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A 17-year-old male patient with left midfoot pain
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A 17-year-old male patient who experienced ongoing left foot pain was presented to the office. He reported his symptoms began in 2013 while playing soccer, but denied any acute injury or trauma. He was initially seen by an outside provider and radiographs did not show any abnormality. Thus, the patient was given a home-exercise program and shoe inserts. The patient experienced persistent midfoot pain and discomfort during the next 2 years.
Approximately 4 months prior to his initial visit to our office, he underwent an MRI of the left foot, which led to concerns for avascular necrosis (AVN) of the medial cuneiform. The patient was subsequently immobilized in a controlled-ankle motion (CAM) walking boot for 6 weeks and was able to bear weight as tolerated. After 6 weeks, he continued to use an Exogen bone stimulator (Bioventus) and participated in outpatient physical therapy. Although the midfoot pain improved from initial presentation, the patient still had pain despite nonoperative treatment. Given these concerns, a second MRI was performed (Figure 1), which showed improvement of his middle cuneiform AVN. The patient denied any mechanical symptoms, numbness or tingling in his left lower extremity.
On physical examination, the patient had a neutral hindfoot with tenderness to palpation over the dorsal midfoot, specifically over the middle cuneiform and the base of the second metatarsal. The patient had normal active ankle range of motion (ROM) in all planes with normal strength.
Images: Lee S
The patient initially denied any past medical history. However, upon further questioning, his mother stated she has a “factor deficiency,” but no one else in the family had any similar history or manifestations. The patient was referred to a hematologist for further work-up regarding a possible blood clotting disorder and was diagnosed with factor VII deficiency.
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Left middle cuneiform avascular necrosis
The patient experienced AVN, also known as osteonecrosis (ON), of his middle cuneiform. Avascular necrosis has a wide variety of causes and can affect nearly any bone in the body, with some more commonly than others. MRI is the most sensitive modality to diagnose AVN and classically demonstrates bony changes before they are visible on plain films. Predisposing factors for AVN include family history, anatomical characteristics, repetitive microtrauma, significant steroid or alcohol use, vascular abnormalities and dietary factors among others.
Infarction begins when the blood supply to a section of bone is interrupted. Factor deficiency, as seen in our patient, also may be a contributory factor leading to AVN. Many factors can often lead to hypercoagulability, preventing fibrinolysis, causing intravascular coagulation and eventually inducing necrosis.
Many musculoskeletal injuries do not heal fully with conservative management and generally require surgical intervention. One of the most contemporary methods used to enhance tissue healing and regeneration, which has promising results, is platelet-rich plasma (PRP) therapy. Blood is withdrawn from a patient and centrifuged to achieve a high concentration of platelets with a proportionally low volume of plasma. The blood is either re-injected at the site of injury, inserted as a gel or in combination with other biomaterials during surgery. Platelet-rich plasma can be used in a mixture with adipose tissue-derived stem cells (ASCs) and hyaluronic acid. For early stage (stage 1) AVN, treatment with ASCs/PRP has proven to show complete resolution.
At control levels, platelet function is a natural reservoir for growth factors, which play an important role in tissue healing and regeneration. These growth factors enhance anabolism, bone and vessel remodeling, cell proliferation, angiogenesis, inflammation control, coagulation and cell differentiation.
Although the patient was diagnosed with AVN of the middle cuneiform, this diagnosis is extremely rare. AVN has been reported in more than 50 anatomical locations, most commonly in the hip, knee, spine, elbow and foot. In regards to AVN in the foot, common areas include the talus, navicular bone (Kohler’s disease), second metatarsal head (Freiberg’s disease), calcaneal apophysis (Sever’s disease) and the apophysis of the fifth metatarsal base. The radiologic findings in this case, including patchy irregularities and mild sclerosis, are similar to those in Kohler’s disease.
Treatment
Plain radiographic imaging of the patient was obtained and showed boney irregularities, including a lucency in the midfoot region and possibly a chronic-appearing fracture (Figure 2). The second MRI of the left foot showed edema within the middle cuneiform with concern for a previous fracture, which led researchers to the diagnosis of left middle cuneiform AVN with a possible chronic fracture. A weight-bearing CT scan of the left lower extremity was also obtained, which did not show any acute fracture. However, the CT scan demonstrated sclerosis throughout the intermediate cuneiform.
After a discussion with the patient and his mother regarding the underlying pathology related to his left foot pain, the decision was made to proceed with operative intervention. He received fresh-frozen plasma to prevent any excessive bleeding preoperatively. Under fluoroscopic guidance, the middle cuneiform was located and marked on the patient’s skin. Using a 0.62-mm K-wire, multiple percutaneous drill holes were created (Figure 3).
The wire was pointed in multiple directions through each hole to ensure the middle cuneiform was adequately drilled. This fanning technique was completed two more times. Skin holes were sealed with topical Liquiband ointment (Advanced Medical Solutions), and PRP was introduced using a 20-gauge needle. The trajectory of the previous K-wire drilling was repeated to deliver the PRP into the holes created by the fanning technique. He was placed into a CAM boot postoperatively.
- For more information:
- Adam Bitterman, DO, can be reached at 196 East Main St., Huntington, NY 11743; email: ABitterman@northwell.edu.
- Simon Lee, MD, can be reached at Midwest Orthopaedics at Rush, 1611 W Harrison St., Ste 300, Chicago, IL 60612; email: slee@rushortho.com.
- Abdul-Samad Mirza, MS, can be reached at email: amirza02@nyit.edu.
Disclosures: Bitterman, Lee and Mirza report no relevant financial disclosures.