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Panel discusses management of navicular stress fractures
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Navicular stress fractures are a relatively common presentation to an orthopedic foot and ankle surgeon. Most involve recreational or high-level athletes who present with vague complaints of pain in the foot or ankle, especially during increased activity levels. In the clinic, it is often difficult to localize the area of pathology. A high index of suspicion must be maintained to diagnose and treat stress reactions or fractures of the navicular bone. Once diagnosed, several treatment options, both operative and nonoperative, exist.
In this Orthopedics Today Round Table, a panel of expert orthopedic foot and ankle surgeons provides readers with perspectives on the treatment of navicular stress fractures.
James J. Sferra, MD
Moderator
Roundtable Participants
-
Moderator
- James J. Sferra, MD
- Pittsburgh
- Robert B. Anderson, MD
- Charlotte, N.C.
- Gregory C. Berlet, MD
- Westerville, Ohio
- Martin J. O'Malley, MD
- New York City
James J. Sferra, MD: In addition to plain radiographs, do you typically obtain a CT scan, MRI scan or both in your work-up for navicular stress fractures?
Martin J. O’Malley, MD: My work-up for navicular stress fractures begins with a MRI if the plain radiographs are negative. The symptoms are so vague that pathology in both the ankle and midfoot can mimic navicular symptoms, and MRI is an excellent screening tool for ankle and hindfoot stress fractures. If the radiograph shows an obvious fracture, then I would bypass MRI and proceed directly to a CT scan.
In most cases, the CT scan is also obtained to get better delineation of the fracture anatomy and determine classification. In addition, CT is used to determine healing so one needs to have a baseline study to monitor progress. I also will look for any anterior ankle osteophytes on the preoperative CT scan as they may be one of the etiologic factors in navicular stress fractures.
Gregory C. Berlet, MD: My work-up for a suspected navicular stress fracture includes standing radiographs of the ankle and foot. The radiograph is poor to identify navicular stress fractures, but it addresses other factors, such as abnormal joint mechanics due to tarsal coalition or foot shape considerations like cavus foot or forefoot adductus.
For advanced imaging, CT provides the best resolution for the fracture plane and differentiating between partial and complete fractures of the navicula. If I am doing a screening test for navicula stress reaction, then I use MRI instead of bone scans.
We also now use single-photon emission CT which combines the advantages of CT with bone scan in one imaging modality. The quality of the CT is sometimes not the same as what you would get with diagnostic CT, so be aware of the CT capabilities before selecting this imaging option.
Robert B. Anderson, MD: As noted in the literature, approximately 30% of navicular stress fractures will not be identified on initial plain radiographs. If a running athlete presents with vague “ankle or midfoot” pain, inconclusive exam and normal radiographs, then I proceed directly to MRI for further evaluation. If the MRI notes edema in the navicular, then CT is preformed to determine if there is a stress reaction or fracture, and if fractured, to what degree. When managing a navicular stress fracture, regardless of the treatment method chosen, a CT is the best tool to follow healing. Therefore, a baseline CT study is invaluable.
Sferra: Which navicular stress fractures do you consider treating nonoperatively?
O’Malley: For me, this is the most controversial fracture as it is an incomplete fracture and the screw would only serve to prevent propagation of the fracture rather than provide compression. I would consider treating a type 1 stress fracture nonoperatively (Figure 1) as long as there are no cystic changes which I believe will lead to re-fracture (Figure 2).
In high-level athletes, I will offer percutaneous screw fixation for type 1 as well, in addition to 6 weeks non-weight-bearing. I believe all type 2 and type 3 fractures should be treated operatively. Torgs meta-analysis concludes that all these fractures should be treated nonoperatively. However, Malleee and colleagues called into question the methodology and conclusions, and many of the studies used plain radiographs to determine healing, which we know is inaccurate. If these patients are followed with serial CT scans, then a complete 100% union rate is much lower than reported.
Type 1 navicular fracture is shown.
Type 1 navicular fracture with a cyst is shown.
Images: O’Malley MJ
Berlet: The decision regarding operative and nonoperative care has both structural and anatomic influences. If there is a complete navicular fracture, then I am pessimistic that this will heal with nonoperative care. Nonoperative care for navicular fractures is reserved for incomplete fractures in a patient with an over-training etiology but otherwise has good biomechanical structure.
In the case of nonoperative treatment, I keep my patients non-weight-bearing for 8 weeks and begin ambulating in a boot walker with pain being the guide. I re-image at 4 months before I return them back to pre-injury activities. If the fracture persists, then we discuss operative fixation.
Operative care is for complete navicular fractures and for patients who have contributing biomechanical problems. There are situations where I will address both the navicular fracture and the biomechanical problem, e.g., for example tarsal coalition, in the same operative setting.
Anderson: I will consider and offer a nonoperative course of treatment for those fractures that are truly incomplete and which occur in recreational athletes or general population. However, incomplete fractures may propagate from dorsal to plantar and it is important to follow the CT to assess healing.
I prefer operative intervention for all complete navicular fractures or for incomplete fractures with documented progression.
Sferra: When performing surgery on a navicular stress fracture, is there any indication for a percutaneous technique? What is your favored mode of internal fixation when performing an open technique?
O’Malley: I believe the percutaneous technique is appropriate for type 1 stress fractures. For most type 2 and type 3 fractures, I prefer open treatment with internal fixation and bone marrow aspirate and autogenous graft. I will use a single, 3.5-mm screw (cannulated technique but solid screw) placed lateral to medial in compression mode for type 1 fractures. For type 2 and type 3 fractures, I prefer an open dorsal approach to bone graft the fracture and place two 3.5-mm (or 2.7-mm in smaller patients) screws through a separate lateral incision. We try to get the screws perpendicular to the fracture site, but that can be difficult.
Berlet: For a complete navicular fracture, I perform open reduction and internal fixation in all cases. I also supplement with bone graft from the calcaneus. The indication for the percutaneous approach is a persistent symptomatic navicula stress response that has not healed despite good nonoperative care with protected ambulation. In the event of a percutaneous approach, the greatest risk is joint space perforation, most notably the concave side at the talonavicular joint.
Anderson: I perform a percutaneous technique for all incomplete fractures and acute complete fractures with absolutely no diastasis or displacement. Whether percutaneous or open technique, I typically place two 4-mm partial threaded screws from lateral to medial, as the fracture is usually in the lateral third of the navicular body. I will use titanium screws for this instance as future MRIs may be necessary to assess bone viability.
Sferra: Do you use autograft, allograft, bone marrow aspirate or other material?
O’Malley: I believe navicular fractures are the most challenging stress fractures of the foot and ankle, so I tend to overtreat patients to avoid a nonunion in the competitive athlete. We often see areas of avascular bone on the imaging studies in the dorsal navicular and feel additional autogenous bone grafting is low morbidity (Figure 3). I use both concentrated bone marrow aspirate as well as autogenous bone (either from the iliac crest taken with the same iliac aspirate needle or calcaneal bone graft) on all patients. For refractures or non-unions, we use the local vascularized bone graft technique that was described by James A. Nunley, MD, MS, at Duke University.
Berlet: I prefer autograft from the calcaneus of the operative limb. The bone quality is usually good, and using this location allows me to use regional popliteal blocks. The complication rate from calcaneal harvest is low. I use the Acumed 6-mm power harvester for efficient bone graft harvest.
Anderson: I use autogenous calcaneal or iliac crest bone graft for the complete fractures which I openly manage. I also use autogenous bone for the management of stress fracture nonunions.
Sferra: What is your postoperative protocol? Is there any role for an external electrical bone stimulator?
O’Malley: I use either ultrasound or electrical stimulation on all patients. In addition, vitamin D is checked on all patients and we add Forteo (teriparatide, Eli Lilly) if there is a delayed union or refracture. The postoperative protocol is 2 weeks in a splint then the patient is transferred to a cam walker boot and non-weight-bearing for 6 weeks.
A CT scan is obtained at 6 weeks (plain radiographs often show complete healing), and we compare it to our baseline CT. If there has been satisfactory progress, then we will begin a graduated partial weight-bearing program with full weight-bearing in the cam boot at 10 weeks.
I will obtain a final CT scan at 12 weeks before letting the patient resume full weight-bearing in a shoe. If you use CT to gauge healing, then the results are not as high as previously reported as there is often some residual lucency and this is a cause for concern. The patient can begin to therapy at 3 months with expected return to play at 4 months to 5 months.
Berlet: These are high risk injuries that take a long time to heal. I emphasize to patients that this will be a slow and tedious recovery, with at least one follow-up advanced imaging needed to prove healing prior to return to sport. My biologic adjuvants to help healing include autogenous bone graft and external bone growth stimulation. In patients where bone quality is suspicious, I will have screening with my endocrinology colleagues for metabolic bone disease.
After surgery, I keep my patients non-weight-bearing in a cast for 6 weeks. I used to go to a boot earlier for range of motion, but I found pain was not a good guide for my athletes and most athletes advanced themselves to walking since it did not hurt. Now, I am firm in my recommendation of non-weight-bearing in a cast for 6 weeks.
If the patient has no pain with direct palpation over the navicula and can ambulate comfortably, then we go to a boot walker at 6 weeks with the boot coming off to bathe, sleep and swim. In the boot, they are allowed weight-bearing to tolerance and, in supervised cases, they can begin stationary bike training for aerobic conditioning. At 4 months, all patients get CT to confirm healing.
Anderson: The patient is immobilized in a non-weight-bearing splint for 2 weeks. Then I advance to a boot to allow for gentle active and passive range of motion, but maintain non-weight-bearing status for an additional 4 weeks. Pool therapy may be initiated when incisional healing allows.
A weight-bearing boot is initiated at 6 weeks postoperatively and continued for 4 weeks to 6 weeks at which time a CT scan is performed to assess union. If the fracture has healed, rehabilitation is advanced in an accommodative shoe with a custom orthosis that includes an arch support and carbon fiber plate. I use an external bone stimulator whenever available.
- References:
- Mallee WH, et al. Br J Sports Med. 2015;doi:10.1136/bjsports-2013-093246.
- Torg JS, et al. Am J Sports Med. 2010;doi:10.1177/0363546509355408.
- For more information:
- Robert B. Anderson, MD, can be reached at OrthoCarolina Foot and Ankle Institute, 2001 Vail Ave., Charlotte, NC 28207; email: randerson@orthocarolina.com.
- Gregory C. Berlet, MD, can be reached at Orthopedic Foot & Ankle Center, Westerville Medical Campus, 300 Polaris Pwky., Suite 2000, Westerville, OH 43082.
- Martin J. O’Malley, MD, can be reached at Hospital for Special Surgery, 420 E 72nd St., Suite 1B, New York, NY 10021; email: omalley@hss.edu.
- James J. Sferra, MD, can be reached at Allegheny Health Network, 307 Federal St., 2nd Floor, Pittsburgh, PA 15212, email: jsferra@wpahs.org.
Disclosures: Anderson, Berlet and Sferra report no relevant financial disclosures; O’Malley reports he is a paid consultant for Curvebeam.