Isolated talonavicular arthrodesis for Müller-Weiss disease

A Novel Update on the Management of Müller-Weiss Disease: Presentation of a Treatment Algorithm

OBJECTIVE

Müller-Weiss disease (MWD) is a challenging condition involving the perinavicular region in the initial stages and subsequently the entire foot in the later stages. The goal of this article is to describe the pathomechanics, clinical evaluation, and nonoperative and operative treatment, including a treatment algorithm, based on current evidence and the combined authors' experience.

DESIGN

We review the related articles and summarize the information about this condition.

RESULTS

A number of related articles reveal that the treatments should focus on the management of degenerative regions and deformity correction to restore normal foot alignment and provide pain relief.

CONCLUSION

This systematic review proposes a treatment algorithm that is comprehensive and practical to apply for the management of MWD.

Müller-Weiss Disease: Midfoot Arthrodesis in Reduction vs Malreduction

BACKGROUND

Midfoot arthrodesis is regarded as the main surgical approach for treating Müller-Weiss disease (MWD). This study aimed to investigate the incidence of postoperative pain during MWD treatment through midfoot reduction or malreduction during arthrodesis and to explore the factors influencing postoperative pain in patients with MWD.

METHODS

A total of 67 patients with MWD were recruited and divided into two groups according to whether midfoot alignment was reduced: reduction group (n = 38) and malreduction group (n = 29). Demographic characteristics before the operation and at the last follow-up, as well as clinical and radiographic parameters, were compared between the two groups. Clinical parameters included the American Orthopaedic Foot & Ankle Society score and visual analog scale score, whereas radiographic parameters included the calcaneal pitch angle, lateral Meary's angle, talometatarsal-1 angle dorsoplantar (TMT1dp), talocalcaneal angle dorsoplantar (Kite angle), talonavicular coverage angle, and medial navicular pole extrusion. Postoperative complications and incidence of midfoot pain were evaluated at the last follow-up visit.

RESULTS

The reduction group exhibited better clinical and radiological parameters, including the TMT1dp and medial navicular pole extrusion, than the malreduction group at the last follow-up (all P < .05). However, the calcaneal pitch angle, lateral Meary's angle, Kite angle, and talonavicular coverage angle did not significantly differ between the two groups (all P > .05). The overall incidence of midfoot pain was 26.4%. The reduction group showed a lower incidence of medial pain than the malreduction group (15.7% vs. 40.0%, P < .05). Regression analysis revealed that midfoot abduction, represented by the TMT1dp, was a critical factor for midfoot arthrodesis failure and that medial navicular pole extrusion was not correlated with postoperative midfoot pain.

CONCLUSION

Midfoot reduction arthrodesis yields better clinical outcomes than malreduction arthrodesis. The TMT1dp, representing midfoot abduction, is a key factor for midfoot arthrodesis failure. The extruded medial navicular bone may not affect postoperative medial midfoot pain.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Towards understanding Müller-Weiss disease from an analysis of 95 cases

BACKGROUND

The single existing classification of Müller-Weiss Disease (MWD), based solely upon Méary's angle, serves neither as guide for prognosis nor treatment. This accounts for lack of gold standard in its management.

METHODS

Navicular compression, medial extrusion, metatarsal lengths, Kite's, lateral and dorsoplantar talo-first metatarsal angles were measured in 95 feet with MWD. Joints involved, presence and location of navicular fracture were recorded.

RESULTS

Group 1 "early-onset" MWD feet (n = 11) had greatest compression and medial extrusion, and lowest Kite's angles. All except 1 were index minus and had lateral navicular fracture. Only 1 had moderate degeneration at the talonavicular joint (TNJ) with none requiring surgery yet. Group 2 "Müller-Weissoid" feet (n = 23) had radiologically normal navicular in their fifties and developed MWD on average 5 years later. They had the lowest compression and extrusion, and highest Kite's angles. None had complete fracture. All had TNJ arthritis, with early changes at lateral naviculocuneiform joint (NCJ) in 43%. Group 3 "late-onset" MWD presented in the sixth decade. Only TNJ was involved in Group 3 A (n = 16). Group 3B (n = 20) affected TNJ more than NCJ and had the greatest number of Maceira stage V disease. Group 3 C "reverse Müller-Weiss disease", which affected NCJ more than TNJ (n = 25), had greatest midfoot abduction and overlength of the second metatarsal. No fracture occurred in group 3 A compared to 65% and 32% in groups 3B and 3 C, respectively.

CONCLUSIONS

With need to compare like-for-like pathology, the proposed classification provides a common platform for reporting outcomes of different treatments. We theorize pathogenetic pathways in the various groups.

Müller-Weiss Disease: The Descriptive Factors of Failure Conservative Treatment

BACKGROUND

Conservative treatment is the first-line approach for Müller-Weiss disease (MWD). However, factors associated with the failure of conservative treatment have never been reported. Our objectives were to compare the differences in demographic and radiographic parameters between "successful" and "failure" conservative treatment in patients with MWD and identify descriptive factors associated with failure conservative treatment.

METHODS

We retrospectively reviewed 68 patients with MWD divided into 29 "failure" and 39 "successful" conservative treatment groups. Demographic characteristics, Foot and Ankle Outcome Score (FAOS), visual analog scale (VAS) scores for pain and walking disability, and radiographic parameters such as calcaneal pitch, lateral Meary, anteroposterior (AP) Meary angle, and talonavicular-naviculocuneiform arthritis were compared. Logistic regression analysis was performed to identify descriptive factors of failure conservative treatment. A P value <.05 was considered a statistically significant difference.

RESULTS

We found more severe VAS pain and walking disability scores and FAOS for the pain, activities of daily living, and quality of life subscales in the failure group (P < .05). Regression analysis demonstrated 2 significant descriptive factors associated with failure conservative treatment: abducted AP Meary angle >13.0 degrees and radiographic talonavicular arthritis. No demographic characteristics were found to be associated with failure conservative treatment.

CONCLUSION

Midfoot abduction (AP Meary angle, >13 degrees) and radiographic talonavicular arthritis were factors associated with failure conservative treatment in MWD and should be determined concurrently with the clinical severity. Classification systems for MWD should include these factors.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

A cadaveric comparison of two methods for isolated talonavicular arthrodesis: Two-screws versus plate with integrated compression screw

BACKGROUND

This study compared stiffness between two constructs for talonavicular arthrodesis: a dorsomedial plating system and two partially threaded cannulated cancellous screws. We hypothesized that the plate would exhibit greater stiffness and resistance to deformation during cyclic loading.

METHODS

The constructs were implanted in eight matched pairs of cadaveric feet and subjected to axial torsion, cantilever bending in two directions, and cyclic loading to failure.

RESULTS

The two-screw constructs were significantly stiffer in plantar-dorsal bending (p = .025) and trended towards a higher number of cycles before failure than the plate group (p = .087). No significant differences were observed in internal torsion (p = .620), external torsion (p = .165), or medial-lateral bending (p = .686).

CONCLUSIONS

This study provided the first biomechanical assessment of a plating system with an integrated compression screw, which was significantly less stiff than a two-screw construct when loaded from plantar to dorsal.

Derotation of the Talus and Arthrodesis Treatment of Stages II-V Müller-Weiss Disease: Midterm Results of 36 Cases

BACKGROUND

Various operative procedures have been reported for the treatment of Müller-Weiss disease (MWD). This study reports the midterm operative treatment results for stages II to V MWD with derotation of the talus and arthrodesis.

METHODS

Thirty-four patients (36 feet) with MWD were treated by talonavicular (TN) or talonavicular-cuneiform (TNC) arthrodesis in our center from 2008 to 2015. The affected feet were staged according to the Maceira staging system (stage II: 9; stage III: 10; stage IV: 9; stage V: 8). The American Orthopaedic Foot & Ankle Society (AOFAS) midfoot scale, the visual analog scale (VAS), and relative radiologic parameters were evaluated preoperatively and also during follow-up. The mean follow-up duration was 38.2 (range, 25-113 months).

RESULTS

The final follow-up showed satisfactory outcomes. Overall, the AOFAS scores improved from 41.5 (range, 20-56) to 85.3 (range, 68-100) points ( P <.001), and the VAS score decreased from 5.7 (range, 3-8) to 0.9 (range, 0-4) points ( P <.001). The Tomeno-Méary angle decreased from -6.7 (range, -26.4 to 17.7) to 0.7 (range, -5.3 to 7) degrees ( P=.001). The calcaneal pitch angle increased from 13.7 (range, 4.1-26.2) to 22.0 (range, 13.3-28.9) degrees ( P < .001). The anteroposterior (AP) talar-first metatarsal angle decreased from -15.8 (range, -30.1 to -13.7) to -7.0 (range, -25.9 to -8.9) degrees ( P < .001), and the AP talocalcaneal angle increased from 14.7 (range, 4.7-22.3) to 22.1 (range, 13.4-29.5) degrees ( P=.005). The AP talonavicular coverage angle decreased from -27.0 (range, -40.4 to -13.3) to -7.8 degrees (range, -20.7 to -1.8) degrees ( P < .001).

CONCLUSION

The midterm results found that the TN or TNC joint fusion could achieve a favorable clinical and radiologic outcome for patients with MWD. Even for the patients with severe deformities (stages IV-V), this treatment strategy could also achieve satisfactory deformity correction and functional improvement. Intraoperative restoration of talus rotation was the key to normal alignment of the subtalar joint/TN joint.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

[Short-term effectiveness of talonavicular joint arthrodesis and calcaneus osteotomy for Müller-Weiss disease]

Objective

To investigate the short-term effectiveness of talonavicular joint arthrodesis and calcaneus osteotomy in the treatment of Müller-Weiss disease.

Methods

Between June 2015 and February 2017, 14 patients diagnosed Müller-Weiss disease, who were ineffective on conservative treatment, were treated with talonavicular joint arthrodesis and calcaneus osteotomy. There are 3 males and 11 females, with an average age of 46.2 years (range, 35-56 years). According to the Maceira grading criteria, 5 patients were rated as stage Ⅲ and 9 patients as stage Ⅳ. The disease duration ranged from 4 to 12 years (mean, 7 years). Preoperative X-ray films showed that all patients were not accompanied with adjacent joint arthritis. The hindfoot axis on Saltzman view was (9.8±2.8)°, calcaneal pitch angle (CPA) on lateral position was (14.7±5.1)°, Meary angle on lateral position was (4.8±2.8)°, and talar 1 meta-tarsal angle (T1MA) on anteroposterior position was (25.0±7.3)°. Preoperative visual analogue scale (VAS) score was 5.9±1.5, American Orthopedic Foot Ankle Society (AOFAS) ankle-hindfoot score was 58.8±17.6.

Results

All patients were followed up 14-27 months (mean, 22.3 months). Medial numbness and incision infection occurred in 2, 2 cases, respectively. The other patients had no obvious discomfort. At last follow-up, VAS score was 1.6±1.3 and AOFAS score was 90.6±2.7, showing significant differences when compared with preoperative ones ( t=8.18, P=0.00; t=-6.95, P=0.00). X-ray films showed that the talonavicular joint and calcaneus osteotomy achieved bony healing. The hindfoot axis on Saltzman view was (-2.5±2.7)°, CPA on lateral position was (25.0±5.2) °, Meary angle on lateral position was (2.6±2.1)°, T1MA on anteroposterior position was (8.1±3.8)°. There was no significant difference in Meary Angle between pre- and post-operation ( t=1.53, P=0.15). And there were significant differences in the hindfoot axis, CPA, and T1MA between pre- and post-operation ( t=11.93, P=0.00; t=-8.89, P=0.00; t=8.05, P=0.00).

Conclusion

For Müller-Weiss disease patients without adjacent joint arthritis, who are ineffective on conservative treatment, the satisfied short-term effectiveness can be obtained when treated by talonavicular joint arthrodesis and calcaneus osteotomy.

Müller-Weiss Disease: Three- to Eight-Year Follow-Up Outcomes of Isolated Talonavicular Arthrodesis

Numerous surgical techniques for the treatment of Müller-Weiss disease (MWD) have been reported. However, no extensive clinical and radiographic studies of isolated talonavicular arthrodesis and MWD have been reported. The present retrospective cohort study examined the outcomes of isolated talonavicular arthrodesis at 3 to 8 years of follow-up in 16 MWD patients with a collapsed longitudinal arch and at least Maceira stage III. Demographic data, pre- and postoperative visual analog scale (VAS) scores for pain on walking and walking disability, foot and ankle outcome scores (FAOSs), and radiographic parameters were analyzed, with statistical significance at p < .05. A survival analysis was used to determine the median time to union. The mean ± standard deviation pre- and postoperative VAS scores for pain on walking were 7.69 ± 1.62 and 2.19 ± 1.52 and the walking disability scores were 7.06 ± 2.11 and 2.31 ± 1.92, respectively. The pre- and postoperative FAOSs were 48.07 ± 21.50 and 82.27 ± 13.86 for activities of daily living, 30.86 ± 19.70 and 76.17 ± 22.39 for quality of life, and 20.93 ± 22.89 and 51.88 ± 23.66 for sports/recreation, respectively. The median pre- and postoperative FAOSs for the symptoms subscale were 73.22 (range 42.88 to 100.00) and 87.50 (35.71 to 100.00) and for pain were 34.72 (range 8.33 to 72.22) and 88.89 (54.41 to 100.00), respectively. Significant improvements occurred from preoperatively to postoperatively for VAS scores and FAOSs (p < .05). The mean pre- and postoperative calcaneal pitch angles were 11.31° ± 4.35° and 13.81^o ± 5.60^o, significant improvement (p = .016). Improvement was also seen midfoot abduction, with a mean pre- and postoperative anteroposterior Meary's angle of 14.38° ± 10.07° and 9.38° ± 12.21°. The survival analysis showed union was achieved in all patients, with a median time to union of 2 (95% confidence interval 1.03 to 3.00) months. Our data indicate that talonavicular arthrodesis provides satisfactory functional outcomes for MWD patients with a collapsed longitudinal arch.

[Effectiveness of talonavicular arthrodesis for Müller-Weiss disease]

Objective

To evaluate the short-term effectiveness of talonavicular arthrodesis for Müller-Weiss disease.

Methods

Between May 2013 and February 2015, 13 patients with Müller-Weiss disease were treated with talonavicular arthrodesis. There were 11 females and 2 males with an average age of 59 years (range, 42-67 years). The disease duration was 8-20 years (mean, 13 years). According to Maceira stage, there were 7 cases of stage Ⅲ, 6 cases of stage Ⅳ. The foot longitudinal arch height measured on weight-bearing X-ray films was (43.1±1.8) mm; the Meary angle and talocalcaneal angle measured on lateral X-ray films were (-2.8±2.3)° and (5.8±2.4)°, respectively; the calcaneal valgus angle measured on Saltzman position X-ray films was (-2.0±0.7)°. The American Orthopaedic Foot and Ankle Society (AOFAS) score was 43.5±12.4, and visual analogue scale (VAS) score was 7.3±1.5.

Results

All the patients were followed up 14-39 months (mean, 20 months). The symptoms of foot pain and intermittent claudication disappeared in all patients. All cases achieved bony union, the fusion time was 12-16 weeks (mean, 13 weeks). There was no complications such as wound infection, skin necrosis, or internal fixator broken. At last follow-up, the foot longitudinal arch height, Meary angle, talocalcaneal angle, and calcaneal valgus angle were (52.5±2.2) mm, (1.3±2.2)°, (16.5±3.7)°, and (0.4±0.7)°, respectively; the AOFAS score and VAS score were 83.8±9.1 and 1.0±0.4, respectively; all were significantly improved when compared with preoperative ones ( P<0.05).

Conclusion

If the subtalar and calcaneocuboid joints are relatively healthy, talonavicular arthrodesis may be a reliable and effective surgical option for Müller-Weiss disease that is resistant to conservative treatment.

Isolated talonavicular arthrodesis and talonavicular-cuneiform arthrodesis for the Müller-Weiss disease

BACKGROUND

The study aimed to introduce the isolated talonavicular and talonavicular-cuneiform arthrodesis for the stage III and IV Müller-Weiss disease and analyze their clinical outcomes.

METHODS

Thirty patients of stage III and IV Müller-Weiss disease were divided into the talonavicular (TN) arthrodesis group and the talonavicular-cuneiform (TNC) arthrodesis group according to the perinavicular osteoarthritis by MRI scans. For the isolated talonavicular arthrodesis group, 16 patients underwent talonavicular arthrodesis with two 4.0 mm hollow headless compression screws. For the TNC arthrodesis group, 14 patients were received the TNC arthrodesis with reverse "V" shape osteotomy and autoallergic iliac bone graft. All patients were followed up at 3, 6, 9, and 12 months, and per 6 months after 1 year, by the AOFAS ankle-midfoot scores, and evaluated by radiographic measurements.

RESULTS

All of them were followed up in two groups and all patients were satisfied with their clinical results. At the TN arthrodesis group, the patients' mean was 39.8 months (range, 11-66 months) follow-up. The mean AOFAS ankle and hindfoot scores had improved from 38.3 ± 5.1 preoperatively to 88.9 ± 1.9 at the last postoperative assessment. At the TNC arthrodesis group, the mean follow-up was 51.7 months (range, 12-90 months). The mean AOFAS ankle and hindfoot scores were 40.1 ± 7.9 preoperatively to 90.1 ± 2.0 at the last postoperative. All of the cases were solid fusion on the radiograph.

CONCLUSIONS

According to MRI evaluation, either TN or TNC arthrodesis for stage III or IV Müller-Weiss disease have the good clinical outcomes with solid fusion rate and obvious improvement of the quality of life of patients.

Individual headless compression screws fixed with three-dimensional image processing technology improves fusion rates of isolated talonavicular arthrodesis

BACKGROUND

Screw fixation is a typical technique for isolated talonavicular arthrodesis (TNA), however, no consensus has been reached on how to select most suitable inserted position and direction. The study aimed to present a new fixation technique and to evaluate the clinical outcome of individual headless compression screws (HCSs) applied with three-dimensional (3D) image processing technology to isolated TNA.

METHODS

From 2007 to 2014, 69 patients underwent isolated TNA by using double Acutrak HCSs. The preoperative three-dimensional (3D) insertion model of double HCSs was applied by Mimics, Catia, and SolidWorks reconstruction software. One HCS oriented antegradely from the edge of dorsal navicular tail where intersected interspace between the first and the second cuneiform into the talus body along the talus axis, and the other one paralleled the first screw oriented from the dorsal-medial navicular where intersected at the medial plane of the first cuneiform. The anteroposterior and lateral X-ray examinations certified that the double HCSs were placed along the longitudinal axis of the talus. Postoperative assessment included the American Orthopaedic Foot & Ankle Society hindfoot (AOFAS), the visual analogue scale (VAS) score, satisfaction score, imaging assessments, and complications.

RESULTS

At the mean 44-months follow-up, all patients exhibited good articular congruity and solid bone fusion at an average of 11.26 ± 0.85 weeks (range, 10 ~ 13 weeks) without screw loosening, shifting, or breakage. The overall fusion rates were 100%. The average AOFAS score increased from 46.62 ± 4.6 (range, 37 ~ 56) preoperatively to 74.77 ± 5.4 (range, 64-88) at the final follow-up (95% CI: -30.86 ~ -27.34; p < 0.001). The mean VAS score decreased from 7.01 ± 1.2 (range, 4 ~ 9) to 1.93 ± 1.3 (range, 0 ~ 4) (95% CI: 4.69 ~ 5.48; p < 0.001). One cases (1.45%) and three cases (4.35%) experienced wound infection and adjacent arthritis respectively. The postoperative satisfaction score including pain relief, activities of daily living, and return to recreational activities were good to excellent in 62 (89.9%) cases.

CONCLUSIONS

Individual 3D reconstruction of HCSs insertion model can be designed with three-dimensional image processing technology in TNA. The technology is safe, effective, and reliable to isolated TNA method with high bone fusion rates, low incidences of complications.

Open triple fusion versus TNC arthrodesis in the treatment of Mueller-Weiss disease

Background

Mueller-Weiss disease is a rarely diagnosed deformity where the navicular bone undergoes spontaneous osteonecrosis in adults. Until now, there is no widely accepted operative treatment for this unusual disease. We aimed to compare clinical and radiological outcomes between the open triple fusion and talonavicular-cuneiform arthrodesis for Mueller-Weiss disease of stage 4.

Methods

During the period from February 2012 to June 2016, 10 patients (11 feet) suffering from Mueller-Weiss disease of stage 4 were treated by the same senior surgeon. Among them, 5 patients (5 feet) were treated with open triple fusion and 5 patients (6 feet) were treated with talonavicular-cuneiform arthrodesis. Clinical outcomes were evaluated by American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score. Radiological results were assessed based on the X-ray and CT. Postoperative complications were also recorded.

Results

There were no significant differences in AOFAS score between the two groups (p = 0.1 > 0.05). For the open triple fusion, the average AOFAS ankle-hindfoot score improved from 30.2 ± 3.27 preoperatively to 79 ± 3.81 at the last follow-up (p = 0.008). And for the talonavicular-cuneiform (TNC) arthrodesis, the average AOFAS ankle-hindfoot score improved from 33.2 ± 5.63 preoperatively to 86.2 ± 3.49 at the last follow-up (p = 0.007).

Conclusions

Both triple fusion and TNC arthrodesis are reasonable methods for the treatment of Mueller-Weiss disease if properly used. It is crucial to use radiological assessment to evaluate the involved joints preoperatively and then chose the appropriate method to treat different patients.

Use of fibula flaps to treat persistent talonavicular nonunion: A report of three cases

Owing to the limited blood supply in the midfoot, multiple arthrodesis attempts in midfood joints may result in severe osteonecrosis, leading to a difficult scenario for bone reconstruction. This article describes the use of fibula flaps (two free and one pedicled flap) to reconstruct bone defects in three cases of persistent nonunion in midfoot joints. Before admission, all patients (aged 32-56 years old) had undergone multiple arthrodesis attempts (range 3-4) aimed at treating joint diseases associated with flatfoot or Müller-Weiss syndrome. All inserted flaps were stable, and bone fusion was confirmed by X-ray examination at month 4. After the follow-up period (range 1-4 years), all patients showed normal, painless gait. No foot deformities or further complications were observed. Our report suggests that fibula flap transfer may be a good alternative for treating persistent nonunion in midfoot joints involving bone loss, and may prevent the osteonecrosis associated with limited blood supply. © 2016 Wiley Periodicals, Inc. Microsurgery 36:430-434, 2016.