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- [00:01]
A
Welcome to AOFAS Ortho Podcast, where leaders in foot and ankle orthopedic surgery discuss the issues that affect you and your practice. Please note that the views expressed on this podcast do not necessarily represent the views of the AOFAS or its members. Welcome to the AOFAS Ortho Podcast. We're here talking about salvage naviculars today. The navicular is quite a tough bone and so sometimes it goes on and needs some help. And so we're here with Dr. Martin O', Malley, who's a clinical professor of orthopedic surgery at HSS. He's the team orthopedic surgeon for the Nets and a consultant for the Giants and Devils. And we're joined also by Joseph park, who's a clinical professor of orthopedic surgery at University of Virginia. I'm Matt Conti from the Hospital for Special Surgery, and thank you both for joining us. And I'm looking forward to hearing about all these disasters.
- [01:05]
B
Can't wait.
- [01:06]
A
Yeah. So let's talk about the navicular and maybe you could just talk about, Dr. O', Malley, your experience with it and, you know, how your evolution has been since over the last few years or decades with the evolution of how you've been fixing them and Vasvaris pine.
- [01:23]
B
Sure. So it went from not being afraid of the NICU to being afraid of the nicu. So at one point we would just put a couple. The big debate was whether you fix it or not. Is there a line there? Do you put a screw across it? So that's gone from okay, I never get him to heal without an operation. So in an adult, a kid, certainly give him a try. But an adult, the line never goes away. If it goes away, it comes back. The last kid I tried was 17, you know, D1 recruit, parents didn't want an operation. We sat up, you know, we didn't do anything. Non weight bearing bone stem, everything healed perfect, goes back first game practice again. And the reason is because it's a combination of foot type and biology. So it's a low blood supply and maybe there is that 10% or 11% of people have a low blood spot at the top of the. These are the ones who get it. And a lot of these people, these patients have a, you know, kind of a cavus foot and have a high arch. And so it's a lot of mechanics involved in the vicar, a lot of stress in that area. So I've gone now. I pretty much will do one or two screws on everybody. Almost everyone gets iliac bone marrow aspirin. And most people get primary bone grafted at the time of the procedure. Make a little incision by the pressure line and pack some. I take the jam sheeting needle, I take the marrow, and then I'll take a couple sleeves. You don't need much because it's not a big line. And those are the primary Vickers truth lateral to medial, and they do pretty well. If it's a straightforward one, that's okay. Be aware of the type 3. The type 3, which is what? You know, the complete navicular fracture. You think it's gonna be so good because when you're putting these screws across a bone that's not broken, you lose it. It doesn't feel that good. But when you put it across one that's broken, you can see it compressed together. It feels so good. Those are the ones in my series as well as in Bob's series that had the refracture rate. So we've had a couple refracture in two years where it looked perfectly healed on cats again for a year, and then they refractured. So those are problematic. So I have a very healthy respect for the navicular. The patients are cautioned that even my first line of my navicular talk is even with optimal, non operative and operative treatment, this cannot heal and it can refracture. That's my slide one. That's why I started the conversation. And so if you don't start like that, then you're overly optimistic on this.
- [03:50]
A
What about. So just to be clear, like little crack, you're still fixing it, or let's talk like all the way from bone marrow edema only on, on MRI to a little crack, like, where's the line?
- [04:02]
B
Right. So bone marrow edema that hasn't gone away is always the big issue. Yeah. Right. So bone marrow edema that hasn't gone away and bone marrow demon hasn't gone away with a fragment of bone at the tail end of victory joint, which is a common combination. Right.
- [04:17]
C
I was just going to ask you about that.
- [04:18]
B
So. So there's something causing the bone marrow edema. Can you take out the fragment at the tail of the victory joint and see if it heals? Obviously you can. And those people. I will prophylactically put a screw across it because I don't know, but. And I don't trust that just taking out that bone will. Will allow the navicular to heal. So That's a type 0.5. A type 1 is a break in the dorsal cortex, those will get just a little break. I'll do a percutaneous screw and percutaneous BMAC right at the fracture. And a lot of times I'm using the xyme scan, so I'm trying to put the needle right in the fracture. Not so sure you really need it. Sometimes it makes me more confused than it is. But I try and use that 3D interoperative imaging. Type 2, they all get bone grafted. Two screws. Type 3 clearly get bone grafted. Screws. You know, it's interesting that Calder and he had a soccer player during COVID who was going to do a. Nunley was going to come over to a vascularized bone graft. Jim Nunley is the one who described the vascularized bone graft, the local rotation bone graft from the Canadian form. Calder was coming over, Covid hit, he couldn't fly. So Calder did it. And he told me he does it almost at all. His primary navigation now, he takes a little piece of bone, traces out the vessel and the vessels actually at a primary navigator without previous surgery, pretty easy. See, you take a little osteotome, take a little wedge, and park it right in the top of the navicular. He told me he's doing it on almost all his naviculars because he had such a high rate of non union. Yeah.
- [05:47]
A
I mean, so that leads us into like, when are you doing the vascularized?
- [05:52]
B
Well, I'll do it if the. There's a huge cyst dorsally, if it just looks like there's dead bone. But most of the time, if it's a primary, you know, athlete, the vacuum fracture, I don't go to the pedophile, the vascularized graft, unless it's a revision, I'll get the graft. Well, we.
- [06:07]
A
Well, we've done one, you know, together in a Juilliard dancer, you know, but it just looked like the lateral part of the navicular was like dead. And so is that like more of a Mueller Weiss? You know, maybe we get into, you know.
- [06:19]
B
Yeah, well, so. But that's a person who's probably had that a long time, right, and didn't know it. That's probably some variation of Mueller Weiss versus the kid who's got like a little bit of a sore foot. You know, they take an X ray, actually looks normal. And then they foot stay sore. They get an mri, cs, edema, seal crack. Then they get CAT scan. You see a real line. Those are the ones. That's the normal scenario. The guys who come in and have had no symptoms at all. And now their foot hurts and they have this big crack. You gotta think that's a variation of human weiss.
- [06:52]
C
So, Marty, you spoke about that little ossicle that's in that talonavicular joint. And I agree with you, 100. I've treated multiple basketball players who had it on both sides. And it's interesting. If you examine them, they really lack hind foot motion. They don't have much inversion eversion. And intraoperatively, when you take that oscill out, you'll see their foot moves so much better. But like you, I always just put, usually just one screw. I just try to, you know, span that dorsal cortex. And it has worked very well. I just feel like later in the season, you know, if they have some soreness, for me, I'm always reassured knowing that screw is already there.
- [07:30]
B
Yeah, I mean, it's pretty benign, a percutaneous screw. And you don't know whether this was a small area of a fracture that then fractured off. Was this some variation of a dorsal navicular fracture or was it really an osteochondral injury? So those are the other ones that are tough. The osteochondrules and the dorsal navicular fragments off the navicular with all the edema. Navicular. Those are hard to manage. Those. No one knows exactly what to do. But we've sort of now probably done. We should actually write up probably done between 5 and 10 of taking out the dorsal fragment and percutasi flu screw. And they've gone back.
- [08:09]
C
Let's do a multi center. I have several Division 1 basketball players that I've had to do it for as well. The other thing, you know, maybe Matt, you've seen this too. But for navicular fractures, I'm always wary of those that really lack dorsiflexion. So sometimes you'll see someone who has a navicular stress fracture. And when you get the lateral X ray, you'll see that Taylor neck spur that is abutting the tibia. And I found many of those patients, if you scope their ankle and remove that spur, you're offloading the navicular as well. Because, as you know, the TN joint is the secondary dorsiflexor for the ankle, or quote, unquote, ankle. And I think in my practice, those are ones that I've had to revise in other physicians who've done that and then noticed that they just really lacked that ankle dorsiflexion.
- [08:59]
B
I agree with that. If you have significant Impingement, I think you have to address it at the same time. It doesn't take that long. And you know, what's the ankle, 60% of your dorsiflexion, plantar flexion, tail end of the joint. For some patients, it's a lot. And it may be that player who has that ankle impingement is just overloading the victor. I think you have to address the ankle impingement. The question is, how much ankle impingement can you tolerate before you have to do something? Every basketball player is going to have some sort of impingement. So most of the basketball players get a little bit of a scope with the navicular fracture.
- [09:33]
C
Yeah, we've been doing sort of standing CT scan in maximal dorsiflexion and just seeing if that tailored neck spur engages. And you know, I have, like you said, I have a low threshold to go in and just clear out the front of the joint. I again, I think missing that at that point, you have to take them back later. It's not a fun course for them.
- [09:52]
B
Yeah, I agree 100%. You have to address the impingement. You have to look at all the. What you can make better. Right.
- [09:59]
C
What do you think about Achilles tightness? Do you. I mean, in an elite athlete, obviously you wouldn't do a Strayer or a TAL on an elite athlete. What's your approach if you think it's the Achilles that's causing the tightness?
- [10:11]
B
I leave it alone in general, for me to lengthen someone's Achilles, it's gotta be there. I mean, I've done two this summer, but both, both the kids were idiopathic toe walkers. I mean, they're both so crazy tight on how they're getting through their life. And both had some ankle foot pathology that we added to it. But I don't think I would do it for navicular. I'm not convinced that a tight Achilles is going to lead. Obviously it can, but I'm not so convinced it's going to add to my navicular fracture. Especially if I'm doing a navicular fracture for an apple. I don't have to have to do Achilles.
- [10:46]
A
Yeah. Going back to these more chronic, so chronic navigator fractures, where they are, the lateral part or whatever, some part doesn't look very good. And then you put some screws across that. Even, like, even in the Mueller Weiss, I think you've gotten some of those.
- [11:00]
B
To heal with a. I've been, I've been lucky. Lucky. So the question is, what do you Put in there. Do you put infused graft in there? Do you put, you know, do you do the vascularized graft? So we do graft on top. We dock the vascularized graft. And once you dock the vascularized graft in there, you don't want to blast through it with your screws too. So it's always a combination. Is there enough bone over there to actually do? I just did a kid who's nine. I mean, it was the smallest little sliver of bone over there that we docked back in. And it was a 20 screw, but it had cartilage on it the whole way. And it was probably 2cm long, you know, just like this long, skinny piece of bone, maybe 8 or 9 millimeters wide. So I'm like, all right, he's going to get a fusion. He's 12 years old. So we got, actually got that to heal. Seems okay. I'm not so sure the long term what's going to happen with that. But at least he has a tailor de vi that may be congruent. The question those I have about all those cases, she would be doing like, we had one player who had a Deicar fracture, and on his other side he had a coalition. There's an African player who came here, had a coalition between his middle Canadian form and his nicu, a big piece of bone. My gut is he had a vacuum fracture on the other side, and that bone healed over there on there. And so the question is, with these fractures, should we be doing these vascularized grafts in these cases or should we be doing an NC fusion? An NC fusion is a good bailout for a chronic victor. For Mere Weiss, everyone's looking at like the tail and a vicar joint. You have to fuse that. But if you get the NC joint diffuse. I have patients who have an NC fusion. If you get an NC fusion that heals well and the patients don't notice it, right? They don't. They feel like they have a normal foot, but a tail end of AER fusion, no way. So we're always looking at, well, if this doesn't work, do we do a T infusion? And I keep thinking maybe we should be looking the other side of the joint, trying to get them to heal early on.
- [13:11]
A
Have you ever taken out like the far lateral? Like, I had another kid who had a. Another dancer actually, who had a big fracture, but it's really far lateral connected to like a coalition. I told him, I was like, I don't think I would fix it because it was like such a small Piece of bones. But I was like, if it bothered him and he actually ended up doing okay, but it bothered him, I would just take off the coalition. And that like, little lateral I had.
- [13:30]
B
Olympic diver with that. We just took out the piece.
- [13:33]
A
Yeah.
- [13:34]
B
But you know, it was basically his last Olympics. Yeah. And he just needed to be able to get pain to go away for his dives. Yeah. So I don't know how he's done now, but he did well with that.
- [13:46]
C
So, I mean, I heard what you said about the NC joints. I would say that of the foot joints to fuse, TN for me is probably my least favorite. And then close second would be medial nc. So I always add the middle NC to try to increase my surface area. But do you have any tricks for NC fusion? I mean, I know that published rates of non union are pretty high, up to 30% in some studies.
- [14:10]
B
Yeah. I mean, the question is, it's always this big combination. Like the thing that I've been seeing a lot of is the NC arthritis with the second tmt. Arthritis.
- [14:19]
C
Oh, yeah, Yep. Medial nc, second and third tmt. Yes.
- [14:23]
B
They start to go. You leave the first TMT alone. You like, you know, you start dancing around the foot. You have these crazy constructs and you go like, why did you leave the first TMT joint alone? I don't. I ran off screws or whatever. I'm just trying to fuse the ones that are bad. The other one looked perfect. Right. Y. I think, you know, combination of plates and screws. I think the plates have made a big difference for me. Some sort of compression plate on top, but I'll still use a screw. Try and go both ways. And a lot of biology, they're not very vascular joints, so a lot of biology either. I won't hesitate to take proximal tibia for those. And so with some bone mar aspirate.
- [14:59]
C
And Matt was talking about earlier with Rafael Nadal, you know, for those of us who love tennis, but many people may not know, but, you know, he's struggled with Mueller, Weiss, I think his whole career since his, like, late teens, early 20s, if I'm not mistaken. And I'm not sure people understand, you know, how devastating of an injury that is to play through. And I, I'm like blown away that he could win, what, 14 French Opens? I think something like that on a just essentially dead navicular. What's your take on that? How does an athlete even do that?
- [15:32]
B
I have no idea. I mean, you do see, we have some nickers in the NBA that are just awful like they've had it fixed, screws are broken. Player doesn't seem to buy too much. You wonder whether it's a little neuropathic joint at some point or, you know, they're just powering through because they can make enough money in three years in the NBA to be set for life. So they just, you know, just mind over matter to go through it. But, you know, you can see some terrible ones. I mean, the doll supposedly have to nerve, the deep peroneal nerve taken out, which is not a. I don't think it's a completely benign procedure, especially in a professional athlete. An older patient, fine for the mid foot arthritis, but I haven't, I've not done that in navicular.
- [16:14]
C
Didn't Matt Conti do that one? Ferdinandol or some guy?
- [16:17]
B
Matt Conti, I think no, I did.
- [16:21]
A
Take out a nerve for. I did take out DPN for an avascular navicular and an 80 year old and it worked great.
- [16:26]
C
80 year old.
- [16:27]
B
Yeah. You know, the problem with the, the vascularized graft, it seems like a big deal and I'm lucky because I work at a place where I have a hand surgeon comes in and get. And takes the vascularized graf. But we've gone from doing the ultrasound, interoperative ultrasound and you know, and all this stuff till now she's just using her loops and she uses her loops and traces out. This looks like a good vessel. Turns around, we take it and put it back down. And so I think that it's not something that's so crazy to try by yourself. I just look at, I say, I'll make the incision, she'll come in. And I've pretty much looked at. I think this vessel looks pretty good. I try and do part of the operation before she gets there, just to practice for when I have to, I'm somewhere by myself and she's not available. Or I get to a situation where, oh, this didn't go so well. I'm doing an amicular. It doesn't look very good or I'm done. So, you know, Calder said he does himself. As long as you keep a soft tissue envelope on that piece of bone, it's probably a good source of bone graft. And one of the most amazing thing is the donor site. So we take all these CAT scans to look at it and most of the time the radiologist will even notice that there's been some bone graft in there. I put a little DBM in there, but it just fills in.
- [17:44]
C
Yeah, I think we spoke about this, but at our institution at uva, we're doing quite a few, like, medial femoral condyle graphs, like free graphs from that. And the one case I used it for was like a 6 foot 7 offensive lineman who's being recruited at multiple colleges, had previous navicular surgery that probably was for Mueller Weiss, but they didn't know it and didn't. Didn't work at all. And then we took a pretty big MFC graft. And actually his was interesting because he didn't have an anterior tibial artery, so we. We had to go really far and take wire back into the posterior tibial artery, which perhaps, you know, maybe that's why he had the problem to begin with, but he actually did well and actually did play in college.
- [18:29]
B
Oh, that's the same. Yeah.
- [18:32]
C
Yeah. I'm not. They don't all turn out that way.
- [18:34]
B
Certainly the section for me, that media femoral thing.
- [18:37]
C
Yes.
- [18:38]
B
Just feel, you know, keep it local in some ways if you can. Yeah, I think there's some good data with really dead bone, like a big fusion. You want to try and do it. That's probably. There's a certain limit of how much, you know, can therefore be take.
- [18:53]
C
Right?
- [18:54]
A
Yeah, but I mean, how much do you need to take? I mean, we. I mean, I've seen it with you. It's only. It's not a big piece, you know, like not even a centimeter. Maybe a centimeter by center.
- [19:03]
B
Yeah. That would be about the most you take. You're basically trying to bring blood supply.
- [19:07]
A
Right.
- [19:08]
B
You're trying to sort of revascularize it. It'd be really interesting to do some studies to see whether that piece is really vascularized. I mean, you get sometimes where it looks so good at six weeks, you're like, oh my God, that piece must have had a great blood supply to it. And sometimes at six weeks you go, that just looks like a little piece of bone we put up there. Yeah, yeah. So then you don't know whether it's other stuff that you did versus the vascular graft, the screw. So you don't know where it goes. But to date, probably have one that's brewing that I'm not so sure. Fused, but. And then the numbers, I mean, it's not huge numbers, but it's probably close 15 to 20. We've done basket Grafton, different people. We've had some huge saves. So, you know, revision to Vickers and professional athletes, mostly the football players. And they're a different crew anyhow, because they'll kind of power through, I think we've gotten them to heal after pretty bad injuries.
- [20:06]
A
What's your like generally? What's your post op protocol with a vascularized bone? 6 weeks off your litters?
- [20:12]
B
No, I'm not weight bearing for six weeks. No matter what the maker is. Yeah, that's the one that I probably keep people. I tell them it's going to take the longest and I keep them off the longest. But you know, I also Vitamin D. Everyone gets a bone stimul, you know, if they can do hyperbaric oxygen, they do that because let's try and get some blood supply to a small area that's low blood supply. If they can, you know, if they can go to foro the professional athletes. If you're in the NBA and you break your nicu, you're going to forget. The teams all do it. They know it, they, the train staff know, they know that they'll make bone and so they're very quick to pull the trigger on forte. They just pay for it. The numbers are so crazy that even though forteo for regular people is so crazy expensive in relation to an NBA player with the average salary is probably 13 million for the year, if you get them back a half a season earlier, you're not going to spend 6 million on Forteo. You know, it's just the numbers are so crazy that they just buy the forte. So I think that combination of everything can really help. But the younger person you can't use for tail, so you don't really want to use infuse. I'll probably use infuse graft for some of the AVN areas. The problem with using infuse is it's so scary. And your radiologist will tell you osteomyelitis because there'll be big holes everywhere because you get the osteoblastic resorption first. So if you use a lot of infused graft, you'll have some sleepless nights until you can get confident that is a normal thing that you're going to see and that you have confidence. That's good filling with the bone.
- [21:46]
C
Marty, speaking about radiology, what for your return to play in these high level athletes, do you routinely get CTs before you let them return?
- [21:55]
B
Yeah. So Bob published a study that showed only 80% of them healed by CT scan. You know, and the big issue is, and look at Nunley Series 2. If there's still a dorsal line, do you let them go back? If everything looks great but above the screws. So above my screw I have my top screw. I Have some Bowie bridging. I'll let them go back because that dorsal line may never go away if I have. If there's still a line through the screw. I tried to hold them off. Yeah.
- [22:24]
C
I think and I think just from a technique perspective, the more of these I've done and more CTs I get, I'm always humbled by how planter I am, even though I think I'm cheating dorsal. And I think that's a good, you know, technique tip to understand is just that you have to be on the very dorsal part of the navicular like you said, lateral to medial to span that dorsal fracture.
- [22:48]
B
Yeah, I mean I. That's why I started using that intraoperative zyme scan because I had one. I'm like, oh my God. I put it right through the dorsal. I mean I. In one side, out the other side. I almost went through the fracture itself and didn't get much to the vicar bone. It looked perfect on X ray. How do I do that? I mean, thankfully it healed. I was so lucky. But I said I'm never doing this again. So. So that's. I usually use it interoperative for most of them.
- [23:16]
A
How about like screws versus plates? Because I've seen you use both. So when do you use and do use cannulated screws or solid screws?
- [23:23]
B
So cannulated technique. Solid screws. No one's broken a solid screw yet, right? No, jinx it. Don't jinx. But they're going to, right? They definitely broke in cannulate screws. And so the plate. I've only used the plate when I have a really unusual situation. I did a. Those claw plates. I thought it'd be perfect. You put a screw on both sides. It's a dorsal fracture. You can squeeze it.
- [23:50]
C
Yeah.
- [23:51]
B
Claw plate. It's look perfect. Refractured 3 months Special Reflexible though.
- [23:57]
C
Right. Of those kind of uni CP or club.
- [24:00]
B
But I thought it would be like a good dorsal compression device because you want to get the compression dorsally. Didn't work out. So most of my. The ones that I've plated are because there is a huge amount of bone loss and it's some revision case that I that so I just. That do we plate that one kid, the kid from.
- [24:22]
A
Yeah, yeah, yeah.
- [24:23]
B
So he had a huge amount of bone loss and an infection and you know, lots of dumb. Almost every complication you could have and seems to be doing okay.
- [24:34]
C
This has been great. Marty. I. I was just thinking, you know, for Matt and I, how Many of our mentors have retired recently. It's been pretty scary for me, just all the people that I have called on for advice. So I guess you can't retire for the next 10 years.
- [24:49]
B
Still pick up the phone?
- [24:50]
C
No, they do, of course.
- [24:52]
B
Still. It's still the thoughts. Oh, still the experience. Yeah. But it is. There's been a big turnover recently.
- [24:58]
C
Yeah.
- [24:59]
B
In terms of the guys doing sports, foot and ankle, which is an opportunity for all the young people to, you know, to come up and start doing these cases.
- [25:07]
A
Yeah. Well, thank you so much to both of you for doing this and taking time out of your night to spend and talk about navicular fractures, especially the more complicated ones. I really appreciate it. And thanks again, Dr. Malley, for all the time spent with us today.
- [25:21]
B
Thanks for asking me, guys. Thank you.
- [25:24]
C
And, Marty, by the way, thank you for also answering the phone calls over all the years that you've helped all of us. So it's huge. Been huge.
- [25:31]
B
It's. We're all still learning.
- [25:33]
C
Yeah, that's true.
- [25:34]
B
Every time I get a call, I learn something. And I do. I definitely learned something.
- [25:37]
C
So thank you, though.
- [25:40]
A
Thank you for listening to the AOFAS Ortho podcast, a Convey Med production. To learn more about joining our dynamic community of highly skilled orthopedic specialists, visit aofas.org.