Talonavicular-cuneiform arthrodesis in the management of Mueller-Weiss Syndrome: a retrospective case series.

Mueller-Weiss Syndrome (MWS), characterized by spontaneous adult-onset tarsal navicular osteonecrosis, is an uncommon cause of chronic midfoot pain that can lead to functional impairment and progressive deformities. This study aimed to present clinical and radiological outcomes of talonavicular-cuneiform (TNC) arthrodesis in the treatment of patients with MWS. A retrospective study was performed on 8 consecutive patients (6 female, 2 male; mean age = 50 years; range = 33-64) who underwent TNC arthrodesis using plate fixation with autologous bone grafting for the treatment of MWS. To evaluate clinical status, the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Midfoot Score was performed immediately preoperatively and at the final follow-up. In radiographic evaluation, talus-first metatarsal angle (Meary's angle) was measured preoperatively and at the final follow-up. Solid fusion was also examined on postoperative radiographs and computerised tomography. The mean follow-up was 35 months (range = 24-52). The mean AOFAS improved from 37 (range = 24-53) preoperatively to 85 (range = 80-93) at the final follow-up (p < 0.001). No major intra- operative complications were observed in any of the patients. According to the Maceira and Rochera radiological staging system, 5 feet was stage 3, and 3 feet was stage 4. The mean union time was 10 months (range = 5-15). Radiographic solid fusion was achieved in all but one foot that developed talonavicular non-union. TNC arthrodesis using plate fixation with autologous bone grafting seems to be an effective surgical method for reconstruction of MWS.

[Postoperative outcome of 30 patients with navicular bone fractures-In connection with AOFAS-Score, SF-12 and fracture classifications]. / Das postoperative Outcome von 30 Patienten mit Os-naviculare-Fraktur ­ im Zusammenhang mit AOFAS-Score, SF-12 und Frakturklassifikationen.

BACKGROUND: Fractures of the navicular bone are rare and the number of those treated surgically is even smaller. Moreover, scientific analyses on this topic are only sporadically present in the literature, therefore this retrospective and monocentric study was initiated. METHODS: A total of 30 patients with 30 fractures were included. With the exception of one primary fusion, all patients underwent open reduction with internal osteosynthesis. Clinical and radiological follow-up was performed at least 2 years postoperatively using AOFAS-Score, SF-12 and a radiological examination. The primary objectives were the clinical and radiologic outcomes as mid-term to long-term outcomes. The secondary objective was to compare these results with two existing computed tomography (CT) fracture classifications in terms of their association with the outcome. RESULTS: The median follow-up was 7.8 years (range 2-16.2 years) postoperatively. One patient suffered an infection, four patients required secondary arthrodesis and eight patients had to change their occupation. The mean AOFAS-Score was 80.8/100 and the mean physical and mental SF-12 component summary scores were 47.1 and 55.7 points, respectively. Male sex and arthrodesis were associated with worse outcomes in both scores but not patient age or ipsilateral concomitant injuries. Both CT fracture classifications showed low predictive value. CONCLUSION: The severity of the injury in the preoperative CT showed no connection with the clinical outcome in the AOFAS-Score and SF-12 scores. Posttraumatic osteoarthritis and secondary arthrodesis are associated with a poor outcome. In the course of the observational period the reduction results improved, which was accompanied by a better clinical outcome.

Müller-Weiss Disease: Midfoot Arthrodesis in Reduction vs Malreduction.

BACKGROUND: Midfoot arthrodesis is regarded as the main surgical approach for treating Müller-Weiss disease (MWD). This study aimed to investigate the incidence of postoperative pain during MWD treatment through midfoot reduction or malreduction during arthrodesis and to explore the factors influencing postoperative pain in patients with MWD. METHODS: A total of 67 patients with MWD were recruited and divided into two groups according to whether midfoot alignment was reduced: reduction group (n = 38) and malreduction group (n = 29). Demographic characteristics before the operation and at the last follow-up, as well as clinical and radiographic parameters, were compared between the two groups. Clinical parameters included the American Orthopaedic Foot & Ankle Society score and visual analog scale score, whereas radiographic parameters included the calcaneal pitch angle, lateral Meary's angle, talometatarsal-1 angle dorsoplantar (TMT1dp), talocalcaneal angle dorsoplantar (Kite angle), talonavicular coverage angle, and medial navicular pole extrusion. Postoperative complications and incidence of midfoot pain were evaluated at the last follow-up visit. RESULTS: The reduction group exhibited better clinical and radiological parameters, including the TMT1dp and medial navicular pole extrusion, than the malreduction group at the last follow-up (all P < .05). However, the calcaneal pitch angle, lateral Meary's angle, Kite angle, and talonavicular coverage angle did not significantly differ between the two groups (all P > .05). The overall incidence of midfoot pain was 26.4%. The reduction group showed a lower incidence of medial pain than the malreduction group (15.7% vs. 40.0%, P < .05). Regression analysis revealed that midfoot abduction, represented by the TMT1dp, was a critical factor for midfoot arthrodesis failure and that medial navicular pole extrusion was not correlated with postoperative midfoot pain. CONCLUSION: Midfoot reduction arthrodesis yields better clinical outcomes than malreduction arthrodesis. The TMT1dp, representing midfoot abduction, is a key factor for midfoot arthrodesis failure. The extruded medial navicular bone may not affect postoperative medial midfoot pain. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Outcomes of Selective Arthrodesis Based on Joints Affected in 33 Feet With Müller-Weiss Disease.

No consensus exists regarding operative treatment of Müller-Weiss disease (MWD). Its only classification is based solely on Méary's angle and serves neither as guide to management nor prognosis. We report on 33 feet that underwent surgery following failed conservative management. Treatment was directed towards joint(s) involved, as determined by clinical examination, plain radiography and SPECT-CT. Thus, surgery consisted of isolated talonavicular in 6 feet, triple in 8, subtalar and talonavicular in 7, talonaviculocuneiform in 4, talonaviculocuneiform with interpositional tricortical iliac crest graft in 6 and pantalar arthrodesis in 2. PROMIS scores for pain interference and depression decreased significantly (p < .001) with significant accompanying increase in physical function (p = .003). Union occurred in 31 of 33 feet (94%) with complete resolution of pain at an average follow-up of 84 months. Of the 2 nonunions, 1 had fracture through the lateral navicular, and the other marked sclerosis and avascularity of the lateral navicular. We describe our pathways for selecting arthrodesis based on the joints affected. Isolated talonavicular arthrodesis was performed in early stages of MWD, which begins at the talonavicular articulation. When disease extended to both sides of the navicular, we performed talonaviculocuneiform arthrodesis. When considering isolated talonavicular, double medial or triple arthrodesis, there should be adequate cancellous bone stock remaining in the lateral part of the navicular, as determined on medial oblique radiographs and CT scan. In case of inadequate bone stock or fracture through the lateral navicular, talonaviculocuneiform arthrodesis with interpositional iliac crest bone graft is recommended.

A Novel Update on the Management of Müller-Weiss Disease: Presentation of a Treatment Algorithm.

OBJECTIVE: Müller-Weiss disease (MWD) is a challenging condition involving the perinavicular region in the initial stages and subsequently the entire foot in the later stages. The goal of this article is to describe the pathomechanics, clinical evaluation, and nonoperative and operative treatment, including a treatment algorithm, based on current evidence and the combined authors' experience. DESIGN: We review the related articles and summarize the information about this condition. RESULTS: A number of related articles reveal that the treatments should focus on the management of degenerative regions and deformity correction to restore normal foot alignment and provide pain relief. CONCLUSION: This systematic review proposes a treatment algorithm that is comprehensive and practical to apply for the management of MWD.

Computed tomography and fluoroscopy versus radiographic guidance for internal fixation of simulated dorsomedial-plantarolateral central tarsal bone fractures in nonracehorses.

OBJECTIVE: The aim of this study was to assess screw placement in simulated dorsomedial-plantarolateral central tarsal bone (CTB) fractures using two imaging guidance techniques - computed tomography (CT) with fluoroscopy compared to digital radiography alone (DR). STUDY DESIGN: Experimental study. SAMPLE POPULATION: Equine cadaver hindlimbs (n = 10 pairs). METHODS: One tarsus per pair was randomly assigned to have a 4.5 mm cortical screw placed across the CTB using CT and fluoroscopy (CT/F group) or digital radiography alone (DR group). Postoperative CT was performed on all limbs. Variables related to marker placement, procedure time, and screw positioning were recorded and compared using a paired t-test for dependent means (p < .05). RESULTS: Time for marker placement was longer for the CT/F group (p = .001), with no difference in total procedure time (p = .12). CT/F was not superior to radiography alone (p > .05) for parameters related to screw positioning. Based on the 95% CI, there was greater range in relative screw length using radiography (76.5%-91.2%) versus CT/F (78.4%-84.0%). CONCLUSION: Internal fixation of CTB fractures can be successfully performed using either technique for imaging guidance. CT and fluoroscopy did not result in faster or more accurate screw placement compared to radiographs alone, except in determining screw length. CLINICAL SIGNIFICANCE: Mild adjustments in fluoroscopic or radiographic angle appeared to be a point of variability in the perception of screw placement. While CT is recommended for improved understanding of fracture configuration and surgical planning, radiographic guidance may be a suitable alternative for internal fixation of dorsomedial-plantarolateral fractures.

Tarsal coalition in adults.

Adult tarsal coalition consists in abnormal union of two or more tarsal bones. Reported incidence ranges between 1 and 13%. It is generally a congenital condition, due to dominant autosomal chromosome disorder, but with some acquired forms following trauma or inflammatory pathology. Poorly specific clinical signs and the difficulty of screening on conventional X-ray may lead to diagnostic failure. The present review of tarsal coalition addresses the following questions: how to define tarsal coalition? How to diagnose it? How to treat it? And what results can be expected? There are 3 types of tarsal coalition, according to the type of tissue between the united bones: bony in pure synostosis, cartilaginous in synchondrosis, and fibrous in syndesmosis. Location varies; the most frequent forms are talocalcaneal (TC) and calcaneonavicular (CN), accounting for more than 90% of cases. Cuneonavicular, intercuneal and cuboideonavicular locations are much rarer, at less than 10%. Tarsal coalition is classically painful, often with valgus spastic flatfoot in young adults. The pain is caused by the biomechanical disturbance induced by the bone, cartilage or fibrous bridges which partially or completely hinder hindfoot and/or midfoot motion. Conventional imaging, with weight-bearing X-ray and CT, is standard practice. Weight-bearing CT is increasingly the gold standard, displaying abnormalities in 3 dimensions. Functional imaging on MRI and tomoscintigraphy assess direct and indirect joint impact at the affected and neighboring joint lines. Non-operative treatment can be proposed, with orthoses, rehabilitation and/or injections. But surgery is the most frequent option: either resection of the bony, cartilaginous or fibrous constructs to restore optimally normal anatomy, or arthrodesis in the affected joint line or the entire joint. Surgery can be open, arthroscopic or percutaneous, depending on the severity of the biomechanical impact on the affected and neighboring joints. Resecting the abnormality is the standard practice in all locations if it affects less than 50% of the talocalcaneal joint line and there is no osteoarthritis to impair the functional outcome. Otherwise, fusion is required. Level of evidence: V; expert opinion.

"Biological Fixation" of Flexor Digitorum Longus: A New Modification of Tendon Transfer for Treatment of Posterior Tibialis Tendon Dysfunction.

Numerous surgical procedures for the treatment of posterior tibialis tendon (PTT) dysfunction have been developed, including tendon transfers, osteotomies, and arthrodesis. Among these methods, foot and ankle surgeons most frequently use flexor digitorum longus (FDL) tendon transfer in conjunction with medial translational osteotomy of the calcaneus. Formerly, some less invasive techniques have been described to reduce surgical-related complications after FDL tendon transfer. Herein, we introduced a new modification of short-stump FDL tendon fixation to the navicular bone and reported the functional outcomes of the current technique in a patient with PTT dysfunction. In the current technique, the FDL tendon was fixed to the navicular bone via a trans-osseous tunnel using a split PTT stump. This method does not require any kind of fixation devices, such as an interference screw or anchor suture.Level of Evidence: V.

Radiologic foot alignment and clinical outcome after percutaneous drilling for symptomatic accessory navicular in skeletally immature children.

Various surgical treatments are available for a symptomatic AN, including percutaneous drilling (PD). PD is reportedly effective for ANs in skeletally immature children. However, no reports have described the foot alignment after PD in skeletally immature children. This study was performed to compare the radiographic parameters between the preoperative period and the final follow-up after PD for symptomatic ANs in skeletally immature children. From October 2013 to December 2020, PD was performed on 13 feet in 10 skeletally immature children. The patients comprised 5 boys and 5 girls with a mean age at surgery of 11.9 years. The mean follow-up period was 14.8 months. We measured 5 radiographic findings preoperatively and at the final follow-up: calcaneal pitch angle (CPA), talocalcaneal angle (TCA), talonavicular coverage angle (TNCA), anteroposterior talo-first metatarsal angle (ATMA), and lateral talo-first metatarsal angle (LTMA). Ten feet were assessed as excellent, 1 as fair, and 2 as poor. Ten unions (76.9%) were achieved among the 13 feet. The mean CPA improved from 16.4 ±â€…4.1 degrees preoperatively to 18.2 ±â€…3.4 degrees at the final follow-up, the TCA improved from 43.0 ±â€…3.7 to 45.2 ±â€…4.4 degrees, and the TNCA improved from 19.9 ±â€…4.4 to 15.4 ±â€…5.0 degrees (P < .05). The ATMA and LTMA were not significantly different between the preoperative period and final follow-up. We found that PD for symptomatic ANs in skeletally immature children was effective treatment, and some radiographic parameters showed significant differences between the preoperative period and final follow-up.

A modified method for reconstruction of posterior tibial tendon after resection of juvenile painful type II accessory navicular.

BACKGROUND: The surgical treatment of accessory navicular (AN) is divided into simple resection of AN and Kidner surgery used to reconstruct posterior tibial tendon (PTT) after AN resection. However, both of these procedures have certain disadvantages. Herein, we proposed a modified method to reconstruct PTT and compared the short-term clinical effect of our method with the modified Kidner procedure. METHODS: We collected data from 23 adolescent children with painful type II AN treated in our department between January 2015 and June 2020. The American Orthopedic Foot and Ankle Society Ankle-Hind foot (AOFAS-AH) Scores, the Meary Angle, and Pitch Angle of the lateral weight-bearing plain radiographs status were recorded before and after the operation to evaluate the treatment outcomes. RESULTS: In the modified Kidner surgery (MK) group, the median AOFAS-AH increased from 61 (59-68) to 87 (83-91) (P < 0.05); the Pitch angle of the lateral weight-bearing plain radiographs increased from 13.0 (8-18) to 17.4 (14-22), and the Meary angle decreased from 18.3 (14-24) to 14.2 (8-20) (P < 0.05). In the PTT preservation folded suture (FS) group, the median AOFAS-AH increased from 61 (59-68) to 87 (85-91) (P < 0.05); the Pitch angle of the lateral weight-bearing plain radiographs increased from 12.3 (7-18) to 18.4 (15-26), and the Meary angle decreased from 17.8 (13-23) to 5.7 (3-8) (P < 0.05). There was no significant difference in AOFAS-AH postoperative scores between the FS group and MK group; however, the improvement on Pitch and Meary angle of the lateral weight-bearing plain radiographs was significantly better in the FS group than in MK group (P < 0.05). CONCLUSIONS: For painful type II AN in juvenile patients, the insertion-preserving folding suture procedure had similar short-term results on AOFAS-AH scores but greater improvement in the Meary angle and the Pitch Angle than the modified Kidner method. LEVEL OF EVIDENCE: III.

Intra-articular Osteoid Osteoma of the Intermediate Cuneiform Bone Causing Articular Degeneration: A Rare Case and Literature Review.

Osteoid osteoma of the cuneiform bone is an exceedingly rare and easily missed cause of foot pain. The uncharacteristic and nonspecific radiographs of such intra-articular osteoid osteoma further increase difficulty in making the diagnosis. To date, there has been no description of intra-articular osteoid osteoma of the intermediate cuneiform bone causing articular degeneration in any published literatures. We present a case of intra-articular osteoid osteoma of the intermediate cuneiform bone causing articular degeneration, who underwent curettage, allograft bone graft, and navicular-cuneiform arthrodesis. The patient presented with radiographic bone union, full motor function recovery and pain-free at the 22-month follow-up. This report adds to the existing literature. Intra-articular osteoid osteoma of the intermediate cuneiform bone causing articular degeneration is an exceedingly rare and easily missed cause of foot pain. It proves a complicated and challenging task to identify intra-articular osteoid osteoma. Clinicians should be particularly careful not to exclude the possibility of arthritis and, thus, vigilant when choosing the surgical option.

Outcomes of surgical management for tarsal coalitions: a systematic review.

PURPOSE: To analyze the outcome of surgical treatment of tarsal coalition, assess the role of the surgical technique, as well as of coalition size and type on outcomes. METHODS: The search followed the Preferred Reporting Items of Systematic Review and Meta-Analysis and was performed in four databases: MEDLINE, Central, Scopus and Web of Science. The protocol has been registered in the international prospective register of systematic reviews. Patient-reported outcomes (PROMs), complications, revisions and radiographic recurrence were collected. Risk of bias was assessed using MINORS criteria. A random-effects model for meta-analysis was applied for analysis of data heterogeneity. RESULTS: Twenty-five studies including 760 tarsal coalitions were included and had a weighted average follow-up of 44 months. Studies scored fair to poor on the risk of bias assessment with a mean MINORS score of 67% (44-81%). In 77.8% (37.5-100%) of surgically treated tarsal coalitions, good/excellent/non-limiting or improved PROMs were reported. Calculated data heterogeneity was moderate (I2 = 57%). Open bar resection with material interposition had a clinical success rate of 78.8% (50-100%). Complications occurred in 4.96% of cases. Coalition size did not prove to be a determining factor in postoperative outcome. The influence of the coalition type was not investigated by any of the studies. CONCLUSION: Data on outcomes of surgical management for tarsal coalitions is limited to retrospective case series with high risk of bias and moderate data heterogeneity. In about ¾ of cases, open resection and interposition of material results in improved PROMs. The arbitrary margin of ≥ 50% of TC coalition size in relation to the posterior facet has little importance in surgical decision-making. None of the studies reported on the influence of the coalition type on postoperative clinical success.

Müller-Weiss disease: a functional and quality of life assessment.

PURPOSE: Evaluate the functional health status and quality of life of patients diagnosed with Müller-Weiss disease and, secondarily, determine the influence of factors such as gender, social status, race, body mass index, and surgical and non-surgical treatment in patient outcome. METHODS: This study included 30 affected feet (18 patients) with follow-up from 2002 to 2016. Five patients were excluded from reassessment, resulting in 20 feet (13 patients). Questionnaires for functional and quality of life assessments were administered, and statistical analysis was performed. RESULTS: Patients with obesity had poor functional results and low quality of life rates. Regarding quality of life, mainly in the mental health domain, there was a significant difference (p < 0.001) that was not observed in other domains investigated, except for surgical treatment, which was superior to non-surgical treatment in terms of the physical domain (p = 0.024). Bilateral treatment was also superior to unilateral treatment in Coughlin's classification (71.4% versus 66.7%). CONCLUSIONS: Müller-Weiss disease evolved with poor functional results and low quality of life rates in patients with obesity, with no method of treatment influence on patient outcome, except for the SF-12 physical domain, where surgical treatment showed better results than conservative treatment.

Tarsal Navicular Bone Stress Injuries: A Multicenter Case Series Investigating Clinical Presentation, Diagnostic Approach, Treatment, and Return to Sport in Adolescent Athletes.

BACKGROUND: Tarsal navicular bone stress injuries (BSIs) are considered "high risk" because of prolonged healing times and higher rates of nonunion in adult populations but, to our knowledge, have not been comprehensively examined in adolescent athletes. PURPOSE: To describe the characteristics of tarsal navicular BSIs in adolescents. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective analysis of patients aged 10 to 19 years with a radiographically diagnosed tarsal navicular BSI was performed at 8 academic centers over a 9-year study period. Age, sex, body mass index (BMI), primary sport, physical examination findings, imaging, treatment, surgical technique, return-to-sport time, and complications were analyzed. RESULTS: Among 110 patients (mean age, 14.7 ± 2.7 years; 65% female), common primary sports were cross-country/track and field (29/92 [32%]) and gymnastics/dance (25/92 [27%]). Grade 4 BSIs were identified in 44% (48/110) of patients, with fracture lines present on radiography or magnetic resonance imaging. Nonoperative treatment (mean age, 14.4 ± 2.6 years), consisting of protected weightbearing and either a protective boot (69/88 [78%]) or a cast (19/88 [22%]), was trialed in all patients and was successful in 94 patients (85%). Operative treatment (mean age, 17.1 ± 1.4 years) was ultimately pursued for 16 patients (15%). Patients who required surgery had a higher BMI and a higher percentage of fracture lines present on imaging (nonoperative: 36/94 [38%]; operative: 14/16 [88%]). The median time to return to weightbearing, running, and full sport was significantly longer in duration for the operative group than the nonoperative group (P <.05). Complications associated with surgery included 1 case each of delayed union, nonunion, and painful implants, the latter of which required secondary surgery. CONCLUSION: Adolescent tarsal navicular BSIs were identified most commonly in female patients in leanness sports. Adolescents who required surgery were more likely to be older, have higher BMIs, and have grade 4 BSIs, and they returned to sport within a median of 5 months after single- or double-screw fixation with a low risk of postoperative complications. A better understanding of the presenting signs and symptoms and appropriate diagnostic imaging of navicular BSIs may lead to an earlier diagnosis and improved outcomes.

Imaging of Müller-Weiss Disease.

Müller-Weiss disease (MWD) is the result of a dysplasia of the tarsal navicular bone. Over the adult years, the dysplastic bone leads to the development of an asymmetric talonavicular arthritis with the talar head shifting laterally and plantarly, thus driving the subtalar joint into varus. From a diagnostic point of view, the condition may be difficult to differentiate from an avascular necrosis or even a stress fracture of the navicular, but fragmentation is the result of a mechanical impairment rather than a biological dysfunction.Standardized weight-bearing radiographs (anteroposterior and lateral views) of both feet are usually enough to diagnose MWD. Other imaging modalities such as multi-detector computed tomography and magnetic resonance imaging in early cases for the differential diagnosis can add additional details on the amount of cartilage affected, bone stock, fragmentation, and associated soft tissue injuries. Failure to identify patients with paradoxical flatfeet varus may lead to an incorrect diagnosis and management. Conservative treatment with the use of rigid insoles is effective in most patients. A calcaneal osteotomy seems to be a satisfactory treatment for patients who fail to respond to conservative measures and a good alternative to the different types of peri-navicular fusions. Weight-bearing radiographs are also useful to identify postoperative changes.

Is Kidner procedure necessary during subtalar arthroereisis for pediatric flexible flatfoot that combined with symptomatic type 2 accessory navicular? A retrospective comparative study.

BACKGROUND: Kidner procedure is thought to be able to eliminate the medial foot pain and contribute to restoring the medial longitudinal foot arch, making it particularly suitable for surgical treatment of pes planus that combined with symptomatic type 2 accessory navicular (AN). However, controversy remains, and the clinical evidence is still lacking. The aim of the current study is to verify the necessity of Kidner procedure during subtalar arthroereisis (STA) for pediatric flexible flatfoot (PFF) that combined with symptomatic type 2 AN. METHODS: Forty pediatric patients (72 feet) who had undergone STA for flexible flatfoot and were also diagnosed with symptomatic type 2 AN concomitantly were reviewed retrospectively and divided into two groups (STA + Kidner vs STA alone). The visual analog scale (VAS), the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale, the Oxford ankle foot questionnaire for children (OAFQC), and the radiographic parameters that quantifying pes planus were evaluated as primary outcomes. Secondary outcomes included the incidence of complications. RESULTS: There were 35 feet in the STA + Kidner group and 37 feet in the STA alone group, with mean follow-up periods of 2.7 years and 2.1 years, respectively. The VAS, AOFAS, OAFQC scores and radiographic parameters presented no significant difference between the two groups both preoperatively and at final follow-up (P > 0.05 for each). The complications of STA surgery occurred equally in both groups, and Kidner procedure could lead to more incision problems (22.9% vs. 2.7%) and a longer time to return to activity. CONCLUSION: Kidner procedure may be unnecessary during surgical treatment of PFF that combined with painful type 2 AN. Correcting the PFF while leaving the AN alone has a high possibility of relieving the pain in the AN region, and tibialis posterior tendon (TPT) rerouting hardly aids in reconstruction of the medial foot arch. LEVEL OF EVIDENCE: III.

Towards understanding Müller-Weiss disease from an analysis of 95 cases.

BACKGROUND: The single existing classification of Müller-Weiss Disease (MWD), based solely upon Méary's angle, serves neither as guide for prognosis nor treatment. This accounts for lack of gold standard in its management. METHODS: Navicular compression, medial extrusion, metatarsal lengths, Kite's, lateral and dorsoplantar talo-first metatarsal angles were measured in 95 feet with MWD. Joints involved, presence and location of navicular fracture were recorded. RESULTS: Group 1 "early-onset" MWD feet (n = 11) had greatest compression and medial extrusion, and lowest Kite's angles. All except 1 were index minus and had lateral navicular fracture. Only 1 had moderate degeneration at the talonavicular joint (TNJ) with none requiring surgery yet. Group 2 "Müller-Weissoid" feet (n = 23) had radiologically normal navicular in their fifties and developed MWD on average 5 years later. They had the lowest compression and extrusion, and highest Kite's angles. None had complete fracture. All had TNJ arthritis, with early changes at lateral naviculocuneiform joint (NCJ) in 43%. Group 3 "late-onset" MWD presented in the sixth decade. Only TNJ was involved in Group 3 A (n = 16). Group 3B (n = 20) affected TNJ more than NCJ and had the greatest number of Maceira stage V disease. Group 3 C "reverse Müller-Weiss disease", which affected NCJ more than TNJ (n = 25), had greatest midfoot abduction and overlength of the second metatarsal. No fracture occurred in group 3 A compared to 65% and 32% in groups 3B and 3 C, respectively. CONCLUSIONS: With need to compare like-for-like pathology, the proposed classification provides a common platform for reporting outcomes of different treatments. We theorize pathogenetic pathways in the various groups.

A Rare Case of Naviculo-medial Cuneiform Coalition Treated with Naviculo-medial Cuneiform Arthrodesis: A Case Report.

CASE: A 19-year-old woman developed spontaneous onset of right midfoot pain in the absence of trauma. Conservative management including orthotics and steroid injection reduced, but did not resolve, pain. Weight-bearing x-ray and CT confirmed naviculo-medial cuneiform coalition. After failure of conservative treatment, the patient elected to undergo right naviculo-medial cuneiform arthrodesis and returned to normal activity without pain postoperatively and at 4-year follow-up. CONCLUSION: Naviculo-medial cuneiform coalition is a rare source of midfoot pain, but should be considered as a differential diagnosis. This case suggests that naviculo-medial cuneiform arthrodesis can successfully resolve symptoms if conservative measures fail.

Anatomic Description of the Calcaneocuboid Joint: Implications for Staple Fixation.

Understanding the anatomy of the calcaneocuboid (CCJ) remains essential when selecting staple fixation to optimize osseous purchase during rearfoot procedures. This anatomic study quantitatively describes the CCJ in relation to staple fixation sites. The calcaneus and cuboid from 10 cadavers were dissected. Widths at 5 mm and 10 mm increments away from the joint were measured in dorsal, midline, and plantar thirds of each bone. The widths between each position's 5 mm and 10 mm increments were compared using the Student's t test. The widths among the positions at both distances were compared using an ANOVA then post hoc testing. Statistical significance was set at p ≤ 0.05. The middle (23 ± 3 mm) and plantar third (18 ± 3 mm) of the calcaneus at the 10 mm interval was greater than the 5 mm interval (p = .04). At 5 mm distal to the CCJ, the dorsal third of the cuboid maintained a statistically significant greater width than the plantar third (p = .02). The 5 mm (p = .001) and 10 mm (p = .005) dorsal calcaneus widths as well as the 5 mm (p = .003) and 10 mm (p = .007) middle calcaneus widths were significantly greater than the plantar widths. This investigation supports the use of 20 mm staple 10 mm away from the CCJ in dorsal and midline orientations. Care should be taken when placing a plantar staple within 10 mm proximal to the CCJ as the legs may extend beyond the medial cortex compared to dorsal and midline placements.

Osteonecrosis of the Tarsal Navicular: Not Always Spontaneous!

BACKGROUND: Mueller-Weiss disease, a rare and complex foot condition, is defined as spontaneous and progressive navicular fragmentation leading to midfoot pain and deformity. However, its exact etiopathogenesis remains unclear. We report a case series of tarsal navicular osteonecrosis to describe the clinical and imaging characteristics and etiologic profile of the disease. METHODS: This retrospective study included five women diagnosed as having tarsal navicular osteonecrosis. The following data were extracted from medical records: age, comorbidities, alcohol and tobacco consumption, history of trauma, clinical presentation, imaging modalities performed, treatment protocol, and outcomes. RESULTS: Five women with a mean age of 51.4 years (range, 39-68 years) were enrolled in the study. Mechanical pain and deformity over the dorsum of the midfoot was the main clinical presentation. Rheumatoid arthritis, granulomatosis with polyangiitis, and spondyloarthritis were reported by three patients. Radiographs revealed bilateral distribution in one patient. Three patients underwent computed tomography. It showed a fragmentation of the navicular bone in two cases.Magnetic resonance imaging was performed in one patient showing flattening of the lateral aspect of the navicular bone with signal abnormalities. Talonaviculocuneiform arthrodesis was performed in all of the patients. CONCLUSIONS: Mueller-Weiss disease-like changes may occur in patients with an underlying inflammatory disease such as rheumatoid arthritis and spondyloarthritis.