Operative Techniques in Foot and Ankle Surgery - (Axial Screw Technique For Midfoot Arthrodesis in Charcot Foot Deformit... )

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Axial Screw Technique for

Chapter 44 Midfoot Arthrodesis in
Charcot Foot Deformities
Vincent James Sammarco and G. James Sammarco
DEFINITION PATHOGENESIS
■ Fracture through the midfoot in the neuropathic patient may ■ Peripheral neuropathy is most commonly related to diabetes
accompany minor or incidental trauma and if unchecked may but may occur with other neurologic disorders as well.
lead to severe deformity or “rocker-bottom” foot deformity. ■ Glycosylation and diminished blood supply to the periph-
■ This chapter will demonstrate a technique used for fusion of eral nerves result in progressive loss of sensation, motor inner-
the unstable midfoot fracture dislocation. vation, and autonomic function.
■ Longer nerves are more severely affected, resulting in the
ANATOMY typical “stocking and glove” sensory deficit.

■ Loss of protective sensation in the lower limb predisposes pa-
■ Charcot fracture-dislocation of the midfoot may occur
through the tarsometatarsal, intercuneiform, or transverse tients to ulceration and may make them oblivious to fractures or
tarsal joints. dislocations.
■ Loss of motor function leads to intrinsic imbalance of mus-
■ Multiple patterns may exist and are often complicated by
bony dissolution. Attempts to classify these dislocations have cles in the lower extremity and commonly leads to equinus
been described by Sammarco and Conti11 and Schon et al14 contracture of the ankle and Achilles, which significantly in-
(FIGS 1 AND 2). creases the forces through the foot during gait.
■ Intrinsic imbalance in the foot musculature also results in
clawing of the hallux and lesser digits.

■ Autonomic sensory loss results in drying and cracking of
the skin, which diminishes integumentary protection from

pathogens.
■ Autonomic dysfunction also is responsible for loss of va-
somotor control, which may lead to edema and stasis.
NATURAL HISTORY
■ Midfoot fracture dislocation in the insensate patient may re-
sult acutely from direct trauma but more commonly is due to
repetitive microtrauma in insensate joints. Once instability de-
velops, bony deformity usually follows and worsens due to neu-
rally stimulated vasomotor response, which increases blood
flow to the area and leads to bony dissolution. Because the
process is typically painless, the patient may be unaware or
Type I Type II Type III

Copyright © 2010. Wolters Kluwer Health. All rights reserved.
Type I
Type II
Type I
Type II
Type III
Type IV
Type II
Type III
Type IV Type V
FIG 1 • Classification of Charcot midfoot fracture-dislocation as FIG 2 • Classification of Charcot midfoot fracture-dislocation by
described by Sammarco and Conti. Schon and Weinfeld.
322
Easley, Mark E., and Sam W. Wiesel. Operative Techniques in Foot and Ankle Surgery, Wolters Kluwer Health, 2010. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/templeuniv-ebooks/detail.action?docID=2031917.
Created from templeuniv-ebooks on 2018-04-03 18:18:38.
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Chapter 44 AXIAL SCREW TECHNIQUE FOR MIDFOOT ARTHRODESIS IN CHARCOT FOOT DEFORMITIES 323
unconcerned that a problem is present until massive soft tissue presenting to the orthopaedist in stage III will typically have a
swelling, gross deformity, ulceration, and infection are present. stable deformity that may or may not be amenable to bracing.
■ Fracture and dissociation through the midfoot may progress ■ Prognosis is significantly affected by four things for these
to a dorsal dislocation of the metatarsals. Once bony dissocia- patients: the presence of infection, the presence of adequate
tion occurs, contracture of the soft tissue envelope makes blood flow in the extremity to the level of the digits, the pres-
reduction of the deformity difficult or impossible without sur- ence of chronic venous stasis with associated poor integument,
gical resection of bone at the fracture site. and the ability for the patient to adequately control his or her
■ Charcot neuroarthropathy was staged by Eichenholz.6 medical comorbidities. Patients who are immunocompromised
■ Stage I is the inflammatory stage. The foot is hyperemic, due to transplant or those receiving dialysis have a much
swollen, and hot. Bony dissolution and fragmentation may worse prognosis than those with diabetes alone.
be present on radiographs. ■ The presence or absence of infection must be established at
■ Stage II is the coalescence phase, where swelling and edema

the onset of treatment. This may be difficult as many of the
decrease, temperature decreases, and redness improves. physical signs of stage I Charcot deformity are indistinguish-
■ In Stage III, bony consolidation occurs, often with signif-
able from an infection.
icant residual deformity. ■ Lack of constitutional symptoms does not preclude infection in
■ Deformity at the level of the midfoot is poorly tolerated and
diabetics, who may not be able to mount an adequate immune
leads to a significant increase in localized plantar pressures at response, and patients are often started on antibiotics at presen-
the apex of the deformity. Commonly these increased soft tis- tation. At the time of consultation, the patient has often already
sue pressures, combined with the previously mentioned loss of been admitted to the hospital with the initiation of intravenous
protective sensation and loss of normal integumentary func- antibiotics, bed rest with elevation of the extremity, and a
tion, may lead to ulceration and potentially deep infection. In non–weight-bearing status, thus blurring the ability to distinguish
diabetics, these problems are worsened by impaired circulation whether the patient improved due to simple rest or medications.
and immunologic function and can lead to amputation of the ■ A history of fevers and chills, inability for diabetics to control
limb. If osteomyelitis develops, limb salvage may still be pos- their blood sugar levels, and a history of previous or current ul-
sible but the risk of amputation is greatly increased. ceration increase the likelihood of active infection at presentation.
■ This technique is one of a series of evolving techniques aimed ■ The physical examination should document the presence or
at reconstructing these significant deformities.1–5,8–13 Standard absence of pulses.

arthrodesis techniques often fail in these patients due to the ■ Neuropathy should be documented with a 5.07 Semmes-
poor bone quality and significant fragmentation that accompa- Weinstein monofilament, and the level of intact sensation
nies these cases.15 The goals of this technique are to aid in re- should be noted in the patient’s record.
duction of deformity and to allow the fixation devices to bridge ■ Protective sensation may be present even with Charcot neu-
the area of dissolution at the apex of the deformity, achieving roarthropathy. Any ulceration should be carefully docu-
fixation in more normal bone proximally and distally. mented, as well as its depth and Wagner grade.16 The presence
of fluctuance may be suspicious for abscess and crepitation of
PATIENT HISTORY AND PHYSICAL the skin may represent gas gangrene; both require prompt di-
FINDINGS agnosis and surgical treatment. It is important to evaluate the
■ The patient with Charcot neuroarthropathy of the foot may contralateral foot and ankle as well as the patient may have
present in any of the Eichenholz stages, but by far the most pathology that is unrecognized.
common presentation to the orthopaedist is the inflammatory ■ Items in the history that suggest that surgical stabilization
stage, with presumed cellulitis and osteomyelitis. may be required include gross instability on physical examina-
■ A history of trauma may or may not be present. Stage I and II tion, acute fracture-dislocation from trauma, and recurrent ul-
patients will present with a swollen, red, and warm foot. Patients cerations despite appropriate nonoperative treatment (FIG 3).
A B C
FIG 3 • A 54-year-old man with Charcot midfoot fracture-dislocation. A. Clinical deformity. B. Lateral radiograph showing midfoot
fracture-dislocation. C. Plantar ulceration recalcitrant to extended contact casting. (Reprinted with permission. Copyright 2006
Cincinnati SportsMedicine Orthopaedic Center.)
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324 Section II MIDFOOT
IMAGING AND OTHER DIAGNOSTIC arterial examination in patients who do not have readily pal-
STUDIES pable pulses on physical examination.
■ Arterial insufficiency is a relative contraindication to surgi-
Radiographs
cal reconstruction. Referral to a vascular surgeon should be
■ Radiographs of the ankle and foot should be taken (weight considered for staged arterial reconstruction if significant in-
bearing when possible) to help stage the deformity. sufficiency is present.
■ Typical radiographic changes include fracture and disloca-
tion, bony destruction, periosteal reaction, and malalignment. DIFFERENTIAL DIAGNOSIS

■ These findings are difficult to distinguish from acute or
■ Osteomyelitis, acute or chronic
chronic osteomyelitis and alone are unreliable for determining ■ Abscess or gangrene
the presence or absence of infection. Radiographs alone are ■ Traumatic dislocation
sufficient for diagnosing the disease process, but other imaging
studies are often necessary to determine the presence or ab-
NONOPERATIVE MANAGEMENT
sence of infection.
■ The majority of patients who develop noninfected Charcot
MRI arthropathy can be treated nonoperatively.
■ Nonsurgical treatment typically entails a period of cast im-
■ MRI is frequently used to help determine the presence of os-
teomyelitis, but caution must be given to interpretation as the mobilization using a total-contact cast, and possibly a period
false-positive rate is very high. Bone destruction and bone and of limited or non–weight-bearing.
■ The goal of nonsurgical treatment with casting is to have the
soft tissue edema may be present in Charcot neuroarthropathy
without infection and alone should not be used to determine foot consolidate to a plantigrade structure without significant
the presence of infection. bony prominence.
■ Enhancement with intravenous gadolinium gives stronger ■ Once the foot has entered Eichenholz stage III, the
support to the presence of infection. patient is fitted for accommodative orthotics and shoe
■ The presence of a fluid collection consistent with abscess for- wear. Accommodative devices may be as simple as an off-
mation or air associated with Charcot deformity and the above the-shelf Plastazote orthotic if there is little residual defor-
MRI findings should be considered diagnostic for deep infection. mity. More commonly, there is some deformity and the
patient will require a custom-molded multidensity foam
CT orthotic.
■ CT scan may show extensive bony destruction, periosteal re- ■ A Charcot restraint orthotic walker (CROW) is necessary
action, and malalignment. if there is severe deformity. Surgery is typically reserved

■ The use of CT is unnecessary for diagnosis, but it can be
for patients with acute fracture dislocations, those with
helpful in surgical planning. progressive or unbraceable deformities, and those with recur-
■ The presence of air on a CT scan is considered diagnostic for
rent ulceration despite multiple attempts at accommodative
deep infection and may represent with gas gangrene, or more bracing.
commonly communication with an ulcer.
Nuclear Imaging
SURGICAL MANAGEMENT
Preoperative Planning
■ Nuclear imaging is particularly useful in helping differenti-
ate an infected Charcot process from a noninfected process. ■ It is important to establish the absence of infection. Active
■ A three-phase technetium bone scan alone will be of little infection or osteomyelitis is a contraindication for this tech-
value as increased uptake will usually be present in all three nique as the hardware is typically permanent and difficult or
phases. However, when this study is immediately followed by impossible to remove without significant bony destruction. As
a labeled white blood cell scan, the combined studies can be noted previously, vascular workup is necessary before the pro-
useful to decide whether the process is Charcot process alone, cedure.

■ The involvement of an astute internist is important in con-
soft tissue infection, or osteomyelitis.
■ Other isotopes may be useful in differentiating infection trol of diabetes and medical comorbidities. The timing of
from a sterile Charcot process and include 99mTc sulfur colloid surgery is important. Acute trauma without bony dissolution
and combined bone and white cell “dual peak imaging.” A de- or significant swelling can be safely reduced and fused within
tailed discussion of nuclear imaging is beyond the scope of this a week or two of injury, providing the dislocation is recog-
text and the reader is referred elsewhere for further study.7 nized and the patient has not entered the inflammatory stage
of the neuroarthropathy process.
Electrodiagnostic Testing ■ Once the patient enters the inflammatory phase, we prefer
■ This is usually unnecessary when peripheral neuropathy can to cast the patient for 6 to 8 weeks to allow the edema to re-
be documented on physical examination. solve and perform the reconstruction in a staged manner.
■ Electrodiagnostic testing can be useful in patients who have
Indications
relatively normal sensory examination but whose radiographic
and clinical findings are suggestive of neuropathic arthropa- ■ This technique involves passing large-bore cannulated screws
thy. It is useful for documentation of deficits and also may be across the uninvolved metatarsal heads through the metatar-
helpful in diagnosis of the underlying reason for neuropathy. sophalangeal (MTP) joints and is contraindicated in patients
without significant sensory neuropathy.
Vascular Testing ■ This technique is most useful for deformity at the tar-
■ We recommend rigorous workup of any suspected vascular sometatarsal level, and can be extended across the naviculo-
insufficiency. This usually entails screening with noninvasive cuneiform joints.
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B E
C
FIG 4 • Case example for technique demonstration: a 71-year-
old woman with idiopathic neuropathy. A, B, C. Clinical pho-
tographs show midfoot deformity after spontaneous midfoot
fracture-dislocation. Ulceration was present medially, which
resolved after 6 weeks of contact casting. D, E. Preoperative
clinical radiographs show dislocation at the tarsometatarsal
joint. Gross instability was present on physical examination.
(A, from Sammarco VJ, Sammarco GJ, Walker EW Jr, Guiao RP.
Midtarsal arthrodesis in the treatment of Charcot midfoot
arthropathy: surgical technique. J Bone Joint Surg Am
D 2010;92(Supplement 1 Part 1):1–19; printed with permission.)
■ A higher rate of failure, screw breakage, and nonunion is as- ■ The insertions of the tibialis anterior and posterior should
sociated with fusions that cross the transverse tarsal joint, and be left undisturbed when possible, but they are often attached
extended non–weight-bearing may be required to achieve fu- to fragmented or dislocated bone and should be secured with
sion at this level (FIG 4). nonabsorbable suture placed in a locking fashion during the
approach, for reattachment at closure.
Positioning ■ A subperiosteal dissection is carried out above and below the
■ The patient is positioned supine with a bump under the hip level of the deformity. The middle column of the foot is ap-
so that the toes face perpendicular to the operating table. proached though a dorsal incision centered between the second
■ A pneumatic tourniquet is used at the thigh.
and third metatarsal bases.
■ The patient is prepared and draped above the knee. A three- ■ Care should be taken to preserve the dorsalis pedis artery
step tendo-Achilles lengthening, gastroc–soleus recession, or at this level. A third incision is usually necessary for expo-
both is performed to achieve ankle dorsiflexion of 15 degrees sure and reduction of the lateral column and is carried out
before inflating the tourniquet. dorsally at the level of the fourth and fifth tarsometatarsal
Approach joints.
■ Care must be taken to provide an adequate skin bridge be-
■ A two- or three-incision approach is used to reduce defor- tween the dorsal incisions or wound necrosis or dorsal slough
mity and to prepare the arthrodesis bed. A medial approach is may occur.
used to expose the medial column.
TECHNIQUES
AXIAL SCREW TECHNIQUE FOR MIDFOOT ARTHRODESIS IN CHARCOT

FOOT DEFORMITIES
Resection and distal fragments. Carry out bone resection medially
■ Perform bone resection with an oscillating saw at the for the medial column, and dorsally for the middle and
level of deformity. lateral columns.
■ Adequate bone resection is necessary to prevent excessive ■ Remove bone from the dorsal incisions with a curved
tension on the dorsal soft tissue envelope and vascular curette or pituitary rongeur. Adequate bone resection is
structures. indicated by the ability to manually reduce the deformity.
■ Bone resection is at the level of the deformity and usu- ■ Resect bone slowly so that a balanced reduction can be
ally involves resection of some bone from the proximal achieved between the metatarsal bases. It is possible to
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resect so much bone that adequate bony apposition can- cannulated drill and then change to a larger guidewire
TECHNIQUES
not be achieved for successful arthrodesis (TECH FIG and larger cannulated drills. The medial column is usu-
1A–C). ally drilled to 5.5 mm and a screw 6.5 mm or 8.0 mm in
■ Place guidewires in the metatarsal shafts without crossing diameter is applied. The lesser metatarsals are usually
the apex of the deformity. This can be done retrograde drilled to 4.5 mm and a screw 4.5 mm or 5.0 mm is
through the MTP joints under fluoroscopic control, al- applied.
though this can be quite time-consuming and technically ■ Once the guidewires are in place in the reamed
demanding. To pass retrograde guidewires, hold the MTP metatarsal shafts, hold the deformity reduced and
joint in hyperdorsiflexion and pass the wire under fluoro- advance the guidewires into the midfoot. Measure
scopic guidance across the joint and into the metatarsal screw length from the middle part of the first
head and into the shaft. Alternatively, pass the guidewires metatarsal head in the medial column, and from
antegrade though the apex of the deformity. After bony the metaphyseal–diaphyseal junction of the lesser
resection, flex the foot through the middle and enter the metatarsals. A counter-sink must be applied through
metatarsal base with a curved curette, then a guidewire, the metatarsal head or it may fracture as the screw
which is passed into the metatarsal shaft. Then dorsiflex head is applied. Use screws with reduced-diameter
the MTP joint and drive the wire out through the plantar heads (TECH FIG 1H,I).
skin distally. The fifth metatarsal can usually not be fixed ■ After applying the screws, sequentially tighten them to
axially because the intramedullary canal typically aligns provide compression across the arthrodesis site.
lateral to the cuboid (TECH FIG 1D–G). ■ Perform a layered closure. Close the skin with 3-0 nylon
■ Ream the metatarsal shafts with cannulated drills. It suture applied with vertical mattress technique. A drain
is best to start with a small guidewire and a small is usually not necessary.
A B
C D
TECH FIG 1 • EUR Bone resection and exposure.

A–C. Medial column is exposed: note the tibialis anterior
tendon insertion, which must be reattached if it is released
for reduction. The saw is used to resect bone plantarly and
medially to restore axial alignment and to relieve soft tis-
sue tension. D–G. Preparation of the intramedullary canals
is done after the bone resection. Fluoroscopic control is
used during wire placement and reaming. D, E. Medial
column. (D, E, from Sammarco VJ, Sammarco GJ, Walker
EW Jr, Guiao RP. Midtarsal arthrodesis in the treatment
of Charcot midfoot arthropathy: surgical technique.
J Bone Joint Surg Am 2010;92(Supplement 1 Part 1):1–19;
E reprinted with permission.) (continued)
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TECHNIQUES
C
H
D
F
G I
J K L
TECH FIG 1 • (continued) F, G. Middle and lateral columns. H. Application of the screws axially across the arthrodesis site after
advancing the guidewires to the desired level. I. Intraoperative photograph of correction. J, K. Postoperative radiographs
showing midfoot fusion without recurrence. L. Clinical photograph taken 1 year postoperatively. (G, H, J–L, from Sammarco
VJ, Sammarco GJ, Walker EW Jr, Guiao RP. Midtarsal arthrodesis in the treatment of Charcot midfoot arthropathy: surgical
technique. J Bone Joint Surg Am 2010;92(Supplement 1 Part 1):1–19; reprinted with permission.)
PEARLS AND PITFALLS

■ Treatment of midfoot arthropathy is controversial and most cases can be managed nonoperatively by casting and bracing.
■ Surgery is indicated for grossly instability, recurrent ulceration, a nonplantigrade foot and unbraceable deformity.
■ When surgery is done: span the area of dissolution; adequate bone resection, use bigger, stronger implants; place implants where
they offer mechanical advantage.

■ Keys to success: do not operate on dysvascular limbs, eradicate infection/ulcer prior to applying internal fixation, aggressive surgical
treatment of equinus, get a good correction.
POSTOPERATIVE CARE ■ Techniques Figure 1J–L shows postoperative radiographs

and a photograph.
■ The patient is placed in a well-padded posterior splint post-
operatively. This is typically changed within a few days of the
surgery and switched to a cast. OUTCOMES
■ The patient is non–weight-bearing for 10 to 16 weeks, and ■ The authors reported on 20 patients followed for an average
may begin weight bearing in a pneumatic walking boot once of 49 months (range 20 to 77 months).17
bony consolidation is evident radiographically (average 12 ■ Complete arthrodesis of all joints was noted in 75% of pa-
weeks). tients and partial fusion with stable correction was noted in all
■ Once edema and swelling are under control, the patient may patients.
be graduated to diabetic shoe wear with a custom multidensity ■ There were five hardware failures and three patients re-
foam orthotic. quired removal of screws that backed out partially.
23353_FA-44.qxd 5/20/10 4:31 PM Page 328
■ All patients returned to functional status with diabetic shoe 4. Cooper PS. Application of external fixators for management of
wear and orthotics. None required above-ankle bracing. Charcot deformities of the foot and ankle. Foot Ankle Clin
■ There were no amputations. 2002;7:207–254.
5. Early JS, Hansen ST. Surgical reconstruction of the diabetic foot: a sal-
vage approach for midfoot collapse. Foot Ankle Int 1996;17:325–330.
COMPLICATIONS 6. Eichneholz SN. Charcot Joints. Springfield, IL: Charles C Thomas;
1966.
■ Screw loosening, backing-out, and hardware failure may 7. Lewis P. Scintigraphy in the foot and ankle. Foot Ankle Clin 2000;
occur as fixation will sometimes cross uninvolved joints. The 5:1–27.
surgeon should avoid crossing the calcaneocuboid and talon- 8. Myerson MS, Henderson MR, Saxby T, et al. Management of mid-
avicular joints when possible. Crossing uninvolved joints is foot diabetic neuroarthropathy. Foot Ankle Int 1994;15:233–241.
acceptable when necessary to achieve adequate fixation in neu- 9. Papa J, Myerson M, Girard P. Salvage, with arthrodesis, in intractable
diabetic neuropathic arthropathy of the foot and ankle. J Bone Joint
ropathic patients. Radiographs should be monitored carefully
Surg Am 1993;75A:1056–1066.
when weight bearing is initiated as screws will sometimes bend 10. Pinzur MS. Charcot’s foot. Foot Ankle Clin 2000;5:897–912.
before failing and can be exchanged percutaneously. Screws 11. Sammarco G, Conti SF. Surgical treatment of neuroarthropathic foot
that back out into the ankle or MTP joint should be removed deformity. Foot Ankle Int 1998;19:102–109.
or exchanged. 12. Schon LC, Easley ME, Weinfeld SB. Charcot neuroarthropathy of the
■ Overcorrection can occur and may result in ulceration be- foot and ankle. Clin Orthop Relat Res 1998;349:116–131.
neath the first metatarsal head. 13. Schon LC, Marks RM. The management of neuroarthropathic frac-
■ Partial nonunion may occur and does not need to be treated
ture-dislocations in the diabetic patient. Orthop Clin North Am
1995;26:375–392.
as long as the foot is plantigrade. All patients in our series 14. Schon LC, Weinfeld SB, Horton GA, et al. Radiographic and clinical
maintained the majority of their correction at final follow-up. classification of acquired midtarsus deformities. Foot Ankle Int
1998;19:394–404.
15. Simon SR, Tejwani SG, Wilson DL, et al. Arthrodesis as an early al-
REFERENCES ternative to nonoperative management of Charcot arthropathy of the
1. Alvarez RG, Barbour TM, Perkins TD. Tibiocalcaneal arthrodesis diabetic foot. J Bone Joint Surg Am 2000;82A:939–950.
for nonbraceable neuropathic ankle deformity. Foot Ankle Int 16. Wagner FW. Transcutaneous Doppler ultrasound in the prediction of
1994;15:354–359. healing and the selection of surgical level for dysvascular lesions of
2. Bono JV, Roger DJ, Jacobs RL. Surgical arthrodesis of the neuropathic the toes and forefoot. Clin Orthop Relat Res 1979;142:110–114.
foot: a salvage procedure. Clin Orthop Relat Res 1993;296:14–20. 17. Walker E, Sammarco VJ, Sammarco GJ. Surgical treatment of
3. Campbell JT. Intra-articular neuropathic fracture of the calcaneal Charcot midfoot collapse with midtarsal arthrodesis using long in-
body treated by open reduction and subtalar arthrodesis. Foot Ankle tramedullary screw fixation. American Orthopaedic Foot and Ankle
Int 2001;22:440–444. Society Summer Meeting, La Jolla, CA.

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Axial Screw Technique for

ANATOMY typical “stocking and glove” sensory deficit.

clawing of the hallux and lesser digits.

the skin, which diminishes integumentary protection from

somotor control, which may lead to edema and stasis.

Type I Type II Type III

■ Stage II is the coalescence phase, where swelling and edema

at reconstructing these significant deformities.1–5,8–13 Standard absence of pulses.

324 Section II MIDFOOT

tion, bony destruction, periosteal reaction, and malalignment. DIFFERENTIAL DIAGNOSIS

action, and malalignment. if there is severe deformity. Surgery is typically reserved

useful to decide whether the process is Charcot process alone, cedure.

AXIAL SCREW TECHNIQUE FOR MIDFOOT ARTHRODESIS IN CHARCOT

326 Section II MIDFOOT

TECH FIG 1 • EUR Bone resection and exposure.

PEARLS AND PITFALLS

they offer mechanical advantage.

treatment of equinus, get a good correction.

POSTOPERATIVE CARE ■ Techniques Figure 1J–L shows postoperative radiographs

foam orthotic. quired removal of screws that backed out partially.

328 Section II MIDFOOT

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