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.

Return to sport following navicular stress fracture: a systematic review and meta-analysis of three hundred and fifteen fractures

Purpose

This meta-analysis aims to provide updated evidence on the success rate, return to play (RTP) rate, time to RTP, and complications of operatively and conservatively managed navicular stress fractures (NSFs) as well as delays in diagnosis while avoiding limitations of previous similar studies.

Methods

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, two independent team members electronically searched MEDLINE (PubMed), EMBASE, Google Scholar, SCOPUS, and Cochrane databases throughout February 2021 using the following keywords with their synonyms: “Navicular stress fracture,” “return to play,” and “athletes.” The primary outcomes were (1) management success rate, (2) RTP rate, and (3) time to RTP. The secondary outcomes were (1) non-union, (2) time to diagnosis, (3) refracture, and (4) other complications. Inclusion criteria were clinical studies on NSFs reporting at least one of the desirable outcomes. Studies not reporting any of the outcomes of interest or the full text was not available in English, German, French, or Arabic were excluded. Case reports, case series with less than ten cases, and studies reporting exclusively on navicular non-union management were also excluded. The Newcastle–Ottawa scale was used for quality assessment while Review Manager (RevMan) Version 5.4 was used for the risk of bias assessment. Data were presented by type of treatment (surgical or conservative). If enough studies were present that were clinically and statistically homogeneous and data on them adequately reported, a meta-analysis was performed using a fixed-effects model. In case of statistical heterogeneity, a random-effects model was used. If meta-analysis was not possible, results were reported in a descriptive fashion. The need to explore for statistical heterogeneity was determined by an I² greater than 40%.

Results

Eleven studies met the inclusion criteria with a total of 315 NSF. Out of those, 307 (97.46%) NSFs were in athletes. One hundred eight (34.29%) NSFs were managed operatively, while 207 (65.71%) NSFs were managed conservatively. Successful outcomes were reported in 104/108 (96.30%) NSF treated operatively with a mean success rate of 97.9% (CI: 95.4–100%, I² = 0%). Successful outcomes were reported in 149/207 (71.98%) NSF treated conservatively, with a mean success rate of 78.1% (CI: 66.6–89.6%, I² = 84.93%). Successful outcome differences were found to be significant in favor of operative management (OR = 5.52, CI: 1.74–17.48, p = 0.004, I² = 4.6%). RTP was noted in 97/98 (98.98%) NSF treated operatively and in 152/207 (73.43%) NSF treated conservatively, with no significant difference between operative and conservative management (OR = 2.789, CI: 0.80–9.67, p = 0.142, I² = 0%). The pooled mean time to RTP in NSF treated operatively was 4.17 months (CI: 3.06–5.28, I² = 92.88%), while NSF treated conservatively returned to play at 4.67 months (CI: 0.97–8.37, I² = 99.46%) postoperatively, with no significant difference between operative and conservative management (SMD =  − 0.397, CI: − 1.869–1.075, p = 0.60, I² = 92.24). The pooled mean duration of symptoms before diagnosis was 9.862 (3.3–123.6) months (CI: 6.45–13.28, I² = 94.92%), reported in ten studies. Twenty (23.53%) refractures were reported after conservative management of 85 NSFs, while one (1.28%) refracture was reported after operative management of 78 NSFs, with a significant difference in favor of operative management (OR = 0.083, CI: 0.007–0.973, p = 0.047, I² = 38.78%).

Conclusion

Operative management of NSF provides a higher success rate, a lower refracture rate, and a lower non-union rate as compared to other non-operative management options. While not significant, there is a notable trend towards superior RTP rates and time to RTP following operative management. Therefore, we recommend operative fixation for all NSFs type I through III in athletes. Athletes continue to exhibit an alarmingly long duration of symptoms before diagnosis is made; a high index of suspicion must be maintained, therefore, and adjunct CT imaging is strongly recommended in the case of any work-up. Unfortunately, the published literature on NSFs remains of lower level of evidence and high-quality studies are needed.

Management of Müller-Weiss Disease

Müller-Weiss disease (MWD) is a dysplasia of the tarsal navicular. The shifting of the talar head laterally over the calcaneus drives the subtalar joint into varus. Failure to identify patients with paradoxic flatfoot varus may lead to the incorrect diagnosis and management. Conservative treatment with the use of rigid insoles with medial arch support and a lateral heel wedge is effective in most patients. Dwyer calcaneal osteotomy combined with lateral displacement seems to be a satisfactory treatment for patients who had failed to respond to conservative measures and a good alternative to the different types of perinavicular fusions.

A rare case of an osteochondral lesion of the tarsal navicular with a subacute stress fracture in a high level athlete

In this report, an osteochondral lesion of the tarsal navicular associated with a subacute stress fracture in a professional basketball player surgical treatment is presented. The surgical technique involved extra-articular curettage, bone grafting and plate stabilisation. Postoperative CT scan confirmed that both the osteochondral lesion and the stress fracture healed. The talonavicular joint showed no signs of arthritis on imaging. Clinical foot scores showed marked improvement after surgery. At 6 months patient managed to return to competitive play without pain in the foot and ankle. The outcome of this case indicates that the combination of curettage, bone grating and plate stabilisation works well for this rare and potentially career ending dual lesions.