Abstract
The talonavicular joint is a common site for osteoarthritis of the foot. Talonavicular arthrodesis is the surgical treatment for symptomatic talonavicular osteoarthritis. Classically, this is performed via an open approach and is associated with a rate of nonunion that ranges from 3% to 37%. Arthroscopic talonavicular arthrodesis has been proposed to provide better intra-articular visualization, conserve bone blood supply to improve the union rate, and reduce soft-tissue complications such as wound dehiscence, infection, and neurovascular injury. The purpose of this Technical Note is to describe the details of arthroscopic talonavicular arthrodesis for management of talonavicular osteoarthritis.
Technique Video
Arthroscopic talonavicular arthrodesis for the management of talonavicular osteoarthritis of the right foot. The patient is in the supine position with the legs spread. With the medial portal as the viewing portal and the dorsomedial portal as the working portal, the cartilage of the dorsal part of the talonavicular joint is removed. The arthroscope is then switched to the dorsomedial portal. The cartilage of the medial and plantar medial parts of the joint is removed via the medial portal and the cartilage of the lateral and plantar lateral parts of the joint is removed via the dorsolateral portal. The arthroscope is then switched back to the medial portal and the subchondral bone of dorsal part of the joint is microfractured via the dorsomedial portal. After that, with the dorsomedial portal as the viewing portal, the subchondral bone of medial and plantar medial parts of the joint is microfractured via the medial portal and the subchondral bone of lateral and plantar lateral parts of the joint is microfractured via the dorsolateral portal. Finally, the talonavicular joint is transfixed with 2 cannulated screws.
Symptomatic radiographic foot osteoarthritis affects 17% of adults aged 50 years and older, with the first metatarsophalangeal joint being most commonly affected, followed by the second cuneometatarsal and talonavicular joints.1 Isolated talonavicular arthrodesis is one of the surgical treatments for talonavicular osteoarthritis.2 Classically, this is performed via an open approach and is associated with a rate of nonunion that ranges from 3% to 37%.3
Because of the recent advances in small joint arthroscopy, techniques of talonavicular arthroscopy have been introduced for the management of various pathologies of the joint, for example, osteochondral lesions, osteoarthritis, arthrofibrosis, and spring ligament tears.4, 5, 6, 7, 8, 9, 10, 11, 12, 13 Arthroscopic talonavicular arthrodesis has been proposed to provide better intra-articular visualization, conserve bone blood supply to improve the union rate, and reduce soft-tissue complications such as wound dehiscence, infection, and neurovascular injury.5,11 The purpose of this Technical Note is to describe the details of arthroscopic talonavicular arthrodesis for the management of talonavicular osteoarthritis. It is indicated in cases of symptomatic talonavicular osteoarthritis recalcitrant to conservative management. It is contraindicated if the pain is not arising from the talonavicular joint; there is significant distortion of local anatomy (e.g., previous unreduced fracture dislocation of the navicular); there is the presence of chronic osteomyelitis involving the navicular or talar head requires bone resection; or there is significant foot deformity requiring open correction (Table 1).
Table 1.
Indications and Contraindications of Arthroscopic Talonavicular Arthrodesis for Management of Talonavicular Osteoarthritis
| Indications | Contraindications |
|---|---|
|
|
Surgical Technique
Preoperative Assessment and Patient Positioning
Clinical palpation of the tender spot is important to differentiate the pain arising from the talonavicular joint from adjacent structures, for example, accessory navicular synchondrosis, posterior tibial tendon insertion, talar head, or navicular bone. Standing radiographs are useful to detect any significant foot deformity (Fig 1). The presence of navicular bone cyst is detected in this illustrated case, and computed tomography scan is useful to study the anatomy of the cyst and to detect any subchondral bone defect communicating the cyst with the talonavicular joint proper (Fig 2).
Fig 1.
Arthroscopic talonavicular arthrodesis for the management of talonavicular osteoarthritis of the right foot. The patient is in the supine position with the legs spread. Foot radiographs of this illustrated case show the presence of talonavicular osteoarthritis and navicular bone cyst. (A) Dorsoplantar view; (B) standing lateral view; (C) lateral oblique view; and (D) medial oblique view. (BC, bone cyst; TNJ, talonavicular joint.)
Fig 2.
Arthroscopic talonavicular arthrodesis for management of talonavicular osteoarthritis of the right foot. The patient is in the supine position with the legs spread. Computed tomography scan of this illustrated case shows no subchondral bone defect communicating the navicular bone cyst and the talonavicular joint proper. (A) transverse image; (B) sagittal image. (BC, bone cyst; TNJ, talonavicular joint.)
The patient is placed in the supine position with the legs spread. A thigh tourniquet is applied to provide a bloodless operative field. A 2.7-mm 30° arthroscope (Henke Sass Wolf GmbH, Tuttlingen, Germany) is used for this procedure. Fluid inflow is driven by gravity, and no fluid inflow is required.
Portal Placement
The midtarsal arthroscopy portals are used for this procedure.11,14 Midtarsal arthroscopy portals include the medial, dorsomedial, dorsolateral, and lateral portals.11,14 The medial, dorsomedial, and dorsolateral portals are used for arthroscopic talonavicular arthrodesis. The medial portal is at the medial corner of the talonavicular joint just dorsal to the posterior tibial tendon. The dorsolateral portal is at the junction point between the talonavicular and calcaneocuboid joints. The dorsomedial portal is at the talonavicular joint midpoint between the medial and dorsolateral portals (Fig 3). This portal can be identified with a needle under arthroscopic visualization via the medial portal. Sometimes, fluoroscopy is needed to identify the dorsomedial portal, especially if there is dorsal osteophyte obscuring the joint line. The lateral portal that is not used for this procedure is at the plantar lateral corner of the calcaneocuboid joint.
Fig 3.
Arthroscopic talonavicular arthrodesis for the management of talonavicular osteoarthritis of the right foot. The patient is in the supine position with the legs spread. The medial, dorsomedial, and dorsolateral portals of midtarsal arthroscopy are used for arthroscopic talonavicular arthrodesis. The medial portal is at the medial corner of the talonavicular joint just dorsal to the posterior tibial tendon. The dorsolateral portal is at the junction point between the talonavicular and calcaneocuboid joints. The dorsomedial portal is at the talonavicular joint midpoint between the medial and dorsolateral portals. (A) Dorsomedial view of the foot; (B) dorsolateral view of the foot. (DLP, dorsolateral portal of midtarsal arthroscopy; DMP, dorsomedial portal of midtarsal arthroscopy; MP, medial portal of midtarsal arthroscopy.)
Cartilage Removal of the Talonavicular Joint
The medial portal is the viewing portal and the dorsomedial portal is the working portal. The cartilage of the dorsal part of the talonavicular joint is removed by an arthroscopic shaver (DYONICS; Smith & Nephew, Andover, MA) and an arthroscopic osteotome (ACUFEX, Smith & Nephew) with preservation of the subchondral bone (Fig 4).
Fig 4.
Arthroscopic talonavicular arthrodesis for management of talonavicular osteoarthritis of the right foot. The patient is in the supine position with the legs spread. The medial portal is the viewing portal and the dorsomedial portal is the working portal. The cartilage of the dorsal part of the talonavicular joint is removed by an arthroscopic shaver with preservation of the subchondral bone. (AS, arthroscopic shaver; N, navicular; TH, talar head.)
The dorsomedial portal is the viewing portal and the medial portal is the working portal. The cartilage of the medial and plantar medial parts of the talonavicular joint is removed by the arthroscopic shaver and arthroscopic osteotome with preservation of the subchondral bone (Fig 5).
Fig 5.
Arthroscopic talonavicular arthrodesis for management of talonavicular osteoarthritis of the right foot. The patient is in the supine position with the legs spread. The dorsomedial portal is the viewing portal and the medial portal is the working portal. The cartilage of the medial and plantar medial parts of the talonavicular joint is removed by an arthroscopic shaver with preservation of the subchondral bone. (AS, arthroscopic shaver; MP, medial portal; N, navicular; TH, talar head.)
The dorsomedial portal is the viewing portal and the dorsolateral portal is the working portal. The cartilage of the lateral and plantar lateral parts of the talonavicular joint is removed by the arthroscopic shaver and arthroscopic osteotome with preservation of the subchondral bone (Fig 6).
Fig 6.
Arthroscopic talonavicular arthrodesis for the management of talonavicular osteoarthritis of the right foot. The patient is in the supine position with the legs spread. The dorsomedial portal is the viewing portal and the dorsolateral portal is the working portal. The cartilage of the lateral and plantar lateral parts of the talonavicular joint is removed the arthroscopic shaver and arthroscopic osteotome with preservation of the subchondral bone. (N, navicular; TH, talar head.)
Microfracture of the Subchondral Bone
The medial portal is the viewing portal and the dorsomedial portal is the working portal. The subchondral bone of the dorsal part of the talonavicular joint is microfractured with an arthroscopic awl (Smith & Nephew) (Fig 7).
Fig 7.
Arthroscopic talonavicular arthrodesis for management of talonavicular osteoarthritis of the right foot. The patient is in the supine position with the legs spread. The medial portal is the viewing portal and the dorsomedial portal is the working portal. The subchondral bone of the dorsal part of the talonavicular joint is microfractured with an arthroscopic awl. (AA, arthroscopic awl; N, navicular; TH, talar head.)
The dorsomedial portal is the viewing portal and the medial portal is the working portal. The subchondral bone of the medial and plantar medial parts of the talonavicular joint is microfractured with the arthroscopic awl (Fig 8). The dorsomedial portal is the viewing portal and the dorsolateral portal is the working portal. The subchondral bone of the lateral and plantar lateral parts of the talonavicular joint is microfractured with the arthroscopic awl (Fig 9).
Fig 8.
Arthroscopic talonavicular arthrodesis for management of talonavicular osteoarthritis of the right foot. The patient is in the supine position with the legs spread. The dorsomedial portal is the viewing portal and the medial portal is the working portal. The subchondral bone of the medial and plantar medial parts of the talonavicular joint is microfractured with an arthroscopic awl. (AA, arthroscopic awl; MP, medial portal; N, navicular; TH, talar head.)
Fig 9.
Arthroscopic talonavicular arthrodesis for management of talonavicular osteoarthritis of the right foot. The patient is in the supine position with the legs spread. The dorsomedial portal is the viewing portal and the dorsolateral portal is the working portal. The subchondral bone of the lateral and plantar lateral parts of the talonavicular joint is microfractured with an arthroscopic awl. (AA, arthroscopic awl; N, navicular.)
Cannulated Screws Insertion
After preparation of the fusion surfaces, the talonavicular joint is put into desired position and transfixed with two 4.0-mm cannulated screws (Fig 10, Table 2, Video 1). Postoperatively, the foot is immobilized in a short leg cast for 6 weeks, and weight-bearing walking as pain tolerates with an arch support is allowed.
Fig 10.
Arthroscopic talonavicular arthrodesis for management of talonavicular osteoarthritis of the right foot. The patient is in the supine position with the legs spread. (A) Dorsoplantar fluoroscopic image; (B) lateral fluoroscopic image. Two guidewires are inserted across the talonavicular joint. (C) Dorsoplantar fluoroscopic image; (D) lateral fluoroscopic image. The talonavicular joint is transfixed with two 4-mm cannulated screws. (CS, cannulated screw; GW, guidewire; TNJ, talonavicular joint.)
Table 2.
Pearls and Pitfalls of Arthroscopic Talonavicular Arthrodesis for the Management of Talonavicular Osteoarthritis
| Pearls | Pitfalls |
|---|---|
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Discussion
The efficacy and safety of the talonavicular joint arthroscopic portals are well studied.14, 15, 16 The portals have a good to acceptable safety margin for the foot neurovascular structures and most of the talar and navicular fusion surfaces can be prepared without the need of excessive bone removal.14, 15, 16 However, caution should still be paid to the establishment of the portals, especially the dorsomedial portal. The dorsolateral portal of midtarsal arthroscopy is actually located at the plantar lateral side of the talonavicular joint and is a good working portal for the lateral and plantar lateral parts of the joint.
If sizable navicular bone cyst is present with talonavicular osteoarthritis, talonavicular arthroscopy can detect any subchondral cortical defect communicating the bone cyst and the joint proper. It also can detect the presence of any pathologic fracture through the bone cyst. These arthroscopic findings determine the subsequent management plan. Debridement of the bone cyst is not necessary in arthroscopic talonavicular arthrodesis if the subchondral bone is intact, as the subchondral bone is preserved for subsequent fusion. Debridement and bone grafting of the bone cyst is indicated if there is a large osteochondral defect of the navicular communicating the bone cyst and the talonavicular joint proper. In this case, the cyst can be debrided via the osteochondral defect by talonavicular arthroscopy. If there is significant tenderness at the navicular bone and no pathologic fracture is present, the bone cyst can be debrided and bone grafted via a uni-osseous portal endoscopic approach in the same setting of arthroscopic talonavicular arthrodesis.17 This single-portal approach reduces the risk of iatrogenic fracture of the navicular bone.17
Various fixation devices have been reported for talonavicular arthrodesis, including screws, staples, plates, K-wires, and intraosseous fixation systems; however, the best fixation technique of talonavicular fusion is still inconclusive.3 In our experience, percutaneous screw fixation together with a short period of cast immobilization is good enough to ensure successful fusion of the joint.
The advantages of this technique include small incisions and better cosmetic outcome, minimal soft-tissue trauma, better intra-articular visualization to avoid of excessive bone resection and malunion, and conservation of bone blood supply to improve the union rate. The potential risks of this technique include injury to the saphenous vein and nerve, the deep peroneal nerve and dorsalis pedis artery, the medial dorsal cutaneous branch of the superficial peroneal nerve, and the intermediate dorsal cutaneous branch of the superficial peroneal nerve, nonunion or malunion of the fusion site, and implant failure (Table 3).14, 15, 16 This procedure is technically not difficult and can be attempted by foot arthroscopists with average experience.
Table 3.
Advantages and Risks of Arthroscopic Talonavicular Arthrodesis for the Management of Talonavicular Osteoarthritis
| Advantages | Risks |
|---|---|
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Disclosures
All authors (W.K. and T. H.L.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Supplementary Data
Arthroscopic talonavicular arthrodesis for the management of talonavicular osteoarthritis of the right foot. The patient is in the supine position with the legs spread. With the medial portal as the viewing portal and the dorsomedial portal as the working portal, the cartilage of the dorsal part of the talonavicular joint is removed. The arthroscope is then switched to the dorsomedial portal. The cartilage of the medial and plantar medial parts of the joint is removed via the medial portal and the cartilage of the lateral and plantar lateral parts of the joint is removed via the dorsolateral portal. The arthroscope is then switched back to the medial portal and the subchondral bone of dorsal part of the joint is microfractured via the dorsomedial portal. After that, with the dorsomedial portal as the viewing portal, the subchondral bone of medial and plantar medial parts of the joint is microfractured via the medial portal and the subchondral bone of lateral and plantar lateral parts of the joint is microfractured via the dorsolateral portal. Finally, the talonavicular joint is transfixed with 2 cannulated screws.
References
- 1.Roddy E., Menz H.B. Foot osteoarthritis: Latest evidence and developments. Ther Adv Musculoskelet Dis. 2018;10:91–103. doi: 10.1177/1759720X17753337. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Nitta Y., Seki H., Suda Y., et al. Isolated talonavicular arthrodesis for traumatic talonavicular arthritis: Report of 2 cases with gait analyses. Foot Ankle Spec. 2022;15:163–170. doi: 10.1177/19386400211030132. [DOI] [PubMed] [Google Scholar]
- 3.Arumugam V., Ranjit S., Patel S., Welck M. What is the best fixation technique for isolated talonavicular arthrodesis? A systematic review. Foot (Edinb) 2023;54 doi: 10.1016/j.foot.2023.101966. [DOI] [PubMed] [Google Scholar]
- 4.Derner B., Derner R. Small joint arthroscopy of the foot. Clin Podiatr Med Surg. 2023;40:445–457. doi: 10.1016/j.cpm.2023.02.005. [DOI] [PubMed] [Google Scholar]
- 5.Fradet J., Lopes R. Subtalar and talonavicular arthrodesis under lateral arthroscopy. Orthop Traumatol Surg Res. 2023;109 doi: 10.1016/j.otsr.2022.103439. [DOI] [PubMed] [Google Scholar]
- 6.Wan Y.T.O., Lui T.H. Arthroscopic debridement and microfracture of osteochondral lesion of the talar head. Arthrosc Tech. 2019;8:e969–e973. doi: 10.1016/j.eats.2019.05.006. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Lui T.H. Arthroscopic and endoscopic management of posttraumatic hindfoot stiffness. Indian J Orthop. 2018;52:304–308. doi: 10.4103/ortho.IJOrtho_337_17. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Lui T.H. Arthroscopic repair of superomedial spring ligament by talonavicular arthroscopy. Arthrosc Tech. 2017;6:e31–e35. doi: 10.1016/j.eats.2016.08.034. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Keller T.C., Dempsey I.J., Park J.S. Arthroscopically assisted treatment of navicular osteochondral defect using flowable collagen, iliac crest bone marrow aspirate and fibrin glue: A case report. Foot Ankle Spec. 2015;8:417–421. doi: 10.1177/1938640014557076. [DOI] [PubMed] [Google Scholar]
- 10.Ross K.A., Seaworth C.M., Smyth N.A., Ling J.S., Sayres S.C., Kennedy J.G. Talonavicular arthroscopy for osteochondral lesions: Technique and case series. Foot Ankle Int. 2014;35:909–915. doi: 10.1177/1071100714540887. [DOI] [PubMed] [Google Scholar]
- 11.Lui T.H. New technique of arthroscopic triple arthrodesis. Arthroscopy. 2006;22:464.e1–464.e5. doi: 10.1016/j.arthro.2005.06.032. [DOI] [PubMed] [Google Scholar]
- 12.Oloff L., Schulhofer S.D., Fanton G., Dillingham M. Arthroscopy of the calcaneocuboid and talonavicular joints. J Foot Ankle Surg. 1996;35:101–108. doi: 10.1016/s1067-2516(96)80025-1. [DOI] [PubMed] [Google Scholar]
- 13.Lui T.H., Chow C.L. Arthroscopic management of osteochondral lesion of plantar medial talar head. Arthrosc Tech. 2019;8:e81–e84. doi: 10.1016/j.eats.2018.09.001. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Lui T.H., Chan L.K. Safety and efficacy of talonavicular arthroscopy in arthroscopic triple arthrodesis. A cadaveric study. Knee Surg Sports Traumatol Arthrosc. 2010;18:607–611. doi: 10.1007/s00167-010-1098-0. [DOI] [PubMed] [Google Scholar]
- 15.Xavier G., Oliva X.M., Rotinen M., Monzo M. Talonavicular joint arthroscopic portals: A cadaveric study of feasibility and safety. J Foot Ankle Surg. 2016;22:205–209. doi: 10.1016/j.fas.2015.08.005. [DOI] [PubMed] [Google Scholar]
- 16.Hammond A.W., Phisitkul P., Femino J., Amendola A. Arthroscopic debridement of the talonavicular joint using dorsomedial and dorsolateral portals: A cadaveric study of safety and access. Arthroscopy. 2011;27:228–234. doi: 10.1016/j.arthro.2010.07.017. [DOI] [PubMed] [Google Scholar]
- 17.Lui T.H. Endoscopically and fluoroscopically assisted curettage and bone grafting of the navicular bone cyst. Arthrosc Tech. 2016;5:e1221–e1227. doi: 10.1016/j.eats.2016.07.016. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
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Supplementary Materials
Arthroscopic talonavicular arthrodesis for the management of talonavicular osteoarthritis of the right foot. The patient is in the supine position with the legs spread. With the medial portal as the viewing portal and the dorsomedial portal as the working portal, the cartilage of the dorsal part of the talonavicular joint is removed. The arthroscope is then switched to the dorsomedial portal. The cartilage of the medial and plantar medial parts of the joint is removed via the medial portal and the cartilage of the lateral and plantar lateral parts of the joint is removed via the dorsolateral portal. The arthroscope is then switched back to the medial portal and the subchondral bone of dorsal part of the joint is microfractured via the dorsomedial portal. After that, with the dorsomedial portal as the viewing portal, the subchondral bone of medial and plantar medial parts of the joint is microfractured via the medial portal and the subchondral bone of lateral and plantar lateral parts of the joint is microfractured via the dorsolateral portal. Finally, the talonavicular joint is transfixed with 2 cannulated screws.
Arthroscopic talonavicular arthrodesis for the management of talonavicular osteoarthritis of the right foot. The patient is in the supine position with the legs spread. With the medial portal as the viewing portal and the dorsomedial portal as the working portal, the cartilage of the dorsal part of the talonavicular joint is removed. The arthroscope is then switched to the dorsomedial portal. The cartilage of the medial and plantar medial parts of the joint is removed via the medial portal and the cartilage of the lateral and plantar lateral parts of the joint is removed via the dorsolateral portal. The arthroscope is then switched back to the medial portal and the subchondral bone of dorsal part of the joint is microfractured via the dorsomedial portal. After that, with the dorsomedial portal as the viewing portal, the subchondral bone of medial and plantar medial parts of the joint is microfractured via the medial portal and the subchondral bone of lateral and plantar lateral parts of the joint is microfractured via the dorsolateral portal. Finally, the talonavicular joint is transfixed with 2 cannulated screws.