High Yield Overview

CALCANEOCUBOID ARTHRITIS

Lateral Column Degenerative Disease | Triple Joint Complex | Often Overlooked

10-15%of midfoot arthritis cases

1:5CC to TN arthritis ratio

80-85%fusion success rate

5-10%isolated CC arthritis

ARTHRITIS SEVERITY

Mild

PatternJoint space narrowing, minimal osteophytes

TreatmentConservative management

Moderate

PatternSignificant narrowing, sclerosis

TreatmentSelective arthrodesis

Severe

PatternBone-on-bone, deformity

TreatmentArthrodesis required

Critical Must-Knows

CC joint is critical for lateral column stability and load transfer
Rarely occurs in isolation - assess talonavicular and subtalar joints
Triple arthrodesis indicated when multiple hindfoot joints involved
Peroneal tendon pathology commonly coexists
Lateral approach risks sural nerve and peroneal tendons

Examiner's Pearls

"
CC joint contributes to lateral column length and forefoot abduction
"
Nutcracker fracture of cuboid predisposes to CC arthritis
"
Isolated CC fusion rare - usually part of triple arthrodesis
"
Sural nerve at risk with lateral approach

Critical Calcaneocuboid Arthritis Exam Points

Lateral Column Importance

CC joint maintains lateral column length. Loss leads to forefoot adduction and cavovarus deformity. Critical for proper foot biomechanics.

Usually Part of Complex

Isolated CC arthritis is rare (5-10%). Typically occurs with talonavicular or subtalar pathology. Always perform comprehensive hindfoot assessment.

Surgical Considerations

Isolated CC fusion has higher nonunion rates than TN. Triple arthrodesis more common. Lateral approach risks sural nerve.

Associated Pathology

Peroneal tendon pathology in 30-40% of cases. Assess for tears or tendinopathy during lateral approach.

At a Glance

Calcaneocuboid (CC) arthritis is a relatively uncommon cause of lateral midfoot pain, representing 10-15% of midfoot arthritis cases, with isolated CC arthritis rare (5-10%). The CC joint is critical for lateral column stability and forefoot alignment—degeneration leads to lateral column shortening and forefoot adduction. CC arthritis rarely occurs in isolation; always assess talonavicular and subtalar joints for concurrent pathology requiring triple arthrodesis. Nutcracker fracture of the cuboid is a common predisposing cause. Peroneal tendon pathology coexists in 30-40% of cases. Isolated CC fusion has higher nonunion rates than TN fusion; surgical approach risks the sural nerve and peroneal tendons.

Mnemonic

COLUMNCalcaneocuboid Joint Function

Calcaneus to cuboid articulation

Anterior facet of calcaneus

Oblique axis contribution

Part of triple joint complex motion

Lateral column stabilizer

Maintains forefoot alignment

Under high compression loads

Transmits body weight laterally

Motion coupled with TN and STJ

Integrated hindfoot motion

Nutcracker mechanism vulnerable

Compression injuries common

Memory Hook:The CC joint is the lateral COLUMN - essential for lateral foot stability!

Mnemonic

TRAUMACC Arthritis Etiologies

Traumatic - calcaneal fractures

30-40% develop CC arthritis

Rheumatoid and inflammatory

Seronegative arthropathies

Abnormal loading from malalignment

Hindfoot varus/valgus

Underlying OA (rare in isolation)

Primary osteoarthritis uncommon

Mechanical - nutcracker injuries

Cuboid compression mechanism

Associated peroneal dysfunction

Chronic tendon pathology alters mechanics

Memory Hook:TRAUMA causes CC arthritis - especially calcaneal fractures!

Mnemonic

SCARECC Fusion Surgical Risks

Sural nerve injury

5-10% incidence, lateral approach

Column shortening

Maintain lateral column length

Adjacent joint arthritis

25-35% at 10 years

Recalcitrant nonunion

15-25% rate, higher than TN

Equipment failure

Hardware irritation requiring removal

Memory Hook:Don't let complications SCARE you - but know them for the viva!

Overview and Epidemiology

Clinical Significance

Calcaneocuboid arthritis represents degeneration of the articulation between the anterior process of the calcaneus and the cuboid bone. As part of the lateral column, CC joint pathology affects forefoot alignment and lateral stability. It rarely occurs in isolation and is commonly associated with adjacent joint pathology, post-traumatic changes, or inflammatory arthropathy.

Etiology

Post-traumatic: Calcaneal fractures, nutcracker injuries
Inflammatory: Rheumatoid arthritis, seronegative arthropathy
Degenerative: Primary osteoarthritis (rare in isolation)
Malalignment: Hindfoot varus/valgus causing abnormal loading
Peroneal pathology: Tendon dysfunction altering mechanics

Associated Conditions

Calcaneal fractures: 30-40% develop CC arthritis
Peroneal tendon tears: 30-40% coexistence
Talonavicular arthritis: 60% have concurrent CC involvement
Subtalar arthritis: 50% association
Cavovarus foot: Chronic lateral column overload

Pathophysiology

Joint Biomechanics

The calcaneocuboid joint is a saddle-shaped articulation that forms the lateral component of the transverse tarsal (Chopart) joint. It contributes to hindfoot-forefoot power transmission and allows limited motion for terrain adaptation. The joint bears approximately 15-20% of forefoot load during stance phase.

Normal Joint Function

Saddle joint morphology: Concave-convex articulation
Coupled motion: Functions with TN joint in transverse tarsal complex
Load transmission: Lateral column weight transfer
Locking mechanism: Stabilizes lateral column during toe-off
Forefoot position: Controls abduction/adduction

The CC joint allows approximately 5-10 degrees of motion in the sagittal and transverse planes.

Pathological Changes

Cartilage degeneration: Progressive articular surface loss
Subchondral sclerosis: Bone stiffening response
Osteophyte formation: Peripheral bone spurs
Synovitis: Inflammatory capsular changes
Lateral column shortening: Loss of joint height

Progressive arthritis leads to abnormal load transfer and compensatory forefoot adduction.

Feature	CC Joint	TN Joint	Subtalar Joint
Primary motion	Minimal (5-10°)	Significant (50-60% hindfoot motion)	Significant (50-70% hindfoot motion)
Load bearing	15-20% lateral	Major medial column	Full body weight
Isolated arthritis	Rare (5-10%)	Common (40% midfoot OA)	Common
Fusion success	75-85%	85-95%	90-95%

Post-Traumatic Mechanism

Following calcaneal fractures, CC arthritis develops through: (1) Direct articular damage from the injury, (2) Malunion causing abnormal joint loading, (3) Lateral column shortening altering biomechanics. The nutcracker mechanism specifically affects the CC joint through forced abduction causing cuboid compression between the calcaneus and 4th/5th metatarsal bases.

Clinical Assessment

History

Pain location: Lateral midfoot, inferior to lateral malleolus
Pain character: Dull ache, worsens with activity
Aggravating factors: Walking on uneven ground, lateral stress
Previous trauma: Calcaneal fracture, midfoot injury
Footwear issues: Difficulty with narrow shoes
Function: Reduced walking tolerance

Ask specifically about prior calcaneal fractures as 30-40% develop CC arthritis.

Examination

Inspection: Lateral column alignment, swelling
Palpation: CC joint tenderness, lateral foot
Range of motion: Reduced forefoot abduction/adduction
Peroneal assessment: Strength, tendon integrity
Gait: Lateral foot stress pattern
Adjacent joints: TN, subtalar examination

The single heel rise test helps assess associated tibialis posterior dysfunction.

Assess Peroneal Tendon Pathology

30-40% of CC arthritis cases have coexisting peroneal tendon pathology. Perform peroneal strength testing, palpate along tendon course for tenderness or thickening, and assess for subluxation. MRI indicated if clinical suspicion high.

Clinical Examination Sequence

Step 1Inspection

Assess lateral column alignment, swelling, skin changes, and overall foot posture in weight-bearing.

Step 2Palpation

Localize tenderness to CC joint (anterior to lateral malleolus). Compare with TN and subtalar joint tenderness.

Step 3Range of Motion

Assess forefoot abduction/adduction with hindfoot stabilized. Compare with contralateral side.

Step 4Special Tests

Single heel rise test, peroneal strength, Coleman block test if cavovarus suspected.

Step 5Adjacent Joints

Systematically assess TN joint, subtalar joint, and ankle for concurrent pathology.

Investigations

Imaging Protocol

First LineWeight-Bearing Radiographs

Views: AP, lateral, oblique foot radiographs standing. CC assessment: Joint space, osteophytes, sclerosis. Alignment: Lateral column length, forefoot position. Adjacent joints: Evaluate TN and subtalar joints.

AdvancedCT Scan

Indications: Surgical planning, assess deformity. Detail: Bone stock, subchondral changes, fusion planning. Role: Identify occult fractures, coalition.

SelectiveMRI

Indications: Assess peroneal tendons, cartilage, soft tissue. Findings: Tendon tears, bone marrow edema, synovitis. Role: Pre-operative planning when tendon pathology suspected.

Axial CT scan of the foot showing calcaneocuboid joint anatomy with labeled midfoot bones and a calcaneal fracture — Axial CT scan demonstrating midfoot anatomy with clearly labeled structures: medial cuneiform, intermediate cuneiform, lateral cuneiform, cuboid bone, and fractured calcaneum. The calcaneocuboid joint is visible where the cuboid articulates with the calcaneus posteriorly. This CT demonstrates a calcaneal fracture - calcaneal fractures are the most common cause of post-traumatic calcaneocuboid arthritis, affecting 30-40% of patients. Axial CT imaging is used to assess joint involvement, fracture extension to the CC joint, and surgical planning. The orientation markers (A=anterior, P=posterior, R=right, L=left) and scale bar provide anatomical reference.Credit: Cerevisae via Wikimedia Commons - CC BY-SA 4.0

Radiographic Features

Key radiographic findings include: joint space narrowing, subchondral sclerosis, osteophyte formation (especially dorsal), subchondral cyst formation, and lateral column shortening. Compare lateral column length with contralateral foot. On lateral view, assess for dorsal CC osteophytes impinging on extensor tendons.

Management

Clinical Algorithm— CC Arthritis Treatment Algorithm

Loading flowchart...

Non-Operative Treatment

Conservative Protocol

InitialActivity Modification

Reduce lateral column stress activities. Supportive footwear with lateral posting.

The goal is to minimize abnormal loading on the degenerative CC joint.

Weeks 0-6Orthotic Management

Custom orthoses with lateral forefoot support. Off-the-shelf lateral wedge insoles.

Orthotics redistribute load and support the lateral column.

OngoingPharmacological

NSAIDs for pain control. Corticosteroid injection under guidance (maximum 2-3 per year).

Fluoroscopic or ultrasound-guided injection improves accuracy.

Weeks 6-12Physical Therapy

Peroneal strengthening. Ankle stabilization exercises. Gait retraining.

Address any associated peroneal weakness or dysfunction.

Conservative management is successful in approximately 60-70% of patients with mild to moderate CC arthritis.

Surgical Technique: Isolated CC Arthrodesis

Lateral Approach to Calcaneocuboid Joint

Surgical Steps

SetupPositioning

Supine with bump under ipsilateral hip. Thigh tourniquet. C-arm for imaging.

Ensure adequate access to lateral foot with hip externally rotated.

Step 1Incision

Oblique incision over CC joint, anterior to lateral malleolus, 6-8cm length.

Follow Langer's lines to minimize scar contracture.

Step 2Superficial Dissection

Identify and protect sural nerve. Elevate peroneal tendons carefully.

Sural nerve typically runs 1-2cm posterior to incision but has variable course.

Step 3Deep Dissection

Incise CC joint capsule. Expose articular surfaces. Assess peroneal tendons.

Systematically inspect peroneal tendons for tears requiring repair.

Sural Nerve at Risk

Sural nerve runs along lateral border of foot, at risk with lateral approach. Identify early in dissection and protect throughout. Injury rate 5-10% in reported series.

Complications

Complication	Incidence	Management
Nonunion	15-25% (higher than TN)	Revision with bone graft and plate
Sural nerve injury	5-10%	Usually resolves; neurolysis if persistent
Adjacent joint arthritis	25-35% at 10 years	Activity modification, possible future fusion
Hardware irritation	10-15%	Hardware removal after union
Wound complications	5-8%	Wound care, antibiotics, possible debridement

Nonunion Risk Factors

Risk factors for CC fusion nonunion include: smoking (strongest predictor), diabetes mellitus, inadequate fixation, poor bone contact, peripheral vascular disease, immunosuppression, and revision surgery. Pre-operative smoking cessation for minimum 4 weeks is recommended.

Evidence Base

CC Fusion Outcomes in Post-Traumatic Arthritis

Rammelt S, Grass R, Zawadski T, et al. • Foot and Ankle International (2013)

Key Findings:

Union rate 82% for isolated CC fusion after calcaneal fracture
Mean time to union 14 weeks
AOFAS score improvement from 45 to 78 at 2-year follow-up
Nonunion risk factors: smoking, diabetes, revision surgery

Clinical Implication: Isolated CC fusion effective for post-traumatic arthritis but higher nonunion rate than triple arthrodesis.

Triple Arthrodesis for Hindfoot Arthritis

Saltzman CL, Fehrle MJ, Cooper RR, et al. • Journal of Bone and Joint Surgery (1999)

Key Findings:

Overall fusion rate 95% for triple arthrodesis
CC joint component fused in 98% of cases within triple
Better outcomes when all three joints fused simultaneously
Adjacent ankle arthritis in 30% at 10-year follow-up

Clinical Implication: Triple arthrodesis has higher fusion success than isolated CC fusion when multiple joints involved.

Peroneal Tendon Pathology with CC Arthritis

Krause FG, Wing KJ, Younger AS. • Foot and Ankle Clinics (2007)

Key Findings:

30-40% coexistence of peroneal tendon pathology with CC arthritis
Peroneal tendon should be inspected during lateral approach
Concurrent tendon repair improves outcomes
Pre-operative MRI recommended if clinical suspicion

Clinical Implication: Always assess and address peroneal tendon pathology when treating CC arthritis surgically.

Nutcracker Fracture and CC Joint Degeneration

Sangeorzan BJ, Swiontkowski MF. • Journal of Bone and Joint Surgery (1990)

Key Findings:

Nutcracker cuboid fractures have high rate of secondary CC arthritis
Anatomic reduction reduces but does not eliminate arthritis risk
Lateral column shortening correlates with worse outcomes
Early fusion may be indicated for comminuted injuries

Clinical Implication: Post-traumatic CC arthritis after nutcracker injuries may require fusion if symptomatic.

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

Scenario 1: Diagnosis and Management

EXAMINER

"A 58-year-old presents with lateral midfoot pain 3 years after calcaneal fracture treated non-operatively. Examination shows lateral column tenderness. Weight-bearing X-rays show CC joint narrowing with sclerosis. How would you manage?"

EXCEPTIONAL ANSWER

This patient has post-traumatic calcaneocuboid arthritis following calcaneal fracture. My approach: First, confirm diagnosis with standing radiographs showing CC arthritis. Second, assess adjacent joints (TN, subtalar) for concurrent pathology. Third, evaluate peroneal tendon function. Initial management would be conservative with NSAIDs, lateral posting orthoses, and activity modification for 6 months. If symptoms persist and significantly impact function, I would offer isolated CC arthrodesis if adjacent joints are preserved, or triple arthrodesis if multiple joints involved. I would counsel about 75-85% fusion success for isolated CC fusion, risks including nonunion (15-25%), sural nerve injury (5-10%), and adjacent joint degeneration.

KEY POINTS TO SCORE

Post-traumatic etiology common after calcaneal fractures

Always assess adjacent joints before deciding on procedure

Conservative trial mandatory before surgery

Higher nonunion rate than TN fusion

COMMON TRAPS

✗Missing concurrent TN or subtalar arthritis

✗Not assessing peroneal tendon integrity

✗Underestimating nonunion risk

LIKELY FOLLOW-UPS

"What if subtalar joint also arthritic?"

"How do you protect sural nerve?"

"What factors increase nonunion risk?"

VIVA SCENARIOChallenging

Scenario 2: Surgical Technique

EXAMINER

"Walk me through your surgical technique for isolated calcaneocuboid arthrodesis."

EXCEPTIONAL ANSWER

For isolated CC arthrodesis, I use a lateral approach. Patient supine with bump under hip, thigh tourniquet. Oblique incision over CC joint anterior to lateral malleolus. I identify and protect the sural nerve early in dissection. Peroneal tendons are elevated carefully and inspected for pathology. After capsulotomy, I expose the CC joint fully. Joint preparation involves complete cartilage removal to bleeding bone using osteotomes and burr. Alignment restoration is critical - maintain lateral column length. Provisional K-wire fixation confirms position. Definitive fixation uses two 4.0mm cannulated screws in parallel configuration from cuboid to calcaneus. Given higher nonunion rate, I consider bone graft for defects or risk factors. Fluoroscopy confirms position. Layered closure with drain. Post-op: below-knee cast, non-weight-bearing 8 weeks.

KEY POINTS TO SCORE

Lateral approach with sural nerve protection mandatory

Complete cartilage removal critical for fusion

Parallel screw fixation standard

Consider bone graft given higher nonunion rate

COMMON TRAPS

✗Sural nerve injury from inadequate protection

✗Shortening lateral column causing forefoot malalignment

✗Underestimating need for bone graft

LIKELY FOLLOW-UPS

"What if you find peroneal tendon tear intraoperatively?"

"How do you manage nonunion?"

"When would you extend to triple arthrodesis?"

VIVA SCENARIOChallenging

Scenario 3: Complex Case with Multiple Joint Involvement

EXAMINER

"A 62-year-old presents with progressive lateral and medial midfoot pain. X-rays show CC arthritis with concurrent TN arthritis. Subtalar joint appears preserved. What is your management approach?"

EXCEPTIONAL ANSWER

This patient has combined calcaneocuboid and talonavicular arthritis with preserved subtalar joint. My approach: First, I would confirm the extent of involvement with CT scan for surgical planning and ensure subtalar joint is truly preserved. I would offer conservative management initially with accommodative orthoses, NSAIDs, and activity modification. If symptoms persist after 6 months, surgical options include: 1) Double arthrodesis (CC + TN fusion) sparing the subtalar joint, or 2) Triple arthrodesis if there is concern about subtalar joint or if patient understands potential need for future subtalar fusion. I would counsel that double arthrodesis preserves some hindfoot motion but has higher revision rate if subtalar joint degenerates. For double arthrodesis, I use combined medial and lateral approaches. Post-operatively: non-weight-bearing 8-10 weeks, then protected weight-bearing.

KEY POINTS TO SCORE

CT confirms extent of joint involvement

Double arthrodesis option preserves subtalar motion

Combined medial and lateral approaches required

Subtalar may degenerate over time requiring future surgery

COMMON TRAPS

✗Recommending isolated CC fusion when TN also involved

✗Not warning about potential subtalar degeneration

✗Using single approach for double arthrodesis

LIKELY FOLLOW-UPS

"What are advantages of triple versus double arthrodesis?"

"How do you approach the TN joint?"

"What is the risk of adjacent joint arthritis after double fusion?"

MCQ Practice Points

Anatomy Question

Q: What percentage of midfoot arthritis cases involve the calcaneocuboid joint? A: 10-15% - CC arthritis is less common than talonavicular arthritis (40% of midfoot arthritis). CC typically occurs as part of triple complex pathology.

Etiology Question

Q: What is the most common cause of calcaneocuboid arthritis? A: Post-traumatic - Calcaneal fractures lead to CC arthritis in 30-40% of cases. Nutcracker mechanism cuboid injuries also predispose.

Surgical Question

Q: What is the nonunion rate for isolated calcaneocuboid arthrodesis? A: 15-25% - Higher than talonavicular fusion (10-15%). Risk factors include smoking, diabetes, inadequate fixation, and poor bone contact.

Complications Question

Q: What nerve is at risk during lateral approach to the calcaneocuboid joint? A: Sural nerve - Runs along lateral foot border. Injury incidence 5-10%. Must be identified and protected throughout surgery.

Associated Pathology Question

Q: What percentage of CC arthritis cases have concurrent peroneal tendon pathology? A: 30-40% - Peroneal tendons should be inspected during lateral approach and any tears addressed with repair or tenosynovectomy.

Biomechanics Question

Q: What happens to the forefoot if lateral column length is not maintained during CC fusion? A: Forefoot adduction - Loss of lateral column length causes relative forefoot adduction and can lead to medial overload and cavovarus deformity.

Australian Context

Calcaneocuboid arthritis is seen with increased frequency in Australian rural and remote populations engaged in heavy manual labour, particularly in the construction and mining sectors. Indigenous Australians may present with higher rates of post-traumatic CC arthritis following workplace injuries and falls, often with delayed presentation due to geographic barriers to specialist care.

Management follows NHMRC guidelines for perioperative care with appropriate DVT prophylaxis using low molecular weight heparin. Given the strong association between smoking and nonunion in CC fusion, referral to smoking cessation programs through Quitline or local public health services is strongly recommended prior to surgical intervention.

Orthopaedic management in rural settings may require coordination with metropolitan centres for complex hindfoot reconstruction. Telehealth consultations and multidisciplinary care pathways can facilitate pre-operative planning and post-operative follow-up for patients in geographically isolated communities.