Use of Remodeled Femoral Head Allograft for Tarsal Reconstruction

The Journal of Foot & Ankle Surgery 50 (2011) 721–726
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The Journal of Foot & Ankle Surgery
journal homepage: www.jfas.org
Use of Remodeled Femoral Head Allograft for Tarsal Reconstruction
€ ller-Weiss Disease
in the Treatment of Mu
€ phel, MD, PhD 2
Anouk Tan, MD 1, Yvonne C.M.M. Smulders, MD 2, Oliver T. Zo
1
2
Resident, Department of Plastic, Reconstructive, and Hand Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
Plastic Surgeon, Department of Plastic, Reconstructive, and Hand Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Keywords:
arthrodesis
avascular necrosis
bone
osteonecrosis
surgery
€ ller-Weiss disease (MWD), spontaneous avascular necrosis of the navicular in adults, is rare. Without
Mu
treatment, it can result in permanent disability. Operative treatment is often required. MWD was suspected in
a 51-year-old woman with spontaneous pain in her right foot. The radiologic tests showed a comma shaped
deformed navicular and severe talonavicular necrosis and sclerosis. After excision of the necrotic navicular,
a 5 5 3-cm defect appeared. A femoral head bone allograft was remodeled to fit this defect precisely.
Autologous cancellous bone was also used. The allograft interposition arthrodesis was stabilized with a low
contact plate. The histopathologic results showed avascular osteonecrosis, supporting the diagnosis of MWD.
After 12 weeks of non–weight-bearing plaster cast immobilization, the radiographs showed consolidation and
no osteolysis. At 6 months after surgery, she was fully weight-bearing. The low contact plate was removed,
because it impeded exercise. After 10 months, she was walking pain free. At 14 months after surgery, her
radiographs still showed good consolidation, with no sign of osteolysis. The use of a bone allograft to cover
a tarsal defect could be a safe and effective operative treatment of MWD that has not yet been reported in
English-language studies. This treatment also results in minimal donor site morbidity.
Ó 2011 by the American College of Foot and Ankle Surgeons. All rights reserved.
Adult-onset osteonecrosis of the navicular can be spontaneous or
secondary to systemic diseases such as rheumatoid arthritis, systemic
lupus erythematosus, or trauma. In adults, spontaneous osteonecrosis
€ ller-Weiss disease (MWD). MWD is
of the navicular is known as Mu
rare and usually occurs bilateral and predominantly in women. In the
past 50 years, it has seldom been reported in the English data (1–9). It
€ ller (10) in 1927, who first thought
was first described by Walther Mu
the disorder was caused by compression of the navicular from adjacent bones. However, 1 year later, he revised this theory and stated
that the deformity was congenital instead of traumatic (11). This new
theory was based on the presence of a histologically normal navicular.
In 1929, Weiss (12) described a similar disorder. Only he believed
osteonecrosis was the primary causative factor (12). The etiopathogenesis of MWD is still not completely clear, and different theories
have been suggested in published studies. Delayed ossification of the
navicular and an abnormal force distribution pattern are necessary to
cause the specific lateral compression of the navicular in this condition. All patients with MWD show rear foot varus to some degree (5).
Financial Disclosure: None reported.
Conflict of Interest: None reported.
Address correspondence to: Anouk Tan, MD, Resident, Department of Plastic,
Reconstructive, and Hand Surgery, Medisch Spectrum Twente, Postbus 50000,
Enschede 7500 KA, The Netherlands.
E-mail addresses: anouktan@hotmail.com, a.tan@mst.nl (A. Tan).
€ ller (10) include
The classic radiologic findings described by Mu
collapse of the lateral aspect of the navicular with medial and dorsal
protrusion. Later studies showed a preceding phase, with an initial
loss of volume and increased radiodensity in the lateral aspect of the
navicular, resulting in the classic comma shaped deformity (Fig. 1) (9).
Maceira et al (5) described 5 radiographic stages of MWD according to
increases in the sagittal plane deformity on the lateral weight-bearing
radiograph of the navicular and the orientation of the intersection of
the talar and first metatarsal axes (Meary-Tomeno’s angle). Stage 1
represents only minimal changes in the navicular, and stage 5
demonstrates formation of a talocuneiform joint with complete
extrusion of the navicular.
The navicular has an important biomechanical role because of its
position between the talus and cuneiforms. The bony articulations
allow for normal pronation and supination of the foot. During stance
propulsion, the navicular is compressed, allowing an axial load to be
transmitted effectively along the longitudinal axis (13,14). If left
untreated, MWD can result in advanced midtarsal osteoarthritis and,
subsequently, permanent disability (8). Conservative treatment with
immobilization by orthoses and anti-inflammatory medications
often fails (6,15). Operative intervention aims at correction of the
deformity and pain alleviation. Histologic inspection of the navicular
in MWD shows decreased bony trabeculae, with bone marrow
fibrosis (16).
1067-2516/$ - see front matter Ó 2011 by the American College of Foot and Ankle Surgeons. All rights reserved.
doi:10.1053/j.jfas.2011.04.043
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A. Tan et al. / The Journal of Foot & Ankle Surgery 50 (2011) 721–726
Fig. 1. (A) Anteroposterior radiograph of the foot. (B) Lateral radiograph of the foot in standing patient, showing severe arthrosis, osteophytes, and joint space narrowing of talonavicular
joint and severe sclerosis of the navicular. The navicular is deformed into a comma shape, showing representation of stage 4 according to the Maceira classification.
Case Report
A 51-year-old woman experienced severe pain concentrated in the
dorsal part of the right foot of 1 year’s duration. She had a medical
history of ankle ligament reconstruction in 1985 and excision of
a neuroma of the dorsalis pedis nerve in the scar in 1995 and 1996.
After these interventions, she was pain free until she presented with
spontaneous new pain symptoms in the dorsal part of the right foot.
The physical examination revealed flat feet. A palpable bony
prominence was present over the talonavicular articulation. No signs
of edema, erythema, or ecchymosis were present. Palpation of the
dorsal midfoot in the talonavicular articulation region was painful.
The area of the incision of the ankle ligament reconstruction was
hyper aesthetic. Additional neurologic examination was unremarkable. To exclude a neuroma as the cause of her pain, a denervation test
was performed. After anesthetizing the neuroma, the pain persisted.
Radiographs revealed severe arthrosis of the talonavicular joint
with osteophytes. Severe sclerosis of the navicular was found (Fig. 1).
According to the 5 radiographic stages described by Maceira et al (5),
the radiographs in our case showed stage 4, with joint space narrowing between the navicular and cuneiform bones and advanced
compression of the navicular.
An additional 3-phase bone scintigraphy scan showed decreased
blood flow in the lateral navicular in the early phase. During the blood
pooling phase, the lateral part of the navicular showed a hotspot
caused by hypervascularity and higher turnover in bone metabolism
(Fig. 2). Single photon emission computed tomography after 795 MBq
technetium methylene-diphosphonate clearly showed an increased
activity in the right navicular (Fig. 3). A magnetic resonance imaging
(MRI) scan showed collapse of the necrotic navicular and arthrosis of
the adjacent bones with multiple degenerative cysts (Fig. 4). MWD was
suspected, and the patient was scheduled for operative treatment. The
old incision located at the third metatarsal was used to expose the
talonavicular joint. A neuroma of the dorsalis pedis nerve was found.
Osteophytes of the navicular were compressing the dorsal pedis nerve
from beneath. This neuroma was excised completely. The navicular,
which felt fragile and showed severe necrosis, was excised in total,
leaving a 5 5 3-cm measuring defect (Fig. 5A). The adjacent cartilage of the head of the talus and the base of the medial, intermediate,
and lateral cuneiform bones were removed. After removal of the
cartilage, a femoral head bone allograft was carefully remodeled to fit
the defect (Fig. 5B). Autologous cancellous bone was obtained from the
iliac crest and used complementary (Fig. 5C). An 8-hole AO low contact
plate, reaching from the head of the talus to the medial cuneiform,
stabilized the allograft interposition arthrodesis. After surgery, the
patient was immobilized by a non–weight-bearing plaster cast for
12 weeks. The histopathologic results of the excised navicular showed
osteocytes without nucleus confirming necrosis and supporting the
diagnosis of MWD (Fig. 6) (16).
After 12 weeks of plaster cast immobilization, the patient started
weight-bearing gradually. At 6 months after the procedure, she was
pain free and fully weight-bearing. At that time, the radiographs
showed consolidation and a normal length and architecture of the
foot (Fig. 7). She was scheduled for removal of the low contact plate,
because it impeded her during exercise. At 14 months after surgery,
she was still pain free. Her radiographs showed consolidation of the
allograft interposition arthrodesis and no signs of osteolysis (Fig. 8).
However, she complained of similar pain in the dorsal part of the left
foot. The clinical examination revealed a bony prominence located at
the talonavicular articulation. The radiographic findings were unremarkable. Because MWD usually affects both feet, MRI was performed
to exclude avascular necrosis of her left navicular. The MRI scan
showed no signs of avascular necrosis of the navicular. A 3-phase bone
scintigram with single photon emission computed tomographycomputed tomography showed no decreased blood flow or any signs
of greater turnover in the bone metabolism in her left navicular.
Discussion
MWD is a rare diagnosis and often needs a long diagnostic workup
with many radiologic tools before it is recognized. The disorder
should not be mistaken by Koehler’s disease, osteochondrosis of the
tarsal navicular in children (17). They are 2 separate pathologic entities and differ in radiographic appearance, patient population, and
clinical findings.
The vascular supply of the navicular is precarious. The branches of
the dorsalis pedis and medial plantar arteries supply the dorsal and
volar part of the bone and leave the middle one third relatively
A. Tan et al. / The Journal of Foot & Ankle Surgery 50 (2011) 721–726
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Fig. 2. Three-phase bone scintigram showing hotspot in right navicular during flow phase.
Fig. 3. Transversal, sagittal, and coronal single photon emission computed tomography-computed tomography images in late skeletal phase showing increased activity in right navicular.
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A. Tan et al. / The Journal of Foot & Ankle Surgery 50 (2011) 721–726
Fig. 4. (A) T1-weighted sagittal MRI scan of the foot. (B) T2-weighted coronal MRI scan of the foot, showing severe degenerative changes, osteophytes, necrosis, and collapse of the
navicular, especially in the lateral part of the navicular.
underperfused (13). Because of its centripetal intraosseous blood flow
with central watershed area, the navicular is at risk of osteonecrosis in
the presence of obstructed peripheral blood flow (18). The limited
arterial access and venous outflow is a direct result of the articular
cartilage covering much of the bone’s exterior (19).
Delayed ossification with an increased body weight can play a role
in MWD. Repetitive stress on the navicular through the medial
longitudinal arch in a valgus hind foot could be responsible for delay
in ossification in pes planus. MWD is characterized by increased
plantar pressure at the midfoot, combined with a reduction in pressures on the toes. This abnormal pressure distribution can be at least
partially responsible for the pain and discomfort (4). The pes planus
deformity in our case might have contributed to the avascular
necrosis of the navicular or is the result of the collapsed necrotic
navicular.
The pain she experienced in 1995 and 1996 was caused by
a neuroma of the dorsalis pedis nerve and disappeared after excision.
Because of the late presentation of the pain, a correlation between the
former surgeries and the avascular necrosis of the navicular was not
suspected. The neuroma of the dorsal pedis nerve that was found
intraoperatively was probably caused by damage owing to the
compression of the osteophytes of the navicular. This neuroma was
presumed to be responsible for her pain in the first place and
contributed to the delay in the diagnosis of MWD.
In published studies, several diagnostic tools have been described
to help diagnose MWD. Owing to the necrosis of the cells of the bone
marrow and bone, a hyperemic reaction can be delineated that allows
us to visualize the necrosis indirectly. The best image methods for
early avascular necrosis are MRI and 3-phase technetium-99m polyphosphate bone scintigraphy. Bone scanning is more sensitive than
MRI, but it is less specific. The usefulness of bone scintigraphy is
dependent on the stage of osteonecrosis. Increased osteoblastic
activity results in high uptake in the entire affected area during the
acute ischemic phase. In later stages, a demarcated rim of increased
Fig. 5. (A) Necrotic navicular was removed en toto. (B) New navicular created from femoral head allograft. (C) Defect in tarsal column after placement of “new navicular” and
complementary autologous cancellous bone.
A. Tan et al. / The Journal of Foot & Ankle Surgery 50 (2011) 721–726
725
Fig. 6. Histopathologic result of excised navicular showing osteocytes without nucleus,
confirming diagnosis of osteonecrosis.
activity surrounding the hypoperfused necrotic core will become
apparent.
Single photon emission computed tomography-computed
tomography can help in maximizing the resolution and will demonstrate a persistent photopenic defect caused by incomplete vascularization. MRI is sensitive to changes in the bone marrow composition.
During early osteonecrosis, diffuse bone marrow edema is seen,
causing low signal intensity on T1-weighted images and high signal
intensity on T2-weighted images. During the advanced stage, both
T1- and T2-weighted images will show low signal intensity owing to
sclerosis and the disappearance of edema (18). It is not possible to
Fig. 8. (A) Anteroposterior radiograph 10 months after surgery. (B) Lateromedial radiograph 14 months after surgery. (C) Lateral radiograph 14 months after surgery, showing
consolidation, normal architecture of the foot, and no signs of osteolysis. However, some
screws broke during removal of the low contact plate. To prevent damage during removal,
they were left in situ.
Fig. 7. (A) Anteroposterior radiograph 6 months after surgery. (B) Lateromedial radiograph 6 months after surgery showing consolidation and normal length and arch of foot.
differentiate between primary and secondary osteonecrosis of the
navicular using radiology alone. Haller et al (9) found no real diagnostic difference between patients with primary osteonecrosis and
those with an underlying cause (i.e., rheumatoid arthritis, renal
failure, trauma, and lupus erythematosus). Our radiologic findings of
dorsal protrusion, collapse of the necrotic navicular, and sclerosis of
the adjacent bones are consistent with those reported for MWD in
published studies (9,10,12,20).
The histopathologic results in our case also supported the diagnosis of MWD (16). Operative intervention is often needed. No
reference standard exists for the operative treatment of MWD. Most
of the surgeries aim at correction of the deformity and pain alleviation. Talonavicular arthrodesis, triple arthrodesis, and talonavicularcuneiform arthrodesis can be considered. Fernandez de Retana et al
(2) showed that triple arthrodesis results in better consolidation than
isolated talonavicular arthrodesis. Triple arthrodesis can provide
medial and lateral control, resulting in good stabilization. We performed arthrodesis using a remodeled bone allograft and autologous
cancellous bone stabilized by a low contact plate that reached from
the head of the talus to the medial cuneiform. The new navicular
allograft was then stabilized between the talus and cuneiform bones.
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A. Tan et al. / The Journal of Foot & Ankle Surgery 50 (2011) 721–726
This solid stabilization might have contributed to the good consolidation of the allograft.
The use of bone allograft to create a new navicular has not yet
been described in English reports. Using mainly bone allograft and
only autologous cancellous bone might have reduced morbidity such
as soft tissue dissection and wound complication. The disadvantage
of this alternative operative management could be inflammatory
reactions and osteolysis. In the present case, the radiographs
showed normal foot architecture and no signs of osteolysis. Vascularized bone grafts could also be used as an alternative, although the
size of the bone defect might cause some limitations. A pedicled
local graft would be difficult to find. A free fibular graft might be an
alternative. However, these options will result in greater donor site
morbidity.
In conclusion, our report highlights the importance of the recognition of MWD. This painful and debilitating illness can result in
advanced midtarsal osteoarthritis and subsequent permanent
disability if left untreated. Operative intervention aimed at correction
of the deformity and pain alleviation is often required. Several forms
of arthrodesis have been suggested in published reports. Our report
also shows that an allograft interposition arthrodesis could be a safe
and effective operative option for treatment of MWD. A femoral head
bone allograft can be remodeled precisely to fit the defect after
removal of the necrotic navicular. This operative treatment results in
lower donor site morbidity. However, more studies are necessary.
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