34 year female OA of T-N joint

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Hi all,

I would appreciate help on a patient who came into our clinic recently

34 year old healthy female diagnosed with avascular necrosis of navicular 2008.
Surgical consult at the time recommended talonavicular arthodesis. Patient didn't go through with surgery as she had small children, at this stage started walking in a compensatory style to avoid pain.
Weightbearing now is on lateral side of foot - patient has created a significant supinated foot type with prominent 5th MTPJ, styloid process and her 5th toe is now sitting dorsally.
She has no pain in navicular area anymore - chronic pain on lateral ankle - limited STJ ROM (very little, if any, eversion and limited inversion), AJ ROM restricted. She is walking with a pronounced limp and is in chronic pain.

Recent Xray showed no evidence to support the prior diagnosis of AVN of the navicular (which itself maintains normal volume and overall appearance), rather there is marked OA of the talonavicular joint. There is a degree of subluxation of the TN joint with the naviuclar slightly medially subluxed relative to the talus.

Pt still doesn't want surgery at this stage.

What would people recommend as the best alternative treatment to allow the patient to function in her normal daily life?

Thanks in advance

 

Hi K, hows the baby? :morning:

Had the same thing myself 20 yrs ago --- needed a bone graft from the pelvis...

Lots of mobilization/manipulation

 

Hi Kirsten :welcome:

Any chance you can post up the X-rays ?

As Craig said lot of FMT especially the Ankle Joint.

I would go with a full contact device no rearfoot posting, making sure that there is a good lateral arch as well a medial as you don´t want the compression forces at the Talo-Navicular joint to increase due to the OA.

I would also pay close attention to the casting process - ie maybe after a full set of FMT cast the foot but do all of the manipulation of the cast during the process. ie reduce the amount of work done on the positive cast to near 0 as you will have done the work during the casting, the only work would be heel expansion.

You will probably need to go with something quite stiff, but be aware that there maybe medial arch irritation and so need to reduce stiffness in the medial arch over time, not shape but stiffness.

Does that make sense

Hope it helps

 

Hi Craig, baby Olive is doing very well, 9months now!
I was thinking about manipulation and mobilisation - who can I refer to in the Mordialloc area?

Mike, I'm not sure I can post the Xrays as I don't receive them electronically - can I photograph and post? (sorry new to this).

Would you think a cam walker with temporary felt padding would be of any assistance in the short term? Her foot is in such pain that I don't feel she would tolerate an orthotic device anytime soon?

 

If she is that much pain then non wieghtbearing might be a better option for period of time then possibly a Camwalker, but with the info we have and not being able to tolerate a device sounds like she needs surgery whether it fits with her life or not.

as for the xrays - not sure how the quality will be with a photo but maybe try anyway

 

I'm with Mike on this - try a CAM walker initially. If you are considering surgery or have doubt about the diagnosis, I would recommend an MR scan to assess for AVN of the Navicular. Please can you post more info on your clinical examination and the presenting complaint for further advice? Where is the main point of pain? Nature, location, duration, etc...

If there is specific pain at the TNJ and OA, once the acute pain is reduced by the CAM walker, you could consider a corticosteroid injection along with an orthotic. If all else fails, a fusion is reasonable, but I would be keen to assess how viable the navicular is (and whether and how much I would need to graft the TN fusion) with an MR scan. I would also be keen to assess the surrounding joints for OA prior to my interventions. Has the rearfoot stiffness been a permanent feature? Are there any signs of a tarsal coalition?

 

Hi Kirsten

Place the XRays on the viewing box with the light on. Take a photo of it without a flash - smartphones and iPads work very well. Email it to yourself and save it on your pc then upload it here.

Regarding the patient, I would say that at this point in time, it is probably best to focus on the area that hurts for now - the lateral aspect of the ankle. According to your description she has injured the area by supinating the foot to a large extend. I would recommend strapping the ankle into eversion (whether eversion is limited or not) with rigid strapping. Strapping should be firm and tight. Leave it in place for 3 days.

The result of that test will tell you exactly what you need to do next.

If she comes back saying how much that strapping has changed her life over the last 3 days then design an orthotic prescription that mimics the action of the strapping or use another device that does.

Hope that helps you.

Regards

Mark

Hope that helps.

 

if you have X-ray confirmed OA of the TN Jt, periosteal acupuncture may resolve her acute symptpms, before embarking on your long term Rx plan.

 

From your description I don't really have an idea of what's going on. Is her foot inverted to the ground because of PT spasm or is it because of arthrosis of the joint. Was the foot always in this position or was she able to get the medial forefoot to the ground at one point in time?

In what position is she least painful when weight bearing? How much pain in that position. Could she benefit from support to help her stay in that position? This support can be added to the cam walker. Another idea is an ankle gauntlet. However, before that was tried, you should know what position is most comfortable.

Is it the TN joint that hurts the most? Or is it the compensation for that pain? Or both?

Good Luck with her

Eric

 

Dear Kirsten
This would be an ideal case for prolotherapy ie injections of 20% glucose and lignocaine.
It is a property of collagen that under sustained load/stretch it lengthens and that leaves the joint it protects, loose and unstable so that the normal wear is increased ie OA. This can be corrected in most cases by restarting the healing cascade with anything, surgery, dry needling etc, but prolotherapy is less painful and more effective than dry needling and less invasive than surgery. When you palpate the joint line it will be tender along the joint line and also on each side where the ligaments of the joint 'capsule' insert on the talus and navicular. There may be 3-4 points about 1-1.5cm apart all around it. Mark them with a pen, dab some antiseptic, then tiny injections of lignocaine (lidocaine) 0.5 or 1% at each spot. Then about 1/2cc at each spot of a mixture in a 5ml syringe of 4ml 25% glucose and 1ml 1% lignocaine. If you have got all the strained ligaments it will feel much better when she walks. Repeat it every 2 weeks until the pain has gone. The OA will not be gone immediately, but probably will improve over a year or so. At 34, when you have fixed it, the pain should stay away forever, but if the deformity is severe or she were, say, 64, she might need 'top-ups' from time to time to keep her pain free. I am in Australia, taylorme@internode.on.net if you want to know more.

 

Dear Kirsten
I couldn't read your letter while I was writing and have missed some of your important points. Sorry.
You will also need to treat lateral joints and ligaments as well as the TN joint. You know the anatomy - treat the outside of the curve on the lateral ankle and foot - trying to 'tighten' the ligaments that have lengthened. They will be tender as well.
complicated but she was normal once, so give it a go. Even if you can't get normal structure again, you should be able to relieve the pain.
Margaret