Injury, Int. J. Care Injured 46 (2015) 1669–1677
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Results and complications of operative and non-operative navicular fracture treatment§ Marlon O. Coulibaly a,b,*, Clifford B. Jones c,d, Debra L. Sietsema c,d, Thomas A. Schildhauer b a
Orthopaedic Research Fellowship, Grand Rapids Medical Education and Research Center, Grand Rapids, MI, United States Ruhr-University Bochum, University Hospital Bergmannsheil GmbH, Department of Traumatology, Bochum, Germany c Orthopaedic Associates of Michigan, Grand Rapids, MI, United States d Michigan State University, College of Human Medicine, Department of Surgery, Grand Rapids, MI, United States b
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 28 April 2015
Background: Navicular fractures (NF) are uncommon. The purpose of this study was to compare results of operative (ORIF) and non-operative (NOT) treatment in NF. Methods: A retrospective analysis was undertaken on patients diagnosed with NF between March 2002 and June 2007 at a Level I teaching trauma centre. Clinical outcome consisted of functional ability and complications. Results: Eighty-eight patients with 90 fractures were identified including 56 males and 32 females with a mean age of 38 (range 17–72) and body mass index of 28.2 (range 18.7–48.9). Twenty-one of 90 (23.3%) injuries were isolated. Ten of 90 (11.1%) injuries were open. Treatment was 49/90 (55%) NOT and 41/90 (45.6%) ORIF. 11/41 (30%) ORIF required bone grafting. Complications included one ipsilateral deep vein thrombosis, one avascular necrosis, one nonunion, seven infections (two deep and five superficial), and 56 cases of secondary osteoarthrosis (SOA). ORIF had significantly more SOA (x2 = 0.000). Secondary surgery was 25 hardware removals (16 for irritation, five for prominent or broken plates), nine arthrodeses/-plasties, two debridements for infection, and one tarsal tunnel release. Pain was present at final follow up in 39/90 (43.3%) feet. Work status was 64 without restrictions, 17 with restrictions, and 5 did not return to work. Sixty-two of 88 (69%) patients were able to wear normal shoes, which were related to return to work without restrictions (r = 0.508, p = 0.000). Inability to return to previous work was related to pain (r = 0.394), SOA (r = 0.280), and poor reduction quality (r = 0.384) with significance at p < 0.01. Increased BMI (>35) related to pain (r = 0.250) and poor reduction quality (r = 0.326) at a s < 0.05. Conclusions: Despite modern surgical techniques, operative treatment of displaced fractures is at high risk for complications. Obesity, pain, and secondary osteoarthrosis determine shoe wear, return to function, and employment status. Level of Evidence: Level III. ß 2015 Elsevier Ltd. All rights reserved.
Keywords: Navicular fracture Operative fixation Spanning plates Spanning external fixation Open reduction internal fixation
Introduction With an incidence of 0.45% of all fractures, midfoot fractures are uncommon [1]. Navicular fractures (NF) are even more rare [2]. The
§ No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. The manuscript submitted does not contain information about medical devices. * Corresponding author at: Orthopaedic Trauma Surgeon, Ruhr-University Bochum, Faculty of Medicine, University Hospital Bergmannsheil GmbH, Department of Surgery, Bu¨rkle-de-la-Camp-Platz 1, Bochum 44789, Germany. Tel.: +49 234 302 3520; fax: +49 234 302 6530. E-mail address: [email protected] (M.O. Coulibaly).
http://dx.doi.org/10.1016/j.injury.2015.04.033 0020–1383/ß 2015 Elsevier Ltd. All rights reserved.
navicular bone is the supporting structure of the medial column of the foot (MCF). It articulates with the talus, the cuneiforms, and inconsistently with the cuboid bone. In conjunction with the talar head, they form one of the foot’s essential joints [3]. An average of approximately 37 degrees range of motion makes this joint responsible for a substantial amount of hind foot motion [4]. Furthermore, the MCF bears the majority of the load applied to the foot [5,6]. An extensive network of plantar and dorsal ligaments rigidly stabilize the midfoot preventing injury to the navicular bone [3]. Acute and stress fractures are the two major types of NF. Often high energy axial loading injuries result in acute fractures [7], while stress fractures result from excessive repetitive stresses [8]. Since 2007, NF has been classified as non-comminuted or
1670
M.O. Coulibaly et al. / Injury, Int. J. Care Injured 46 (2015) 1669–1677
comminuted [9]. Avulsion fractures are the most common NF [10] and body type NF are subdivided into three different categories [7]. Treatment options are non-operative (NOT), and open reduction internal fixation (ORIF) including primary arthrodesis (PA). NOT results in frequent displacement and late deformity [10,11]. Because of the impact on foot kinetics, PA should remain a salvage procedure [11–13]. However, more commonly ORIF without arthrodesis is the treatment of choice for adequate union and improved outcome [7]. Adequate reduction is crucial for restoring normal gait mechanics and avoiding arthrosis [7,14]. Since different treatment options exist, variable results may be expected. The purpose of this study was to describe and analyze the results and complications of non-operative and operative NF treatment.
2.7 mm plates. Techniques of fixation and supplemental support varied depending on fracture pattern and surgeon preference. If necessary, a medial external fixator was applied adjunct to ORIF. A two-point fixator with 2.5 mm terminally threaded Schantz pins (Synthes, Paoli, PA) was placed between the 1st-metatarsal (MT) and the calcaneal tuber for fracture reduction and reconstitution of overall MCF alignment (see Fig. 1a and b). Alternatively, an internal spanning plate was used when applicable. For maintenance of overall MCF length, a four- to eight-hole 2.0 mm semitubular or 2.7 mm plate was placed over the medial aspect of the MCF (see Fig. 2a and b). In case of severe destruction or
[(Fig._1)TD$IG]
Materials and methods This was an IRB approved, retrospective, cohort study of nonoperatively and operatively treated NF at a Level I teaching trauma centre. Five fellowship trained orthopaedic surgeons performed all operative procedures. Consecutively treated patients were identified by Current Procedural Terminology (CPT) codes 28450, 28456, and 28465 for NF that had initial treatment from March 2002 through June 2007. Inclusion criteria were radiographically diagnosed NF, skeletal maturity, and initial treatment at the study institution. Exclusion criteria were stress fractures, unavailable radiographic images at injury and at final follow-up, and follow-up of less than three months. Age, gender, body mass index (BMI), comorbidity index (CMI) [15], and associated injuries were recorded. Non-operative protocol When non-operative treatment was elected, patients remained toe-touch weight bearing in a splint, short leg cast, or Foot Ankle Support (DonJoy, Vista, CA) for ten to twelve weeks. Progressive weight bearing was initiated for those with isolated injuries based on radiographic and clinical assessment indicating healing and maintenance of reduction. As needed with associated injuries, weight bearing progression was delayed until other injuries warranted. Patients were instructed to begin range-of-motion (ROM) exercises at home and organized physical therapy for weight bearing, gait, ROM, and conditioning. Radiographic and clinical evaluation was recorded during follow up at 2, 6, 12, 26, and 52 weeks. Operative technique A dorso-medial incision was carried out centred over the tarsal navicular. The extensor hallucis longus tendon and the neurovascular bundle were retracted and protected. The NF was identified. Fracture edges and articular fragments were cleaned and refined keeping as many soft tissue attachments to the fracture fragments as possible. With the aid of a temporary spanning 2.5 mm fixator from the talar neck into the middle cuneiform, the fracture was disimpacted and reduced. Articular reduction was accomplished using the articular template of talar head or cuneiforms, respectively. Temporary fixation was maintained with 0.045 Kirschner wires. Osseous defects were filled with bone graft, harvested via a small lateral incision at the calcaneus or at the distal medial part of the tibia. Alternatively allograft was inserted. After bone graft augmentation the cortical fragments were closed on top of the graft. Intra-operative reduction and alignment reconstruction was assessed with fluoroscopic anterior–posterior (AP), oblique (OBL), and lateral (Lat) views. Internal fixation was performed with a small onequarter tubular plate, mini fragment (2.0 mm mini-T-plate) or
Fig. 1. ORIF and adjunct external fixation of the medial column of the foot. (a) Lateral view. (b) Anterior–posterior view.
[(Fig._2)TD$IG]
M.O. Coulibaly et al. / Injury, Int. J. Care Injured 46 (2015) 1669–1677
1671
examinations were recorded during follow-up at 2, 6, 12, 26, and 52 weeks. Image review All interval standard radiographic images of anterior–posterior (AP), oblique (OBL), and lateral (Lat) and/or a CT scan were retrospectively reviewed in a blinded fashion by one of the authors not involved in patient care. Radiographs were used to assess the degree and direction of displacement, degree of comminution, MCF alignment, presence of associated injuries, adequacy of reduction, presence of avascular necrosis (AVN) and non-unions, time to healing, and degree of secondary osteoarthritis (SOA). Furthermore, the injury images were utilized to compare and contrast current classification systems (AO/OTA 1996 & 2007 [9,16], modified Sangeorzan [7,17]). Reduction Adequacy of reduction was assessed from immediate postoperative radiographs based on a modification from Kuo et al. [18]. Reduction was rated as: (1) excellent anatomical reconstruction reduction (no gaps/steps) and re-establishment of MCF alignment; (2) good with intact alignment and near anatomical (gaps/steps 0.05). Use of bone graft also did not relate to healing time, time to weight bearing, infection, SOA, or functional outcome. Reduction following operative treatment was excellent in 13, good in 12, satisfactory in seven, and bad in nine patients. Satisfactory or bad reduction related to pain (r = 0.439, p < 0.01) and decreased association of returning to previous level of activity or work (r = 0.384, p < 0.01). Table 6 provides frequencies of each classification by treatment group. Avulsion fractures were associated with NOT (x2 = 0.001). Operative treatment related to increasing severity of fracture (p < 0.01, modified Sangeorzan: r = 0.427; AO/OTA 1996: r = 0.536; AO/OTA 2007: r = 0.486). Increasing severity of fracture also related to the development of SOA (p < 0.01; modified Sangeorzan: r = 0.308; AO/OTA-96: r = 0.356; AO/OTA-07: r = 0.366).
n = 62
(%)
34 9 6 5 4 4
(54.8) (14.5) (9.7) (8.1) (5.5) (6.4)
Road accidents: includes motor vehicle and motor cycle accident.
Complications are outlined in Table 8. Infections (7/90, 7.8%) were rated [20] as SSI 1a, 1c, and 1d (antibiotics), and SSI 2c and 2d (irrigation and drainage). SOA associated with ORIF (x2 = 0.000) and related to inferior results (r = 0.368, p = 0.000). Secondary surgery to the midfoot Twenty-two of 41 (53.7%) patients who had ORIF also had secondary surgery for implant removal due to local irritation (16/ 41), breakage (3/41), and prominence (2/41). No significant difference was found in the rate of plate removal when comparing 2.0–2.7 mm plates. All spanning plates were removed. Eight
M.O. Coulibaly et al. / Injury, Int. J. Care Injured 46 (2015) 1669–1677
1673
Table 3 Associated foot injuries.
Cuboid Metatarsal Talus Cuneiform Calcaneus Lisfranc Ankle Pilon Phalanx
Total (n = 64)
(%)
ORIF (n = 35)
(%)
NOT (n = 29)
(%)
x2
36 28 28 23 23 17 8 4 2
(56.3) (43.8) (43.8) (35.9) (35.9) (26.6) (12.5) (6.3) (3.1)
19 14 18 15 10 9 3 2 1
(53.4) (40.0) (51.4) (42.9) (28.6) (25.7) (8.6) (5.7) (2.9)
17 14 10 8 13 8 5 2 1
(58.6) (48.3) (34.5) (27.6) (44.8) (27.6) (17.2) (6.9) (3.4)
ns ns ns ns ns ns ns ns ns
ORIF, open reduction internal fixation; NOT, non-operative treatment.
arthrodeses, two joint debridements, and one arthroplasty were carried out. One tarsal tunnel release was performed. Table 9 summarizes patients receiving secondary arthrodesis or arthroplasty. Hardware removal was performed in conjunction with a secondary procedure such as arthrodesis in six cases.
Discussion Treatment and clinical/functional outcome Acute fracture treatment of the tarsal navicular is still controversial. Non-operative treatment should be performed if articular displacement is less than 2 mm, no evident subluxation, and the MCF is intact [3,17,21,22]. Treatment of choice is immobilization in a short leg cast with non-weight bearing for
[(Fig._3)TD$IG]
6–8 weeks. Historic reports recommend non-operative treatment for non-displaced fractures [10,11]. However, non-operative treatment in combined midfoot injuries can lead to instabilityrelated disability [23]. Modern functional anatomy changed the understanding of treatment needs. Restoration of MCF length and articular reconstruction form the basis of the two main methods of reconstructive acute fracture care [3,7,17,24,25]. ORIF is considered the gold standard in displaced fractures. An open approach with visualization of the fracture components facilitates restoration of length and articular congruity (see Fig. 4a–e) [3,7,26,27]. ORIF is recommended since MCF shortening will restrict foot mechanics and articular incongruity results in painful arthritis. K-wire placement [26,28–30], screw fixation [21,28,31], and plating [7,31] have been described. Also external fixation [21,32] and cerclage wire fixation [27] are optional. Overall, ORIF has been
Table 5 Operative treatment. ORIF (n = 41)
(%)
ORIF ORIF & ExFix ORIF & Spanning Plate Proximal (TN joint) Distal (NC joint) Proximal & Distal
24 5 12 0 2 10
(58.5) (12.2) (29.3) (0.0) (4.9) (24.4)
Implants 2.0 Plate 2.7 Plate 2.0 Plate & ExFix 2.7 Plate & ExFix Screws
21 9 4 1 9
(51.2) (22.0) (9.8) (2.4) (22.0)
ORIF, open reduction internal fixation; ExFix, external fixator; TN, talo-navicular; NC, naviculo-cuneiform.
Table 6 Navicular fracture classifications. Fig. 3. Level of activity (LOA), customized shoe wear, secondary osteoarthritis (SOA), and pain in groups of 2-or-less and 3-or-more of associated foot injuries (AFI). *p < 0.01. Mod. Sangeorzan (Type)
Table 4 Associated injuries.
Ipsilateral foot Ipsilateral lower extremity Contralateral lower extremity Pelvic injury Upper extremity Traumatic brain injury Thoracic/abdominal injury Spine injury
n = 90
(%)
70 21 16 7 4 4 2 1
(77.8) (23.3) (17.8) (7.8) (4.4) (4.4) (2.2) (1.1)
AO/OTA 1996 (74)
AO/OTA 2007 (83)
x2
Comprehensive
ORIF (n = 41)
(%)
NOT (n = 49)
(%)
A B C D E Not classifiable
7 2 4 6 21 1
(17.1) (4.9) (9.8) (14.6) (51.2) (2.4)
16 12 7 9 5 0
(32.7) (24.5) (14.3) (18.4) (10.2) (0.0)
A B C Not classifiable
9 17 14 1
(22.0) (41.5) (34.1) (2.4)
30 18 0 1
(61.2) (36.7) (0.0) (2.0)
0.000
A B
16 25
(39.0) (61.0)
42 7
(85.7) (14.3)
0.000 0.000
ORIF, open reduction internal fixation; NOT, non-operative treatment.
0.000
0.000
M.O. Coulibaly et al. / Injury, Int. J. Care Injured 46 (2015) 1669–1677
1674 Table 7 Clinical and functional outcome. ORIF (n = 41)
(%)
NOT (n = 49)
(%)
x2
Pain Yes
21
(51.2)
18
(36.7)
NS
Result Good Fair Poor Not available
16 12 12 1
(39.0) (29.3) (29.3) (2.4)
36 10 3 0
(73.5) (20.4) (6.1) (0.0)
NS NS NS NS
Shoe wear Normal Tennis shoe Orthotic Custom shoe Not available
26 1 12 1 1
(63.5) (2.4) (29.3) (2.4) (2.4)
36 0 8 1 2
(73.5) (0.0) (16.3) (6.1) (4.1)
NS NS NS NS NS
Level of activity Full recovery With restriction No recovery
26 10 2
(68.4) (26.3) (5.3)
38 7 3
(79.2) (14.6) (6.3)
NS NS NS
ORIF, open reduction internal fixation; NOT, non-operative treatment.
Table 8 Complications.
SOA Infection ATX I&D Non-union AVN Comp. syndrome DVT CRPS
ORIF (n = 41)
(%)
NOT (n = 49)
(%)
x2
35
(85.4)
21
(42.9)
0.000
1 2 2 1 1 1 0
(2.4) (4.9) (4.9) (2.4) (2.4) (2.4) (0.0)
2 0 1 0 0 0 0
(4.1) (0.0) (2.0) (0.0) (0.0) (0.0) (0.0)
ORIF, open reduction internal fixation; NOT, non-operative treatment; SOA, secondary osteoarthritis; ATX, antibiotic treatment; I&D, irrigation and drainage; DVT, deep vein thrombosis; CRPS, complex regional pain syndrome.
reported as leading to good results [7,13]. Bridge plating has recently been described for navicular [33] and severe crush injuries [34]. The plate serves as an internal buttress with screw positioning into the talar head, cuneiforms, and/or the base of the 1st-MT depending on the degree of instability. Restoration of column length and prevention of collapse can be achieved. Loss of motion of the essential talo-navicular joint can be prevented with sequential bridge plating [33]. Adjunct to closed reduction internal fixation with screws or K-wires, external fixation is optional [25,32,35]. MCF length restoration and maintenance can be achieved. Fixators can be left for 4–6 weeks to neutralize retracting forces. However, with articular involvement, the impacted zones are not restored even though adequate length has been re-established. The value of external fixators as an adjunct to ORIF in NF care has not been sufficiently supported by the present literature. Adjunct external fixation to ORIF was safe and effective. Reduction and congruity was preserved with this technique. Primary arthrodesis is optional if reconstruction of articular surfaces in the face of severe comminution and destruction is not viable. But primary fusion is seldom necessary [25]. Fusion is highly recommended as a salvage procedure by others [13,26]. NC fusion facilitates reconstruction of severely destructed tarsal navicular bones, while preserving the mobile TN-joint [11,26]. TN fusion is not well tolerated as it locks the talocalcaneo-navicular complex leading to adduction and extension deformity [13]. In late symptomatic cases a triple arthrodesis is preferred [11]. However, TN arthrodesis can lead to good results but a reduction in muscle strength and ankle kinematics has been reported [36]. Pain relief with persistent gait disturbances was reported by others [37]. In the present series, primary arthrodesis has been performed in four cases (two TN- and NC-joint fusions, respectively). SOA was present in all and disabling pain in 3/4 patients. One secondary CC and NC arthrodesis was performed. Primary arthrodesis in NF treatment showed unsatisfying results. Bone graft is recommended for restoration of bony integrity and to promote healing and remodelling [7,13,14,35]. The site of origin is variable and usually cortico-cancellous grafts are taken from the
Table 9 Patients with major secondary foot surgery. Pat. ID
Gender
BMI
Side
Mech
Associated injuries
Associated foot injury
Sangeorzan (Type)
OTA 96 (74)
OTA 07 (83)
1 2 3 4 5 6 7 8 9
M M M F M F M F M
32.7 34.5 28.0 43.8 25.1 25.9 48.8 19.5 28.7
L L L R L R L R L
MCA MVA Fall, height MVA MVA MVA Crush MVA Crush
– ipsLE, conLE, Pelvis – ipsLE, Pelvis ipsLE – – UE –
– Calc, Cub, Cun, MT, Tal Cun, Pilon, Tal Ank, Calc, Cub, Tal Cub, Cun, MT, Tal Cun, Tal Cub, Cun, MT Cun, Lisfr, MT –
E E E C A E B A E
C1 displ. B2.3 B2.3 B2.1 A1.3 C1 displ. A1.2 B1.1 C1 displ.
B B B A A B A A B
Pat. ID
Prim Surg
Reduction
Sec Surg
Time [mo]
HDWR
SOA
Pain
RTW
Shoe wear
FU [mo]
1 2 3 4 5 6 7 8 9
ORIF ORIF ORIF PA NOT ORIF NOT ORIF ORIF
Good Good Bad Bad – Satisfactory – Excellent Good
TN fusion TN/CC fusion Ankle Distraction Arthroplasty CC fusion, NC fusion CC fusion, exploration 4th & 5th TMT-J NC fusion TN/NC/1st-TMT fusion NC fusion, 1st & 2nd-TMT fusion TN fusion, NC fusion, 1st-TMT fusion
20 8 19 15 36 26 18 18 25
Y Y N Y – Y – Y Y
Y Y Y Y Y Y Y Y Y
Y Y Y Y Y N Y N N
Y N Changed Changed N Y Changed Y Y
Orthotic Orthotic Orthotic Normal Normal Normal Custom Orthotic Custom
37 57 37 62 43 52 56 23 50
BMI, body mass index; OTA, orthopaedic trauma association; MVA, motor vehicle accident; MCA, motor cycle injury; ipsLE, ipsilateral lower extremity; conLE, contralateral lower extremity; UE, upper extremity; Ank, ankle; Calc, calcaneus; Cub, cuboid; Cun, cuneiform; Lisf, lisfranc injury; MT, metatarsal; Nav, navicular; Tal, talus; HDWR, hardware removal; SOA, secondary osteoarthritis; RTW, return-to-work/activity; FU, follow-up; ORIF, open reduction internal fixation; PA, primary arthrodesis; NOT, nonoperative treatment; CC, calcaneo-cuboid; TN, talo-navicular; NC, naviculo-cuneiform; TMT, tarso-metatarsal.
[(Fig._4)TD$IG]
M.O. Coulibaly et al. / Injury, Int. J. Care Injured 46 (2015) 1669–1677
1675
Fig. 4. (a) 3D CT-reconstruction in a 29 year old male with a Type-E navicular fracture according to the modified Sangeorzan classification (AO/OTA 74-C1). (b) Axial and (c) coronal CT reconstruction view at injury. (d) Lateral view and (e) AP view at final radiographic follow up 12 months after ORIF.
iliac crest [7,25] or the proximal tibial metaphysis [3]. Locally extruded cancellous bone is an alternative but for stable bony support cortico-cancellous blocks are recommended [7,25]. In the present study, donor sites were the distal tibia, the lateral calcaneus, or locally extruded. No recorded donor site complications were recorded and patient morbidity was low (no deep infection, pain, refracture, AVN, or non-union). The subjective perception of facilitated reduction and articular reconstruction is not supported; therefore, the use of bone grafts needs to be determined within a future study. Bone grafts did not improve rehabilitation, clinical, or functional outcome similar to findings from calcaneus fracture care [38]. Reduction quality is the key to achieving superior results [7]. The study data support the relationship of reduction quality and excellent results. Reduction-dependent outcome has been evidenced in Lisfranc injuries [18,19,39]. Furthermore, improved outcome with column restoration has been reported for midfoot injuries [25]. Classification and clinical/functional outcome The ‘‘ideal classification’’ considers fracture severity and serves as a basis for treatment and evaluation of the results [40]. None of the present classifications fulfilled this idealized vision of Mu¨ller. Sangeorzan et al. [7] showed that operative treatment can be based on the type and direction of displacement (fracture classification) with relation between injury severity and functional outcome. These observational conclusions have not been statistically substantiated. The most common injury of the tarsal navicular are avulsion flake fractures [10]. Most often these can be treated non-operatively [2,10,11,17,26]. Larger fragments involving articular surfaces should be treated operatively [26]. Most often a satisfying result can be achieved [11]. However, secondary osteoarthritis is a possible complication [41]. Furthermore, potential more serious injuries, such as a midtarsal subluxation and instability, should be taken into account [22,26,42,43]. Taking the good (24/36, 67%) results of avulsion fractures into account, the authors agree that most often non-operative treatment should be recommended. Nevertheless, development of secondary osteoarthritis was seen in 47% (17/36). Suspicion should always be present in patients with minor avulsion fractures. To exclude all possibilities of doubt, weight bearing and/or stress radiographs should be taken to rule out unstable or occult injuries of the midtarsal joint complex. All too often, these complex injuries are misdiagnosed as simple sprains [10].
Associated injuries and clinical/functional outcome The navicular bone forms a functional unit with the talus, calcaneus, and cuboid at the midtarsal junction [11]. Because of anatomical boundaries and embedment into a firm capsuloligamentous netting, the tarsal navicular is seldom a single injury [17,26]. Associated foot injuries are common [10] and should always be ruled out before final treatment decision [44]. Furthermore, most often, this injury is derived from a high energy mechanism [17,29,30,44–46] and additional associated injuries of other body areas and organs can be expected, which might influence patient outcome [47,48]. Having a foot injury can prevent patients from returning to full employment leading to subsequent psychological, social and economical problems [47]. In addition, associated foot injuries can have an effect on physical scores, pain, emotional, and social health perception. Navicular fractures should not be considered in isolation [11]. Associated CC joint injuries are common leading to significant long term disability [10,23]. The incidence of associated injuries in the present study is comparable to previous reports of navicular and other midfoot injuries [10,13,23,25,28,29,34,35,43,46,49–52]. Patients suffering from more complex foot injuries, represented by a higher number of associated injuries, were more prone to long term disability. The literature supports the concept of combined midfoot fracture and Chopart/Lisfranc injuries having a worse outcome [25,30,45] or inferior results [39,51]. We conclude that in cases of talar and/or cuboidal injury, the treatment regimen should be aggressive and operative even with minor displacement and/or medial or lateral column instability. However, the present data also show, that pelvic and lower extremity injuries influence clinical and functional outcome. This is an important finding as the outpatient clinical work of the orthopaedic surgeon is among others still challenged by the treatment of multiple injured patients. The period of rehabilitation is of special importance as it builds the foundation of social and economic reintegration. When taking care of the impaired polytrauma patient, pain and function measurements are multifactorial in aetiology. Complications and secondary surgery The overall complication rate as displayed in Table 7 is comparable to previous reports. Regarding secondary surgery most problems were attributable to implants and led to secondary
1676
M.O. Coulibaly et al. / Injury, Int. J. Care Injured 46 (2015) 1669–1677
intervention in more than half of patients in the operative group. Secondary osteoarthritis is the most common sequelae complicating navicular fracture treatment [3,17]. Early onset of arthrosis has been reported in navicular [10,33,46] and midfoot [11,25,45] injuries. Degenerative changes after fracture dislocation, especially the talo-navicular joint, have been described after both treatments [23,45,46]. Others noted greatest arthritic changes in combined midfoot fracture/dislocation injuries [23,25]. In the present study secondary osteoarthritis is a major contributor to disability and predominance in the operative group. Arthrosis relates to pain, functional outcome, and more severe fracture pattern. Furthermore, associated injuries and injury mechanism influence the development of secondary osteoarthrosis. The risk to develop a non-union or osteonecrosis of the navicular bone has been described [14,17,21,22,44,53]. The poorly vascularized central zone of the navicular body [54] predisposes the bone to healing disturbance after severe fracture. Nevertheless, no sufficient evidence substantiates this. Non-union after navicular fracture seems to be rare and more commonly seen in more severe fracture types [7]. In midfoot injuries no healing disturbance has been described [25]. AVN has been described after navicular dislocation [30]. In the present series healing disturbances were rare. Nonunion was seen in a patient with a Type-D fracture and AVN in a Type-E fracture (modified Sangeorzan). Pain, instability, and arthrosis are the primary reasons for secondary intervention. Primary hardware removal was reported for operative treatment of navicular [33] and midfoot injuries [13,25,34,35]. If debilitating osteoarthritis is present, an arthrodesis can be performed leading to satisfying results [37]. No justification for early arthrodesis was seen by some authors [11]. Medial column arthrodesis can achieve excellent results, whereas triple arthrodesis can lead to pain relief at the price of loss of mobility [10]. Higher incidence of arthrodesis was found in a historic report on midtarsal joint injuries [11]. In the present series, 10% of cases needed intervention at the joints and primary implant removal was performed in approximately 50% of operatively treated patients. Arthrodeses were performed due to persistent pain and secondary osteoarthritis. Limitations/strengths Strengths of this study are related to a consecutive series of navicular fractures with five orthopaedic fellowship trained surgeons. The surgical technique was well described and was reproducible. The limitations of this study are related to the inherent issues in the retrospective nature of data collection at a single Level I teaching trauma centre. Major confounding factors must be considered to allow a deeper understanding of the interplay between the specific variables, treatment, and outcome. Severity of injury represents one potential confounding factor. Furthermore, patients were followed until healing for an average of 21 months. The attrition of some patients may be a limitation, but the statistical analysis showed no difference in baseline demographic data. The patients in this study outnumber the patients of all other known published studies combined. To strengthen these findings, a prospective study is warranted. Extrapolation to general orthopaedic surgeons may be limited. Non-operative treatment is feasible for non-displaced fractures. A high suspicion for associated injuries and medial column instability should guide decision making. In displaced fractures, operative treatment is recommended and three different surgical strategies have been presented. Realignment and anatomic reconstruction is desired. In most circumstances sole ORIF leads to sufficient stability. An internal bridging device allows stable fixation and, while buttressing the medial column, minimizes loss of fixation. Indications are severely comminuted fracture patterns and instability of the adjacent joints. Furthermore, despite
satisfactory reduction and high rate of union, fractures of the navicular bone have severe impact on long term clinical and functional outcome. McKeever [2] already noticed that because of the injury-related damage to the articular cartilage, a severe traumatic arthritis of the TN joint develops, resulting in loss of rotational flexibility and pain. Others concluded that fractures of the body most often result in severe long-term disability [7]. This is supported by the present data taking into account that development of secondary osteoarthritis was significantly more often seen in more severe fracture patterns. However, persistence of pain was present in less than half of all patients without influence of treatment strategy. This might be related to a small subgroup sample size or bias (confounding factors). Despite pain and imminent osteoarthritis, loss of function is only seen in 25% of patients. Because of the diversity of follow up times, these data cannot be fully generalized. A prospective study with prolonged follow up of the entire study population over a two year period would be desirable. The follow up data of the patients requiring secondary surgery indicate that severe injuries have a worse end result. Patients with less severe fracture pattern and lower associated injuries should perform better in the long term [25]. Conclusion Navicular fractures are uncommon and usually are associated with other injuries. Operative intervention is enhanced with bone grafting to support impacted fracture fragments. Despite alignment and anatomical restoration, secondary arthritis and pain are common. More severe injuries have worse results. Reduction quality relates to pain and return to function. Conflict of interest None declared. References [1] Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury 2006;37:691–7. [2] McKeever FM. Fractures of tarsal and metatarsal bones. Surg Gynecol Obstet 1950;90:735–45. [3] Hansen Jr ST. Acute trauma and fracture surgery. Functional reconstruction of the foot and ankle. Philadelphia: Lippincott Williams & Wilkins; 2000. [4] Astion DJ, Deland JT, Otis JC, Kenneally S. Motion of the hindfoot after simulated arthrodesis. J Bone Joint Surg Am 1997;79:241–6. [5] Sarrafian SK. Functional characteristics of the foot and plantar aponeurosis under tibiotalar loading. Foot Ankle 1987;8:4–18. [6] Sammarco GJ, Hockenbury RT. Biomechanics of the foot and ankle. In: Nordin M, Frankel VH, editors. Basic biomechanics of the musculoskeletal system. 3rd edn, New York City: Lippincott Williams & Wilkins; 2001. p. 222–55. [7] Sangeorzan BJ, Benirschke SK, Mosca V, Mayo KA, Hansen Jr ST. Displaced intra-articular fractures of the tarsal navicular. J Bone Joint Surg Am 1989;71: 1504–10. [8] de Clercq PF, Bevernage BD, Leemrijse T. Stress fracture of the navicular bone. Acta Orthop Belg 2008;74:725–34. [9] Marsh JL, Slongo TF, Agel J, Broderick JS, Creevey W, DeCoster TA, et al. Fracture and dislocation classification compendium – 2007. Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma 2007;21:S1–33. [10] Eichenholtz SN, Levine DB. Fractures of the tarsal navicular bone. Clin Orthop Relat Res 1964;34:142–57. [11] Main BJ, Jowett RL. Injuries of the midtarsal joint. J Bone Joint Surg Br 1975;57:89–97. [12] Nyska M, Margulies JY, Barbarawi M, Mutchler W, Dekel S, Segal D. Fractures of the body of the tarsal navicular bone: case reports and literature review. J Trauma 1989;29:1448–51. [13] Klaue K. Chopart fractures. Injury 2004;35(Suppl. 2):SB64–70. [14] Rammelt S, Grass R, Zwipp H. Nutcracker fractures of the navicular and cuboid. Ther Umsch 2004;61:451–7. [15] Groll DL, To T, Bombardier C, Wright JG. The development of a comorbidity index with physical function as the outcome. J Clin Epidemiol 2005;58: 595–602. [16] Amendola A, Petrik J, Webster-Bogaert S. Ankle arthroscopy: outcome in 79 consecutive patients. Arthroscopy 1996;12:565–73.
M.O. Coulibaly et al. / Injury, Int. J. Care Injured 46 (2015) 1669–1677 [17] Early JS. Fractures and dislocations of the midfoot and forefoot. In: Bucholz RW, Heckman JD, Court-Brown CM, editors. Rockwood and Green’s fractures in adults. 6th edn, Philadelphia: Lippincott Williams & Wilkins; 2006. p. 2347–53. [18] Kuo RS, Tejwani NC, Digiovanni CW, Holt SK, Benirschke SK, Hansen Jr ST, et al. Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am 2000;82-A:1609–18. [19] Arntz CT, Veith RG, Hansen Jr ST. Fractures and fracture-dislocations of the tarsometatarsal joint. J Bone Joint Surg Am 1988;70:173–81. [20] Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999, Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999;20:250–78. quiz 279–80. [21] Rammelt S, Grass R, Schikore H, Zwipp H. Injuries of the Chopart joint. Unfallchirurg 2002;105:371–83. quiz 384–5. [22] Miller CM, Winter WG, Bucknell AL, Jonassen EA. Injuries to the midtarsal joint and lesser tarsal bones. J Am Acad Orthop Surg 1998;6:249–58. [23] Howie CR, Hooper G, Hughes SP. Occult midtarsal subluxation. Clin Orthop Relat Res 1986;206–9. [24] Sangeorzan BJ, Hansen Jr ST. Early and late posttraumatic foot reconstruction. Clin Orthop Relat Res 1989;86–91. [25] Richter M, Wippermann B, Krettek C, Schratt HE, Hufner T, Therman H. Fractures and fracture dislocations of the midfoot: occurrence, causes and long-term results. Foot Ankle Int 2001;22:392–8. [26] Pinney SJ, Sangeorzan BJ. Fractures of the tarsal bones. Orthop Clin North Am 2001;32:21–33. [27] Naidu V, Singh SK. Cerclage wire fixation of navicular body fractures – a treatment based on mechanism of injury. Foot Ankle Int 2005;26:267–9. [28] Kimura K, Adachi H, Ogawa M, Sakamoto H. Supplementary transverse wire fixation through cuneiforms and cuboid in combination with a screw for the comminuted tarsal navicular fractures. Arch Orthop Trauma Surg 2002;122: 410–3. [29] Rymaszewski LA, Robb JE. Mechanism of fracture-dislocation of the navicular: brief report. J Bone Joint Surg Br 1988;70:492. [30] Dhillon MS, Nagi ON. Total dislocations of the navicular: are they ever isolated injuries? J Bone Joint Surg Br 1999;81:881–5. [31] Sangeorzan BJ, Mayo KA, Hansen ST. Intraarticular fractures of the foot. Talus and lesser tarsals. Clin Orthop Relat Res 1993;135–41. [32] Chandran P, Puttaswamaiah R, Dhillon MS, Gill SS. Management of complex open fracture injuries of the midfoot with external fixation. J Foot Ankle Surg 2006;45:308–15. [33] Apostle KL, Younger AS. Technique tip: open reduction internal fixation of comminuted fractures of the navicular with bridge plating to the medial and middle cuneiforms. Foot Ankle Int 2008;29:739–41. [34] Schildhauer TA, Nork SE, Sangeorzan BJ. Temporary bridge plating of the medial column in severe midfoot injuries. J Orthop Trauma 2003;17:513–20.
1677
[35] Randt T, Dahlen C, Schikore H, Zwipp H. Dislocation fractures in the area of the middle foot-injuries of the Chopart and Lisfranc joint. Zentralbl Chir 1998; 123:1257–66. [36] Fishco WD, Cornwall MW. Gait analysis after talonavicular joint fusion: 2 case reports. J Foot Ankle Surg 2004;43:241–7. [37] Fogel GR, Katoh Y, Rand JA, Chao EY. Talonavicular arthrodesis for isolated arthrosis: 9.5-year results and gait analysis. Foot Ankle 1982;3:105–13. [38] Longino D, Buckley RE. Bone graft in the operative treatment of displaced intraarticular calcaneal fractures: is it helpful? J Orthop Trauma 2001;15: 280–6. [39] Myerson MS, Fisher RT, Burgess AR, Kenzora JE. Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment. Foot Ankle 1986;6:225–42. [40] Mu¨ller ME, Nazarian S, Koch P. Classification AO des fractures: les os longs. Berlin/Heidelberg/New York: Springer-Verlag; 1987. [41] Penner MJ. Late reconstruction after navicular fracture. Foot Ankle Clin 2006;11:105–19. ix. [42] Dewar FP, Evans DC. Occult fracture-subluxation of the midtarsal joint. J Bone Joint Surg Br 1968;50:386–8. [43] Tountas AA. Occult fracture-subluxation of the midtarsal joint. Clin Orthop Relat Res 1989;195–9. [44] Di Giovanni CW. Fractures of the navicular. Foot Ankle Clin 2004;9:25–63. [45] Ip KY, Lui TH. Isolated dorsal midtarsal (Chopart) dislocation: a case report. J Orthop Surg (Hong Kong) 2006;14:357–9. [46] Meister K, Demos HA. Fracture dislocation of the tarsal navicular with medial column disruption of the foot. J Foot Ankle Surg 1994;33:135–7. [47] Stiegelmar R, McKee MD, Waddell JP, Schemitsch EH. Outcome of foot injuries in multiply injured patients. Orthop Clin North Am 2001;32:193–204. x. [48] Tran T, Thordarson D. Functional outcome of multiply injured patients with associated foot injury. Foot Ankle Int 2002;23:340–3. [49] Preidler KW, Peicha G, Lajtai G, Seibert FJ, Fock C, Szolar DM, et al. Conventional radiography, CT, and MR imaging in patients with hyperflexion injuries of the foot: diagnostic accuracy in the detection of bony and ligamentous changes. Am J Roentgenol 1999;173:1673–7. [50] Newton Ede MP, Miller C, Malik MH, Khan SA. An unusual case of talonavicular dislocation with associated ipsilateral foot fractures. J R Army Med Corps 2006;152:102–3. [51] Weber M, Locher S. Reconstruction of the cuboid in compression fractures: short to midterm results in 12 patients. Foot Ankle Int 2002;23:1008–13. [52] Ebizie AO. Crush fractures of the cuboid from indirect violence. Injury 1991;22:414–6. [53] Adelaar RS. The treatment of tarsometatarsal fracture-dislocation. Instr Course Lect 1990;39:141–5. [54] Waugh W. The ossification and vascularisation of the tarsal navicular and their relation to Kohler’s disease. J Bone Joint Surg Br 1958;40-B:765–77.
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Results and complications of operative and non-operative navicular fracture treatment§ Marlon O. Coulibaly a,b,*, Clifford B. Jones c,d, Debra L. Sietsema c,d, Thomas A. Schildhauer b a
Orthopaedic Research Fellowship, Grand Rapids Medical Education and Research Center, Grand Rapids, MI, United States Ruhr-University Bochum, University Hospital Bergmannsheil GmbH, Department of Traumatology, Bochum, Germany c Orthopaedic Associates of Michigan, Grand Rapids, MI, United States d Michigan State University, College of Human Medicine, Department of Surgery, Grand Rapids, MI, United States b
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 28 April 2015
Background: Navicular fractures (NF) are uncommon. The purpose of this study was to compare results of operative (ORIF) and non-operative (NOT) treatment in NF. Methods: A retrospective analysis was undertaken on patients diagnosed with NF between March 2002 and June 2007 at a Level I teaching trauma centre. Clinical outcome consisted of functional ability and complications. Results: Eighty-eight patients with 90 fractures were identified including 56 males and 32 females with a mean age of 38 (range 17–72) and body mass index of 28.2 (range 18.7–48.9). Twenty-one of 90 (23.3%) injuries were isolated. Ten of 90 (11.1%) injuries were open. Treatment was 49/90 (55%) NOT and 41/90 (45.6%) ORIF. 11/41 (30%) ORIF required bone grafting. Complications included one ipsilateral deep vein thrombosis, one avascular necrosis, one nonunion, seven infections (two deep and five superficial), and 56 cases of secondary osteoarthrosis (SOA). ORIF had significantly more SOA (x2 = 0.000). Secondary surgery was 25 hardware removals (16 for irritation, five for prominent or broken plates), nine arthrodeses/-plasties, two debridements for infection, and one tarsal tunnel release. Pain was present at final follow up in 39/90 (43.3%) feet. Work status was 64 without restrictions, 17 with restrictions, and 5 did not return to work. Sixty-two of 88 (69%) patients were able to wear normal shoes, which were related to return to work without restrictions (r = 0.508, p = 0.000). Inability to return to previous work was related to pain (r = 0.394), SOA (r = 0.280), and poor reduction quality (r = 0.384) with significance at p < 0.01. Increased BMI (>35) related to pain (r = 0.250) and poor reduction quality (r = 0.326) at a s < 0.05. Conclusions: Despite modern surgical techniques, operative treatment of displaced fractures is at high risk for complications. Obesity, pain, and secondary osteoarthrosis determine shoe wear, return to function, and employment status. Level of Evidence: Level III. ß 2015 Elsevier Ltd. All rights reserved.
Keywords: Navicular fracture Operative fixation Spanning plates Spanning external fixation Open reduction internal fixation
Introduction With an incidence of 0.45% of all fractures, midfoot fractures are uncommon [1]. Navicular fractures (NF) are even more rare [2]. The
§ No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. The manuscript submitted does not contain information about medical devices. * Corresponding author at: Orthopaedic Trauma Surgeon, Ruhr-University Bochum, Faculty of Medicine, University Hospital Bergmannsheil GmbH, Department of Surgery, Bu¨rkle-de-la-Camp-Platz 1, Bochum 44789, Germany. Tel.: +49 234 302 3520; fax: +49 234 302 6530. E-mail address: [email protected] (M.O. Coulibaly).
http://dx.doi.org/10.1016/j.injury.2015.04.033 0020–1383/ß 2015 Elsevier Ltd. All rights reserved.
navicular bone is the supporting structure of the medial column of the foot (MCF). It articulates with the talus, the cuneiforms, and inconsistently with the cuboid bone. In conjunction with the talar head, they form one of the foot’s essential joints [3]. An average of approximately 37 degrees range of motion makes this joint responsible for a substantial amount of hind foot motion [4]. Furthermore, the MCF bears the majority of the load applied to the foot [5,6]. An extensive network of plantar and dorsal ligaments rigidly stabilize the midfoot preventing injury to the navicular bone [3]. Acute and stress fractures are the two major types of NF. Often high energy axial loading injuries result in acute fractures [7], while stress fractures result from excessive repetitive stresses [8]. Since 2007, NF has been classified as non-comminuted or
1670
M.O. Coulibaly et al. / Injury, Int. J. Care Injured 46 (2015) 1669–1677
comminuted [9]. Avulsion fractures are the most common NF [10] and body type NF are subdivided into three different categories [7]. Treatment options are non-operative (NOT), and open reduction internal fixation (ORIF) including primary arthrodesis (PA). NOT results in frequent displacement and late deformity [10,11]. Because of the impact on foot kinetics, PA should remain a salvage procedure [11–13]. However, more commonly ORIF without arthrodesis is the treatment of choice for adequate union and improved outcome [7]. Adequate reduction is crucial for restoring normal gait mechanics and avoiding arthrosis [7,14]. Since different treatment options exist, variable results may be expected. The purpose of this study was to describe and analyze the results and complications of non-operative and operative NF treatment.
2.7 mm plates. Techniques of fixation and supplemental support varied depending on fracture pattern and surgeon preference. If necessary, a medial external fixator was applied adjunct to ORIF. A two-point fixator with 2.5 mm terminally threaded Schantz pins (Synthes, Paoli, PA) was placed between the 1st-metatarsal (MT) and the calcaneal tuber for fracture reduction and reconstitution of overall MCF alignment (see Fig. 1a and b). Alternatively, an internal spanning plate was used when applicable. For maintenance of overall MCF length, a four- to eight-hole 2.0 mm semitubular or 2.7 mm plate was placed over the medial aspect of the MCF (see Fig. 2a and b). In case of severe destruction or
[(Fig._1)TD$IG]
Materials and methods This was an IRB approved, retrospective, cohort study of nonoperatively and operatively treated NF at a Level I teaching trauma centre. Five fellowship trained orthopaedic surgeons performed all operative procedures. Consecutively treated patients were identified by Current Procedural Terminology (CPT) codes 28450, 28456, and 28465 for NF that had initial treatment from March 2002 through June 2007. Inclusion criteria were radiographically diagnosed NF, skeletal maturity, and initial treatment at the study institution. Exclusion criteria were stress fractures, unavailable radiographic images at injury and at final follow-up, and follow-up of less than three months. Age, gender, body mass index (BMI), comorbidity index (CMI) [15], and associated injuries were recorded. Non-operative protocol When non-operative treatment was elected, patients remained toe-touch weight bearing in a splint, short leg cast, or Foot Ankle Support (DonJoy, Vista, CA) for ten to twelve weeks. Progressive weight bearing was initiated for those with isolated injuries based on radiographic and clinical assessment indicating healing and maintenance of reduction. As needed with associated injuries, weight bearing progression was delayed until other injuries warranted. Patients were instructed to begin range-of-motion (ROM) exercises at home and organized physical therapy for weight bearing, gait, ROM, and conditioning. Radiographic and clinical evaluation was recorded during follow up at 2, 6, 12, 26, and 52 weeks. Operative technique A dorso-medial incision was carried out centred over the tarsal navicular. The extensor hallucis longus tendon and the neurovascular bundle were retracted and protected. The NF was identified. Fracture edges and articular fragments were cleaned and refined keeping as many soft tissue attachments to the fracture fragments as possible. With the aid of a temporary spanning 2.5 mm fixator from the talar neck into the middle cuneiform, the fracture was disimpacted and reduced. Articular reduction was accomplished using the articular template of talar head or cuneiforms, respectively. Temporary fixation was maintained with 0.045 Kirschner wires. Osseous defects were filled with bone graft, harvested via a small lateral incision at the calcaneus or at the distal medial part of the tibia. Alternatively allograft was inserted. After bone graft augmentation the cortical fragments were closed on top of the graft. Intra-operative reduction and alignment reconstruction was assessed with fluoroscopic anterior–posterior (AP), oblique (OBL), and lateral (Lat) views. Internal fixation was performed with a small onequarter tubular plate, mini fragment (2.0 mm mini-T-plate) or
Fig. 1. ORIF and adjunct external fixation of the medial column of the foot. (a) Lateral view. (b) Anterior–posterior view.
[(Fig._2)TD$IG]
M.O. Coulibaly et al. / Injury, Int. J. Care Injured 46 (2015) 1669–1677
1671
examinations were recorded during follow-up at 2, 6, 12, 26, and 52 weeks. Image review All interval standard radiographic images of anterior–posterior (AP), oblique (OBL), and lateral (Lat) and/or a CT scan were retrospectively reviewed in a blinded fashion by one of the authors not involved in patient care. Radiographs were used to assess the degree and direction of displacement, degree of comminution, MCF alignment, presence of associated injuries, adequacy of reduction, presence of avascular necrosis (AVN) and non-unions, time to healing, and degree of secondary osteoarthritis (SOA). Furthermore, the injury images were utilized to compare and contrast current classification systems (AO/OTA 1996 & 2007 [9,16], modified Sangeorzan [7,17]). Reduction Adequacy of reduction was assessed from immediate postoperative radiographs based on a modification from Kuo et al. [18]. Reduction was rated as: (1) excellent anatomical reconstruction reduction (no gaps/steps) and re-establishment of MCF alignment; (2) good with intact alignment and near anatomical (gaps/steps 0.05). Use of bone graft also did not relate to healing time, time to weight bearing, infection, SOA, or functional outcome. Reduction following operative treatment was excellent in 13, good in 12, satisfactory in seven, and bad in nine patients. Satisfactory or bad reduction related to pain (r = 0.439, p < 0.01) and decreased association of returning to previous level of activity or work (r = 0.384, p < 0.01). Table 6 provides frequencies of each classification by treatment group. Avulsion fractures were associated with NOT (x2 = 0.001). Operative treatment related to increasing severity of fracture (p < 0.01, modified Sangeorzan: r = 0.427; AO/OTA 1996: r = 0.536; AO/OTA 2007: r = 0.486). Increasing severity of fracture also related to the development of SOA (p < 0.01; modified Sangeorzan: r = 0.308; AO/OTA-96: r = 0.356; AO/OTA-07: r = 0.366).
n = 62
(%)
34 9 6 5 4 4
(54.8) (14.5) (9.7) (8.1) (5.5) (6.4)
Road accidents: includes motor vehicle and motor cycle accident.
Complications are outlined in Table 8. Infections (7/90, 7.8%) were rated [20] as SSI 1a, 1c, and 1d (antibiotics), and SSI 2c and 2d (irrigation and drainage). SOA associated with ORIF (x2 = 0.000) and related to inferior results (r = 0.368, p = 0.000). Secondary surgery to the midfoot Twenty-two of 41 (53.7%) patients who had ORIF also had secondary surgery for implant removal due to local irritation (16/ 41), breakage (3/41), and prominence (2/41). No significant difference was found in the rate of plate removal when comparing 2.0–2.7 mm plates. All spanning plates were removed. Eight
M.O. Coulibaly et al. / Injury, Int. J. Care Injured 46 (2015) 1669–1677
1673
Table 3 Associated foot injuries.
Cuboid Metatarsal Talus Cuneiform Calcaneus Lisfranc Ankle Pilon Phalanx
Total (n = 64)
(%)
ORIF (n = 35)
(%)
NOT (n = 29)
(%)
x2
36 28 28 23 23 17 8 4 2
(56.3) (43.8) (43.8) (35.9) (35.9) (26.6) (12.5) (6.3) (3.1)
19 14 18 15 10 9 3 2 1
(53.4) (40.0) (51.4) (42.9) (28.6) (25.7) (8.6) (5.7) (2.9)
17 14 10 8 13 8 5 2 1
(58.6) (48.3) (34.5) (27.6) (44.8) (27.6) (17.2) (6.9) (3.4)
ns ns ns ns ns ns ns ns ns
ORIF, open reduction internal fixation; NOT, non-operative treatment.
arthrodeses, two joint debridements, and one arthroplasty were carried out. One tarsal tunnel release was performed. Table 9 summarizes patients receiving secondary arthrodesis or arthroplasty. Hardware removal was performed in conjunction with a secondary procedure such as arthrodesis in six cases.
Discussion Treatment and clinical/functional outcome Acute fracture treatment of the tarsal navicular is still controversial. Non-operative treatment should be performed if articular displacement is less than 2 mm, no evident subluxation, and the MCF is intact [3,17,21,22]. Treatment of choice is immobilization in a short leg cast with non-weight bearing for
[(Fig._3)TD$IG]
6–8 weeks. Historic reports recommend non-operative treatment for non-displaced fractures [10,11]. However, non-operative treatment in combined midfoot injuries can lead to instabilityrelated disability [23]. Modern functional anatomy changed the understanding of treatment needs. Restoration of MCF length and articular reconstruction form the basis of the two main methods of reconstructive acute fracture care [3,7,17,24,25]. ORIF is considered the gold standard in displaced fractures. An open approach with visualization of the fracture components facilitates restoration of length and articular congruity (see Fig. 4a–e) [3,7,26,27]. ORIF is recommended since MCF shortening will restrict foot mechanics and articular incongruity results in painful arthritis. K-wire placement [26,28–30], screw fixation [21,28,31], and plating [7,31] have been described. Also external fixation [21,32] and cerclage wire fixation [27] are optional. Overall, ORIF has been
Table 5 Operative treatment. ORIF (n = 41)
(%)
ORIF ORIF & ExFix ORIF & Spanning Plate Proximal (TN joint) Distal (NC joint) Proximal & Distal
24 5 12 0 2 10
(58.5) (12.2) (29.3) (0.0) (4.9) (24.4)
Implants 2.0 Plate 2.7 Plate 2.0 Plate & ExFix 2.7 Plate & ExFix Screws
21 9 4 1 9
(51.2) (22.0) (9.8) (2.4) (22.0)
ORIF, open reduction internal fixation; ExFix, external fixator; TN, talo-navicular; NC, naviculo-cuneiform.
Table 6 Navicular fracture classifications. Fig. 3. Level of activity (LOA), customized shoe wear, secondary osteoarthritis (SOA), and pain in groups of 2-or-less and 3-or-more of associated foot injuries (AFI). *p < 0.01. Mod. Sangeorzan (Type)
Table 4 Associated injuries.
Ipsilateral foot Ipsilateral lower extremity Contralateral lower extremity Pelvic injury Upper extremity Traumatic brain injury Thoracic/abdominal injury Spine injury
n = 90
(%)
70 21 16 7 4 4 2 1
(77.8) (23.3) (17.8) (7.8) (4.4) (4.4) (2.2) (1.1)
AO/OTA 1996 (74)
AO/OTA 2007 (83)
x2
Comprehensive
ORIF (n = 41)
(%)
NOT (n = 49)
(%)
A B C D E Not classifiable
7 2 4 6 21 1
(17.1) (4.9) (9.8) (14.6) (51.2) (2.4)
16 12 7 9 5 0
(32.7) (24.5) (14.3) (18.4) (10.2) (0.0)
A B C Not classifiable
9 17 14 1
(22.0) (41.5) (34.1) (2.4)
30 18 0 1
(61.2) (36.7) (0.0) (2.0)
0.000
A B
16 25
(39.0) (61.0)
42 7
(85.7) (14.3)
0.000 0.000
ORIF, open reduction internal fixation; NOT, non-operative treatment.
0.000
0.000
M.O. Coulibaly et al. / Injury, Int. J. Care Injured 46 (2015) 1669–1677
1674 Table 7 Clinical and functional outcome. ORIF (n = 41)
(%)
NOT (n = 49)
(%)
x2
Pain Yes
21
(51.2)
18
(36.7)
NS
Result Good Fair Poor Not available
16 12 12 1
(39.0) (29.3) (29.3) (2.4)
36 10 3 0
(73.5) (20.4) (6.1) (0.0)
NS NS NS NS
Shoe wear Normal Tennis shoe Orthotic Custom shoe Not available
26 1 12 1 1
(63.5) (2.4) (29.3) (2.4) (2.4)
36 0 8 1 2
(73.5) (0.0) (16.3) (6.1) (4.1)
NS NS NS NS NS
Level of activity Full recovery With restriction No recovery
26 10 2
(68.4) (26.3) (5.3)
38 7 3
(79.2) (14.6) (6.3)
NS NS NS
ORIF, open reduction internal fixation; NOT, non-operative treatment.
Table 8 Complications.
SOA Infection ATX I&D Non-union AVN Comp. syndrome DVT CRPS
ORIF (n = 41)
(%)
NOT (n = 49)
(%)
x2
35
(85.4)
21
(42.9)
0.000
1 2 2 1 1 1 0
(2.4) (4.9) (4.9) (2.4) (2.4) (2.4) (0.0)
2 0 1 0 0 0 0
(4.1) (0.0) (2.0) (0.0) (0.0) (0.0) (0.0)
ORIF, open reduction internal fixation; NOT, non-operative treatment; SOA, secondary osteoarthritis; ATX, antibiotic treatment; I&D, irrigation and drainage; DVT, deep vein thrombosis; CRPS, complex regional pain syndrome.
reported as leading to good results [7,13]. Bridge plating has recently been described for navicular [33] and severe crush injuries [34]. The plate serves as an internal buttress with screw positioning into the talar head, cuneiforms, and/or the base of the 1st-MT depending on the degree of instability. Restoration of column length and prevention of collapse can be achieved. Loss of motion of the essential talo-navicular joint can be prevented with sequential bridge plating [33]. Adjunct to closed reduction internal fixation with screws or K-wires, external fixation is optional [25,32,35]. MCF length restoration and maintenance can be achieved. Fixators can be left for 4–6 weeks to neutralize retracting forces. However, with articular involvement, the impacted zones are not restored even though adequate length has been re-established. The value of external fixators as an adjunct to ORIF in NF care has not been sufficiently supported by the present literature. Adjunct external fixation to ORIF was safe and effective. Reduction and congruity was preserved with this technique. Primary arthrodesis is optional if reconstruction of articular surfaces in the face of severe comminution and destruction is not viable. But primary fusion is seldom necessary [25]. Fusion is highly recommended as a salvage procedure by others [13,26]. NC fusion facilitates reconstruction of severely destructed tarsal navicular bones, while preserving the mobile TN-joint [11,26]. TN fusion is not well tolerated as it locks the talocalcaneo-navicular complex leading to adduction and extension deformity [13]. In late symptomatic cases a triple arthrodesis is preferred [11]. However, TN arthrodesis can lead to good results but a reduction in muscle strength and ankle kinematics has been reported [36]. Pain relief with persistent gait disturbances was reported by others [37]. In the present series, primary arthrodesis has been performed in four cases (two TN- and NC-joint fusions, respectively). SOA was present in all and disabling pain in 3/4 patients. One secondary CC and NC arthrodesis was performed. Primary arthrodesis in NF treatment showed unsatisfying results. Bone graft is recommended for restoration of bony integrity and to promote healing and remodelling [7,13,14,35]. The site of origin is variable and usually cortico-cancellous grafts are taken from the
Table 9 Patients with major secondary foot surgery. Pat. ID
Gender
BMI
Side
Mech
Associated injuries
Associated foot injury
Sangeorzan (Type)
OTA 96 (74)
OTA 07 (83)
1 2 3 4 5 6 7 8 9
M M M F M F M F M
32.7 34.5 28.0 43.8 25.1 25.9 48.8 19.5 28.7
L L L R L R L R L
MCA MVA Fall, height MVA MVA MVA Crush MVA Crush
– ipsLE, conLE, Pelvis – ipsLE, Pelvis ipsLE – – UE –
– Calc, Cub, Cun, MT, Tal Cun, Pilon, Tal Ank, Calc, Cub, Tal Cub, Cun, MT, Tal Cun, Tal Cub, Cun, MT Cun, Lisfr, MT –
E E E C A E B A E
C1 displ. B2.3 B2.3 B2.1 A1.3 C1 displ. A1.2 B1.1 C1 displ.
B B B A A B A A B
Pat. ID
Prim Surg
Reduction
Sec Surg
Time [mo]
HDWR
SOA
Pain
RTW
Shoe wear
FU [mo]
1 2 3 4 5 6 7 8 9
ORIF ORIF ORIF PA NOT ORIF NOT ORIF ORIF
Good Good Bad Bad – Satisfactory – Excellent Good
TN fusion TN/CC fusion Ankle Distraction Arthroplasty CC fusion, NC fusion CC fusion, exploration 4th & 5th TMT-J NC fusion TN/NC/1st-TMT fusion NC fusion, 1st & 2nd-TMT fusion TN fusion, NC fusion, 1st-TMT fusion
20 8 19 15 36 26 18 18 25
Y Y N Y – Y – Y Y
Y Y Y Y Y Y Y Y Y
Y Y Y Y Y N Y N N
Y N Changed Changed N Y Changed Y Y
Orthotic Orthotic Orthotic Normal Normal Normal Custom Orthotic Custom
37 57 37 62 43 52 56 23 50
BMI, body mass index; OTA, orthopaedic trauma association; MVA, motor vehicle accident; MCA, motor cycle injury; ipsLE, ipsilateral lower extremity; conLE, contralateral lower extremity; UE, upper extremity; Ank, ankle; Calc, calcaneus; Cub, cuboid; Cun, cuneiform; Lisf, lisfranc injury; MT, metatarsal; Nav, navicular; Tal, talus; HDWR, hardware removal; SOA, secondary osteoarthritis; RTW, return-to-work/activity; FU, follow-up; ORIF, open reduction internal fixation; PA, primary arthrodesis; NOT, nonoperative treatment; CC, calcaneo-cuboid; TN, talo-navicular; NC, naviculo-cuneiform; TMT, tarso-metatarsal.
[(Fig._4)TD$IG]
M.O. Coulibaly et al. / Injury, Int. J. Care Injured 46 (2015) 1669–1677
1675
Fig. 4. (a) 3D CT-reconstruction in a 29 year old male with a Type-E navicular fracture according to the modified Sangeorzan classification (AO/OTA 74-C1). (b) Axial and (c) coronal CT reconstruction view at injury. (d) Lateral view and (e) AP view at final radiographic follow up 12 months after ORIF.
iliac crest [7,25] or the proximal tibial metaphysis [3]. Locally extruded cancellous bone is an alternative but for stable bony support cortico-cancellous blocks are recommended [7,25]. In the present study, donor sites were the distal tibia, the lateral calcaneus, or locally extruded. No recorded donor site complications were recorded and patient morbidity was low (no deep infection, pain, refracture, AVN, or non-union). The subjective perception of facilitated reduction and articular reconstruction is not supported; therefore, the use of bone grafts needs to be determined within a future study. Bone grafts did not improve rehabilitation, clinical, or functional outcome similar to findings from calcaneus fracture care [38]. Reduction quality is the key to achieving superior results [7]. The study data support the relationship of reduction quality and excellent results. Reduction-dependent outcome has been evidenced in Lisfranc injuries [18,19,39]. Furthermore, improved outcome with column restoration has been reported for midfoot injuries [25]. Classification and clinical/functional outcome The ‘‘ideal classification’’ considers fracture severity and serves as a basis for treatment and evaluation of the results [40]. None of the present classifications fulfilled this idealized vision of Mu¨ller. Sangeorzan et al. [7] showed that operative treatment can be based on the type and direction of displacement (fracture classification) with relation between injury severity and functional outcome. These observational conclusions have not been statistically substantiated. The most common injury of the tarsal navicular are avulsion flake fractures [10]. Most often these can be treated non-operatively [2,10,11,17,26]. Larger fragments involving articular surfaces should be treated operatively [26]. Most often a satisfying result can be achieved [11]. However, secondary osteoarthritis is a possible complication [41]. Furthermore, potential more serious injuries, such as a midtarsal subluxation and instability, should be taken into account [22,26,42,43]. Taking the good (24/36, 67%) results of avulsion fractures into account, the authors agree that most often non-operative treatment should be recommended. Nevertheless, development of secondary osteoarthritis was seen in 47% (17/36). Suspicion should always be present in patients with minor avulsion fractures. To exclude all possibilities of doubt, weight bearing and/or stress radiographs should be taken to rule out unstable or occult injuries of the midtarsal joint complex. All too often, these complex injuries are misdiagnosed as simple sprains [10].
Associated injuries and clinical/functional outcome The navicular bone forms a functional unit with the talus, calcaneus, and cuboid at the midtarsal junction [11]. Because of anatomical boundaries and embedment into a firm capsuloligamentous netting, the tarsal navicular is seldom a single injury [17,26]. Associated foot injuries are common [10] and should always be ruled out before final treatment decision [44]. Furthermore, most often, this injury is derived from a high energy mechanism [17,29,30,44–46] and additional associated injuries of other body areas and organs can be expected, which might influence patient outcome [47,48]. Having a foot injury can prevent patients from returning to full employment leading to subsequent psychological, social and economical problems [47]. In addition, associated foot injuries can have an effect on physical scores, pain, emotional, and social health perception. Navicular fractures should not be considered in isolation [11]. Associated CC joint injuries are common leading to significant long term disability [10,23]. The incidence of associated injuries in the present study is comparable to previous reports of navicular and other midfoot injuries [10,13,23,25,28,29,34,35,43,46,49–52]. Patients suffering from more complex foot injuries, represented by a higher number of associated injuries, were more prone to long term disability. The literature supports the concept of combined midfoot fracture and Chopart/Lisfranc injuries having a worse outcome [25,30,45] or inferior results [39,51]. We conclude that in cases of talar and/or cuboidal injury, the treatment regimen should be aggressive and operative even with minor displacement and/or medial or lateral column instability. However, the present data also show, that pelvic and lower extremity injuries influence clinical and functional outcome. This is an important finding as the outpatient clinical work of the orthopaedic surgeon is among others still challenged by the treatment of multiple injured patients. The period of rehabilitation is of special importance as it builds the foundation of social and economic reintegration. When taking care of the impaired polytrauma patient, pain and function measurements are multifactorial in aetiology. Complications and secondary surgery The overall complication rate as displayed in Table 7 is comparable to previous reports. Regarding secondary surgery most problems were attributable to implants and led to secondary
1676
M.O. Coulibaly et al. / Injury, Int. J. Care Injured 46 (2015) 1669–1677
intervention in more than half of patients in the operative group. Secondary osteoarthritis is the most common sequelae complicating navicular fracture treatment [3,17]. Early onset of arthrosis has been reported in navicular [10,33,46] and midfoot [11,25,45] injuries. Degenerative changes after fracture dislocation, especially the talo-navicular joint, have been described after both treatments [23,45,46]. Others noted greatest arthritic changes in combined midfoot fracture/dislocation injuries [23,25]. In the present study secondary osteoarthritis is a major contributor to disability and predominance in the operative group. Arthrosis relates to pain, functional outcome, and more severe fracture pattern. Furthermore, associated injuries and injury mechanism influence the development of secondary osteoarthrosis. The risk to develop a non-union or osteonecrosis of the navicular bone has been described [14,17,21,22,44,53]. The poorly vascularized central zone of the navicular body [54] predisposes the bone to healing disturbance after severe fracture. Nevertheless, no sufficient evidence substantiates this. Non-union after navicular fracture seems to be rare and more commonly seen in more severe fracture types [7]. In midfoot injuries no healing disturbance has been described [25]. AVN has been described after navicular dislocation [30]. In the present series healing disturbances were rare. Nonunion was seen in a patient with a Type-D fracture and AVN in a Type-E fracture (modified Sangeorzan). Pain, instability, and arthrosis are the primary reasons for secondary intervention. Primary hardware removal was reported for operative treatment of navicular [33] and midfoot injuries [13,25,34,35]. If debilitating osteoarthritis is present, an arthrodesis can be performed leading to satisfying results [37]. No justification for early arthrodesis was seen by some authors [11]. Medial column arthrodesis can achieve excellent results, whereas triple arthrodesis can lead to pain relief at the price of loss of mobility [10]. Higher incidence of arthrodesis was found in a historic report on midtarsal joint injuries [11]. In the present series, 10% of cases needed intervention at the joints and primary implant removal was performed in approximately 50% of operatively treated patients. Arthrodeses were performed due to persistent pain and secondary osteoarthritis. Limitations/strengths Strengths of this study are related to a consecutive series of navicular fractures with five orthopaedic fellowship trained surgeons. The surgical technique was well described and was reproducible. The limitations of this study are related to the inherent issues in the retrospective nature of data collection at a single Level I teaching trauma centre. Major confounding factors must be considered to allow a deeper understanding of the interplay between the specific variables, treatment, and outcome. Severity of injury represents one potential confounding factor. Furthermore, patients were followed until healing for an average of 21 months. The attrition of some patients may be a limitation, but the statistical analysis showed no difference in baseline demographic data. The patients in this study outnumber the patients of all other known published studies combined. To strengthen these findings, a prospective study is warranted. Extrapolation to general orthopaedic surgeons may be limited. Non-operative treatment is feasible for non-displaced fractures. A high suspicion for associated injuries and medial column instability should guide decision making. In displaced fractures, operative treatment is recommended and three different surgical strategies have been presented. Realignment and anatomic reconstruction is desired. In most circumstances sole ORIF leads to sufficient stability. An internal bridging device allows stable fixation and, while buttressing the medial column, minimizes loss of fixation. Indications are severely comminuted fracture patterns and instability of the adjacent joints. Furthermore, despite
satisfactory reduction and high rate of union, fractures of the navicular bone have severe impact on long term clinical and functional outcome. McKeever [2] already noticed that because of the injury-related damage to the articular cartilage, a severe traumatic arthritis of the TN joint develops, resulting in loss of rotational flexibility and pain. Others concluded that fractures of the body most often result in severe long-term disability [7]. This is supported by the present data taking into account that development of secondary osteoarthritis was significantly more often seen in more severe fracture patterns. However, persistence of pain was present in less than half of all patients without influence of treatment strategy. This might be related to a small subgroup sample size or bias (confounding factors). Despite pain and imminent osteoarthritis, loss of function is only seen in 25% of patients. Because of the diversity of follow up times, these data cannot be fully generalized. A prospective study with prolonged follow up of the entire study population over a two year period would be desirable. The follow up data of the patients requiring secondary surgery indicate that severe injuries have a worse end result. Patients with less severe fracture pattern and lower associated injuries should perform better in the long term [25]. Conclusion Navicular fractures are uncommon and usually are associated with other injuries. Operative intervention is enhanced with bone grafting to support impacted fracture fragments. Despite alignment and anatomical restoration, secondary arthritis and pain are common. More severe injuries have worse results. Reduction quality relates to pain and return to function. Conflict of interest None declared. References [1] Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury 2006;37:691–7. [2] McKeever FM. Fractures of tarsal and metatarsal bones. Surg Gynecol Obstet 1950;90:735–45. [3] Hansen Jr ST. Acute trauma and fracture surgery. Functional reconstruction of the foot and ankle. Philadelphia: Lippincott Williams & Wilkins; 2000. [4] Astion DJ, Deland JT, Otis JC, Kenneally S. Motion of the hindfoot after simulated arthrodesis. J Bone Joint Surg Am 1997;79:241–6. [5] Sarrafian SK. Functional characteristics of the foot and plantar aponeurosis under tibiotalar loading. Foot Ankle 1987;8:4–18. [6] Sammarco GJ, Hockenbury RT. Biomechanics of the foot and ankle. In: Nordin M, Frankel VH, editors. Basic biomechanics of the musculoskeletal system. 3rd edn, New York City: Lippincott Williams & Wilkins; 2001. p. 222–55. [7] Sangeorzan BJ, Benirschke SK, Mosca V, Mayo KA, Hansen Jr ST. Displaced intra-articular fractures of the tarsal navicular. J Bone Joint Surg Am 1989;71: 1504–10. [8] de Clercq PF, Bevernage BD, Leemrijse T. Stress fracture of the navicular bone. Acta Orthop Belg 2008;74:725–34. [9] Marsh JL, Slongo TF, Agel J, Broderick JS, Creevey W, DeCoster TA, et al. Fracture and dislocation classification compendium – 2007. Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma 2007;21:S1–33. [10] Eichenholtz SN, Levine DB. Fractures of the tarsal navicular bone. Clin Orthop Relat Res 1964;34:142–57. [11] Main BJ, Jowett RL. Injuries of the midtarsal joint. J Bone Joint Surg Br 1975;57:89–97. [12] Nyska M, Margulies JY, Barbarawi M, Mutchler W, Dekel S, Segal D. Fractures of the body of the tarsal navicular bone: case reports and literature review. J Trauma 1989;29:1448–51. [13] Klaue K. Chopart fractures. Injury 2004;35(Suppl. 2):SB64–70. [14] Rammelt S, Grass R, Zwipp H. Nutcracker fractures of the navicular and cuboid. Ther Umsch 2004;61:451–7. [15] Groll DL, To T, Bombardier C, Wright JG. The development of a comorbidity index with physical function as the outcome. J Clin Epidemiol 2005;58: 595–602. [16] Amendola A, Petrik J, Webster-Bogaert S. Ankle arthroscopy: outcome in 79 consecutive patients. Arthroscopy 1996;12:565–73.
M.O. Coulibaly et al. / Injury, Int. J. Care Injured 46 (2015) 1669–1677 [17] Early JS. Fractures and dislocations of the midfoot and forefoot. In: Bucholz RW, Heckman JD, Court-Brown CM, editors. Rockwood and Green’s fractures in adults. 6th edn, Philadelphia: Lippincott Williams & Wilkins; 2006. p. 2347–53. [18] Kuo RS, Tejwani NC, Digiovanni CW, Holt SK, Benirschke SK, Hansen Jr ST, et al. Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am 2000;82-A:1609–18. [19] Arntz CT, Veith RG, Hansen Jr ST. Fractures and fracture-dislocations of the tarsometatarsal joint. J Bone Joint Surg Am 1988;70:173–81. [20] Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999, Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999;20:250–78. quiz 279–80. [21] Rammelt S, Grass R, Schikore H, Zwipp H. Injuries of the Chopart joint. Unfallchirurg 2002;105:371–83. quiz 384–5. [22] Miller CM, Winter WG, Bucknell AL, Jonassen EA. Injuries to the midtarsal joint and lesser tarsal bones. J Am Acad Orthop Surg 1998;6:249–58. [23] Howie CR, Hooper G, Hughes SP. Occult midtarsal subluxation. Clin Orthop Relat Res 1986;206–9. [24] Sangeorzan BJ, Hansen Jr ST. Early and late posttraumatic foot reconstruction. Clin Orthop Relat Res 1989;86–91. [25] Richter M, Wippermann B, Krettek C, Schratt HE, Hufner T, Therman H. Fractures and fracture dislocations of the midfoot: occurrence, causes and long-term results. Foot Ankle Int 2001;22:392–8. [26] Pinney SJ, Sangeorzan BJ. Fractures of the tarsal bones. Orthop Clin North Am 2001;32:21–33. [27] Naidu V, Singh SK. Cerclage wire fixation of navicular body fractures – a treatment based on mechanism of injury. Foot Ankle Int 2005;26:267–9. [28] Kimura K, Adachi H, Ogawa M, Sakamoto H. Supplementary transverse wire fixation through cuneiforms and cuboid in combination with a screw for the comminuted tarsal navicular fractures. Arch Orthop Trauma Surg 2002;122: 410–3. [29] Rymaszewski LA, Robb JE. Mechanism of fracture-dislocation of the navicular: brief report. J Bone Joint Surg Br 1988;70:492. [30] Dhillon MS, Nagi ON. Total dislocations of the navicular: are they ever isolated injuries? J Bone Joint Surg Br 1999;81:881–5. [31] Sangeorzan BJ, Mayo KA, Hansen ST. Intraarticular fractures of the foot. Talus and lesser tarsals. Clin Orthop Relat Res 1993;135–41. [32] Chandran P, Puttaswamaiah R, Dhillon MS, Gill SS. Management of complex open fracture injuries of the midfoot with external fixation. J Foot Ankle Surg 2006;45:308–15. [33] Apostle KL, Younger AS. Technique tip: open reduction internal fixation of comminuted fractures of the navicular with bridge plating to the medial and middle cuneiforms. Foot Ankle Int 2008;29:739–41. [34] Schildhauer TA, Nork SE, Sangeorzan BJ. Temporary bridge plating of the medial column in severe midfoot injuries. J Orthop Trauma 2003;17:513–20.
1677
[35] Randt T, Dahlen C, Schikore H, Zwipp H. Dislocation fractures in the area of the middle foot-injuries of the Chopart and Lisfranc joint. Zentralbl Chir 1998; 123:1257–66. [36] Fishco WD, Cornwall MW. Gait analysis after talonavicular joint fusion: 2 case reports. J Foot Ankle Surg 2004;43:241–7. [37] Fogel GR, Katoh Y, Rand JA, Chao EY. Talonavicular arthrodesis for isolated arthrosis: 9.5-year results and gait analysis. Foot Ankle 1982;3:105–13. [38] Longino D, Buckley RE. Bone graft in the operative treatment of displaced intraarticular calcaneal fractures: is it helpful? J Orthop Trauma 2001;15: 280–6. [39] Myerson MS, Fisher RT, Burgess AR, Kenzora JE. Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment. Foot Ankle 1986;6:225–42. [40] Mu¨ller ME, Nazarian S, Koch P. Classification AO des fractures: les os longs. Berlin/Heidelberg/New York: Springer-Verlag; 1987. [41] Penner MJ. Late reconstruction after navicular fracture. Foot Ankle Clin 2006;11:105–19. ix. [42] Dewar FP, Evans DC. Occult fracture-subluxation of the midtarsal joint. J Bone Joint Surg Br 1968;50:386–8. [43] Tountas AA. Occult fracture-subluxation of the midtarsal joint. Clin Orthop Relat Res 1989;195–9. [44] Di Giovanni CW. Fractures of the navicular. Foot Ankle Clin 2004;9:25–63. [45] Ip KY, Lui TH. Isolated dorsal midtarsal (Chopart) dislocation: a case report. J Orthop Surg (Hong Kong) 2006;14:357–9. [46] Meister K, Demos HA. Fracture dislocation of the tarsal navicular with medial column disruption of the foot. J Foot Ankle Surg 1994;33:135–7. [47] Stiegelmar R, McKee MD, Waddell JP, Schemitsch EH. Outcome of foot injuries in multiply injured patients. Orthop Clin North Am 2001;32:193–204. x. [48] Tran T, Thordarson D. Functional outcome of multiply injured patients with associated foot injury. Foot Ankle Int 2002;23:340–3. [49] Preidler KW, Peicha G, Lajtai G, Seibert FJ, Fock C, Szolar DM, et al. Conventional radiography, CT, and MR imaging in patients with hyperflexion injuries of the foot: diagnostic accuracy in the detection of bony and ligamentous changes. Am J Roentgenol 1999;173:1673–7. [50] Newton Ede MP, Miller C, Malik MH, Khan SA. An unusual case of talonavicular dislocation with associated ipsilateral foot fractures. J R Army Med Corps 2006;152:102–3. [51] Weber M, Locher S. Reconstruction of the cuboid in compression fractures: short to midterm results in 12 patients. Foot Ankle Int 2002;23:1008–13. [52] Ebizie AO. Crush fractures of the cuboid from indirect violence. Injury 1991;22:414–6. [53] Adelaar RS. The treatment of tarsometatarsal fracture-dislocation. Instr Course Lect 1990;39:141–5. [54] Waugh W. The ossification and vascularisation of the tarsal navicular and their relation to Kohler’s disease. J Bone Joint Surg Br 1958;40-B:765–77.
