Fractures of the navicular

Morphological measurements and classification of the navicular bone: a study based on computed tomography imaging

OBJECTIVE

The purpose of this study was to present the classification of navicular bones and the anatomical basis for the diagnosis and treatment of navicular fractures of the foot.

METHOD

351 computed tomographic (CT) images of the navicular bone were analyzed and classified. The navicular bone's anatomical morphology was measured by three independent researchers in each type. Analysis and recording of the measurement results followed.

RESULT

Navicular bones were assorted into three types: I shape(37.04%), II shape(54.41%), and III shape(8.55%). The left and right sides did not differ in any appreciable ways, except ab, bc, and ∠abc (P < 0.05); And all data were statistically different between men and women except for ∠abc (p > 0.05).

CONCLUSION

The classification of the navicular bone in this study may be helpful in making the treatment decision for navicular fracture.

LEVEL OF CLINICAL EVIDENCE

4.

Talonavicular Osteochondral Lesions: Surgical Technique and Clinical Outcomes from the Boston and Amsterdam Perspectives

PURPOSE

The primary purpose of the present study was to assess the patient-reported outcomes, complications, and reoperation rate of patient who underwent surgical treatment for symptomatic osteochondral lesions of the talonavicular joint (TNJ).

METHODS

Patients undergoing surgical treatment for symptomatic osteochondral lesions of the TNJ with a minimum of 12-month follow-up were included. Outcomes included clinical patient-reported outcome measures (PROMs), return to sports and work outcomes, and postoperative complications or reoperations. Medical records were screened by 2 independent reviewers. Patients were contacted by phone and underwent an in-depth interview. Additionally, operative techniques for both arthroscopic and open surgical approaches for treating TNJ osteochondral lesions were described.

DESIGN

Retrospective Case Series (Level IV) and Surgical Technique.

RESULTS

A total of 7 patients were included with a final follow-up time of 25.4 (SD: 15.2) months follow-up. PROMs were considered satisfactory for 5 out of 7 patients, 6 out of 7 patients returned to any level of sports at a mean of 3.7 (SD: 4.2) months, and 5 out of 6 patients returned to preinjury level of sports at a mean of 14 (SD: 7.5) months. All patients returned to work at an average of 5.4 (SD: 3.6) weeks. No complications or reoperations after index surgery were reported.

CONCLUSION

Surgical treatment of TNJ osteochondral lesions is a feasible procedure that may offer successful clinical, sport, and work outcomes in the majority of patients. Both open and arthroscopic surgical treatments are available and can be considered in a patient-specific treatment plan.

Human navicular bone: a morphometric and morphological evaluation

BACKGROUND

The composition of navicular joint complex is crucial to perform surgical interventions for multiple pathological foot aetiologies. The data on human navicular bone and its facets from Indian population remain scarce in literature.

AIMS AND OBJECTIVES

To evaluate the morphometry and morphology of navicular bone.

METHODOLOGY

A total of 77 (right: 40; left: 37) dried human navicular bones were used. The collected data were entered and analysed in SPSS software.

RESULTS

The anteroposterior diameter of navicular bone on right side was 15.19 mm (13.92, 16.77) and on left side was 15.87 mm (13.83, 17.27). The transverse diameter on right and left sides were 34.21 mm (31.74, 36.6) and 33.59 mm (30.23, 35.43), respectively. The vertical diameter measured on the right was 22.31 mm (21.19, 23.94) and on left 22.53 mm (20.8, 24.24). Morphometric evaluation showed no significant difference between right and left navicular bones. The commonest shape for posterior facet was quadrilateral, on the right (62.5%) and left (40.5%). The most common shape of anterior facet for medial cuneiform is quadrilateral, on the right (85%) and left (89.1%). For intermediate cuneiform, triangular facet was common on the right side (72.5%) and on the left (59.5%). The lateral cuneiform facet was bean shaped on right side (72.5%) and quadrilateral on the left side (32.5%). There was a significant difference in shape distribution between right and left (P < 0.05). The median length of the groove for tibialis posterior tendon was 18.01 mm and 16.19 mm on right and left side, respectively. Cuboid facet was observed in 28 (70%) and 26 (65.9%) navicular bones on right and left sides, respectively.

CONCLUSION

There is no significant difference between right and left bones with regards to morphometric parameters. Morphological evaluation revealed significant difference in the distribution of shape between right and left bones.

Republication of "Stress Fractures of the Foot and Ankle in Athletes"

Stress fractures of the foot and ankle are common injuries in athletes. Management differs considerably based on fracture location and predisposing factors. Repetitive loading of the foot and ankle in athletes should result in physiologic bone remodeling in accordance with Wolff's law. However, when there is not sufficient time for complete healing to occur before additional loads are incurred, this process can instead lead to stress fracture. Assessment of the athlete's training regimen and overall bone health is paramount to both the discovery and treatment of these injuries, although diagnosis is often delayed in the setting of normal-appearing initial radiographs. While most stress fractures of the foot or ankle can usually be treated nonoperatively with a period of activity modification, fractures in certain locations are considered "high risk" due to poor intrinsic healing and may warrant more proactive operative management.

Robot-assisted percutaneous screw fixation in the treatment of navicular fracture

Background

Long recovery time, large scar, postoperative swelling and pain are possible side effects of open reduction internal fixation (ORIF) for tarsal navicular fractures. Early exercise instruction is made possible by the use of an intraoperative robot-assisted percutaneous invasive closed reduction internal fixation. The goal of the trial was to determine whether percutaneous screw internal fixation with robot assistance might be used to treat navicular fractures.

Methods

27 patients with navicular fractures had surgical treatment between June 2019 and December 2021. Of those, 20 instances were treated with ORIF, while 7 cases had robot-assisted percutaneous screw internal fixation. At the final follow-up, the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score and the visual analogue scale (VAS) score were compared to determine outcomes and function.

Results

Follow-up was obtained in all 27 patients after surgery, with a mean follow-up time of 21.81 months, ranging from 15 to 29 months . In the 7 instances of robot-assisted group, percutaneous guide wire insertion and screw placement only needed one attempt and the depth and position of the implant were both satisfactory. In the ORIF group, there were two patients who sustained cutaneous nerve injuries. The AOFAS score and the VAS score of the group receiving robot-assisted navigation percutaneous screw fixation were 92.25 ± 2.22 and 0.75 ± 0.25 respectively at the last follow-up, while 82.25 ± 7.15 and 0.50 ± 0.29 were the respective values for the ORIF group.

Conclusion

Intraoperative robot-assisted percutaneous closed reduction internal fixation for tarsal navicular fractures can accomplish exact localization of fracture site, reduce soft tissue damage and operative time. According to current view, this method offers fewer complications, a faster recovery after surgery, and more patient satisfaction.

Navicular Fracture

The tarsal navicular is an essential component of the Chopart joint and crucial for most of hindfoot motion. Most fractures are low-energy dorsal avulsions that may be treated nonoperatively. Displaced comminuted fractures require open reduction and internal fixation, sometimes with external fixation, bridge plating, and bone grafting. Diagnosis of stress fractures is commonly delayed. Conservative treatment is associated with good results, but surgery allows for quicker return-to-play in athletes. Nonunion in acute and stress fractures needs open debridement, grafting, and stable fixation. Müller-Weiss disease may present with a fragmented navicular and mimic an acute or a stress fracture.

The Use of Low-Profile Angular-Stability Plates in a "Nutcracker" Tarsal Navicular Fracture Combined with a Cuboid Fracture: ORIF Experience

BACKGROUND

Clear recommendations about the optimal treatment of traumatic tarsal navicular fractures are still very debated in the literature, and this is due to several factors: navicular fractures are rare and often misdiagnosed injuries, they are frequently associated with other fractures or a dislocation of the midfoot, and the current knowledge is based on few papers mainly considering a limited number of cases and dealing with different therapeutic approaches. The treatment of navicular body fractures is controversial and burdened by a high incidence of complications; in particular, Sangeorzan type III comminuted fractures represent a real challenge for the orthopedic surgeon. An accurate preoperative planning, a scrupulous surgical technique aimed at restoring volume and bony anatomy, and the use of low-profile angular-stability plates can lead to optimal clinical and functional results, decreasing the chances of arthritic evolution of mid-foot joints.

Staged Surgical Management of Open Navicular Fracture Secondary to a Gunshot Injury

The management guidelines of gunshot wound (GSW) injuries to the lower extremities have primarily been described more recently in the literature. A navicular fracture with adjacent joint involvement is presented from a GSW with initial external fixation management to prevent loss of anatomical alignment and successful staged definitive treatment with internal fixation. Based on previous experiences with rearfoot joint involvement from GSW injuries, we were able to direct definitive treatment with arthrodesis of violated joints. After a 1-year follow-up, the patient has returned to normal activities without any limitations. This case report demonstrates a stepwise approach to management of an open navicular fracture secondary to a GSW.

A review of the management and outcomes of tarsal navicular fracture

Fractures of the navicular are uncommon. This review focusses on the anatomy, classification, surgical management, post-operative rehabilitation, and outcomes of tarsal navicular fractures, to better inform decision making for clinicians managing these injuries. This review does not discuss navicular stress fractures because of the differing aetiology compared to other fractures of the navicular.

External Fixation Diastasis Management of Kohler's Disease in a 14-Year-Old Boy: A Case Report

A case presentation of an adolescent with tarsal navicular avascular necrosis is presented. External fixation with tarsal navicular diastasis is a simple, straightforward management option to allow osseous regrowth and bone healing. In this case, the external fixator was well tolerated and the patient demonstrated a quick return to function without pain or discomfort. The external fixation technique with tarsal navicular diastasis is an uncommon but effective means of reversing the tarsal navicular avascular process and avoiding an open technique such as arthrodesis.

Fratura do escafoide társico em um praticante de parkour, uma lesão rara – Relato de Caso e Revisão da Literatura

Tarsal navicular fractures, as well as other midfoot injuries, are rare, and can result in severe impairment if not properly treated. Parkour, a modern sport, is gaining popularity among young individuals in urban areas, and is prone to result in high-energy trauma, which is scarcely described in the literature. The following is a report of a rare case of tarsal navicular fracture in a 17-year-old male, sustained during parkour practice, which was treated successfully with open reduction and internal fixation. The description of the case emphasizes the challenges of its approach; the discussion highlights the treatment options and goals. The case should also raise awareness about the increasing occurrence of these uncommon lesions.

Stress Fractures of the Foot and Ankle in Athletes

Stress fractures of the foot and ankle are common injuries in athletes. Management differs considerably based on fracture location and predisposing factors. Repetitive loading of the foot and ankle in athletes should result in physiologic bone remodeling in accordance with Wolff’s law. However, when there is not sufficient time for complete healing to occur before additional loads are incurred, this process can instead lead to stress fracture. Assessment of the athlete’s training regimen and overall bone health is paramount to both the discovery and treatment of these injuries, although diagnosis is often delayed in the setting of normal-appearing initial radiographs. While most stress fractures of the foot or ankle can usually be treated nonoperatively with a period of activity modification, fractures in certain locations are considered “high risk” due to poor intrinsic healing and may warrant more proactive operative management.

Primary Arthrodesis in Severely Comminuted Fractures

At present there is controversy regarding the appropriate treatment of severely comminuted fractures of the lower extremity. Even with near-perfect anatomic reduction of severely comminuted fractures, development of posttraumatic arthritis is still present at an increased rate. Primary fusion of comminuted fractures of the foot and ankle creates successful and predictable outcomes, which dismisses the chance of developing posttraumatic arthritis and decreases complications and the need for revisional procedures.

Epidemiology of Navicular Injury at the NFL Combine and Their Impact on an Athlete's Prospective NFL Career

Background:

Navicular injuries can result in persistent pain, posttraumatic osteoarthritis, and diminished performance and function.

Purpose:

To determine the epidemiology of navicular fracture in players participating in the National Football League (NFL) Scouting Combine and evaluate the impact of a navicular injury on the NFL draft position and NFL game play compared with matched controls.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Data were collected on players who previously sustained a navicular injury and participated in the NFL Combine between 2009 and 2015. The epidemiology of navicular injury was determined through an evaluation of the number of injuries, surgeries, and collegiate games missed as well as the position played, a physical examination, the surgical technique, and imaging findings. Players with a previous navicular injury (2009-2013) were compared with a set of matched controls. NFL performance outcomes included the draft position, career length ≥2 years, and number of games played and started within the first 2 years.

Results:

Between 2009 and 2015, 14 of 2285 (0.6%) players were identified as having sustained a navicular injury. A total of 11 of 14 (79%) athletes had sustained an overt navicular fracture, while 3 of 14 (21%) were diagnosed with stress reactions on magnetic resonance imaging. Eight patients who sustained a navicular fracture underwent surgery. There was evidence of ipsilateral talonavicular arthritis in 75% of players with a navicular fracture versus only 60% in the uninjured foot (odds ratio, 1.3; P = .04). Fifty-seven percent of players with navicular injury (72.7% of fractures) were undrafted versus 30.9% in the control group (P = .001). Overall, 28.6% of players with navicular fracture played ≥2 years in the NFL compared with 69.6% in the control group (P = .02).

Conclusion:

A previous navicular fracture results in a greater risk of developing posttraumatic osteoarthritis. Although only a low prevalence of navicular injury in prospective NFL players was noted, players with these injuries had a greater probability of not being drafted and not competing in at least 2 NFL seasons when compared with matched controls without an injury history to the NFL Combine.

Fractures and Dislocations of the Tarsal Navicular

Fractures of the tarsal navicular are commonly the result of trauma or chronic overload. Because of its complex anatomy and blood supply, the tarsal navicular is susceptible to osteonecrosis, and injury to this bone can lead to posttraumatic arthrosis of the surrounding joints. Diagnosis of the injury, especially in patients with stress fractures, can require a high index of suspicion and the use of advanced imaging. The treatment of stress fracture is controversial and ranges from immobilization in a non-weight-bearing cast or boot to internal fixation with or without bone grafting. Traumatic fractures are treated with open reduction and internal fixation with or without external fixation for medial and lateral column stabilization. To avoid a poor outcome, concomitant injuries must be recognized and treated. Despite appropriate treatment, patients may ultimately require fusion procedures to address ongoing pain and disability.

Osseous injuries of the foot: an imaging review. Part 2: the midfoot

Injuries to the foot are a common cause for presentation to the emergency department (ED), and imaging is often used to aid in the diagnosis. The foot can be divided into three distinct anatomic regions: the forefoot, midfoot and hindfoot. Our manuscripts comprise a three-part imaging review in which we address the use of radiography as well as advanced imaging modalities. We provide pearls to radiographic interpretation and discuss prognostic implications and classification systems. Part 1 addressed forefoot injuries, Part 2 reviews midfoot injuries and Part 3 covers the hindfoot.

Results and complications of operative and non-operative navicular fracture treatment

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 (χ(2)=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 (ρ=-0.508, p=0.000). Inability to return to previous work was related to pain (ρ=-0.394), SOA (ρ=-0.280), and poor reduction quality (ρ=-0.384) with significance at p<0.01. Increased BMI (>35) related to pain (ρ=0.250) and poor reduction quality (ρ=0.326) at a σ<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.

Localized naviculocuneiform arthrodesis combined with osteosynthesis of fracture nonunion of the tarsal navicular bone using a locked plating system

AIMS

Navicular fracture is still challenging disorder to treat because there is a risk of nonunion, avascular necrosis and symptomatic osteoarthritis.

PATIENTS METHODS AND RESULTS

A 40-year-old woman with an ununited fracture of the tarsal navicular bone was treated with localized naviculocuneiform arthrodesis (arthrodesis of the navicular, the middle cuneiform, and the lateral cuneiform). Fusion with the navicular, the middle cuneiform, and the lateral cuneiform as well as union of fracture of the navicular was confirmed on the radiographs.

CONCLUSION

Localized naviculocuneiform arthrodesis using a locked plating system is one of the options to treat nonunion of the navicular bone.

Isolated talonavicular fusion with tension band for Müller-Weiss syndrome

BACKGROUND

There are still controversies with regard to the operative treatment in advanced Müller-Weiss syndrome (MWS), where the navicular undergoes avascular necrosis and the talonavicular (TN) joint becomes arthritic. Most authors advocate extended fusion, sacrificing hindfoot mobility. To restore TN alignment and to achieve stable fixation, we developed a new isolated TN fusion technique applying the principles of a static tension band. The aim of the present study was to report the midterm results of a preliminary series of patients and their clinical and radiographic outcomes.

METHODS

Ten feet (10 patients; 8 females, 2 males; age 63 ± 16.7 [range, 34-83] years) with advanced deformity of MWS (3 Maceira's stage III and 7 stage IV) were treated with isolated TN arthrodesis using the tension band technique. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was used to evaluate the functional outcome. Standard angles were measured to determine the amount of correction achieved through the operative treatment. The minimum follow-up was 24 (range, 24-43) months.

RESULTS

Trabeculation was seen to cross the fusion site on radiographs in 8 patients after 2 and in 1 patient after 3 months. One case needed revision after 13 months due to implant failure; after additional screw fixation, bony healing was achieved 2 months later. At last follow-up, all cases described a high level of satisfaction. Postoperatively, the AOFAS score improved from 33 (range, 18-48) to 88.3 (range, 79-100) (P < .0001) points, the AP talocalcaneal angle increased from 14.2 (range, 1-22) to 22.7 (range, 12-30) degrees (P = .0007), and the calcaneal pitch increased from 10.3 (range, 3-22) to 14.7 (range, 8-22) degrees (P = .0006).

CONCLUSION

The static tension band technique is a new, promising technique to treat MWS patients, providing stability against the counteracting deforming forces. Therefore, we consider this technique as our treatment of choice in patients with stage III and stage IV MWS.

LEVEL OF EVIDENCE

Level IV, prospective case series.

Midfoot crush injuries

Treatment of midfoot injuries is surgical or nonsurgical, depending on the injury, the location, and the extent of the injury. Minor injuries usually heal with casting or bracing, whereas more unstable injuries typically need surgery for stability. Whether the injury is in a weight-bearing portion of the foot is also a consideration for surgery. The importance of treating midfoot injuries adequately is shown in how the midfoot is needed for function with weight bearing and its relationship between the front and the back of the foot. It is also important to ensure that the patient is able to ambulate with a reasonably normal gait.

Imaging of tarsal navicular disorders: a pictorial review

The tarsal navicular is a bone within the midfoot that plays a critical role in maintaining the arch of the foot. This bone is clinically relevant because it may be affected by a wide array of pathologies. Our approach includes a detailed description of the imaging characteristics and disorders affecting the tarsal navicular. Organization includes (a) normal imaging, (b) accessory ossicles, (c) coalition, (d) fractures, (e) Kohler's disease, (f) osteonecrosis, (g) osteochondral lesions, (h) arthropathies, and (i) tumors. The purpose of this article is to discuss normal variants and pathological processes that can affect the tarsal navicular, with emphasis on the often-overlooked imaging findings.

Open reduction-internal fixation of a navicular body fracture with dorsal displacement of the first and second cuneiforms: a case report

Body fractures of the tarsal navicular are relatively uncommon. To date, there is little literature discussing a navicular body fracture with dorsal subluxation of the first and second cuneiforms over the navicular. This case study presents a 30-year-old patient with this injury. He underwent open reduction internal fixation of the navicular body fracture successfully but failed adequate reduction of the navicular cuneiform joint after ligamentous reconstruction. After revisional surgery, he also failed 6 weeks of percutanous pinning with Kirschner-wire fixation. When comparing the literature of a similar injury, the Lisfranc fracture disclocation, the same principles may apply. One should consider rigid open reduction internal fixation or even primary fusion to treat disclocation of the naviculocuneiform joint following a navicular body fracture.

Assessment of compromised fracture healing

No standard criteria exist for diagnosing fracture nonunion, and studies suggest that assessment of fracture healing varies among orthopaedic surgeons. This variability can be problematic in both clinical and orthopaedic trauma research settings. An understanding of risk factors for nonunion and of diagnostic tests used to assess fracture healing can facilitate a systematic approach to evaluation and management. Risk factors for nonunion include medical comorbidities, age, and the characteristics of the injury. The method of fracture management also influences healing. Comprehensive evaluation includes an assessment of the patient's symptoms, signs, and immune and endocrine status as well as the biologic capacity of the fracture, presence of infection, and quality of reduction and fixation. Diagnostic tests include plain radiography, CT, ultrasonography, fluoroscopy, bone scan, MRI, and several laboratory tests, including assays for bone turnover markers in the peripheral circulation. A systematic approach to evaluating fracture union can help surgeons determine the timing and nature of interventions.

Navicular stress reactions in runners: a review of evaluation and management of a competitive athlete

Navicular stress injuries in athletes can be devastating. Clinical findings are frequently nonspecific until significant progression of the abnormality has occurred. The use of diagnostic imaging techniques early in the discovery period increases the likelihood of establishing an immediate diagnosis and avoids frank fracture of the navicular bone. Delayed diagnosis of navicular stress injuries in athletes can cause dire consequences. The physician must be aware of the injury in establishing a high index of clinical suspicion. The timing and sequencing of diagnostic imaging studies is essential in establishing a diagnosis to manage the patient and minimize time away from competition. This case study examines the history and management of an elite high school track athlete who sustained a navicular stress injury. The timing and use of diagnostic imaging studies is reviewed.

Opening wedge and anatomic-specific plates in foot and ankle applications

As surgeons continually push to improve techniques and outcomes, anatomic-specific and procedure-specific fixation options are becoming increasingly available. The unique size, shape, and function of the foot provide an ideal framework for the use of anatomic-specific plates. These distinctive plate characteristics range from anatomic contouring and screw placements to incorporated step-offs and wedges. By optimizing support, compression, and stabilization, patients may return to weight bearing and activity sooner, improving outcomes. This article discusses anatomic-specific plates and their use in forefoot and rearfoot surgical procedures.

Percutaneous reduction and external fixation for foot and ankle fractures

Percutaneous reduction with external fixation is an advanced technique for surgical management in foot and ankle trauma. In the high-risk patient, closed or percutaneous reduction followed by external fixation for reduction and stabilization is a unique alternative to achieve anatomic stabilization without increased physical strain to the patient. The significant advantages of this approach include minimizing damage to the vascular supply, maintaining and preserving a stable soft tissue envelope, and allowing for correction to be performed acutely or adjusted gradually over time. This article provides an overview of closed or percutaneous reduction with limited soft tissue dissection and external fixation stabilization techniques, and their role in foot and ankle trauma for the high-risk patient.

Osteonecrosis in the foot

Osteonecrosis, also referred to as avascular necrosis, refers to the death of cells within bone caused by a lack of circulation. It has been documented in bones throughout the body. In the foot, osteonecrosis is most commonly seen in the talus, the first and second metatarsals, and the navicular. Although uncommon, osteonecrosis has been documented in almost every bone of the foot and therefore should be considered in the differential diagnosis when evaluating both adult and pediatric foot pain. Osteonecrosis is associated with many foot problems, including fractures of the talar neck and navicular as well as Kohler's disease and Freiberg's disease. Orthopaedists who manage foot disorders will at some point likely be faced with the challenges associated with patients with osteonecrosis of the foot. Because this disease can masquerade as many other pathologies, physicians should be aware of the etiology, presentation, and treatment options for osteonecrosis in the foot.

Late reconstruction after navicular fracture

The tarsal navicular is the figurative and literal keystone of the medial longitudinal arch of the foot. Therefore, injuries to the navicular may have a disproportionately profound effect on the overall function of the foot and ankle in comparison with its small size. Even optimally treated injuries can go on to significant posttraumatic sequelae, and leave the midfoot with chronic deformity, arthritis, and loss of motion. This article reviews the posttraumatic sequelae that can be seen after navicular fracture and provides an overview of the treatment principles and alternatives that are available.