The AOFAS Orthopod-Cast

Episode: Salvage Navicular MasterClass

Date: February 11, 2026
Host: AOFAS Podcast Committee (Matt Conti)
Guests: Dr. Martin O’Malley (HSS), Dr. Joseph Park (UVA)

Episode Overview

This episode dives deep into the complexities of navicular fractures, focusing on the "salvage" scenarios orthopedic surgeons encounter—especially ones that don’t heal or recur despite intervention. Dr. Martin O’Malley and Dr. Joseph Park, both leaders in foot and ankle orthopaedic surgery, candidly discuss their evolving approaches to navicular injury management, the challenges of chronic cases, surgical techniques, return-to-play decisions for elite athletes, and nuances in operative and non-operative care. The conversation is technical but infused with real-world anecdotes and humor, making it valuable for any specialist facing tough navicular cases.

Key Discussion Points and Insights

1. Evolution in Treating Navicular Fractures

• Growing Respect for Navicular Complexity
  • Dr. O’Malley describes his transition from not fearing navicular fractures to having "a very healthy respect" for them, especially considering the risk of non-union and refracture.
  • Quote (Dr. O’Malley, 02:44):

    “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.”

• Impact of Foot Type and Blood Supply
  • Poor vascularity and certain foot types (like cavus or high-arched feet) increase risk (02:00-02:40).

2. Indications for Surgery and Fixation

• Severity Threshold & Imaging
  • Persistent bone marrow edema or visible fracture lines after conservative care push Dr. O’Malley towards surgical intervention (04:02–04:18).
  • MRI and CT used to evaluate ambiguous cases.
• Surgical Methods by Fracture Type:
  • Type 0.5: Remove dorsal fragment & prophylactically fix with screw.
  • Type 1: Percutaneous screw and bone marrow aspirate concentrate (BMAC).
  • Type 2–3: Open bone grafting, multiple screws.
• Vascularized Bone Grafts
  • Used mainly for revisions or extensive cystic changes/necrosis (05:51–06:18).
  • Dr. O’Malley notes an international trend towards more frequent use for primary management in certain high-risk cases.

3. Managing Challenging Patterns and Associated Pathologies

• Mueller-Weiss Disease and Lateral Lesions
  • Differentiates acute athletic fractures from chronic pathology (like Mueller-Weiss) (06:06–06:51).
• Ossicle in the Talonavicular Joint
  • Removing the fragment improves hindfoot motion; percutaneous screw is effective (06:51–07:30).
    • Quote (Dr. Park, 06:51):

      “If you examine them, they really lack hind foot motion … when you take that ossicle out, you'll see their foot moves so much better.”

• Chronic/Challenging Cases
  • In cases of poor bone quality or "dead" fragments, vascularized bone, or sometimes just removing problematic small bone fragments is discussed (13:10–13:32).

4. Managing Adjacent Pathologies (Impingement, Achilles Tightness)

• Dorsiflexion Limitation & Bony Spurs
  • Ankle impingement must be addressed to prevent overload of navicular (08:09–09:33).
  • Quote (Dr. Park, 08:09):

    “If you scope their ankle and remove that spur, you're offloading the navicular as well.”

• Achilles Tightness
  • Tendon lengthening rarely indicated except for extreme cases like idiopathic toe walkers (09:58–10:45).

5. Salvage Options: Fusion and Grafting

• Fusion Choices
  • Naviculocuneiform (NC) fusion as a bailout for chronic or failed cases—generally well tolerated if successful (10:59–12:49).
  • Plates and screws, use of proximal tibial/iliac graft, and bone marrow aspirate to compensate for poor vascularity (14:22–14:58).
• Tricks for Fusion
  • Plates for compression, additional biology (bone grafts) for poor vascular zones.

6. Return-to-Play Protocols & Imaging Criteria

• Imaging for Healing
  • CT scan recommended before return for elite athletes; dorsal fracture line can persist but if bridging bone is present above screws, return may be allowed (21:55–22:24).
  • Importance of dorsal screw placement and use of intraoperative 3D imaging for precision (22:22–23:16).

7. Protocols and Adjunct Therapies

• Post-Operative Protocols
  • Strict non-weightbearing for 6 weeks post-op for any navicular repair, especially with vascularized bone graft (20:05–20:12).
  • Vitamin D supplementation, bone stimulation devices, hyperbaric oxygen, and (in pro athletes) use of Forteo are adjuncts to enhance bone healing (20:12–21:46).

8. Special Cases and Memorable Athletes

• Rafael Nadal & Professional Athletes
  • Nadal’s long career success on a “dead navicular” amazes the hosts; pro athletes sometimes cope by nerve resection or "powering through" the injury (15:32–16:20).
  • Quote (Dr. O’Malley, 15:32):

    “I have no idea. … 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 … just mind over matter to go through it.”

9. Surgical Tips & Lessons Learned

• Avoiding Hardware Failure
  • Solid screws preferred over cannulated for durability; claw plates can fail in some chronic revisions (23:22–24:22).
• Learning is Ongoing
  • Value of mentor experience and ongoing learning highlighted at episode’s end (25:30–25:37).

Notable Quotes & Memorable Moments

• “Even with optimal, non operative and operative treatment, this cannot heal and it can refracture. That's my slide one.”
  — Dr. O’Malley [02:44]

• “If you examine them, they really lack hind foot motion … when you take that ossicle out, you'll see their foot moves so much better.”
  — Dr. Park [06:51]

• “If you scope their ankle and remove that spur, you're offloading the navicular as well.”
  — Dr. Park [08:09]

• “I have no idea. … 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.”
  — Dr. O’Malley [15:32]

• “We're all still learning. Every time I get a call, I learn something.”
  — Dr. O’Malley [25:30]

Timestamps for Key Segments

| Timestamp | Segment | |-----------|-----------------------------------------------------------------------------------------| | 01:22 | Dr. O’Malley’s personal evolution in navicular injury management | | 03:50 | When to operate: imaging findings and indications | | 05:46 | Vascularized bone graft—when and why | | 06:51 | Ossicles and hindfoot motion in athletes | | 08:09 | Ankle impingement’s role in navicular injuries | | 09:58 | Tight Achilles: management decisions | | 10:45 | Chronic cases, lateral lesions, and fusion as salvage | | 13:29 | Managing far lateral fractures/coalitions | | 14:10 | Naviculocuneiform (NC) fusion techniques and pitfalls | | 15:32 | Notable athletes (Rafael Nadal, NBA) and nerve excision | | 19:03 | Harvesting size and efficacy of vascularized grafts | | 20:05 | Post-op protocols, bone stimulators, Forteo, adjunct therapies | | 21:55 | Imaging before return to play | | 22:22 | Technical tip: dorsal screw placement and intraoperative imaging | | 23:22 | Plate versus screw fixation; hardware considerations | | 24:33 | Value of mentorship and experience as senior colleagues retire | | 25:30 | Importance of lifelong learning and peer support |

Overall Tone & Takeaways

The discussion is collegial, candid, and packed with "real-life" pearls and technical tips. The conversation balances clinical sophistication with humility about what remains unknown—and a recognition that navicular fractures, especially salvage cases, remain among the most challenging problems in foot and ankle surgery.

For specialists dealing with navicular fractures, this episode is a masterclass in both the art and science of treating one of orthopaedics’ most vexing problems.