Fractures of the navicular

Generally, large or significantly displaced intra-articular navicular fractures are treated best by surgical intervention. Open reduction and internal fixation of these injuries allow anatomic restoration of adjacent joint surfaces and preservation of length and stability along the medial column of the foot; intervention must not disrupt the already tenuous blood Supply of the tarsal navicular because of the associated risks of avascular necrosis and nonunion. The unique morphology and vital role of the navicular as a cornerstone of the talonavicular joint require every effort to maintain the congruity and motion of this joint to avoid later fusion. The likelihood for successful reduction decreases with increasing grades of injury. The naviculo-cuneiform joint, alternatively, requires stability for proper foot function and can be fused, if necessary, to improve fixation or enhance vascularity to the navicular. External fixation, bone grafting (often and early), and limited peritarsal fusion also have evolved into useful aids, under certain circumstances, to facilitate the goals of navicular fracture management. Early postoperative range of motion, prolonged protected weight bearing, and aggressive patient counseling as to the severity and long-term implications of these injuries also are paramount to success. Caution also must be exercised in managing navicular dislocations because of the potential long-term complications of redislocation or painful flatfoot deformity if alignment is not maintained.Navicular fracture care remains a challenge to the orthopedic surgeon; successful surgical intervention continues to hinge upon a careful balance between an operative exposure that is limited enough to avoid further devascularization but extensive enough to permit anatomic reduction and rigid internal fixation.     

Imaging of the navicular

This article presented a rational approach to imaging of navicular pathology. The indications, techniques, and limitations of conventional radiographic imaging were discussed. In addition, the role of advanced imaging techniques, including MRI, CT, and NMI, in the diagnosis of navicular pathology was presented. By appropriately combining plain radiographic imaging with advanced imaging modalities, an accurate diagnosis is typically obtained.     

Non-union of the carpal navicular

An analysis of methods of treatment with special regard to compression screw osteosynthesis. During the years 1965 to 1980 a total of 96 patients was treated with different types of procedure for non-union of the carpal navicular. The location and type of the fractures confirms previous reports that the chances of healing of proximal and oblique fractures of the navicular are poor. Most of the patients were operated on with compression screw osteosynthesis. In our experience which was confirmed by a follow-up examination at two to fifteen years following treatment, compression screw ostheosynthesis seems to be the better method of handling navicular non-unions.     

Arthrodesis of the shoulder

Shoulder arthrodesis is an end-stage salvage option for the failing, painful joint that cannot undergo or has failed reconstruction. It is indicated for irreversible and nonreconstructible massive rotator cuff tears and deltoid muscle denervation as well as for detachment of the deltoid from its origin. Rarely, arthrodesis is done to stabilize the glenohumeral joint after many failed attempts at shoulder reconstruction. Arthrodesis for failed prosthetic arthroplasty or tumor resection presents additional challenges because of the associated bone loss on the humeral and/or glenoid side of the joint. Primary arthrodesis requires rigid internal plate fixation and both an extra- and an intra-articular site of fusion. Depending on bone volume and quality needed, the patient may require bracing for 8 to 10 weeks, autogenous or allograft bone grafting, or a vascularized fibular bone graft to reconstruct the bone deficiency, along with prolonged spica cast immobilization. The optimal position for arthrodesis is 20 degrees of forward flexion, 20 degrees of abduction, and 40 degrees of internal rotation, with modifications based on patient body size or other patient-specific factors. Bone fusion is attained in nearly all patients, with marked pain reduction and improved function. Postoperatively, the patient should be able to lift the arm to near shoulder height and to reach the top of the head, the mouth, the ipsilateral back pocket, and the groin. Complications include nonunion, malposition, pain associated with prominent hardware, and periarticular fractures.     

Arthrodesis of the knee

The most common indication for arthrodesis of the knee is an infection at the site of a total knee arthroplasty. Deficiencies in bone stock and poor bone apposition adversely affect the success of a knee arthrodesis. Arthrodesis of the knee can provide a stable, painless extremity for high-functioning patients who are able to walk. Patient function after arthrodesis of the knee is superior to that after above-the-knee amputation. Conversion of a solid knee fusion to a total knee arthroplasty has a substantial complication rate.     

Arthrodesis of the elbow

Elbow arthrodesis (EA) is a procedure reserved for the salvage of failed elbow reconstruction or elbow injuries that defy reconstruction of a useful joint. Although arthrodesis of some joints is often straightforward and predictable, EA is technically difficult and associated with a high rate of complications. Furthermore, a successful EA does not translate to a gratifying clinical success. The functional limitations to activities of daily living and personal care are significant.     

Arthrodesis of the wrist

In a retrospective study, the wrists of 18 patients who underwent arthrodesis by the AO technique were assessed clinically, for hand strength and function. Follow-up averaged 4 years (range from 1 to 7 years). Although wrist arthrodesis improved grip strength, it was still only 50% to 60% of normal. Hand function improved to within normal limits in 78% of patients and bony union occurred in 94.4%. Thirteen patients were back at work within 18 months. The AO technique of wrist arthrodesis allows correction of deformity, relief of pain, increased grip strength and improved hand function.