Challenge of the Week / Foot & Ankle / 04.16.2021

A 50-year-old male patient presents with persistent midfoot pain for 1 year. He has been treated nonoperatively, including custom orthotics, a supramalleolar orthosis, immobilization, and oral nonsteroidal anti-inflammatory drugs without success. Radiographs initially demonstrated a comma-shaped navicular with sclerosis. They now show collapse and degeneration through both the naviculocuneiform and talonavicular joints. Which of the following would be an appropriate treatment option at this point?
    • Core decompression of the navicular
    • Although decompression may be beneficial in the early stages of avascular disease, by the time there are arthritic changes, the joint will need to be fused to provide predictable pain relief.

 

    • Navicular excision
    • Removal of the navicular in isolation would lead to a shortened medial column and flaccid foot. This would not be beneficial.

 

    • Medial column fusion with or without structural bone graft
    • The clinical scenario presented is consistent with Mueller Weiss syndrome. Nonoperative strategies have been unsuccessful. Once arthritic changes at the navicular cuneiform and talonavicular joints have occurred, fusion to correct any medial column shortening is the best treatment option.

 

    • Open reduction and internal fixation of the navicular
    • Attempting to fix an avascular bone in isolation will likely be unsuccessful. Additionally, fixing it in isolation does not address the arthritic changes at the adjacent joints.

 

 

 

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