described.¹¹ The patient provided written informed consent for print and electronic publication of this case report.

Case Report

An otherwise healthy 45-year-old woman presented to our institution’s emergency department (ED) complaining of right foot pain after a motor vehicle accident. She was the restrained driver in a head-on collision. Primary survey revealed a swollen, ecchymotic, and tender right foot. Radiographs demonstrated fractures of her first, second, third, and fourth metatarsals, and a comminuted cuboid fracture with lateral column shortening and disruption of the fifth TMT joint (Figure 1).

Due to swelling, initial management consisted of soft-tissue management through the use of a well-padded splint. As this was her only injury, she was instructed to remain non-weight-bearing, ambulate with crutches, and return to our outpatient office for close follow-up. The need for delayed surgical intervention of her multiple foot injuries, due to her compromised soft-tissue envelope, was discussed prior to discharge.

Surgical intervention was performed 15 days after the injury, when the soft-tissue swelling had dissipated. The surgical plan included fixation of the multiple metatarsal fractures and lateral column reconstruction and stabilization. With regard to the lateral column, we obtained patient consent for several possible procedures, including fifth TMT joint closed reduction and percutaneous pinning, open reduction and internal fixation (ORIF), and TMT joint reconstruction with iliac crest bone graft (ICBG).

The metatarsals were addressed first via a dorsomedial incision, using a 5-hole 2.7-mm Limited Contact Dynamic Compression Plate (Synthes) to stabilize the first metatarsal and 2.0-mm Kirschner wires (K-wires) to maintain the length and alignment of the second, third, and fourth metatarsals (Figure 2). Closed reduction and percutaneous pinning of the fifth metatarsal was then attempted but abandoned because of persistent instability and subsidence of the cuboid in the proximal and plantar direction. ORIF was then attempted through a dorsolateral incision extending from just distal to the sinus tarsi to the base of the fourth metatarsal. However, the lateral cuboid was too comminuted to accommodate any fixation and prevent fifth TMT joint subluxation and lateral column shortening.

Autograft reconstruction of the lateral column was therefore performed, using radiographs of the patient’s uninjured, contralateral foot as a template for our lateral column shelf arthroplasty (Figure 3). Based on this template, the length and alignment of the lateral column were provisionally maintained with two 2.0-mm K-wires placed between the fifth metatarsal and intact cuboid (Figure 4). Tricortical ICBG was then harvested through an anterior approach to the iliac crest and contoured accordingly to fill the osseous void. To facilitate graft incorporation, comminuted fragments of cuboid bone were removed, with the remaining bone decorticated. The graft was then fixed to the remaining cuboid with two 4.0-mm partially threaded cannulated screws (Synthes; Figures 2, 4). This construct restored the length of the lateral column and effectively buttressed the fifth TMT joint, preventing subsidence and dislocation of the TMT joint.

After a 2-day postoperative course in the hospital, the patient was discharged. She remained non-weight-bearing in a splint with Robert Jones cotton bandage. At her 2-week postoperative visit, all hardware was intact and there was no evidence of infection. Her sutures were removed and she was placed in a new splint. At the patient’s 5-week postoperative visit, all K-wires were removed. At this time she remained non-weight-bearing but was transitioned into a controlled ankle movement (CAM) boot and was allowed to begin active and passive ankle exercises. At her 10-week follow-up, radiographs revealed appropriate interval healing and callus formation. The patient began weight-bearing as tolerated in the CAM boot at that time. At 12 weeks, she was transitioned into a hard-soled shoe for comfort and was allowed to ambulate in the footwear of her choice as tolerated. Her activity levels were slowly advanced, and, at her 12-month follow-up, the patient had returned to playing tennis in her recreational league with no residual sequelae (Figure 5).

Discussion

Although rare, cuboid fractures are critical to identify and can result in significant disability, as they are frequently associated with additional foot trauma, as demonstrated in this case.^1-4When isolated cuboid fractures are present, further imaging must be performed, including additional radiographic views and computed tomography, to search for other injuries, such as TMT joint complex disruption.

Only those cuboid fractures that are low-energy, stable, or nondisplaced can be effectively managed conservatively.¹²In the presence of instability, articular incongruity, or lateral column shortening, operative intervention is warranted. Arthritic degeneration, pain, and deformity result from residual incongruity at the calcaneocuboid or TMT joints, or when lateral column length is not restored.^4-6,13 The latter leads to forefoot abduction and lateral subluxation of the lesser metatarsals, with ensuing posttraumatic pes planus or planovalgus deformity, which often necessitates secondary reconstructive procedures or arthrodesis.^14,15 Stable reduction and restoration of lateral column length can be challenging, particularly in the setting of comminution and bone loss. Common methods of treatment involve lifting the dorsolateral cortex of the cuboid and buttressing the impacted articular surface with bone graft or bone graft substitutes. Fixation can be achieved with K-wires, small fragment plates and screws, and distraction external fixation.¹¹ The latter is a particularly beneficial technique, as it can be used independent of or in conjunction with ORIF.

In a study by Weber and Locher,¹¹ the short-term to midterm results of cuboid ORIF were assessed in 12 patients. Results were found to be good with respect to restoration of length, joint reconstruction, and overall return to function.¹¹ Admittedly, these authors at times employed a similar but conceptually different approach to our patient. In their 7 patients with severe comminution and lateral column shortening, corticocancellous ICBG was used. However, Weber and Locher¹¹did not describe this as a shelf arthroplasty, but instead as an adjunct to primary ORIF.

In our case, the tricortical ICBG shelf arthroplasty was used as it is in the hip, as a salvage procedure. Although little is known about outcomes following shelf arthroplasty for lateral column reconstruction in the foot, a 50% failure rate has been observed in the hip.¹⁶ As such, our preference was to perform an anatomic ORIF of the cuboid and lateral column, with the shelf arthroplasty only indicated if we were unable to achieve this. We believe that the need for tricortical ICBG in the treatment of cuboid fractures is indicative of a more severe injury and that it is a less optimal and more technically demanding intervention compared with primary ORIF. Furthermore, in other studies devoted to the treatment of cuboid fractures, patients requiring reconstruction with structural graft are not included in primary ORIF cohorts.¹⁷

As in the hip, suboptimal outcomes may occur when shelf arthroplasty is performed in the foot. There are additional considerations unique to the foot that surgeons must also contemplate when considering shelf arthroplasty. As demonstrated in the literature for adult-acquired flatfoot deformity, lateral column reconstruction is challenging and controversial and is associated with overload, pain, and the need to remove prominent hardware.¹⁸ These complications may also occur after shelf arthroplasty for cuboid fractures.

The work by Weber and Locher¹¹ did not elucidate such considerations, and outcomes of ORIF and ICBG reconstruction were not compared. This is a limitation of their study, as differences in functional outcomes between the 2 procedures remain unknown. Given the degree of comminution that precludes ORIF and necessitates a graft reconstruction, we believe that the description of the shelf arthroplasty as a salvage procedure more accurately reflects the severity of injury. This may have implications regarding outcomes and patient expectations that the orthopedic surgeon must address. Future studies must further evaluate the outcomes of this technique, independent of and in comparison with ORIF.

Conclusion

In this case, we describe shelf arthroplasty for cuboid fractures. It is a reconstructive salvage procedure that is indicated when ORIF cannot be achieved. This useful approach to a complex injury must remain in the armamentarium of orthopedic surgeons. As we have demonstrated, it can effectively restore a damaged lateral column, providing length and, in our case, enabling the patient to return to her pre-injury level of activity.

Veterans Health Administration (VA) hospitals have received notoriety due to episodes of misdiagnosis, poor management, and negligent care described in many recent reports and news articles.^1-3 While veterans are appropriately the primary focus of these investigative reports, physicians are also challenged in this setting, as they often meet resistance when advocating for patients and attempting to improve a flawed system.² Although my residency training includes 6 months at a VA hospital mired in controversy, the hospital has played a critical role in my training.³

Despite my many frustrations with the VA and the daily stresses incurred because of barriers impeding the timing and quality of care, I have several reasons to see the glass as “half full” when reflecting on my experiences as an orthopedic surgery resident at a VA medical center. This editorial will focus on the most important of these reasons—the special opportunity and pride associated with caring for veterans and these patients’ extremely appreciative nature.

The VA is one of the largest integrated health care systems in the United States, offering both inpatient and outpatient care to eligible veterans. Although eligibility has historically been based on military service–related medical conditions, disability, and financial need, reforms from 1996 to 2002 expanded enrollment to veteran populations previously deemed ineligible for VA care.^4,5 Despite this, studies suggest that some uninsured veterans do not seek VA care, even when eligible for VA coverage. This troubling notion is further complicated by research suggesting that veterans who use the VA for all of their health care are more likely to be from poor, less-educated, and minority populations, and are more likely to report fair or poor health and seek more disability days.⁶

Such disheartening realities can mask the most important attributes of VA patients, which pertain to their selfless commitment to our country. Orthopedic surgery residents must appreciate these attributes as well as the tremendous need for musculoskeletal care in this setting, as musculoskeletal conditions are some of the most common reasons for patient visits at the VA.⁷ Although combat-related high-energy blast injuries and the reconstructive procedures used to treat them have received a lot of attention, it is the more common musculoskeletal disorders that are most responsible for the tremendous burden of musculoskeletal disease in the VA. In a study by Dominick and colleagues,⁸ veterans had significantly greater odds of reporting doctor-diagnosed arthritis compared with nonveterans. Furthermore, veterans are also more vulnerable to overuse injuries, a finding attributed to the intense physical activity associated with military training and service.⁹

The busy orthopedic surgery clinic at my VA hospital is a fulfilling experience and a reminder of the large demand for musculoskeletal care. However, it is the patient population that makes it most gratifying. Most of the veterans seeking care are appreciative, regularly expressing their gratitude. They view me and the other residents as their physicians, not simply as doctors in training, like so many other non-VA patients do. Despite the fact that VA patients sometimes have to wait several hours to be seen in clinic and several months for surgery, I have never been subjected to their inevitable disdain or frustration. This is true in even the most trying and infuriating times, such as when an operation is cancelled on the day of surgery for reasons that many surgeons in non-VA hospitals would consider trivial. And even when witness to my visible irritation with the VA system, the veterans remain respectful and understanding; if they ever share similar feelings, they most certainly never voice them to me.

I cannot refute the notion that the VA must change and that the veterans deserve an improved health care system. However, this editorial is not written as a call to action. Instead, I hope it helps to humanize the patients of the VA, serving as a reminder to residents and other providers that the VA is a unique and extraordinary opportunity to give back and say thank you to veterans.

This editorial is dedicated to CPT David Huskie, USAR (Ret.), a veteran of Operation Desert Storm and orthopedic nurse at my VA hospital. It was he who first reminded me, and the other orthopedic residents, of the importance of our time at the VA. The Figure depicts the letter he gives to orthopedic residents at our program, along with a pewter coin, after their first VA rotation.

Veterans Health Administration (VA) hospitals have received notoriety due to episodes of misdiagnosis, poor management, and negligent care described in many recent reports and news articles.^1-3 While veterans are appropriately the primary focus of these investigative reports, physicians are also challenged in this setting, as they often meet resistance when advocating for patients and attempting to improve a flawed system.² Although my residency training includes 6 months at a VA hospital mired in controversy, the hospital has played a critical role in my training.³

Despite my many frustrations with the VA and the daily stresses incurred because of barriers impeding the timing and quality of care, I have several reasons to see the glass as “half full” when reflecting on my experiences as an orthopedic surgery resident at a VA medical center. This editorial will focus on the most important of these reasons—the special opportunity and pride associated with caring for veterans and these patients’ extremely appreciative nature.

The VA is one of the largest integrated health care systems in the United States, offering both inpatient and outpatient care to eligible veterans. Although eligibility has historically been based on military service–related medical conditions, disability, and financial need, reforms from 1996 to 2002 expanded enrollment to veteran populations previously deemed ineligible for VA care.^4,5 Despite this, studies suggest that some uninsured veterans do not seek VA care, even when eligible for VA coverage. This troubling notion is further complicated by research suggesting that veterans who use the VA for all of their health care are more likely to be from poor, less-educated, and minority populations, and are more likely to report fair or poor health and seek more disability days.⁶

Such disheartening realities can mask the most important attributes of VA patients, which pertain to their selfless commitment to our country. Orthopedic surgery residents must appreciate these attributes as well as the tremendous need for musculoskeletal care in this setting, as musculoskeletal conditions are some of the most common reasons for patient visits at the VA.⁷ Although combat-related high-energy blast injuries and the reconstructive procedures used to treat them have received a lot of attention, it is the more common musculoskeletal disorders that are most responsible for the tremendous burden of musculoskeletal disease in the VA. In a study by Dominick and colleagues,⁸ veterans had significantly greater odds of reporting doctor-diagnosed arthritis compared with nonveterans. Furthermore, veterans are also more vulnerable to overuse injuries, a finding attributed to the intense physical activity associated with military training and service.⁹

The busy orthopedic surgery clinic at my VA hospital is a fulfilling experience and a reminder of the large demand for musculoskeletal care. However, it is the patient population that makes it most gratifying. Most of the veterans seeking care are appreciative, regularly expressing their gratitude. They view me and the other residents as their physicians, not simply as doctors in training, like so many other non-VA patients do. Despite the fact that VA patients sometimes have to wait several hours to be seen in clinic and several months for surgery, I have never been subjected to their inevitable disdain or frustration. This is true in even the most trying and infuriating times, such as when an operation is cancelled on the day of surgery for reasons that many surgeons in non-VA hospitals would consider trivial. And even when witness to my visible irritation with the VA system, the veterans remain respectful and understanding; if they ever share similar feelings, they most certainly never voice them to me.

I cannot refute the notion that the VA must change and that the veterans deserve an improved health care system. However, this editorial is not written as a call to action. Instead, I hope it helps to humanize the patients of the VA, serving as a reminder to residents and other providers that the VA is a unique and extraordinary opportunity to give back and say thank you to veterans.

This editorial is dedicated to CPT David Huskie, USAR (Ret.), a veteran of Operation Desert Storm and orthopedic nurse at my VA hospital. It was he who first reminded me, and the other orthopedic residents, of the importance of our time at the VA. The Figure depicts the letter he gives to orthopedic residents at our program, along with a pewter coin, after their first VA rotation.

Veterans Health Administration (VA) hospitals have received notoriety due to episodes of misdiagnosis, poor management, and negligent care described in many recent reports and news articles.^1-3 While veterans are appropriately the primary focus of these investigative reports, physicians are also challenged in this setting, as they often meet resistance when advocating for patients and attempting to improve a flawed system.² Although my residency training includes 6 months at a VA hospital mired in controversy, the hospital has played a critical role in my training.³

Despite my many frustrations with the VA and the daily stresses incurred because of barriers impeding the timing and quality of care, I have several reasons to see the glass as “half full” when reflecting on my experiences as an orthopedic surgery resident at a VA medical center. This editorial will focus on the most important of these reasons—the special opportunity and pride associated with caring for veterans and these patients’ extremely appreciative nature.

The VA is one of the largest integrated health care systems in the United States, offering both inpatient and outpatient care to eligible veterans. Although eligibility has historically been based on military service–related medical conditions, disability, and financial need, reforms from 1996 to 2002 expanded enrollment to veteran populations previously deemed ineligible for VA care.^4,5 Despite this, studies suggest that some uninsured veterans do not seek VA care, even when eligible for VA coverage. This troubling notion is further complicated by research suggesting that veterans who use the VA for all of their health care are more likely to be from poor, less-educated, and minority populations, and are more likely to report fair or poor health and seek more disability days.⁶

Such disheartening realities can mask the most important attributes of VA patients, which pertain to their selfless commitment to our country. Orthopedic surgery residents must appreciate these attributes as well as the tremendous need for musculoskeletal care in this setting, as musculoskeletal conditions are some of the most common reasons for patient visits at the VA.⁷ Although combat-related high-energy blast injuries and the reconstructive procedures used to treat them have received a lot of attention, it is the more common musculoskeletal disorders that are most responsible for the tremendous burden of musculoskeletal disease in the VA. In a study by Dominick and colleagues,⁸ veterans had significantly greater odds of reporting doctor-diagnosed arthritis compared with nonveterans. Furthermore, veterans are also more vulnerable to overuse injuries, a finding attributed to the intense physical activity associated with military training and service.⁹

The busy orthopedic surgery clinic at my VA hospital is a fulfilling experience and a reminder of the large demand for musculoskeletal care. However, it is the patient population that makes it most gratifying. Most of the veterans seeking care are appreciative, regularly expressing their gratitude. They view me and the other residents as their physicians, not simply as doctors in training, like so many other non-VA patients do. Despite the fact that VA patients sometimes have to wait several hours to be seen in clinic and several months for surgery, I have never been subjected to their inevitable disdain or frustration. This is true in even the most trying and infuriating times, such as when an operation is cancelled on the day of surgery for reasons that many surgeons in non-VA hospitals would consider trivial. And even when witness to my visible irritation with the VA system, the veterans remain respectful and understanding; if they ever share similar feelings, they most certainly never voice them to me.

I cannot refute the notion that the VA must change and that the veterans deserve an improved health care system. However, this editorial is not written as a call to action. Instead, I hope it helps to humanize the patients of the VA, serving as a reminder to residents and other providers that the VA is a unique and extraordinary opportunity to give back and say thank you to veterans.

This editorial is dedicated to CPT David Huskie, USAR (Ret.), a veteran of Operation Desert Storm and orthopedic nurse at my VA hospital. It was he who first reminded me, and the other orthopedic residents, of the importance of our time at the VA. The Figure depicts the letter he gives to orthopedic residents at our program, along with a pewter coin, after their first VA rotation.