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Arthrodesis of the navicular
Foot Ankle Clin N Am 9 (2004) 73 – 83
Arthrodesis of the navicular Michael D. Castro, DO Orthopaedic Foot & Ankle Service, Cooper University Hospital, 3 Cooper Plaza, Suite 411, Camden, NJ 08103, USA
The talonavicular articulation is multi-axial, and, therefore, is subject to multidirectional forces during weight bearing [1,2]. The naviculocuneiform articulations also are subject to multi-axial motion, but, in fact, move little because of their bony architecture and intact ligamentous constraints. The delicate balance of the forces that act on this complex facilitates motion in the transverse, coronal, and sagittal planes essential to adaptive plantigrade gate. Disruption of the balance of forces that act on these articulations can result in painful arthrosis or deformity. The goals of surgical management for dysfunction of the navicular and its articulations are to establish a stable, plantigrade foot and minimize pain, thereby improving function. Arthrodesis of the talonavicular joint as an isolated procedure or extending the fusion mass to include the naviculocuneiform joints, can restore the integrity of the medial column and accomplish these goals in selected patients. This procedure can be combined with other techniques that are directed at restoration of alignment and soft tissue balance of the foot depending on the character and degree of concomitant pathology [3]. Although talonavicular arthrodesis has a profound effect on mid- and hindfoot motion [4], with careful preoperative planning and meticulous technique, the net result yields a consistent functional improvement.
Indications Arthrodesis of the navicular articulations is indicated in several conditions that affect this complex. Painful arthrosis (primary, traumatic, or inflammatory) may demonstrate little or no associated deformity but may cause significant dysfunction [5– 9]. The pain with weight bearing may be debilitating and alter gait mechanics. Patients who have medial column pain tend to ambulate with a varus thrust and may develop associated secondary symptoms. Commonly, patients may complain of lateral heel or midfoot pain. Further, synovitis of the lateral metatarsophalangeal
E-mail address: [email protected] 1083-7515/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/S1083-7515(03)00171-2
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joints may develop. Overuse can cause peroneal tendonitis. In such cases, successful fusion of the arthritic joints can relieve pain and improve gait. Rigid dorsolateral peritalar subluxation (grade III posterior tibial tendon insufficiency [PTTI]) with degenerative changes that are limited to the navicular complex can be corrected with arthrodesis of these joints [10]. Forefoot position and longitudinal arch can be restored with a well-positioned fusion of the talonavicular joint [11]. With attenuation of the plantar ligaments that support this complex, sag may occur at the naviculocuneiform joint. This may cause dorsal impingement and pain. To further augment medial column stability and alleviate associated pain, the fusion mass can be extended. The naviculo-first cuneiform joint can be included without any further appreciable functional deficit [3]. The ideal candidate for isolated fusion of the talonavicular joint is one who demonstrates a pes plenovalgus deformity with fixed forefoot abduction secondary to degenerative changes of the talonavicular joint or reducible deformity with pain localizing to the talonavicular joint. Several factors should be considered in an effort to optimize the outcome. The subtalar joint must be supple and pain-free. Selective lidocaine blocks may be useful in defining the extent of involvement. Hindfoot alignment should promote congruent load application through the subtalar and ankle joints. To this end, this deformity commonly requires further realignment and balancing of the hindfoot. Lateral column lengthening, medializing calcaneal osteotomy, and Achilles tendon lengthening or gastrocnemius recession may be considered [3,12]. Fixed cavovarus deformities can result from incomplete correction of congenital clubfoot or acquired deformities secondary to neuromuscular imbalance [7,13]. Alignment of the foot can be corrected and the integrity of the medial column restored by addressing the navicular complex. Because of the plantar medial peritalar subluxation, contact pressure is altered which causes arthrosis of the talonavicular joint. In severe deformity, naviculectomy and talocuneiform fusion may be necessary to allow adequate reduction of the deformity and avoid soft tissue compromise. Osseous necrosis of the navicular may be idiopathic or posttraumatic [14,15]. Deformity may be mild but results in articular incongruity and painful arthrosis. With severe deformity or dissolution of the navicular, naviculectomy and structural bone graft may be necessary. Osseous necrosis that involves the talar head may have the same outcome. Extensive grafting may be necessary to maintain length of the medial column. MRI may be helpful in determining the extent of compromised tissue.
Technique This technique is technically demanding. Every effort should be made to maintain length and orientation of the medial column. Careful attention must also be paid to forefoot position with regard to pronation/supination and abduction/adduction.
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The talonavicular joint is approached through a longitudinal medial midfoot incision. A dissection plane can be developed between the tibialis anterior and tibialis posterior tendons. The talonavicular joint capsule is incised to expose the joint. Soft tissue about the neck of talus should be left intact to avoid compromise of the blood supply to the head and neck of the talus. At this point, osteophytes can be removed from the dorsomedial and medial aspect of the navicular to facilitate visualization and debridement of the joint itself. Placing a small curved elevator across the joint as a lever or using a small lamina spreader can facilitate distraction of the talonavicular joint. Articular cartilage is removed from the head of the talus and the navicular. The subchondral bone is prepared by placing multiple drill holes in the talar head and body of the navicular with a 2-mm drill. Maintenance of the subchondral bone precludes excessive loss of medial column length. The talonavicular joint is reduced and may be provisionally fixed with K-wires. This may be accomplished by directing a lateral force at the head and neck region of the talus while adducting and pronating the forefoot. Cancellous autograft or allograft matrix may be used to augment areas of decreased apposition of subchondral bone [16]. At this point, fluoroscopic evaluation may be helpful to ensure restoration of the talar-first metatarsal axis in the anteroposterior (AP) and lateral planes. The tuberosity of the navicular and junction of the head and neck of the talus are well-suited for lag screw placement. A 6.5-mm partially threaded cancellous screw can be placed from distal to proximal through the tuberosity of the navicular; a 3.5-mm or 4.0-mm fully threaded cortical screw may be placed from proximal to distal buttressing against the junction of the neck and head of the talus (the type and size of screw may vary with bone size and quality). These screws can be tightened sequentially to provide uniform compression across the talonavicular joint. The fusion mass can be extended to include the naviculocuneiform joints. Debridement and preparation of the joint is conducted. The joint complex is reduced with attention to restoration of anatomic alignment and length of the medial column. Fixation is provided by crossed lag screws or medial plate. Bone loss is managed with structural graft. In cases of necrosis, nonviable bone is debrided to a bleeding surface. The surfaces to be fused should be parallel to one another and perpendicular to the long axis of the medial column. This makes contouring the graft less tedious. A structural graft is positioned. Allograft may be used on otherwise healthy individuals. Fixation is provided by a medial plate or crossed lag screws. Again, the alignment and length of the medial column should be restored anatomically (Figs. 1– 5).
Results Few studies have reported the results of talonavicular arthrodesis for the treatment of isolated traumatic arthrosis. Chen et al [5], reported successful fusion in 15 of 16 patients with an average follow-up 4.2 years. Eight of 16 patients had a history of trauma, osteoarthritis (OA) was the preoperative diagnosis in 6 patients,
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Fig. 1. Oblique (A) and lateral (B) radiographs demonstrating talonavicular arthrodesis using two crossed screws.
1 patient had pes planus, and 1 patient had lupus. Five of 16 patients demonstrated radiographic evidence of arthrosis in adjacent joints at 1-year follow-up (three traumatic, one OA); however, these changes had no effect on the functional score through the follow-up period. Chiodo et al [5] reported successful fusion in 19 of 20 rheumatoid patients who had at an average of 11 weeks. Sixteen results were excellent, three were
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Fig. 2. (A) Lateral radiograph of a 64-year-old woman who has grade III PTTI. Arthrosis was limited to the talonavicular joint and corrected with a talonavicular joint arthrodesis using a single 6.5-mm partially threaded screw. (B) A shear-strain relief bone graft was harvested from the calcaneus and placed in a drill hole removing subchondral bone on both sides of the joint line.
good, and one was poor. Three patients experienced complications, including nonunion, deep vein thrombosis, and superficial infection. These results were consistent with those of Ljung et al [9] who reported pain relief in 17 of 19 feet. Osseous union occurred in 12 feet; of seven nonunions, five were pain-free and two had mild pain. Six feet demonstrated mild progressive degenerative changes in adjacent joints. Four feet demonstrated moderate changes, three of these were spontaneous talocalcaneal fusion. Similarly, Kindsfater et al [8] reported a 95% fusion rate in which good to excellent results were obtained in their study of 104 cases. Of the five nonunions, no comment was made about symptoms. These investigators further noted that through an average follow-up of 52 months, no patient required revision to a triple arthrodesis. Harper and Tisdel [17] reported on 27 patients who had PTTI that was treated with isolated talonavicular joint arthrodesis. The average age was 57 years (range,
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Fig. 3. AP (A) and lateral (B) radiograph demonstrating naviculocuneiform arthrodesis using two crossed screws. The fusion mass can be extended to include the talonavicular joint by crossing this joint with screws paralleling those crossing the naviculocuneiform joints.
39 to 74 years). Good or excellent results were reported in 24 of 27 patients who were followed for a minimum of 1 year. Progressive adjacent joint arthrosis was noted in four patients. In a later report, Harper [18] reported satisfactory results in 25 of 29 patients who were treated with isolated talonavicular arthrodesis for grade III PTTI.
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Fig. 4. AP (A) and lateral (B) radiographs illustrating talonavicular arthrodesis performed with a cervical H-plate. The patient is a 36-year-old man who has osseous necrosis of the head of the talus. The necrotic tissue was debrided and the defect was packed with cancellous autograft. The patient was pain-free and returned to work as a laborer 12 weeks after surgery.
The patient population primarily consisted of older individuals whose lifestyle was not limited by the loss of motion. These patients were followed for a minimum of 1 year. Progressive midfoot arthrosis was noted in four patients. Scranton [4] reported good results in four patients who were treated with isolated talonavicular arthrodesis.
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Fig. 5. AP (A) and lateral (B) radiographs of a 15-year-old boy who fell from a height and sustained a severely comminuted pilon fracture of the navicular and fracture-dislocation of the calcaneocuboid joint. The medial column was reconstructed using tricortical allograft (arrow). Subchondral bone of the medial cuneiform and talar head were fashioned to provide flat surfaces at the host-graft interface. The tuberosity of the navicular was maintained to provide vascular supply. A similar technique is useful in the treatment of symptomatic osseous necrosis that involves the navicular complex.
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Fortin and Grant [19] reported satisfactory results in 12 of 14 patients who were treated with isolated talonavicular arthrodesis and calcaneal osteotomy for severe peritalar subluxation secondary to PTTI. Bone grafting and lag screw fixation was used in all patients. These investigators reported one case of nonunion that went on to demonstrate bony healing without further surgery. In contrast, Below and McCluskey [20] reported their results of 11 patients who had stage II posterior tibial tendon dysfunction (8 women, 3 men) who were treated with isolated talonavicular arthrodesis. The 11 patients were examined at a mean of 35.5 months (range, 23 to 47 months) after surgery. Two patients were completely satisfied, three were satisfied with minor reservations, four were satisfied with major reservations, and two patients were dissatisfied. Seven of the 11 patients developed subtalar joint degenerative changes. Osseous necrosis of the navicular complex is rare. Reports regarding occurrence and treatment are based mainly on individual cases [14,15,21]. The most recent report was related to dislocation of the navicular [14]. Open reduction, internal fixation failed when the navicular collapsed. The navicular was excised and a talocuneiform arthrodesis was performed successfully. This author’s experience with osseous necrosis is limited. Two patients were treated with excision of the navicular and structural grafting. In a third patient, osseous necrosis of the head of the talus was treated with debridement of nonviable bone and cancellous grafting. In these three cases, the primary objective was to restore medial column length.
Complications Nonunion Reported rates of nonunion of isolated talonavicular joint arthrodesis range from 0% to 70% [17,22,23]. When evaluating these results, however, one must appreciate the variety of techniques that are used in this procedure. Mann and Beaman [24] reported a 25% nonunion rate of the talonavicular joint in 14 patients who were treated with double arthrodesis for acquired flat foot deformity. These investigators did not use bone graft; fixation was provided with staples rather than lag screws.
Malalignment Failure to completely reduce the peritalar subluxation of the forefoot results in incomplete restoration of the longitudinal arch. Poorly distributed weight-bearing forces may result in compromise of the skin in the medial or plantarmedial aspect of the talonavicular joint. Overcorrection of the midfoot deformity may result in a cavus alignment and overload of the lateral column. Lateral column overload also may occur with failure to adequately reduce forefoot supination upon reduction of the talonavicular joint.
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Persistent hindfoot valgus can result in the mechanical aspect passing medial to the hindfoot. This can cause attenuation of the deltoid ligament and result in grade IV PTTI or a valgus deformity at the tibiotalar joint. Adjacent joint arthrosis Because motion of the ankle and foot is coupled, the elimination of motion in any joint or group of joints results in alterations of forces that are distributed to adjacent joints under weight-bearing conditions. The development of degenerative changes in adjacent joints after talonavicular joint arthrodesis were reported [5,6,17,19,20]. To alleviate the stress on adjacent joints, custom orthosis or shoe modification, such as rigid rocker bottom soles, should be prescribed.
Summary Isolated arthrodesis of the navicular complex is a means of restoring the integrity of the medial column. This facilitates pain relief and improved function. This option should be considered in the treatment of degenerative disease in these joints. Grade III PTTI may be managed with arthrodesis of the navicular complex, provided degenerative changes are limited to the talonavicular-naviculocuneiform joints. This procedure must include concomitant correction of the hindfoot. Osseous necrosis or bone loss that is due to severe degeneration may be managed successfully with cancellous or structural grafting that is sufficient to maintain length of the medial column. If extensive grafting increases the risk of nonunion, the navicular or its remnants can be excised and a talocuneiform fusion may be performed. Successful management of conditions that affect the navicular complex requires meticulous attention to restoration of the medial column. Optimal results also demand consideration of overall alignment and condition of adjacent joints.
References [1] Cornwall MW, McPoil TG. Relative movement of the navicular bone during normal walking. Foot Ankle Int 1999;20(8):507 – 12. [2] Wulker N, Stukenborg C, Savory KM, Aifke D. Hindfoot motion after isolated and combined arthrodeses: measurements in anatomic specimens. Foot Ankle Int 2000;21(11):921 – 7. [3] Chi TD, Toolan BC, Sangeorzan BJ, Hansen ST. The lateral column lengthening and medial column stabilization procedures. Clin Orthop 1999;365:81 – 90. [4] Scranton PE. Results of arthrodesis of the tarsus: talocalcaneal, midtarsal, and subtalar. Foot Ankle Int 1991;12:156 – 64. [5] Chen CH, Huang PJ, Chen TB, Cheng YM, Lin SY, Chiang HC, et al. Isolated talonavaicular arthrodesis for talonavicular arthritis. Foot Ankle Int 2001;22(8):633 – 6. [6] Chiodo CP, Martin T, Wilson MG. A technique for isolated arthrodesis for inflammatory arthritis of the talonavicular joint. Foot Ankle Int 2000;21(4):307 – 10. [7] Donatto KC. Arthritis and arthrodesis of the hindfoot. Clin Orthop 1998;349:81 – 92. [8] Kindsfater K. Management of the rheumatoid hindfoot with special reference to talonavicular arthrodesis. Clin Orthop 1997;340:69 – 74.
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[9] Ljung P, Kaji H, Kuntson K, Pettersson H, Rydholm U. Talonavicular arthrodesis in the rheumatoid foot. Foot Ankle Int 1992;13(6):313 – 6. [10] Johnson K, Strom DE. Tibialis posterior tendon dysfunction. Clin Orthop 1989;239:197 – 206. [11] O’Malley MJ, Deland JT, Lee KT. Selective hindfoot arthrodesis for the treatment of adult aquired flatfoot deformity: an in vitro study. Foot Ankle Int 1995;16:411 – 6. [12] Mosier-LaClair S, Pomeroy G, Manoli II A. Operative treatment of the difficult stage 2 adult acquired flatfoot deformity. Foot Ankle Clin 2001;6(1):95 – 119. [13] Giannini S, Ceccarelli F, Benedetti MG, Faldini C, Grandi G. Surgical treatment of adult idiopathic cavus foot with plantar fasciotomy, cuneiform arthrodesis, and cuboid osteotomy. A review of thirty-nine cases. J Bone Joint Surg 2002;84A(Suppl 2):62 – 9. [14] Dhillon MS, Nagi ON. Total dislocations of the navicular: are they ever isolated injuries? J Bone Joint Surg 1999;81B(5):881 – 5. [15] Patheria MN, Rosenstein A, Bjorkengren AG, Gershuni D, Resnick D. Isolated dislocation of the tarsal navicular: a case report. Foot Ankle 1988;9:146 – 9. [16] Sammarco VJ, Chang L. Modern issues in bone graft substitutes and advances in bone tissue technology. Foot Ankle Clin 2002;7(1):19 – 41. [17] Harper MC, Tisdel CL. Talonavicular arthrodesis for the painful adult acquired flatfoot. Foot Ankle Int 1996;17:658 – 61. [18] Harper MC. Talonavicular arthrodesis for the acquired flatfoot in the adult. Clin Orthop 1999; 365:65 – 8. [19] Fortin PR, Grant AM. Limited midfoot fusion with calcaneal osteotomy for adult flatfoot. Presented at the American Orthopaedic Foot and Ankle Society Summer Meeting. Monterey, California, July 1997. [20] Below SK, McCluskey LC. Isolated talonavicular arthrodesis for posterior tibial tendon dysfunction and degenerative joint disease of the talonavicular joint. Presented at the American Orthopaedic Foot and Ankle Society Summer Meeting. Traverse City, Michigan, July 2002. [21] Dhillon MS, Guptra R, Nagi ON. Inferomedial (subsustantacular) dislocation of the navicular: a case report. Foot Ankle Int 1999;20(3):196 – 200. [22] Bibbo C, Anderson RB, Davis WH. Complications of midfoot and hindfoot arthrodesis. Clin Orthop 2001;391:45 – 58. [23] Wulker N, Falmme CH, Muller A. 10 years follow-up of arthrodesis of the hindfoot and upper ankle joint. Z Orthop Ihre Grenzgeb 1997;135:509 – 15. [24] Mann RA, Beaman DN. Double arthrodesis in the adult. Clin Orthop 1999;365:74 – 80.
Arthrodesis of the navicular Michael D. Castro, DO Orthopaedic Foot & Ankle Service, Cooper University Hospital, 3 Cooper Plaza, Suite 411, Camden, NJ 08103, USA
The talonavicular articulation is multi-axial, and, therefore, is subject to multidirectional forces during weight bearing [1,2]. The naviculocuneiform articulations also are subject to multi-axial motion, but, in fact, move little because of their bony architecture and intact ligamentous constraints. The delicate balance of the forces that act on this complex facilitates motion in the transverse, coronal, and sagittal planes essential to adaptive plantigrade gate. Disruption of the balance of forces that act on these articulations can result in painful arthrosis or deformity. The goals of surgical management for dysfunction of the navicular and its articulations are to establish a stable, plantigrade foot and minimize pain, thereby improving function. Arthrodesis of the talonavicular joint as an isolated procedure or extending the fusion mass to include the naviculocuneiform joints, can restore the integrity of the medial column and accomplish these goals in selected patients. This procedure can be combined with other techniques that are directed at restoration of alignment and soft tissue balance of the foot depending on the character and degree of concomitant pathology [3]. Although talonavicular arthrodesis has a profound effect on mid- and hindfoot motion [4], with careful preoperative planning and meticulous technique, the net result yields a consistent functional improvement.
Indications Arthrodesis of the navicular articulations is indicated in several conditions that affect this complex. Painful arthrosis (primary, traumatic, or inflammatory) may demonstrate little or no associated deformity but may cause significant dysfunction [5– 9]. The pain with weight bearing may be debilitating and alter gait mechanics. Patients who have medial column pain tend to ambulate with a varus thrust and may develop associated secondary symptoms. Commonly, patients may complain of lateral heel or midfoot pain. Further, synovitis of the lateral metatarsophalangeal
E-mail address: [email protected] 1083-7515/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/S1083-7515(03)00171-2
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joints may develop. Overuse can cause peroneal tendonitis. In such cases, successful fusion of the arthritic joints can relieve pain and improve gait. Rigid dorsolateral peritalar subluxation (grade III posterior tibial tendon insufficiency [PTTI]) with degenerative changes that are limited to the navicular complex can be corrected with arthrodesis of these joints [10]. Forefoot position and longitudinal arch can be restored with a well-positioned fusion of the talonavicular joint [11]. With attenuation of the plantar ligaments that support this complex, sag may occur at the naviculocuneiform joint. This may cause dorsal impingement and pain. To further augment medial column stability and alleviate associated pain, the fusion mass can be extended. The naviculo-first cuneiform joint can be included without any further appreciable functional deficit [3]. The ideal candidate for isolated fusion of the talonavicular joint is one who demonstrates a pes plenovalgus deformity with fixed forefoot abduction secondary to degenerative changes of the talonavicular joint or reducible deformity with pain localizing to the talonavicular joint. Several factors should be considered in an effort to optimize the outcome. The subtalar joint must be supple and pain-free. Selective lidocaine blocks may be useful in defining the extent of involvement. Hindfoot alignment should promote congruent load application through the subtalar and ankle joints. To this end, this deformity commonly requires further realignment and balancing of the hindfoot. Lateral column lengthening, medializing calcaneal osteotomy, and Achilles tendon lengthening or gastrocnemius recession may be considered [3,12]. Fixed cavovarus deformities can result from incomplete correction of congenital clubfoot or acquired deformities secondary to neuromuscular imbalance [7,13]. Alignment of the foot can be corrected and the integrity of the medial column restored by addressing the navicular complex. Because of the plantar medial peritalar subluxation, contact pressure is altered which causes arthrosis of the talonavicular joint. In severe deformity, naviculectomy and talocuneiform fusion may be necessary to allow adequate reduction of the deformity and avoid soft tissue compromise. Osseous necrosis of the navicular may be idiopathic or posttraumatic [14,15]. Deformity may be mild but results in articular incongruity and painful arthrosis. With severe deformity or dissolution of the navicular, naviculectomy and structural bone graft may be necessary. Osseous necrosis that involves the talar head may have the same outcome. Extensive grafting may be necessary to maintain length of the medial column. MRI may be helpful in determining the extent of compromised tissue.
Technique This technique is technically demanding. Every effort should be made to maintain length and orientation of the medial column. Careful attention must also be paid to forefoot position with regard to pronation/supination and abduction/adduction.
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The talonavicular joint is approached through a longitudinal medial midfoot incision. A dissection plane can be developed between the tibialis anterior and tibialis posterior tendons. The talonavicular joint capsule is incised to expose the joint. Soft tissue about the neck of talus should be left intact to avoid compromise of the blood supply to the head and neck of the talus. At this point, osteophytes can be removed from the dorsomedial and medial aspect of the navicular to facilitate visualization and debridement of the joint itself. Placing a small curved elevator across the joint as a lever or using a small lamina spreader can facilitate distraction of the talonavicular joint. Articular cartilage is removed from the head of the talus and the navicular. The subchondral bone is prepared by placing multiple drill holes in the talar head and body of the navicular with a 2-mm drill. Maintenance of the subchondral bone precludes excessive loss of medial column length. The talonavicular joint is reduced and may be provisionally fixed with K-wires. This may be accomplished by directing a lateral force at the head and neck region of the talus while adducting and pronating the forefoot. Cancellous autograft or allograft matrix may be used to augment areas of decreased apposition of subchondral bone [16]. At this point, fluoroscopic evaluation may be helpful to ensure restoration of the talar-first metatarsal axis in the anteroposterior (AP) and lateral planes. The tuberosity of the navicular and junction of the head and neck of the talus are well-suited for lag screw placement. A 6.5-mm partially threaded cancellous screw can be placed from distal to proximal through the tuberosity of the navicular; a 3.5-mm or 4.0-mm fully threaded cortical screw may be placed from proximal to distal buttressing against the junction of the neck and head of the talus (the type and size of screw may vary with bone size and quality). These screws can be tightened sequentially to provide uniform compression across the talonavicular joint. The fusion mass can be extended to include the naviculocuneiform joints. Debridement and preparation of the joint is conducted. The joint complex is reduced with attention to restoration of anatomic alignment and length of the medial column. Fixation is provided by crossed lag screws or medial plate. Bone loss is managed with structural graft. In cases of necrosis, nonviable bone is debrided to a bleeding surface. The surfaces to be fused should be parallel to one another and perpendicular to the long axis of the medial column. This makes contouring the graft less tedious. A structural graft is positioned. Allograft may be used on otherwise healthy individuals. Fixation is provided by a medial plate or crossed lag screws. Again, the alignment and length of the medial column should be restored anatomically (Figs. 1– 5).
Results Few studies have reported the results of talonavicular arthrodesis for the treatment of isolated traumatic arthrosis. Chen et al [5], reported successful fusion in 15 of 16 patients with an average follow-up 4.2 years. Eight of 16 patients had a history of trauma, osteoarthritis (OA) was the preoperative diagnosis in 6 patients,
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Fig. 1. Oblique (A) and lateral (B) radiographs demonstrating talonavicular arthrodesis using two crossed screws.
1 patient had pes planus, and 1 patient had lupus. Five of 16 patients demonstrated radiographic evidence of arthrosis in adjacent joints at 1-year follow-up (three traumatic, one OA); however, these changes had no effect on the functional score through the follow-up period. Chiodo et al [5] reported successful fusion in 19 of 20 rheumatoid patients who had at an average of 11 weeks. Sixteen results were excellent, three were
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Fig. 2. (A) Lateral radiograph of a 64-year-old woman who has grade III PTTI. Arthrosis was limited to the talonavicular joint and corrected with a talonavicular joint arthrodesis using a single 6.5-mm partially threaded screw. (B) A shear-strain relief bone graft was harvested from the calcaneus and placed in a drill hole removing subchondral bone on both sides of the joint line.
good, and one was poor. Three patients experienced complications, including nonunion, deep vein thrombosis, and superficial infection. These results were consistent with those of Ljung et al [9] who reported pain relief in 17 of 19 feet. Osseous union occurred in 12 feet; of seven nonunions, five were pain-free and two had mild pain. Six feet demonstrated mild progressive degenerative changes in adjacent joints. Four feet demonstrated moderate changes, three of these were spontaneous talocalcaneal fusion. Similarly, Kindsfater et al [8] reported a 95% fusion rate in which good to excellent results were obtained in their study of 104 cases. Of the five nonunions, no comment was made about symptoms. These investigators further noted that through an average follow-up of 52 months, no patient required revision to a triple arthrodesis. Harper and Tisdel [17] reported on 27 patients who had PTTI that was treated with isolated talonavicular joint arthrodesis. The average age was 57 years (range,
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Fig. 3. AP (A) and lateral (B) radiograph demonstrating naviculocuneiform arthrodesis using two crossed screws. The fusion mass can be extended to include the talonavicular joint by crossing this joint with screws paralleling those crossing the naviculocuneiform joints.
39 to 74 years). Good or excellent results were reported in 24 of 27 patients who were followed for a minimum of 1 year. Progressive adjacent joint arthrosis was noted in four patients. In a later report, Harper [18] reported satisfactory results in 25 of 29 patients who were treated with isolated talonavicular arthrodesis for grade III PTTI.
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Fig. 4. AP (A) and lateral (B) radiographs illustrating talonavicular arthrodesis performed with a cervical H-plate. The patient is a 36-year-old man who has osseous necrosis of the head of the talus. The necrotic tissue was debrided and the defect was packed with cancellous autograft. The patient was pain-free and returned to work as a laborer 12 weeks after surgery.
The patient population primarily consisted of older individuals whose lifestyle was not limited by the loss of motion. These patients were followed for a minimum of 1 year. Progressive midfoot arthrosis was noted in four patients. Scranton [4] reported good results in four patients who were treated with isolated talonavicular arthrodesis.
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Fig. 5. AP (A) and lateral (B) radiographs of a 15-year-old boy who fell from a height and sustained a severely comminuted pilon fracture of the navicular and fracture-dislocation of the calcaneocuboid joint. The medial column was reconstructed using tricortical allograft (arrow). Subchondral bone of the medial cuneiform and talar head were fashioned to provide flat surfaces at the host-graft interface. The tuberosity of the navicular was maintained to provide vascular supply. A similar technique is useful in the treatment of symptomatic osseous necrosis that involves the navicular complex.
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Fortin and Grant [19] reported satisfactory results in 12 of 14 patients who were treated with isolated talonavicular arthrodesis and calcaneal osteotomy for severe peritalar subluxation secondary to PTTI. Bone grafting and lag screw fixation was used in all patients. These investigators reported one case of nonunion that went on to demonstrate bony healing without further surgery. In contrast, Below and McCluskey [20] reported their results of 11 patients who had stage II posterior tibial tendon dysfunction (8 women, 3 men) who were treated with isolated talonavicular arthrodesis. The 11 patients were examined at a mean of 35.5 months (range, 23 to 47 months) after surgery. Two patients were completely satisfied, three were satisfied with minor reservations, four were satisfied with major reservations, and two patients were dissatisfied. Seven of the 11 patients developed subtalar joint degenerative changes. Osseous necrosis of the navicular complex is rare. Reports regarding occurrence and treatment are based mainly on individual cases [14,15,21]. The most recent report was related to dislocation of the navicular [14]. Open reduction, internal fixation failed when the navicular collapsed. The navicular was excised and a talocuneiform arthrodesis was performed successfully. This author’s experience with osseous necrosis is limited. Two patients were treated with excision of the navicular and structural grafting. In a third patient, osseous necrosis of the head of the talus was treated with debridement of nonviable bone and cancellous grafting. In these three cases, the primary objective was to restore medial column length.
Complications Nonunion Reported rates of nonunion of isolated talonavicular joint arthrodesis range from 0% to 70% [17,22,23]. When evaluating these results, however, one must appreciate the variety of techniques that are used in this procedure. Mann and Beaman [24] reported a 25% nonunion rate of the talonavicular joint in 14 patients who were treated with double arthrodesis for acquired flat foot deformity. These investigators did not use bone graft; fixation was provided with staples rather than lag screws.
Malalignment Failure to completely reduce the peritalar subluxation of the forefoot results in incomplete restoration of the longitudinal arch. Poorly distributed weight-bearing forces may result in compromise of the skin in the medial or plantarmedial aspect of the talonavicular joint. Overcorrection of the midfoot deformity may result in a cavus alignment and overload of the lateral column. Lateral column overload also may occur with failure to adequately reduce forefoot supination upon reduction of the talonavicular joint.
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Persistent hindfoot valgus can result in the mechanical aspect passing medial to the hindfoot. This can cause attenuation of the deltoid ligament and result in grade IV PTTI or a valgus deformity at the tibiotalar joint. Adjacent joint arthrosis Because motion of the ankle and foot is coupled, the elimination of motion in any joint or group of joints results in alterations of forces that are distributed to adjacent joints under weight-bearing conditions. The development of degenerative changes in adjacent joints after talonavicular joint arthrodesis were reported [5,6,17,19,20]. To alleviate the stress on adjacent joints, custom orthosis or shoe modification, such as rigid rocker bottom soles, should be prescribed.
Summary Isolated arthrodesis of the navicular complex is a means of restoring the integrity of the medial column. This facilitates pain relief and improved function. This option should be considered in the treatment of degenerative disease in these joints. Grade III PTTI may be managed with arthrodesis of the navicular complex, provided degenerative changes are limited to the talonavicular-naviculocuneiform joints. This procedure must include concomitant correction of the hindfoot. Osseous necrosis or bone loss that is due to severe degeneration may be managed successfully with cancellous or structural grafting that is sufficient to maintain length of the medial column. If extensive grafting increases the risk of nonunion, the navicular or its remnants can be excised and a talocuneiform fusion may be performed. Successful management of conditions that affect the navicular complex requires meticulous attention to restoration of the medial column. Optimal results also demand consideration of overall alignment and condition of adjacent joints.
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