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Naviculocuneiform Arthrodesis

Adam M. Budny, DPM*,Jordan P. Grossman, DPM, FACFAS

Department of Surgery, Saint Vincent Charity Hospital, 2351 East 22nd Street,

Cleveland, OH 44115, USA

The adult acquired flatfoot is a complex, multiplanar, structural defor-mity characterized by several distinct clinical features and radiographicabnormalities. Typical physical findings include flattening of the mediallongitudinal arch, abduction of the forefoot, valgus of the heel, and somedegree of equinus contracture [1–6]. Deformity is possible in varying degreesand at a number of joint levels, with multiple soft tissue and osseous influ-ences making objective assessment difficult. Posterior tibial tendon dysfunc-tion has received much attention as a primary etiology for progressivesymptomatic collapse of the arch in the adult population, and the classifica-tion put forth by Johnson and Strom [5] has been widely accepted with latermodification by Myerson [6].

Acquired flatfoot is a continuum frommild to severe deformity in all threecardinal planes and has been termed peritalar subluxation as a result of alter-ations in the relationships of themidtarsal and subtalar joints; however, fault-ing can occur at any level of the medial column, including the talonavicular(TN), naviculocuneiform (NC), or first tarsometatarsal (TMT) joints [4,6].Due to these factors, a myriad of surgical procedures have been describedfor the correction of pes planus foot types, with no clear-cut approach tothe deformity [4,6–14]. In a supple stage II flatfoot, the NC arthrodesis,with appropriate ancillary soft tissue augmentation and other adjunctive osse-ous procedures as necessary, has been shown to be effective with reproduciblesuccess [1,2,4,7,15–17].

Anatomy

The NC joint is comprised of the articulations between the navicularproximally and the three cuneiforms distally, each having a distinct facet.

* Corresponding author.

E-mail address: [email protected] (A.M. Budny).

0891-8422/07/$ - see front matter � 2007 Elsevier Inc. All rights reserved.

doi:10.1016/j.cpm.2007.06.001 podiatric.theclinics.com

Clin Podiatr Med Surg

24 (2007) 753–763


The navicular is boat shaped, with the proximal concave surface articulatingover the head of the talus and a large tuberosity serving as a significant in-sertion for the posterior tibial tendon. The NC capsule is reinforced plan-tarly, with strong ligamentous attachments to aid in supporting thelongitudinal arch. The cuneiforms themselves are wedge shaped, with thewidest portion dorsally, creating a keystone arch appearance in cross-sectional evaluation. Appreciation of these relationships is paramount forsuccessful placement of internal fixation due to the small surface area avail-able for screw purchase on the plantar aspect of the cuneiforms.

The medial column has been described as a ‘‘post’’ for the talus and isstrongly linked to hindfoot valgus [4]. If the post is compromised by medialcolumn faulting, peritalar subluxation will occur. In addition, the NC jointalong with the calcaneocuboid, intercuneiform, and medial TMT jointshave been defined as ‘‘non-essential’’ for normal gait [2,7], that is, loss ofa non-essential joint will not be detrimental to normal foot function. This phi-losophy suggests that the NC joint may be sacrificed to allow restoration ofmedial column stability without having a significant effect on gait followingarthrodesis.

Clinical evaluation

Patients presenting with symptomatic pes planus generally demonstratecollapse of the medial longitudinal arch, worsening pain with activity, anddecreased endurance with extended ambulation. Often, patients describe‘‘ankle pain’’ along the course of the posterior tibial tendon that has beenan insidious process or recurrent problem for weeks to months. In advanceddeformity, patients may subjectively relate lateral ankle pain as a result ofsinus tarsi or caneofibular impingement, or subtalar joint arthrosis. Exami-nation of the foot and ankle should be comprehensive, taking into accountneurovascular status as well as musculoskeletal evaluation in weight-bearingand non–weight-bearing positions including reducibility of the deformity.With the patient in angle and base of gait, one will appreciate collapse ofthe arch medially, whereas a posterior vantage point will afford assessmentof heel valgus and forefoot abduction via the ‘‘too many toes sign’’ (Fig. 1)[5]. Function of the posterior tibial tendon can be tested dynamicallythrough double and single heel rise tests by observing the amount of inver-sion of the calcaneus. Open kinetic chain evaluation should include the Sil-verskiold examination for equinus as well as noting any hypermobility of themidtarsal, NC, or first TMT joints. In depth clinical examination of thiscomplex deformity is covered elsewhere in this issue.

Radiographic analysis

Typical findings in a patient requiring NC arthrodesis include a fault orsag on the dorsal side of the joint, resulting in a deviation of the talo–first

754 BUDNY & GROSSMAN


metatarsal angle (Meary’s) on a lateral radiograph. Other sagittal plane ob-servations are decreased calcaneal inclination, increased talar declination,and decreased cuneiform height (Fig. 2). Recreation of the longitudinalarch via activation of the windlass mechanism (Jack’s test) [13] will alsodemonstrate the ability to reduce a flexible flatfoot to aid in planning anNC fusion (Fig. 3). Dorsoplantar radiographs allow evaluation of transverseplane deformity including talar head uncovering, the talo–first metatarsalangle, and cuboid abduction [1–3,18,19]. Periarticular osteophytosis orfrank degenerative changes of the NC joint may be appreciated as well. Ad-vanced imaging such as CT and MRI may be used to evaluate the viabilityof the posterior tibial tendon, spring ligament, and bone quality or extent ofjoint arthrosis at the proposed surgical site.

Preoperative considerations

An optimal outcome is dependent on accurate diagnosis and proceduralselection as well as precise surgical execution. The goal is to recreate a func-tional tripod of the heel and first and fifth metatarsal heads to allow a stablefunctional foot through the gait cycle. Correction of a multiplanar defor-mity such as an adult acquired flatfoot requires adjunctive procedures in

Fig. 1. Clinical demonstration of loss of the medial longitudinal arch (A) and heel valgus with

too many toes sign (B).

Fig. 2. Radiographic features of NC fault, altered Meary’s angle, decreased calcaneal inclina-

tion, and increased talar declination.

755NAVICULOCUNEIFORM ARTHRODESIS


addition to the NC fusion. Examples of such procedures include musculo-tendon balancing procedures, osteotomies, and arthrodeses, which are dis-cussed elsewhere in this issue.

Indications for the NC arthrodesis include a sagittal plane deformity (faultor sag) at the level of the NC joint, hypermobility of the NC joint, and degen-erative arthrosis. Relative contraindications in the authors’ practice includepatient noncompliance, tobacco/drug abuse, and poor bone stock.

Surgical technique

An equinus deformity, if present, is addressed through a gastrocnemiusrecession or tendoachilles lengthening (TAL) before dissection of the medialfoot and ankle. Exposure of the NC joint is accomplished through a medialutility incision that allows access to the posterior tibial tendon, which mayrequire repair or be augmented with a flexor digitorum longus tendon trans-fer in addition to the arthrodesis (Fig. 4). This incision is curvilinear in na-ture beginning proximal and posterior to the medial malleolus and extendsdistally to the first TMT joint (Fig. 5). Upon incision, the superficial venoustributaries of the medial marginal vein are ligated as necessary and dissec-tion performed to the deep fascia. The extensor retinaculum is released dis-tally, at which time attention is directed to the superior aspect of the incisionand the course of the anterior tibial tendon identified. The tibialis anterior isprotected and retracted dorsally for the remainder of the procedure (Fig. 6).

Next, the NC joint is opened through a medial capsulotomy, followed byrelease of the dorsal and plantar ligamentous structures. Joint distractionmay be necessary for direct visualization and joint preparation. The authorsuse a Steinman pin retractor (Weinraub joint and calcaneal spreader;Innomed, Savannah, GA), with one pin in the medial cuneiform and one

Fig. 3. Radiographic demonstration of Jack’s test. (From Jack E. Naviculo-cuneiform fusion in

the treatment of flatfoot. Journal of Bone and Joint Surgery 1953;35(B):78; with permission.)



in the medial navicular (Fig. 7). Joint preparation for arthrodesis is a funda-mental principle that necessitates removal of cartilage and debris and viola-tion of the subchondral plate. This preparation can be accomplishedthrough a combination of curettes, ronguers, and osteotomes. Fenestrationof the subchondral plate is achieved with a small drill or K-wire. Typically,the medial and intermediate cuneiforms are accessible; however, complete de-nuding of the cartilage on the lateral cuneiformmay not be possible due to thecontour of the articular surface and is not required for the final construct. Anin situ fusion technique does not require additional bone grafting becausethere is minimal shortening associated with it; however, packing the jointspace with cancellous chips or demineralized bone matrix or augmentationwith autologous platelet gel is left to the surgeon’s preference.

Reduction of the deformity via recreation of the windlass mechanism andcounter-pressure on the navicular tuberosity is paramount to recreate thetripod effect and establish the longitudinal arch (Fig. 8). While maintaining

Fig. 5. Tibialis posterior sheath is incised. Note the inferior retractor mobilizing the posterior

tibial tendon (distal is to the right of the picture).

Fig. 4. Incision planning for NC arthrodesis allowing complete exposure along the course of

the posterior tibial tendon for open repair and flexor digitorum longus transfer.



this reduction manually, an assistant places three temporary guidewires inthe following orientations: (1) from the navicular tuberosity into the medialcuneiform (plantarly), (2) from the medial navicular (just superior to previ-ous wire) to the intermediate cuneiform, and (3) from the distal medial as-pect of the medial cuneiform into the lateral body of the navicular (Fig. 9).These wires are replaced by 3.5-mm fully threaded cortical screws in lagtechnique. Alternative internal fixation constructs include staples and me-dial cervical or H-plates. Occasionally, a fourth screw can be placed fromthe medial cuneiform to the lateral body of the navicular (Fig. 10). Intrao-perative fluoroscopy is used to confirm placement of internal fixation anddeformity reduction. Closure is achieved in layers. An absorbable subcutic-ular stitch is used for skin, obviating the need for suture removal and allow-ing placement in a short leg cast at the first postoperative visit (Fig. 11). Thepatient is placed into a Jones compression dressing and posterior splint inthe operating room.

Fig. 6. Tibialis anterior is identified (distal is to the right of the picture).

Fig. 7. Joint exposure with retractor in foreground (distal is to the right of the picture). The

medial and intermediate cuneiforms are visible.



Postoperative course

At the first postoperative visit, pending evaluation of soft tissues, a shortleg cast is applied. The patient remains non–weight bearing for 6 to 8 weekswith routine radiographic monitoring. Transition to a fracture boot andpartial weight bearing is determined by radiographic arthrodesis as evi-denced by trabeculation across the fusion site. Physical therapy is usuallyinitiated at 6 weeks, with a return to full weight bearing in shoes at 10to 12 weeks. Deep venous thrombosis prophylaxis is based on riskstratification.

Fig. 8. Activation of the windlass mechanism for reduction of the deformity and temporary

pinning. Pressure is placed on the navicular tuberosity with the left thumb to assist in

correction.

Fig. 9. Cartoon illustrating ideal placement of internal fixation (A). Intraoperative fluoroscopy

indicating placement of temporary K-wire fixation (B).



Potential complications

As is true for most arthrodeses and reconstructive foot and ankle proce-dures, there are several potential complications. These complications includewound dehiscence, infection (superficial or deep), deep venous thrombosis,nerve entrapment, hardware failure, and delayed union, malunion, or non-union along with over- or undercorrection of deformity.

Discussion

In a comprehensive surgical approach to the adult acquired flatfoot, oneneeds to address each aspect of the deformity including soft tissue influencesand osseous abnormalities in addition to alterations in joint function.Medial column stabilization through NC fusion, with appropriately selectedancillary procedures, will allow reconstruction and stabilization of themedial column and preservation of essential joint motion. In a retrospectivereview of 52 patients by Chi and colleagues [2], the results of isolated medial

Fig. 10. Final radiographs of NC arthrodesis screw fixation. (A) Anteroposterior. (B) Lateral.

Fig. 11. Postoperative wound closure.



column stabilization, lateral column lengthening (calcaneocuboid joint boneblock arthrodesis), and combined medial and lateral procedures were ana-lyzed. All of the osseous procedures were augmented with a flexor digitorumlongus transfer and gastrocnemius recession or TAL. Objectively, in the me-dial column fusion group they found a decrease in Meary’s angle from a pre-operative value of 25 � 1 degrees to a postoperative value of 5 � 2 degrees.In addition, the anteroposterior TN coverage decreased from 25 � 6 degreesto 15 � 1 degrees, with 80% of patients less painful or pain free at 1 to 3 yearfollow-up. The authors developed a clinical algorithm for decision makingbased on their findings (Fig. 12). They concluded that medial column stabi-lization is a valuable procedure in patients with radiographic midfoot sagthrough the NC joint and forefoot abduction without significant hindfootvalgus. If hindfoot valgus is present, a concomitant posterior calcanealosteotomy is recommended.

Radiographic outcomes followingmedial column fusion have also been an-alyzed in regard to alignment of the forefoot and rearfoot via measurement ofestablished roentgenographic parameters [4]. Although restorations of thelongitudinal arch and normal bony architecture are postoperative goals, nostudy has clearly demonstrated how much correction is required for positiveoutcomes. In a retrospective radiographic evaluation, 19 patients who under-went medial column fusion were reviewed to determine how much correctioncould be obtained through changes in Meary’s angle, calcaneal inclination,and TN coverage. Mean improvements were found in all three on the orderof 16, 5, and 14 degrees, respectively. All of the procedures were performedin conjunction with flexor digitorum longus transfer and TAL or gastrocne-mius recession. It was concluded that isolated arthrodesis of the medialcolumn can realign and improve rearfoot deformity associated with peritalar

Fig. 12. Clinical algorithm. (Adapted from Chi T, Toolan B, Sangeorzan B, et al. The lateral

column lengthening and medial column stabilization procedures. Clin Orthop Relat Res

1999;365:88; with permission.)



subluxation. In addition, the procedure allows three-dimensional correctionwhilemaintainingmotion at the tri-tarsal joint complex.The studywas limitedby a small cohort with no control, as well as by a lack of evaluation of frontalplane deformity. Because the study was a review of radiographic findings, theresearchers could not assess the amount of correction influenced by ancillarysoft tissue procedures.

Other investigators have described the NC fusion in conjunction withvarious combinations of soft tissue augmentation, arthrodeses, or osteoto-mies and using a wide assortment of fixation [1,15–17,20–23]. The primaryindications in adult acquired flatfoot, as previously outlined, include loss ofstructural integrity, deformity, or both along the medial column with radio-graphic evidence of a breach at the NC joint. The subjective complaints ofprogressive deformity, pain, and a decrease in arch height aid in proceduralselection. Often, hypermobility or arthrosis of the medial column includingthe NC and first TMT may require primary arthrodesis of both joints. Thisapproach allows adequate correction and restoration of the tripod effect forefficient load transfer and stability during gait.

The surgeon must be cognizant of the fact that there are few indicationsfor an isolated NC arthrodesis. It is most commonly employed in conjunc-tion with posterior tibial tendon repair with or without flexor digitorum lon-gus transfer, selected calcaneal osteotomies, and hindfoot arthrodesis.Lengthening of the posterior muscle group via a TAL or gastrocnemius re-cession is also typically performed. Although there is limited evidence-basedmedicine, based on small cohorts and short-term outcomes, this procedurehas a distinct niche in the foot and ankle surgeon’s armamentarium.

Summary

The NC arthrodesis may be used to balance a symptomatic flatfoot,re-establishing medial column stability and alignment while maintainingessential tri-tarsal joint motion. The clinical findings, perioperative decisionmaking, and surgical technique for NC arthrodesis have been described, inaddition to a review of the limited literature concerning outcomes in correc-tion of the adult acquired flatfoot. When used appropriately, excellent resultsare possible in regard to patient satisfaction, a decrease in pain and deformity,and restoration of normal function. Although it does not have the power tocorrect significant heel valgus, it provides an alternative to hindfoot fusionsthat would significantly decrease biomechanical accommodation and affectreduced mobility of the foot during gait.

Acknowledgment

The authors thank Paul Dressel for his assistance in creation of theoriginal artwork for this text.



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