Combined Hindfoot, Midfoot Fusion for Severe Flatfoot: The New 'Triple This procedure can also relieve symptoms of back problems like degenerative disk disease and scoliosis. The calcaneocuboid joint is part of the mid-tarsal (Chopart) joint. This type of surgery is performed under general anesthesia. Calcaneocuboid distraction arthrodesis (CCDA) is regarded as an effective method for reconstructing adult-acquired flatfoot deformity. Sometimes, your surgeon will place a small piece of bone between the two ends of your joint. You may need to ask a family member or friend to assist with household tasks. Because we find that our patients are careful during the recovery time, we allow our patients to put full weight on their ankle after their first post-op visit. Biomechanical evaluation of calcaneocuboid distraction arthrodesis: a cadaver study of two different fixation methods. If fused at normal length, no loss of motion in the rest of the hindfoot occurs. What Are the Risks of Joint Fusion Surgery? Joint fusion surgery can be done on many different joints, such as your: Spine Ankles. Dr. Ebert will begin treatment by making a small incision on both the outer and inner side of the ankle. . After spinal fusion Depending on the location and extent of your surgery, you may experience some pain and discomfort but the pain can usually be controlled well with medications. Zhou H, Ren H, Li C, Xia J, Yu G, Yang Y. Biomed Res Int. Just to give a brief run down, back in 1999 I fell 50 foot and smashed my heels which had to be built back up with many many months of . 1998 Jan;19(1):19-25. doi: 10.1177/107110079801900104. cpt code for lateral column lengthening Subperiosteal dissection was carried out over the calcaneocuboid joint. and transmitted securely. The calcaneocuboid joint is a type of saddle joint between the calcaneus and the cuboid bone.[1]. 6000 Poplar Ave., Ste. This significantly reduces the normal movement, although this has usually already been lost due to the arthritis. 2014 Nov;43(11):1025-39; quiz 40. doi: 10.1007/s00132-014-3037-0. 520 East 70th Street Starr Pavilion, 2nd Floor, New York, NY 10021 4.46 miles The joint is integral to several types of foot movement. 3. It may not display this or other websites correctly. These findings demonstrate the need for clinical investigation of this procedure, which could preserve motion in the talonavicular and subtalar joints, correct deformity, and obviate calcaneocuboid arthritis. Think of the thigh bone and shin bone. The defect can be grafted using a corticocancellous bone graft for structural support. Located on the outside of the foot, in front of the heel bone, the cuboid bone is characterised by its cube shape. Each sterile screw package has 6 self-adhesive labels per Implant and easily identifiable by style, diameter and length on the color-coded end cap. What is a Talonavicular Fusion? Beimers L, Louwerens JW, Tuijthof GJ, Jonges R, van Dijk CN, Blankevoort L. Foot Ankle Int. Normal Anatomy and Traumatic Injury of the Midtarsal (Chopart) Joint Complex: An Imaging Primer. In fact, joint pain is relieved for most patients. It can also make your joint more stable and help you bear more weight on it. The surfaces were osteotomized to expose cancellous bone and remove the surfaces. BioV Bioactive Matrix is a novel bone graft substitute expressly designed to optimize surgical handling, graft stability and osteoproductivity. It fuses together two bones, the talus and the navicular bone hence talonavicular fusion. Bookshelf [3], The calcaneocuboid joint may be affected by a calcaneal fracture. What is it? The anterior area is left free of plaster to allow for swelling. A mesh plate can be used for larger defects and a cuboid plate for smaller defects. Before the simulated arthrodeses, the talonavicular joint had the greatest range of motion (36.7 13 degrees [mean and standard deviation]), followed by the subtalar joint (20.4 8 degrees) and the calcaneocuboid joint (14.4 6 degrees), in all ten feet. What is the extra bone in your ankle called? This procedure can be technically challenging. Foot & Ankle Fusion Surgery | MedStar Health Plates feature an Oblong Compression Slot option. Epub 2017 Apr 10. The patient should be counseled to keep the leg on a cushion and elevated. Since there is very little movement in the small joints of the midfoot, the function of the foot can be preserved. 2007 Mar;21(3):255-8. Calcaneocuboid fusion - The hindfoot consists of four bones and three joints. Consisting of hydroxyapatite, tri-calcium phosphate and bioactive glass in a collagen matrix, the Backfill Plugs are sized to easily fit in surgically created osseous defects; 5.5mm dia. Using custom orthotics, walking aids, or foot braces are also alternatives. You may need to ask a family member or friend to assist with household tasks. This means that not enough bone is able to form for the joint to fully fuse. 2007. Triple fusion is the joining together of three joints (the talonavicular, subtalar and calcaneocuboid joints) as a treatment for arthritis or as a method of correcting a . Each blister pack contains all the necessary instruments for implanting: 2.0, 2.5, 3.0 and 3.5mm Compression Screws. Lateral column lengthening with calcaneocuboid fusion: range - PubMed Lateral column lengthening for acquired adult flatfoot deformity caused by posterior tibial tendon dysfunction stage II: a retrospective comparison of calcaneus osteotomy with calcaneocuboid distraction arthrodesis. Bridging may be achieved using either an external fixator or a reconstruction plate until the cuboid has healed. When two bones come together they form a joint. Mosier-LaClair S, Pomeroy G, Manoli A 2nd. A talonavicular dislocation is a rare luxation of the foot, often after a high-velocity trauma. You have solved my problem. This swelling will eventually completely subside with time and can take up to 12 months but often goes well before this. The talus, calcaneus, cuboid, and navicular bones are separated by cartilage and create the talocalcaneal, talonavicular, and calcaneocuboid joints. Careers. Calcaneocuboid Distraction Arthrodesis With Synthetic Bone Grafts Unauthorized use of these marks is strictly prohibited. This procedure fuses, or welds, together the two bones that make up your aching joint. You will remain in the boot for about 12-14 weeks after surgery and will continue to increase your activity at that point. An appropriate locking plate is selected to bridge the defect. Until that happens, youll need to protect the area. The articular surfaces of the two bones are relatively flat with some irregular undulations, which seem to suggest movement limited to a single rotation and some translation. Kafka RM, Aveytua IL, Choi PJ, DiLandro AC, Tubbs RS, Loukas M, Mintz DN, Baidya R, Kumar S, Sangari SK, Mtui EP, D'Antoni AV. Before Once the swelling goes down and the incisions are healing, your doctor may put on a cast or a removable boot. Contact Related categories Orthopaedics Hindfoot This video is age-restricted and only available on YouTube. [1] Ligaments [ edit] There are five ligaments connecting the calcaneus and the cuboid bone, forming parts of the articular capsule : the dorsal calcaneocuboid ligament. The plate length should allow for fixation using a minimum of three screws both proximally and distally. You will not be able to put weight onto the foot for a total of 8-10 weeks after surgery. Case Report: An Unexpected Outcome of In Situ Fusion of the Calcaneo A calcaneocuboid fusion fuses together the calcaneus and cuboid bones of the hindfoot. This occurs more typically in the mid and hind-foot. [Effect of calcaneocuboid arthrodesis on three-dimensional kinematics of talonavicular joint]. It is a surgical procedure that fuses or connects the bones with screws, prohibiting motion in the foot or ankle and creating a permanent joining of the bones. Corticosteroid Injections for Osteoarthritis, Smart Grocery Shopping When You Have Diabetes, Surprising Things You Didn't Know About Dogs and Cats, Smoking Pot Every Day Linked to Heart Risks, Artificial Sweetener Linked to Heart Risks, FDA Authorizes First At-Home Test for COVID and Flu, New Book: Take Control of Your Heart Disease Risk, MINOCA: The Heart Attack You Didnt See Coming, Health News and Information, Delivered to Your Inbox. It is a modified saddle-type joint. J Am Acad Orthop Surg. The soft tissues, including capsule and periosteum, are often disrupted. This allows them to rest comfortably throughout the procedure without feeling any pain. What does the binary number 0111 represent? 25 (5): 349-56. Insert the external fixator pins in the calcaneum through stab incisions, proximally in the calcaneum, and distally in the fifth metatarsal. It is continuous with the thickening of the dorsal articular capsule of the calcaneocuboid joint and can have a variable appearance due to anatomic variations. Therefore, the cuboid length must be maintained. 8600 Rockville Pike The procedure can also be used to treat a flatfoot deformity or arthritis, osteoarthritis, or rheumatoid arthritis of the foot. 2019 Jan 8;11(1):e3847. (Calcaneocuboid labeled at bottom center. The calcaneocuboid joint involves the anterior surface of the calcaneus and the posterior surface of the cuboid. As with all foot surgery it is common for minor discomfort and swelling to persist for some months after surgery and is completely normal. The .gov means its official. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Patient preparation and surgical approach 115 Memphis, TN 38119, Available in flowable, formable putty and crunch in syringe, Donor recovery and screening performed according to AATB and FDA guidelines, Crunch consists of DBM putty & cortical cancellous bone chips, Moldable, sterile, demineralized/compressive bone matrix, Cut and molded as needed, sponge-like fit and fill capabilities, Natural porous scaffold encourages osteoconductivity and promotes vascularization and stimulates new bone growth, Add bone marrow aspirate or platelet rich plasma to create a composite graft. - arthrodesis of 1st metatarsal-tarsal joint and. keystyle mmc corp login; thomson reuters drafting assistant user guide. Methods: Twelve fresh-frozen cadaveric specimens were cyclically loaded to 720 N at 0.5 Hz for 30 cycles. This article reviews the main conditions of the lateral column and calcaneocuboid joint in particular. PMC 89 (9): 1247-8. The talonavicular and calcaneocuboid joints: anatomy - PubMed At the time the article was last revised Joachim Feger had no recorded disclosures. You should rest and keep your leg elevated to control swelling. The step-by-step bending procedure is analog to the bending of reconstruction plates. The foot should be immobilized for the first two weeks, which can be achieved using a three-sided plaster splint. FOIA The calcaneocuboid joint is stabilized by ligaments on its superior and inferior aspects. Disclaimer. It is demonstrated that when fusing the calcaneocuboid joint, attention should be paid to maintaining a neutral position of the foot, which resulted in significant decreases in motion in the talocalcaneal and talonavicular joints. Malik C, Najefi AA, Patel A, Vris A, Malagelada F, Parker L, Heidari N, Jeyaseelan L. Eur J Trauma Emerg Surg. What is a Calcaneocuboid Fusion? - Studybuff 5. A replacement retains movement of the joint after surgery, unlike a fusion. [vid_icon]Gout: Risk Factors and Triggers, Slideshow: Knee Surgery Recovery Timeline, Slideshow: Ankle Replacement Recovery Timeline, Taking Care of Your Joints After Ankle Replacement, A nervous system (neurological) problem that may keep you from healing. 1. Your doctor will help you control this. Federal government websites often end in .gov or .mil. Comparison of two fixation methods for arthrodesis of the sharing sensitive information, make sure youre on a federal The dorsal calcaneocuboid ligament attaches to the anterolateral calcaneus (lateral to the bifurcate ligament) and to the dorsolateral cuboid. It is a synovial articulation between the calcaneus and the cuboid bones of the foot. Calcaneocuboid joint arthroplasty and foot fusion are surgical alternatives to the procedure. Publication types Review How it helps arthritis, migraines, and dental pain. PMC MeSH Patients with subtalar joint problems frequently limp, favor the painless other foot, and notice swelling in this region. An official website of the United States government. The differential threads combined with a low profile head apply a compression lock to the fragment. Its joint capsule is thickened superiorly and also inferiorly 1. The calcaneocuboid joint can be rarely associated with lateral ankle instability and pain if it is dislocated or subluxed 3. Our goal is for you to experience the following benefits after surgery: Location: The OR dressing is usually left in place and not changed until the first postoperative visit at two weeks when x-rays are obtained once the dressing is removed. Learn more Watch on YouTube Watch on Calcaneo-cuboid arthrodesis with VariAx plate SI Joint Fusion near New York, NY | WebMD An official website of the United States government. How would I coding these procedures: - arthrodesis of the calcaneocuboid joint with. Thank you for taking a look at our site. Cureus. The distraction vector should be parallel to the plantar aspect of the lateral foot. 2001 Mar;6(1):95-119. doi: 10.1016/s1083-7515(03)00083-4. Lateral column length is critical to maintaining the shape and function of the foot. Change location A bridge plate or an external fixator may be used to supplement the cuboid reconstruction. During the second week after your operation, you should be able to walk short distances using your crutches, but it is crucial to remember to refrain from putting any weight on your foot. 1998 May-Jun;6(3):188-96. doi: 10.5435/00124635-199805000-00007. At the time the article was created Ihab Mikhail had no recorded disclosures. Youll probably need to wear a cast or brace. Finding top-rated doctors who perform SI Joint Fusion near you is simple on WebMD Care. This leaflet tells you what to expect as you recover from having foot fusion surgery. It can also be injured in combined plantarflexion-inversion injuries, as is the case with Chopart fracture 4. Other possible risks include blood clotting, failed fusion and arthritis in nearby joints. They are fused together with metal plates, pins, or screws. Check for errors and try again. Your doctor might also choose to use a special manmade substance in place of an actual bone. Calcaneocuboid arthritis is a form of osteoarthritis which affects the calcaneocuboid joint, that is located between the cuboid bone and the heel bone. The traditional fixation for a calcaneocuboid (CC) arthrodesis in triple arthrodesis is with a 6.5-mm cancellous screw. After you go home, contact your doctor if you exhibit signs of infection, such as: Redness, tenderness or swelling. Soft-tissue stripping should be avoided if possible. Calcaneocuboid Joint Arthrodesis | Orange County Surgeons Background: Isolated subtalar arthrodesis is generally successful, with reported fusion rates of 84% to 100%. Our surgeons are fellowship-trained and specialize exclusively in caring for lower extremity conditions. 14.17). The calcaneocuboid joint is a type of saddle joint between the calcaneus and the cuboid bone. Calcaneocuboid arthrodesis is more commonly performed as an adjunct procedure with other rearfoot procedures such as triple arthrodesis and is less used as isolated fusion. Platelet gel was placed into the gap. Calcaneocuboid joint arthrodesis involves the fusion of the cuboid and calcaneus bones. Use a lateral-column distractor to achieve the articular surface visualization needed for accurate reduction and fixation. The medial calcaneocuboid ligament is the lateral band of the bifurcate ligament. Epub 2010 May 28. HHS Vulnerability Disclosure, Help Non-steroidal anti-inflammatory drugs (NSAIDs) are a safer choice than opioids, which are highly addictive. Calcaneocuboid Arthritis - Sussex Foot And Ankle Clinic hope this helps. 4. Potential Complications from Calcaneocuboid Joint Arthrodesis: The potential complications of calcaneocuboid joint arthrodesis include bleeding, infection and a negative reaction to the anesthesia that is used. sharing sensitive information, make sure youre on a federal (for 6mm void) and 7.5mm dia. It causes the bones to become one solid bone, and it can lessen your pain. The joint will then be rigid and no longer painful. Next, theyll use metal plates, screws, or wires to close the space within your joint. Churchill Livingstone. It is commonly performed to help correct the condition of pes planus (commonly called flat foot or fallen arch). 8600 Rockville Pike Surgical outcome of subtalar fusion Rest assured, the screws are permanent fixtures and will last for decades. The talus, calcaneus, cuboid, and navicular bones are separated by cartilage and create the talocalcaneal, talonavicular, and calcaneocuboid joints. We look forward to hearing your thoughts. So too with the bones in the foot. After they are finished, your surgeon will close your incisions with sutures or staples. The talonavicular joint is critical in allowing the foot to move inwards and outwards, as well as in a circular motion. registered for member area and forum access. It is a synovial articulation between the calcaneus and the cuboid bones of the foot. Bookshelf 2012 Jan;29(1):91-102. doi: 10.1016/j.cpm.2011.09.004. ), The ligaments of the foot from the lateral aspect. MeSH Calcaneocuboid joint | Radiology Reference Article | Radiopaedia.org Walking on flat ground will be almost unaltered, but walking on uneven ground will be the most apparent. Instead of bridge plating, the lateral column distractor can be replaced with an external fixation construct, which can be left in place while the bone heals. Kimball HL, Aronow MS, Sullivan RJ, Tarinelli DJ, Nowak MD. New arthritis in nearby joints (very common). The osteoconductive scaffold rapidly absorbs the surrounding blood and fluids to aid in new bone formation during the healing process. 2nd metatarsal-tarsal joint with plantar-flexory. These alternatives include pain medication, strength training, physical therapy, or steroid injections. Unlike the TN joint, which is responsible for complex hindfoot circumduction, the CC joint is less important for normal function. The demonstration is performed by. Foot Ankle Int. In general, doctors believe this procedure is safe. The present study aimed to investigate changes in hallux alignment after corrective surgery for adult-acquired flatfoot deformity (AAFD).The present s It may blend with the dorsal calcaneocuboid ligament and in such a case these two structures cannot be distinguished. Joint Fusion Surgery: Purpose, Procedure, Risks, Recovery - WebMD J Foot Ankle Surg. The site is secure. Formal physical therapy should not begin in the early postoperative period. The long plantar ligament lies superficial to the short plantar ligament. In some cases, general anesthesia may be used. Make sure you stop taking them as soon as your pain lessens. Analysis of the inversion and eversion ranges of motion suggests that the lengthening fusion limits eversion more than inversion. This procedure can be technically challenging. 1. Calcaneocuboid Fusion - In2Bones Podiatry Management Online While seated, the foot should be on a cushion and elevated, but if badly swollen, the patient must be supine since elevating the foot while seated decreases swelling less effectively. REQUEST AN APPOINTMENT Its joint capsule is thickened superiorly and also inferiorly 1. After 10 -14 days you will need to come back to have your stitches removed. INDIVIDUALLY PACKAGED Compression Screws are delivered in STERILE, cylindrical cases enclosing a series of capped sleeves. Subtalar Fusion | FootCareMD Running after talonavicular fusion is often impaired, shortened by concentrated pain and tense, overworked and neighboring ligaments. Analysis of the inversion and eversion ranges of motion suggests that the lengthening fusion limits eversion more than inversion. You are using an out of date browser. The strict non-weight bearing should be maintained until there is evidence of healing and any transfixion K-wires (612 weeks) or bridging devices (min 12 weeks) are removed. Lateral column lengthening with calcaneocuboid fusion, which lengthens the lateral column of the foot and prevents calcaneocuboid arthritis, was investigated in a cadaver model to determine the remaining range of motion in the talonavicular and subtalar joints. government site. After this type of surgery, you can expect to lose some of your range of motion and feel stiff in your joint. doi: 10.7759/cureus.3847. Calcaneocuboid arthrodesis - PubMed The goal of the treatment is bone healing with appropriate intra- and extra-articular reduction to maintain lateral column length. 2012 Jun;17(2):309-22. doi: 10.1016/j.fcl.2012.03.008. Thank you so much - I have been having trouble deciding which of those codes are correct. Inversion/eversion motion was produced by tendon pulls and the range of motion was measured in three dimensions using a magnetic space tracker. Non-surgical alternatives may be used prior to calcaneocuboid joint arthrodesis. Calcaneo-cuboid fusions are performed to relieve pain from arthritic or unstable joints, or as part of a lateral column lengthening procedure. Fusion eliminates the normal motion that occurs between two bones. In some cases fusion of the bones in your midfoot may ease your pain and aid your mobility. (for 8mm void) by 40mm in length. Please enable it to take advantage of the complete set of features! Conditions Treated with Calcaneocuboid Joint Arthrodesis: Calcaneocuboid joint arthrodesis is utilized to relieve foot pain or to correct misalignment of the calcaneocuboid joint. Before You wont be able to move it anymore. In other cases, you may have local anesthesia. Lateral column length is critical to maintaining the shape and function of the foot. Get personalized tips to reduce discomfort. Theyll carefully take this bone from your pelvic bone, heel, or just below your knee. However, the cuboid rotates as much as 25 about an oblique axis during inversion-eversion in a movement that could be called involution. Biomechanical principles are used to illustrate orthotic management of diseases that affect the transverse tarsal joint. The talonavicular joint is a joint formed by the talus, the bottom half of the ankle joint, and the foot bone immediately in front of it called the navicular. (2018) RadioGraphics. While the artificial ankle can wear out and may need to be replaced, research shows 90% are still functioning well 10 years after surgery. The metalwork usually stays in the foot for the rest of your life. Over time, arthritis can cause severe damage to your joints. This is an operation to fuse or stiffen a joint in the middle part of the foot. Sci Rep. 2016 Oct 18;6:35493. doi: 10.1038/srep35493. Irrigate the fracture site using, eg, a syringe. It covers the incision, the desired outcome, the osteotomy and fixation. Once the fusion site is prepared, the distraction can be adjusted to achieve the correct length of the lateral column. This will allow your bones to fuse. After six weeks and once an X-ray confirms that your bones are healing correctly, you can start to put weight on your foot. Enter your location, Please Enable Location Services in Your Browser Settings to Continue, Foot & Ankle Fusion Surgery | MedStar Health, Show All Foot and Ankle Orthopedic Surgery, Good Faith Estimate and No Surprise Billing, Improved ability to bear weight on the affected foot and ankle, Ability to return to normal activities without pain. Calcaneocuboid fusion The hindfoot consists of four bones and three joints. The https:// ensures that you are connecting to the This article describes the osseous and ligamentous anatomy of the talonavicular and calcaneocuboid joints and describes the biomechanical role of the transverse tarsal joint in standing and gait. The site is secure. A few weeks following surgery, your doctor will take X-rays to monitor the healing of your fused joint. PDF Foot and Ankle Systems Coding Reference Guide - Zimmer Biomet Gardner, E. and Gray, D. (1968). Query: Multiple Arthrodesis Procedure Coding l. Procedure Coding. The plate is fixed with locking head screws. Physical therapy can help keep your other joints in good working shape. The exposure is via the distal end of the incision used for the subtalar fusion. Would you like email updates of new search results? Such a plate or distractor must be removed subsequently to permit restoration of some joint motion. Once youve had anesthesia, your doctor will make an incision (cut) in your skin. The surgical technique for isolated calcaneocuboid arthrodesis is discussed. document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); Send us an email and we'll get back to you asap. Sterility Extra side and posterior cushion padding are added. They are fused together with metal plates, pins, or screws. Calcaneocuboid fusion with lengthening of the lateral column of the foot has been advocated as a method of treating flatfoot deformity. Copyright 2012 Elsevier Inc. All rights reserved. 27871 Arthrodesis, tibiofibular joint, proximal or distal 28705 Arthrodesis; pantalar 28715 Arthrodesis; triple . [2] the long plantar ligament. HHS Vulnerability Disclosure, Help Reference article, Radiopaedia.org (Accessed on 04 Mar 2023) https://doi.org/10.53347/rID-70289, see full revision history and disclosures, posterior suprapatellar (prefemoral or supratrochlear) fat pad, anterior suprapatellar (quadriceps) fat pad, accessory anterior inferior tibiofibular ligament, superficial posterior tibiotalar ligament, superficial posterior compartment of the leg (calf), accessory extensor digiti secundus muscle, descending branch of the lateral circumflex. Plantar and calcaneocuboid joint pressures were measured in neutral, inversion, and eversion in the intact foot, with isolated medial column fusion, and with medial and lateral column fusion. Primary fusion of unreconstructable calcaneocuboid joint Comparison of Two Fixation Methods for Arthrodesis of the Also Known As: Calcaneocuboid joint fusion Foot joint arthrodesis Orthopedic surgery Heel surgery Conditions Treated with Calcaneocuboid Joint Arthrodesis: Accessibility The calcaneocuboid joint is the joint between the calcaneus and the cuboid bone. Penetrate the subchondral bone using a high-speed burr or drill to promote bone growth. My thesis aimed to study dynamic agrivoltaic systems, in my case in arboriculture. bone block, lateral column lengthening; and. The plate may be pre-contoured using a saw-bone foot model and fine-tuned in situ as an alternative to using a template. You will need to wear the cast until the foot or ankle has fused, which usually takes six weeks to three months. A calcaneocuboid fusion fuses together the calcaneus and cuboid bones of the hindfoot. Bethesda, MD 20894, Web Policies When contouring locking plates, care must be taken not to deform the screw holes. In a midfoot fusion, your foot and ankle orthopaedic surgeon fuses together the different bones that make up the arch of the foot. What are the main outcomes of US involvement in the Korean War? This site needs JavaScript to work properly. Continue to learn and join meaningful clinical discussions, Revised proximal femur module is now online, patient placed supine with the knee flexed 90, Restoration of the appropriate length of the lateral column, In-plane bending to adapt to the arch of the lateral foot, Out of plane bending to adapt to the lateral contour of the lateral column, Torquing to fit both the vertical wall of the calcaneus proximally and the dorsal aspect of the fourth metatarsal distally.