CASE REPORT |
https://doi.org/10.5005/jp-journals-10040-1176 |
Nonunion of the Navicular with Associated Talonavicular and Calcaneocuboid Joint Degenerative Arthritis and Its Management: A Case Report
1-4Department of Orthopaedics, Grant Government Medical College, Mumbai, Maharashtra, India
Corresponding Author: Prasanna Kumar GS, Department of Orthopaedics, Grant Government Medical College, Mumbai, Maharashtra, India, e-mail: prasannakumargs5@gmail.com
ABSTRACT
Introduction: Tarsal navicular bone fractures most commonly occur as a result of either trauma or undue stress. The stress causes higher incidence in younger individuals and athletes. These fractures are at higher risk of going to nonunion and osteonecrosis because of the bone’s tenuous blood supply as well as the joint complexity.
Case description: A 40-year-old male patient presented with complaints of right foot pain for 2 years with an old history of trauma. Radiological examination revealed nonunion of the right navicular with adjacent joint degeneration. We managed with open reduction and internal fixation using a cannulated cancellous screw. At 1-year follow-up, the patient has got a good radiological and functional outcome.
Conclusion: Navicular nonunions are well managed with open reduction and internal fixation using cannulated cancellous screws, which helps in getting compression at the nonunion site and provides stability. Early surgical intervention helps to prevent adjacent joint degenerative arthritis. CT scan evaluation is very essential to diagnose the nonunion navicular as the X-rays appear normal in most cases.
How to cite this article: Mahajan NP, Prasanna Kumar GS, Pande KP, et al. Nonunion of the Navicular with Associated Talonavicular and Calcaneocuboid Joint Degenerative Arthritis and Its Management: A Case Report. J Foot Ankle Surg (Asia Pacific) 2022; 9(2):96-98.
Source of support: Nil
Conflict of interest: None
Keywords: Degenerative arthritis, Navicular, Nonunion
INTRODUCTION
Tarsal navicular bone fractures are most commonly occurs as a result of either trauma or undue stress. The stress causes higher incidence in younger individuals and athletes. Fractures of the midfoot are uncommon, navicular stress fractures represent one-third of all stress fractures.1,2 These fractures are at higher risk of going to nonunion and osteonecrosis because of the bone’s tenuous blood supply as well as the joint complexity.1 These fractures most often require surgical fixation and some fractures can also be managed conservatively. The axis of the navicular lies in the dorsoplantar and lateromedial direction. The base and the apex are situated dorsolaterally and plantar medial, respectively.3 Large part of the navicular bone is covered with articular cartilage as it has multiple articulations with the adjacent bones. The medial and lateral tarsal arteries supply the dorsal aspect of the navicular, tibialis posterior artery branch supplies the medial plantar aspect.4 We present a case of an adult male patient with right foot navicular nonunion and its management.
CASE DESCRIPTION
A 40-year-old male patient, a truck driver by occupation, presented with a complaint of pain and swelling of the right foot while walking for 2 years, which was aggravated for 2 months. The patient had a history of fall from height 15 years back which was managed by a quack with plaster for 8 days. The patient was not a known case of diabetes or hypertension. On examination, the patient had tenderness over the medial aspect of the midfoot with no external wound and no neurovascular deficit. The X-ray of the right foot was suggestive of decreased joint space in the talonavicular joint with a mild gap in the navicular which was inconclusive (Fig. 1). CT scan of the right foot revealed old nonunion of the navicular with degenerative arthritis of the talonavicular and calcaneocuboid joints (Figs 2 and 3). As the patient had chronic foot pain with nonunion and failed conservative measures, surgical intervention was planned.
Fig. 1: Preoperative X-ray right foot showing talonavicular and calcaneocuboid arthritis
Fig. 2: 3D CT right foot showing navicular nonunion
Fig. 3: 2D CT foot showing navicular non-union
The patient was operated on in a supine position under spinal anesthesia using a tourniquet. The dorsomedial approach was used. The incision was made between the extensor hallucis longus tendon (EHL) and tibialis anterior tendon. The dissection was made deep from the skin to the periosteum without raising flaps. The EHL was retracted laterally and tibialis anterior medially, which exposed the nonunion site (Fig. 4). The nonunion site was freshened using a curette and fibrous tissue was removed. The graft was placed in the nonunion site, which was taken from the calcaneum and fixed with a 4-mm cannulated cancellous screw. The position of the screw was confirmed intraoperatively using fluoroscopy (Fig. 5) and the wound was closed in layers. The immediate postoperative X-ray right foot showed the good position of the screw with no joint penetration (Fig. 6). Postoperatively, the patient was advised nil weight-bearing for 3 weeks and weight-bearing as tolerable using sports shoes after 3 weeks along with foot physiotherapy. The patient was able to weight bear without any pain after 8 weeks postoperatively. At the present 1-year follow-up, the patient is comfortable with no pain and swelling while walking and no other complaints with a good radiological outcome (Fig. 7).
Figs 4A and B: Picture showing dorsomedial incision marking (A) and nonunion site after retraction of EHL and tibialis anterior tendon (B)
Fig. 5: Intraoperative fluoroscopic image showing the position of the screw
Fig. 6: Immediate postoperative X-ray foot AP and oblique views showing the position of the screw and compression at the nonunion site
Fig. 7: Follow-up X-ray foot AP view at 1 year
DISCUSSION
The surgical or conservative management of the navicular fractures depends on the individual fracture morphologies, i.e., size, displacement, location, the comminution of the fracture, and condition of the surrounding soft tissue. The general condition of the patient, associated fractures, and patient comorbidities also help in deciding the management options in these fractures.5 The conservative management can be considered in cases of avulsion fractures, tuberosity fractures, and undisplaced body fractures. These fractures are conservatively managed using a weight-bearing short leg cast and walking boot.6 The displaced navicular fractures are best managed with open reduction and internal fixation using screws or small plates. The main intention of the surgical management of navicular displaced fractures is an anatomical reduction by restoring the length of the medial column which in turn helps in early mobilization with fewer complications.6
The complications associated with a navicular fracture are osteonecrosis, malunion, nonunion, persistent stiffness, and chronic pain. The nonunion of the navicular can also lead to deformity. The primary surgical intervention in displaced fractures helps in preventing the above-mentioned complications. nonunion of the navicular can leads to adjacent joint degeneration as observed in our patient. Careful clinical examination along with proper investigations are very important in preventing missed navicular injuries which later presents as nonunions and adjacent joint arthritis. The symptomatic nonunions of the navicular should be surgically managed with internal fixation which helps in getting a better outcome.
CONCLUSION
Navicular nonunions are well managed with open reduction and internal fixation using cannulated cancellous screws, which helps in getting compression at the nonunion site and provides stability. Early surgical intervention helps to prevent adjacent joint degenerative arthritis. CT scan evaluation is very essential to diagnose the nonunion navicular as the X-rays appear normal in most cases.
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