midfoot fractures and dislocations are uncommon because of the intrinsic stability of the tarsal structure .
the arthrodesis of the talonavicular joint and calcaneal - cuboid joint is technically complex in the presence of bone defect and there is a high incidence of nonunion .
furthermore , in the presence of large skin exposures , the possibility of infection and the consequent negative effect on bone fusion associate the surgical procedure with a high risk of failure [ 1 , 2 ] .
in august 2012 , a 49-year - old - man presented to our hospital with a traumatic forefoot subamputation after a work accident . the trauma caused a lacerated wound in correspondence of the dorsal surface of the right foot .
radiographs and computed tomography ( ct ) examination confirmed the diagnosis of the loss of talus head during the trauma ( fig .  1 ) . 

figure  1:ap ( a ) and lateral ( b ) radiographs and ct images ( c , d ) confirm the diagnosis of the loss of talus head during the trauma .
ap ( a ) and lateral ( b ) radiographs and ct images ( c , d ) confirm the diagnosis of the loss of talus head during the trauma .
injuries of dorsalis pedis artery , tibialis anterior tendon , estensor digitorum longus tendons , peroneus tertium tendon were revealed , with the loss of talus head and with a complex lesion of the talonavicular ligament .
tendinous structures damaged were surgically sutured and subsequently an antibiotic - loaded cement spacer was positioned into the bone gap to re - establish the joint congruence .
the foot was put in a cast and kept non - weight bearing for 8 weeks ( fig .  2 ) . 

figure  2:an image of the foot before the first - time surgical repair reveals the injuries of dorsalis pedis artery , tibialis anterior tendon , estensor digitorum longus tendons , peroneus tertium tendon , with the loss of talus head and with a complex lesion of the talonavicular ligament .
( a ) tendinous structures damaged were surgically sutured and subsequently an antibiotic - loaded cement spacer was positioned into the bone gap to reestablish the joint congruence ( b ) .
ap ( c ) and lateral ( d ) radiographs of the foot in the cast after the surgical time . an image of the foot before the first - time surgical repair reveals the injuries of dorsalis pedis artery , tibialis anterior tendon , estensor digitorum longus tendons , peroneus tertium tendon , with the loss of talus head and with a complex lesion of the talonavicular ligament .
( a ) tendinous structures damaged were surgically sutured and subsequently an antibiotic - loaded cement spacer was positioned into the bone gap to reestablish the joint congruence ( b ) .
ap ( c ) and lateral ( d ) radiographs of the foot in the cast after the surgical time .
two months after the primary surgery , the patient underwent salvage arthrodesis of chopart joint via double dorsal incision .
the patient was placed in a supine position with a support under the ipsilateral hip to allow easy access to the medial and lateral aspects of the foot .
the skin incision was made along the lateral aspect of the foot , starting at the base of the fourth metatarsal , and extended proximally toward the tip of the fibula , stopping 1 cm short of the tip .
the capsule of the extensor digitorum brevis was opened , its origin was released and the muscle was reflected distally 1 cm distal to the calcaneocuboid joint .
the calcaneocuboid joint was identified and the soft tissue stripped plantarward and dorsally using a periosteal elevator .
the articular cartilage was removed from the calcaneocuboid joint using a small , sharp osteotome . placing a deep retractor into the wound along the dorsal aspect , the lateral aspect of the talonavicular joint opposite the calcaneocuboid joint was identified and articular cartilage was removed .
the medial approach was through a longitudinal incision , starting at the tip of the medial malleolus and carried distally 1 cm past the naviculocuneiform joint .
figure  3:lateral approach at the base of the fourth metatarsal , and extended proximally toward the tip of the fibula , 1 cm short of the tip to identify the calcaneocuboid joint ( a ) .
medial approach through a longitudinal incision , starting at the tip of the medial malleolus and carried distally 1 cm past the naviculocuneiform joint .
lateral approach at the base of the fourth metatarsal , and extended proximally toward the tip of the fibula , 1 cm short of the tip to identify the calcaneocuboid joint ( a ) .
medial approach through a longitudinal incision , starting at the tip of the medial malleolus and carried distally 1 cm past the naviculocuneiform joint .
an elevator was passed over the dorsal aspect of the talonavicular joint , completely freeing the joint .
it was removed the antibiotic - loaded cement spacer . using a towel clip embedded into the proximal portion of the navicular ,
the talonavicular joint was distracted by pulling the foot in an adducted position and longitudinally .
an autologous graft , harvested from the omolateral iliac crest , was placed into the talonavicular joint .
it was evaluated that there was no gap at the calcaneocuboid joint when the foot was brought into a plantigrade position .
before placing the internal fixation , the bone ends were heavily scaled using a 4 mm osteotome .
the talonavicular joint was fused in situ using two 4.0-mm cannulated screws across the talonavicular joint .
the foot was then manipulated into proper alignment ; the guide pin for the 4.0-mm cannulated screw was placed across the talonavicular joint starting at the distal end of the navicular at the naviculocuneiform joint .
the navicular was overdrilled with a 4.0-mm drill bit , after which 4.0-mm long threaded screws were inserted .
the screws were brought from proximal to distal , starting in the anterior process area and brought obliquely across into the cuboid ( fig . 
figure  4:the placement of an autologous graft into the talonavicular joint harvested from the omolateral iliac crest ( a ) .
the fixation of the calcaneocuboid joint was carried out using two 4.0-mm cannulated screws ( b ) and the talonavicular joint was fused in situ using two 4.0-mm cannulated screws across the talonavicular joint ( c ) .
the placement of an autologous graft into the talonavicular joint harvested from the omolateral iliac crest ( a ) .
the fixation of the calcaneocuboid joint was carried out using two 4.0-mm cannulated screws ( b ) and the talonavicular joint was fused in situ using two 4.0-mm cannulated screws across the talonavicular joint ( c ) .
the foot was put in a cast and kept non - weight bearing for 10 weeks , with range - of - movement exercises of the knee and hip allowed .
the patient was reevaluated during a clinical and radiographic follow - up at 1 , 3 , 6 months after surgery .
there were no infectious problems and the patient has resumed normal work activities . at the sixth month follow - up , the patient had returned to work and remained pain free while walking , with good fusion of both joints ( fig . 
figure  5:ap ( a ) and lateral ( b ) radiographs of the foot in the cast after the surgical time . ap ( c ) and lateral ( d ) radiographs of the foot at the sixth month follow - up . ap ( a ) and lateral ( b ) radiographs of the foot in the cast after the surgical time .
ap ( c ) and lateral ( d ) radiographs of the foot at the sixth month follow - up .
dislocations of the midfoot are uncommon because of the constrained configuration of multiple articular surfaces augmented by capsular attachments , strong ligaments and tendons [ 5 , 6 ] .
foot trauma of this severity can result in articular incongruities , complex derangement of the arc geometry , ligamentous instability , and , eventually , long - term disability secondary to joint subluxation and posttraumatic arthritis . in our patient ,
the surgical management was based on the principles for treatment of chopart joint fracture dislocations : realignment of both medial and lateral columns of the foot , restoration of joint congruity , alignment of axes , temporary fixation and ligament reconstruction to ensure proper ligament healing [ 7 , 8 ] .
early anatomic reduction , stable fixation and ligament reconstruction could have achieved a better outcome .
primary arthrodesis is a viable option for severe midfoot fracture dislocations , because it facilitates rehabilitation and functional recovery and obviates the need for a secondary arthrodesis should arthritis arise .
furthermore , in the presence of large skin exposures , the possibility of infection and the consequent negative effect on bone fusion make the surgical procedure at high risk of failure .
the manuscript is original , it is not under consideration for publication elsewhere , and has not been previously published . the manuscript has been read and approved by all the authors .
 we present a 49-year - old man with a traumatic subamputation of the forefoot , associated with lacerated wound in correspondence of the dorsal surface of the right foot , with injuries of tendinous , ligamentous and vascular structures and with the loss of talus head . 
 the patient underwent salvage arthrodesis of the talonavicular and calcanealcuboid joints with graft bone harvested from the iliac crest . 
 the patient was re - evaluated during a clinical and radiographic follow - up . 
 the arthrodesis was consolidated in 3 months . 
 there were no infectious problems and the patient has resumed normal work activities . at a sixth month follow - up , the patient had returned to work and remained pain free while walking . 
 early anatomic reduction , stable fixation and ligament reconstruction are essential for a good outcome . 
 primary arthrodesis is a viable option for severe midfoot fracture dislocations , because it facilitates rehabilitation and functional recovery and obviates the need for a secondary arthrodesis should arthritis arise . 