SLR - September 2023 - Thompson
Title: Efficacy of Triple and Talonavicular Arthrodesis for the Treatment of III-IV Muller-Weiss DiseaseReference: Lu L, Liu B, Zeng J, Chen W, Hu F, Ma Q, Yu G. Efficacy of Triple and Talonavicular Arthrodesis for the Treatment of III-V Müller-Weiss Disease. Tohoku J Exp Med. 2022 Sep 3;258(2):97-102. doi: 10.1620/tjem.2022.J062. Epub 2022 Jul 28. PMID: 35896365.
Level of Evidence: Level IV Evidence
Scientific Literature Review
Reviewed By: Anna-Kay Thompson, DPM, MS
Residency Program: Boston University Medical Center, Boston, MA
Podiatric Relevance: Muller-Weiss Disease (MWD) is a rare foot disease of unclear etiology, usually noted in middle-aged women. Many factors may contribute to the damage of the navicular’s blood supply, leading to vascular necrosis. Patients may complain of longstanding mechanical pain in the midfoot typically induced by foot deformities such as hindfoot varus and medial arch deformation. A 5-stage system to estimate the severity of MWD was developed by Maceira and Rocheira (2004) and widely used clinically. Conservative management such as anti-inflammatory medications, foot orthosis, and short leg casts are recommended for early stages. For patients who have failed conservative treatment, joint fusion surgery may be a reliable and effective method to correct the deformity, restore function, and relieve pain. Data for this study is provided via functional outcome scores and radiographic analysis support surgical reconstruction of MWD.
Methods: Twelve patients with MWD (III-V) who failed conservative therapy after 3 months were enrolled in this 4-year prospective study at the University Hospital Department of Orthopedic Surgery. Inclusion criteria were for patients that had normal inflammatory labs and radiographic evidence of comma-shaped deformation or partial fragmentation in the navicular bone, consistent with avascular necrosis (AVN). Exclusion criteria were for patients with Kohler disease, Charcot neuroarthropathy, metabolic or autoimmune disease, ulcers, stress-induced or trauma-induced AVN. Surgical procedure involving Talonavicular (TN) or triple arthrodesis with 4.0 mm cannulated screws angulated into the anterior subtalar joint is performed. Post-operative care includes a protected cast for 2 months and weight-bearing walking with a rocker boot. Follow-up was evaluated within 18 months, and the final clinical outcome score was analyzed using the American Orthopedics Foot and Ankle Society- midfoot score (AOFAS). Three-view weight-bearing radiographs were obtained at the last follow-up visit to evaluate lateral Meary’s angle, foot length, and arch height.
Results: Eight females and four males with a mean age of 52.1 were enrolled. Seven patients were diagnosed with MWD stage III, two with stage IV, and two with stage V. The average follow-up time was 16 months, with improved pain and walking function in the affected foot. Bony union time of 13.6 weeks was observed. No wound infection was documented. AOFAS scores dramatically increased from 43.4 to 85.3 one-year post-op. Radiograph increase in medial column length and arch height was noted. Meary’s angle reduced from an average of 2.14 to 1.3 degrees.
Conclusions: Patients with advanced-stage MWD noted satisfactory therapeutic effects after Triple and TN arthrodesis. In these patients, the complete union was achieved without post-operative complication and patients have a notable clinical improvement in AOFAS. The study notes the disadvantage of TN and triple arthrodesis, including long recovery time and high complication rate. A limitation of this study is the small sample size. Further study is recommended to evaluate the effect of TN and triple arthrodesis on patients within the same stage of disease progress to clarify it’s scope of application. When conservative management has failed, joint fusion surgery is a reliable and effective treatment for advanced MWD to correct deformation, restore function and eliminate foot pain.