Results of simple excision technique in the surgical treatment of symptomatic accessory navicular bones

doi:10.1016/j.fas.2007.12.002

Foot and Ankle Surgery

Volume 14, Issue 2, 2008, Pages 57-61

https://doi.org/10.1016/j.fas.2007.12.002 Get rights and content

Abstract

Introduction

Accessory navicular bones might cause not only cosmetic problems but also be a reason of discomfort and pain. In case of inefficient conservative treatment symptomatic accessory naviculars are treated surgically.

Aim of paper: Presentation of results of simple excision of symptomatic accessory navicular.

Material and methods

Material consists of 22 patients (34 feet), 17 women and 5 men, treated surgically between 1992 and 2006. Mean age at surgery was 14.1 years (9–22 years). Accessory navicular type I was present in 5 feet (14.7%), type II in 17 (50%) and type III—in 12 (35.3%). Main symptom was localized pain on the medial arch of the foot, in the height of navicular bone. Surgery consisted of simple accessory navicular excision and if needed partial resection of navicular bone.

The mean follow-up period was 5.6 years (1–13 years). We analyzed: intensity of pain (VAS score system), daily and sport acitvity.

Subjective results were analyzed using a questionnaire.

Results

The questionnaire was returned from 21 patients: 9 patients had total pain relief, 11 considerable and one patient had persistent pain. Mean VAS results before surgery was 5.9 and 1.7 after surgery. Only one patient required analgesics occasionally. Complications were present in two patients (6.1%). All active patients returned to their sport activities.

Concluison

Surgical treatment of symptomatic accessory navicular by simple excision technique gives satisfying results, surgery is minimally traumatic and risk of complications low.

Introduction

Accessory ossicles derive from unfused accessory ossification centres, in most cases they are asymptomatic and are generally considered accidental radiological findings [1], [2]. Most common locations of accessory ossicles are foot and ankle and hand [3]. In the foot accessory naviculars are most frequent, with prevalence in radiological examination of 4–14% [4]. Familial occurrence of this defect was demonstrated, inheritance type is autosomal dominant with incomplete penetrance [5].

On the basis of radiological findings three types of accessory navicular may be distinguished. Type I is an oval or round, well separated ossicle, size 2–6 mm, with no contact with proper navicular bone. It is embedded within distal portion of tibialis posterior tendon (os naviculare accessorium) (Fig. 1a and b). It comprises approximately 30% of all the accessory naviculars. Type II, the most frequent (50–60%) is separated from navicular bone by 1–2 mm of fibrocartilaginous synchondrosis (os naviculare bifurcatum, prehallux) (Fig. 2a and b). Type III, the least frequent (10–20%), is modified type II that has been incorporated to the navicular tuberosity (os naviculare cornutum) (Fig. 3a and b) [1], [6].

Presence of accessory navicular may be reason of pain and tenderness. They are called “symptomatic” accessory navicular. Pain is increased in stiff shoes like skiing boots, rollerblades, etc. Clinically main symptoms are tenderness on medial arch palpation in the navicular bone height [7].

Symptomatic accessory navicular may be treated conservatively–shoe modification, insoles, physiotherapy, local and oral anti-inflammatory agents; if no improvement is noticed surgical treatment is proposed.

Results of surgical treatment of symptomatic accessory navicular using simple excision technique are presented and discussed.

Section snippets

Material and methods

Material consists of 22 patients; 17 women, 5 men; treated surgically between 1992 and 2006. Mean age in the group at time of surgery was 14.1 year (9–22 years). 34 procedures of accessory navicular removal were performed all together; 12 patients underwent bilateral surgery. In all cases the major clinical symptom was localized pain on the medial arch of the foot, in the height of navicular bone, no tenderness during palpation of tibialis tendon was present. Pain was intensified in stiff shoes

Results

Radiological type of accessory navicular in all cases was confirmed intraoperatively. Type I was present in 5 feet (14.7%), type II in 17 (50%) and type III in 12 feet (35.3%).

Wound healed typically in all cases. In 2 cases, patients with accessory navicular type III prolonged wound healing was noticed, oral antibiotics were prescribed. In 1 case scar hypertrophy was recorded, with no clinical symptoms. In all other feet the scar was linear, 2–3 cm long, no shoe conflict with the wound was

Discussion

Surgical treatment of symptomatic accessory navicular is known for years, in the 20^ties of 20th century Kidner proposed a technique consisting of accessory navicular removal and main insertion of the tibialis tendon re-routing [8]. On the other extreme minimally invasive techniques like percutaneous drilling should be pointed out [9]. But still the most popular surgical technique is simple excision of the symptomatic accessory navicular with anatomical suture of the tibialis tendon if needed [2]

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The accessory navicular and its association with flatfoot
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Another study confirmed a 34% improvement rate through conservative measures in the normal population which was reduced to 6.9% in athletes [20]. A number of retrospective studies have reported favorable results with satisfaction rates around 80% following the original Kidner procedure, i. e. excision of the painful accessory navicular and reattachment of the PTT into the navicular body [4,16,19,27,29,30,46,60]. Scott et al. [50] noted radiographic evidence of loss of the medial arch following a Kidner procedure in 3 of 10 patients with an average age of 25 years (range, 10 to 52) while Lee et al. [30] saw no loss of the medial arch in any of the 50 feet in their study with an average patient age of 17 years (range, 8 to 48).
The accessory navicular (os tibiale externum, prehallux) is a frequent skeletal variation. It may become symptomatic and is reported to be associated with flatfoot in children and adults.
We conducted an extensive review of the literature and reviewed the experience from two centers of foot and ankle surgery in Germany and the United States.
The majority of accessory navicular ossicles is asymptomatic. Symptoms may arise from local pressure in shoewear, loosening of the connection to the navicular body as well as irritation and functional elongation of the tibialis posterior tendon (PTT). A symptomatic accessory navicular is frequently associated with flexible flatfoot. Resection of the ossicle with debridement of the medial aspect of the navicular and attachment of the PTT to the navicular body (modified Kidner procedure) leads to good and excellent results in about 80% of patients and some heightening of the arch mainly in adolescents. In more severe deformities, augmentation of the Kidner technique with fusion of the accessory navicular to the navicular proper, transfer of the flexor digitorum longus tendon, arthroereisis, osteotomies, calf gastrocnemius release and midfoot fusions have lead to favorable results in smaller series.
Das Os tibiale externum (akzessorisches Os naviculare, Prähallux) ist eine häufige Skelettvariation. Es kann symptomatisch werden und wird bei Kindern und Erwachsenen mit einer Plattfußdeformität in Verbindung gebracht.
Eine ausgedehnte Literaturrecherche wurde durchgeführt und die Erfahrungen an zwei Zentren für Fuß- und Sprunggelenkchirurgie in Deutschland und den Vereinigten Staaten zusammengetragen.
In der Mehrzahl der Fälle ist das Os tibiale externum asymptomatisch. Beschwerden können durch lokalen Druck im Schuhwerk, eine Lockerung der bindegewebigen Verbindung zum Os naviculare sowie eine Irritation funktionelle Verlängerung der Tibialis posterior Sehne (PTT) entstehen. Ein symptomatisches Os tibiale externum ist regelmäßig mit einem flexiblen Plattfuß assoziiert. Die Resektion des Ossikels mit Debridement der medialen Kante des Os naviculare und Adaptation der PTT an das Os naviculare (modifizierte Kidner-Technik) führt zu guten und sehr guten Ergebnissen bei etwa 80% der Patienten und einer gewissen Anhebung des Fußgewölbes vor allem bei Jugendlichen. Bei schwereren Fehlstellungen führt die Augmentation der Kidner-Technik mit Fusion des Os tibiale externum an das Os naviculare, Transfer der Flexor digitorum longus-Sehne, Arthrorise, Osteotomien, Verlängerung des Gastrocnemius-Sehnenspiegels und Arthrodesen zu günstigen Ergebnissen in kleineren Serien.
Pediatric Problems and Rehabilitation Geared to the Young Athlete
2020, Baxter’s The Foot And Ankle In Sport
Foot and ankle problems in the young athlete differ from those in adults. These differences relate primarily to skeletal maturity, as the presence of open growth plates and secondary ossification centers and the more cartilaginous nature of pediatric bone impact the injury patterns and treatment approaches for children. Coalitions tend to present during childhood, as bones begin to ossify, and may require resection. Pes planus is normal in infancy but may cause problems in adolescence, especially if rigid. Hallux valgus is primarily managed conservatively, and surgery, if needed, is often delayed until skeletal maturity. Accessory naviculars are common in up to 20% of the population but may be excised if persistently painful. Osteochondroses such as Sever’s disease, Iselin’s disease, Kohler’s disease, and Freiberg’s disease can present in adolescent athletes; these typically resolve with conservative management. Osteochondritis dissecans (OCDs) usually occurs in the talus and requires drilling or grafting when advanced. Distal tibial fractures in an open physis pose a risk of leg length discrepancy and must be carefully evaluated; triplane and Tillaux fractures are unique fracture types found in adolescents nearing skeletal maturity. Most adolescent athletes will recover well from foot fractures and ankle sprains without surgery, but some variants require more aggressive intervention.
Comparison of outcomes of osteosynthesis in type II accessory navicular by variable fixation methods
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Although the relationship between the presence of accessory navicular and the pes planovalgus is controversial, the Kidner procedure is commonly used to treat a symptomatic accessory navicular [3,14–17]. Other operative methods have been devised to treat symptomatic accessory naviculars, including simple excision, percutaneous drilling of the synchondrosis, and fusion [3,15,18–22]. Anatomically the main portion of tibialis posterior tendon inserts into navicular tuberosity and if accessory navicular is present, it serves as insertion for the tibialis posterior tendon and tibialis posterior tendon ended at the accessory navicular without continuity to primary navicular bone [11,12].
To compare the outcomes of fixation methods for osteosynthesis of a type II symptomatic accessory navicular between screw and tension band wiring.
Forty-four patients (mean age, 29.2 years; range, 13–54 years; 21 males and 23 females) who had undergone operative treatment after failed conservative treatment were chosen for the study between 2007 and 2014. The patients were divided into two groups by the method of osteosynthesis: group 1 (screw) and group 2 (tension band wiring). Pre and postoperative evaluations were performed, using the midfoot scale from the American Orthopaedic Foot and Ankle Society (AOFAS), a visual analog scale, time to return to social activities, and plain radiography.
The AOFAS midfoot and visual analog scale scores of both groups were improved at the last postoperative follow-up. The time to return to social activities was 12.3 weeks in the screw group and 11.9 weeks in the tension band wiring group (p = 0.394). A broken screw was observed in one case in the screw group and a broken k-wire was detected in two cases in the tension band wiring group. Nonunion was observed in two cases in each group.
The tension band wiring technique could be another treatment choice of osteosynthesis for fixation of the accessory navicular bone.
Level III, Retrospective Case Control Study.
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Arthrodesis of the first tarsometatarsal joint and/or navicular-cuneiform are additional procedures used to correct pes planus deformities of the foot. In the presence of a painful accessory navicular (type II), simple resection of the os naviculare is the treatment of choice,92 which has also been the established treatment of other symptomatic accessory ossa in the musculoskeletal system; for example, an os trigonum or at the acromioclavicular joint (os acromiale).93,94 When patients present with stage IV deformity, additional procedures are warranted.
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In cases of pain recalcitrant to conservative measures, surgery is a suitable alternative. Simple excision has been shown to produce satisfactory results, as has a modified Kidner procedure, which involves a reattachment of the posterior tibialis tendon.21,22 Arthrodesis of the accessory navicular bone has also been attempted.
Medial displacement calcaneal osteotomy with posterior tibial tendon reconstruction for the flexible flatfoot with symptomatic accessory navicular
2014, Journal of Foot and Ankle Surgery
We investigated the clinical outcomes after medial displacement calcaneal osteotomy with reconstruction of the posterior tibial tendon insertion on the navicular, in patients with flexible flatfoot with accessory navicular symptoms. From December 2008 to July 2011, 16 patients (21 feet) with a flexible flatfoot, symptomatic accessory navicular, and obvious heel valgus underwent medial displacement calcaneal osteotomy and reconstruction with posterior tibial tendon insertion on the navicular bone. The patients were evaluated preoperatively, 6 weeks and 3, 6, and 12 months postoperatively, and every 6 months thereafter. The clinical examination was undertaken using the American Orthopaedic Foot and Ankle Society ankle and midfoot scores. The radiologic assessments included the arch height, calcaneus inclination angle, talocalcaneal angle, and talar first metatarsal angle on the lateral weightbearing radiograph. The talocalcaneal angle and talar first metatarsal angle was assessed on the anteroposterior view of the weightbearing foot. Heel valgus alignment was assessed on the axial hindfoot radiographs. The mean follow-up duration was 28.5 months (range 18 to 48). All patients were satisfied with the clinical results and were pain free 6 months postoperatively. No cases of wound infection or nerve injury developed. The mean American Orthopaedic Foot and Ankle Society score improved from 53.3 ± 6.5 to 90.8 ± 1.4 at the last follow-up visit (p < .01). The improvements in all radiographic parameters were statistically significant between the preoperative and last follow-up examinations (p < .01). The heel valgus of all patients was corrected. Our results have shown that medial displacement calcaneal osteotomy with reconstruction of the posterior tibial tendon insertion on the navicular bone is an effective treatment of flexible flatfoot with symptomatic accessory navicular, associated with excellent clinical outcomes and correction of the deformity.

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ReviewResults of simple excision technique in the surgical treatment of symptomatic accessory navicular bones

Abstract

Introduction

Material and methods

Results

Concluison

Introduction

Section snippets

Material and methods

Results

Discussion

Clin Radiol

J Orthop Sci

The painful accessory navicular

Skeletal Radiol

Surgical treatment of symptomatic accessory tarsal navicular

J Pediatr Orthop

Accessory ossicles and sesamoid bones of the ankle and foot: imaging findings, clinical significance and differential diagnosis

Eur Radiol

The accessory scaphoid bone

J Bone Joint Surg Am

Inheritance of the accessory navicular bone

Arch Orthop Trauma Surg

Review
Results of simple excision technique in the surgical treatment of symptomatic accessory navicular bones