pISSN 1738-3757 eISSN 2288-8551 Case Report J Korean Foot Ankle Soc 2015;19(2):69-72 http://dx.doi.org/10.14193/jkfas.2015.19.2.69

Isolated Talonavicular Arthrodesis as an Option for Severe Deformity: A Case Report

Stephanie Stephanie*, Jun Young Choi, Abhishek Kumar, Jin Soo Suh

Department of Orthopaedic Surgery, Inje University Ilsan Paik Hospital, Goyang, Korea, *Department of Surgery, Howard University College of Medicine, Washington, DC, USA

We report on a case of post-burn and right foot deformity in a 37-year-old female who underwent two surgical interventions at the age of seven years. The patient remained well without any associated problems until she presented to our hospital at the age of 37 years with severe pain and right foot deformity. A few treatment modalities have been reported, and amputation has been suggested as the best approach. However, our patient was treated with a talonavicular arthrodesis and a soft tissue procedure, which resulted in a stable, plantigrade, and pain-free foot with an unsupported, bipedal gait.

Key Words: Rocker bottom foot, Arthrodesis, Foot deformities

The objective of arthrodesis of the foot is to correct the deformi- TN joint has been associated with a high non-union rate5) due to ty of the involved joint and achieve a stable, pain-free plantigrade poor visualization of the entire cartilage area, and the great chance foot.1) This provides a better functional outcome for the patient of avascular necrosis (AVN) of both talus and navicular. It is also with the increased stress in the surrounding non-fused joints. difficult to obtain a stable fixation because of the morphometric An arthrodesis of the foot joint can be performed in situ in pa- shape, the short length and the small size of navicular bone.6) tients with a chief complaint of pain in the foot but has no foot deformity, or in patients who cannot maintain gait stability after CASE REPORT surgery for correction of the foot deformity.2) Double and triple arthrodesis are common procedures that are A 37-year-old female with a history of burn injury to the right often performed to restore and maintain the physiologic alignment foot was presented to our clinic with a sharp pain on the navicu- of the hindfoot. It is also performed in severely deformed rocker- lar bone that was aggravated with weight bearing and right foot bottom foot correction surgery where we reconstruct a destroyed deformity area. The patient reported being burned by hot water at midfoot joint.3) The need for an isolated talonavicular (TN) joint the age of 6 months, and was operated twice at the age of 7 years fusion can arise, although rarely, in cases of navicular fracture, iso- to correct the foot deformity (details not available). For the past lated degenerative or idiopathic TN joint etiology.4) 36 years, the patient has been doing well and walking with mini- Gross visualization of the entire cartilage area is required for mal pain. However, she noted that the pain has been increasing complete denudation of the cartilage. Thus, isolated fusion of the in severity within the last year and she was unable to walk, and complained of pain even at rest. There was no history of recent Received February 24, 2015 Revised April 22, 2015 Accepted April 22, 2015 Corresponding Author: Jin Soo Suh trauma. Department of Orthopaedic Surgery, Inje University Ilsan Paik Hospital, 170 Juhwa-ro, Ilsanseo-gu, Goyang 411-706, Korea Upon physical examination, the patient had an antalgic gait with Tel: 82-31-910-7968, Fax: 82-31-910-7967, E-mail: [email protected] limb shortening of 3.5 cm on the right lower extremity. She also

Financial support: None. had a valgus hindfoot, abducted midfoot and scarred skin over Conflict of interest: None.

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www.jkfas.org 70 Vol. 19 No. 2, June 2015 her right anterolateral ankle (Fig. 1). There was an anterolateral ed cancellous screws (Fig. 5). Both peroneal tendons of the lateral post-burn scars and band contracture (Fig. 2) on the patient’s right compartments were lengthened and the extensor digitorum ten- ankle, and a tender bony prominence on the surface of the medial don was transferred to the extensor hallucis longus (EHL) muscle. midfoot. The second distal toe was also amputated and the toe tip Then we excised the tip of the second toe, along with the corn was protruding over the skin, giving rise to a corn. There was no and anterolateral scar of the right foot. A myocutaneous free flap evidence of previous or ongoing infection. was obtained from the ipsilateral latissimus dorsiand used to cover Radiologic examinations (Fig. 3) revealed a talo-first metatarsal the defect. Postoperatively, the patient was kept on a cast stabiliza- angle of 75o on weight bearing anteroposterior (AP) view and 60o tion of non-weight bearing for 6 weeks, followed by 6 weeks of on lateral view. The angle of the calcaneal pitch was 17o while gradual weight-bearing as tolerated. the midfoot was abducted, pronated, and the navicular bone held Three months postoperatively, the patient obtained a planti- down against the floor. Scanogram showed a 3.5 cm shortening of grade foot and was able to walk pain free without any support (Fig. the right lower limb (Fig. 4). 6). Radiologically, an assessment of the AP talo-first metatarsal The patient underwent the TN fusion using two partially thread- angle revealed 41o with forefoot valgus and 11.8o on lateral view, while the calcaneal pitch angle measured 5o (Fig. 7).

FFigureigure 1.1. Burn scar over extensor digitorum longus tendon (arrow). FFigureigure 2.2. Anterolateral scar over ankle.

FFigureigure 3.3. Radiologic examinations revea- led a talo-first metatarsal angle to be 75o A B on weight bearing anteroposterior view (A) and 60o on lateral view (B). Stephanie Stephanie, et al. Isolated Talonavicular Arthrodesis 71

DISCUSSION This condition is of rare occurrence. Besides, it is very difficult to generalize the specific treatment plan for all cases because each There has been very few reports published on the treatment of case is unique and has specific conditions.7,8) rocker-bottom feet deformity complicated by burn contracture. Lateral column lengthening is generally used to correct hindfoot valgus and severe flat foot deformity. However, our patient has a very tight soft tissue tension on the lateral aspect of the foot de- spite previous resection, scar band release, and lateral side tendon lengthening. It is generally believed that isolated TN fusion is not commonly recommended for the relieve of pain or functional restoration of the midfoot,9,10) with the great chance of AVN, non- union, malunion and progressive posttraumatic arthritic changes. However, in our particular case, isolated TN fusion became the treatment of choice because the patient suffered from a severe shortening of the lateral ray, along with an extreme valgus of the forefoot. A double or triple arthrodesis would require a substantial amount of bone resection, especially at the talar neck. This is not always a good choice because it leads to further shortening of

FFigureigure 4.4. Scanogram showed a shortening of 3.5 cm of the right lower foot. limb. It would be prudent to mention here that one of the presenting

FFigureigure 5.5. Postoperative radiographs showed talonavicular arthrodesis state with two cannulated screws. Anteropos- A B C terior (A), lateral (B), and hindfoot (C) alignment view on standing.

FFigureigure 6.6. The patient obtained a planti- grade foot and was able to walk pain free without any support at three months postoperatively.

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A B C

FFigureigure 77.. Radiologic assessment of the anteroposterior (AP) talo-first metatarsal angle revealed 38o (A) on AP view with hindfoot valgus (B) and 12o on lateral view, while the calcaneal pitch angle measured -9.6o (C). chief complaints of the patient was difficulty in managing her daily REFERENCES footwear. The patient’s feet would slide off her shoes with every step. Amputation at the level of trans-metatarsal would have ag- 1. Thelen S, Rütt J, Wild M, Lögters T, Windolf J, Koebke J. The gravated this problem postoperatively. influence of talonavicular versus double arthrodesis on load Next, we also excised the second toe tip because it was protrud- dependent motion of the midtarsal joint. Arch Orthop Trauma Surg. 2010;130:47-53. ing out of the dorsum of the foot and producing a corn. Peronei 2. Kiesau CD, Larose CR, Glisson RR, Easley ME, Deorio JK. Ta- lengthening was done to correct the overall abduction inclination lonavicular joint fixation using augmenting naviculocalcaneal of the foot. Transfer of the extensor digitorum longus to the EHL screw in modified double hindfoot arthrodesis. Foot Ankle Int. 2011;32:244-9. had caused the force of the tendon to be diverted medially. The 3. Swaroop VT, Wenger DR, Mubarak SJ. Talonavicular fusion for anterolateral thigh flap was based on the perforator derived from dorsal subluxation of the navicular in resistant . Clin the descending branch of the lateral circumflex femoral artery. Orthop Relat Res. 2009;467:1314-8. An alternative treatment option for a patient with severe rocker 4. Popelka S, Hromádka R, Vavrík P, Stursa P, Pokorný D, Jahoda D, et al. Isolated talonavicular arthrodesis in patients with rheuma- bottom deformity is to amputate the foot at the level of the trans- toid arthritis of the foot and tibialis posterior tendon dysfunc- metatarsal bone. The rationale is that such procedure is less tion. BMC Musculoskelet Disord. 2010;11:38. complicated and has a rapid recovery time. However, the patient 5. Ljung P, Kaij J, Knutson K, Pettersson H, Rydholm U. Talona- vicular arthrodesis in the rheumatoid foot. Foot Ankle. 1992; refused this treatment modality. 13:313-6. Therefore, we performed an isolated TN arthrodesis of the foot 6. Philippot R, Wegrzyn J, Besse JL. Arthrodesis of the subtalar and and the lateral side soft tissue reconstructive surgery. This proce- talonavicular joints through a medial surgical approach: a series dure can be an excellent treatment option for the patients with of 15 cases. Arch Orthop Trauma Surg. 2010;130:599-603. 7. Carmichael KD, Maxwell SC, Calhoun JH. Recurrence rates of a severe rocket-bottom foot deformity and especially in selected burn contracture ankle equinus and other foot deformities in cases like this where the foot length is shortened, and this proce- children treated with Ilizarov fixation. J Pediatr Orthop. 2005; dure would result in a reduction of lever after fusion. 25:523-8. 8. Saghieh S, El Bitar Y, Berjawi G, Harfouche B, Atiyeh B. Distrac- tion histogenesis in ankle burn deformities. J Burn Care Res. 2011;32:160-5. 9. Faraj AA. Talonavicular joint arthrodesis for paralytic post polio- myelitis forefoot instability. J Foot Ankle Surg. 1996;35:166-8. 10. Fortin PT. Posterior tibial tendon insufficiency. Isolated fusion of the talonavicular joint. Foot Ankle Clin. 2001;6:137-51.