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David Shepherd, MBBS, reviewed multiple treatments of avascular necrosis (AVN) of the talus: core decompression, vascularized bone graft, tibiotalocalcaneal arthrodesis, total talus replacement, and total ankle/total talus replacement.¹
 
Sultan and Mont reviewed 4 studies of 199 ankles in 139 patients who had core decompression and bone grafting for osteonecrosis of the talus.² They found 83% of patients did not have clinical or radiological progression of the disease, while 21% progressed, and 11% needed ankle fusion. In the same study, the authors reviewed 5 studies with 64 patients who had vascularized bone grafts, noting that after a mean follow-up time of 14 months, 80% had near normal function and good pain relief.²
 
Cody and Nunley, in a study of 13 patients of patients with talar osteonecrosis who had vascularized pedicle bone grafting, found 85% needed no additional surgery at a mean 6-year follow-up, while all patients had revascularization on magnetic resonance imaging (MRI), noted Dr. Shepherd.³
 
As for arthroscopic ankle fusion for AVN of the talus, Dr. Shepherd cited retrospective data by Kendal and colleagues finding 100% clinical and radiologic fusion in 16 patients, with no further talar collapse and 81% of patients noting resolution of the original pain at final follow-up.⁴
 
Dr. Shepherd noted Pellegrini and colleagues, in a retrospective review of subtalar arthrodesis for 12 patients with AVN of the talus, found a fusion rate of 58% at a minimum follow-up of 12 months.⁵ Researchers noted 17% had diabetes while 17% smoked. The authors suggested caution when considering an isolated subtalar arthrodesis for AVN of the talus, instead considering extending the arthrodesis site to include the tibiotalar or talonavicular joint or considering revascularization procedures such as concomitant vascularized bone grafts.
 
Union rates can vary with tibiotalocalcaneal arthrodesis. Gross and colleagues, in a review of 6 studies, found a pooled delayed union rate of 32% in 62 patients with AVN of the talus who had tibiotalocalcaneal fusion.⁶ In a study of 32 patients who had a tibiotalocalcaneal arthrodesis with a bulk femoral head allograft, Jeng and colleagues found a 50% fusion rate.⁷ Dr. Shepherd noted diabetes was the only predictive outcome factor, with all patients with diabetes developing a nonunion. Tenenbaum and colleagues found a 100% union rate in a retrospective case series of 4 patients who had a tibiotalocalcaneal arthrodesis.⁸
 
Kadakia and colleagues studied 3D-printed total talus replacements for AVN of the talus in 27 patients.⁹ Dr. Shepherd noted the authors found no cases of progressive subtalar or talonavicular arthritis at a mean follow-up of 22.2 months. Johnson and colleagues studied total talus replacement, with 84 patients receiving ceramic replacements, 49 receiving cobalt chrome, and 24 receiving titanium.¹⁰ Dr. Shepherd noted 52 of the total 191 patients developed arthritis in the adjacent joint.
 
Dr. Shepherd concluded that there have been some changes in total talus design but limited results. There has also been little change in management of AVN.

Treating Freiberg’s Disease

David Lunz, MBBCh, FRACS, reviewed that Freiberg’s disease disrupts the blood flow and leads to osteonecrosis of the metatarsal head. He said this leads to flattening and collapse of the metatarsal head, which in turn causes degenerative changes and arthritis.
 
The etiology of Freiberg’s disease is multifactorial, including trauma, altered foot biomechanics, hypovascularity, systemic conditions such as diabetes, and genetic causes such as a long second metatarsal, according to Dr. Lunz. He added that the condition is 5 times more common in women, most commonly presents between ages 1 and 17, and mostly affects the second metatarsal.
 
Dr. Lunz notes Freiberg’s disease presents with a gradual onset of pain and swelling in the forefoot as well as swelling of the metatarsophalangeal joint (MTPJ). Patients may experience reduced range of motion, a positive Lachman test, and malalignment.
 
Smillie classified Freiberg’s disease as the following:¹¹
 
Stage I. A narrow fissure fracture in an ischemic epiphysis with sclerosis between cancellous surfaces.
 
Stage II. Absorption of cancellous bone in the metatarsal head with sinking of the articular surface dorsally and no involvement of the plantar aspect.
 
Stage III. Further absorption and sinking of the articular surface with larger projections on either side.
 
Stage IV. Deeper sinking of the articular surface with peripheral projections/fractures. Restoration of the normal articular surface is impossible.
 
Stage V. Degenerative arthrosis with flattening and deformity of the metatarsal head. The plantar aspect of the metatarsal head is involved. The shaft of the metatarsal bone is thickened and dense.
 
The rationale of nonoperative treatment for Freiberg’s is to alleviate symptoms and limit epiphyseal deformity to slow the condition’s progression to arthritis, noted Dr. Lunz. As he said, nonoperative treatment includes activity modification, protected weight-bearing, analgesics and nonsteroidal anti-inflammatory drugs, and bisphosphonates.
 
Dr. Lunz noted operative treatment has the goal of altering the patient’s abnormal physiology and biomechanics and can take the form of core decompression¹² or corrective osteotomies. He said surgical treatment also restores articular congruency and addressing arthritic sequelae, via debridement, microfracture, osteotomy, osteochondral grafting, interposition arthroplasty, or implant arthroplasty.
 
As for joint preserving options, Dr. Lunz noted surgeons can perform open joint debridement at any stage of Freiberg’s disease, and Sproul and colleagues reported on this technique in 11 patients with 80% improvement in range of motion.¹³ Arthroscopic joint debridement is useful as an adjuvant treatment following other established Freiberg’s procedures, noted Dr. Lunz. He said Smith and colleagues reported on an extra-articular osteotomy, noting 14 of 15 patients had pain relief in a month, but 4 patients had decreased flexion and their toes did not contact the ground.¹⁴
 
A Gaulthier osteotomy is one of the best known joint preserving procedures for Freiberg’s, noted Dr. Lunz. He said this intra-articular dorsal closing wedge osteotomy is recommended for Smillie stages III and IV, and has shown high patient satisfaction with minimal complications.¹⁵
 
Osteochondral grafting consists of an autograft from the ipsilateral knee and is recommended for large Smillie stage III and IV lesions.¹⁶ Dr. Lunz said the procedure can restore normal anatomy and promote early bone-to-bone healing.
 
How does osteochondral autologous transplantation (OAT) compare with dorsiflexion closing wedge metatarsal osteotomy (DCWMO)? Dr. Lunz notes AOFAS scores were better in Kim and colleagues’ study of 27 patients, and that OATS was better than or equal to DCWMO as far as clinical outcome, ROM, complications and return to sport.¹⁷
 
Dr. Lunz noted joint sacrificing procedures include interposition arthroplasty and is recommended for Smillie stages IV and V. He said it is difficult to restore the metatarsal head and relieve symptoms in late Smillie stage IV and V. Other joint sacrificing procedures include silicone and ceramic implants, which he said have shown good results in the literature.^18,19 He noted mixed results with a hydrogel implant.²⁰

What You Should Know About Müller-Weiss Disease

Patrick Maloney, MD, noted that Müller-Weiss disease is a rare disease that is more common in women in their 30s to 50s and is often bilateral. The condition is exacerbated by activity and patients can tolerate it for years. Radiographic findings include dorsal talonavicular osteophytes, a navicular shaped like a comma or hourglass, lateral fragmentation, or a wide talar head with lateral displacement.
 
The differential diagnosis for Müller-Weiss disease includes insufficiency fracture, acute fracture, stress-adaptive sclerosis, and Charcot arthropathy, according to Dr. Maloney. He said the pathogenesis of the disease includes a delay in ossification and an excessive compression force distribution laterally, as well as related conditions causing a lateral force shift, such as subtalar varus, first brachymetatarsalgia, and misdiagnosed clubfoot. Other pathogenesis factors are flattening and fragmentation of the dorsolateral navicular, and a secondary lateral shift in the talar head and hindfoot varus.
 
In a study of 8 feet in 6 patients with Müller-Weiss disease, Hetsroni and colleagues found that compared to 18 normal feet, patients with the disease had increased plantar pressure distribution in the midfoot, reduced plantar pressure in the toe, and decreased pressure in the medial heel.²¹
 
Dr. Maloney noted the “vast majority” of patients with Müller-Weiss disease can be treated nonoperatively and options include orthotics with a lateral wedge or medial longitudinal arch support, or immobilization.
 
Dr. Maloney noted surgical options for this condition include calcaneal osteotomy and arthrodesis of degenerative joints. Monteagudo and Maceira studied a combination of a Dwyer osteotomy and lateral displacement in 18 patients and found it to be satisfactory, with only 1 patient needing arthrodesis 4 years later.²² In a study of 14 feet in 13 patients with Müller-Weiss disease stages II–V, Li and colleagues found 4 excellent results, 8 good results and 2 fair results following calcaneal osteotomies at an average follow-up of 3.7 years.²³
 
Options for arthrodesis include talonavicular, naviculocuneiform, talonaviculocuneiform, triple, and plantar, according to Dr. Maloney. Fornaciari and colleagues, in a study of 10 patients, found improved AOFAS scores in 10 patients with stages III and IV Müller-Weiss disease who had isolated talonavicular fusion with a tension band.²⁴ Doyle and colleagues suggested surgically managing Müller-Weiss disease with triple arthrodesis and extending that to include a naviculocuneiform fusion if computed tomography findings indicate.²⁵ Fernández de Retana and colleagues found a talonaviculocuneiform approach was appropriate for the disease, finding that autologous bone graft was effective and fixation was not necessary.²⁶ Cao and colleagues studied 9 patients who had a dorsal closing wedge osteotomy, finding all 9 had fused at 3 months, and they also had improved arch height and better AOFAS hindfoot scores.²⁷

 
References
 
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3. Cody EA, Nunley JA. Vascularized pedicle graft for talar osteonecrosis. Foot Ankle Clin. 2019;24(1):121-129. doi:10.1016/j.fcl.2018.11.001
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5. Pellegrini MJ, Schiff AP, Dekker TJ, et al. Subtalar arthrodesis in patients with avascular necrosis of the talus. Foot & Ankle Orthopaedics. 2016;1(1). doi:10.1177/2473011416S00281
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9. Kadakia RJ, Akoh CC, Chen J, Sharma A, Parekh SG. 3D Printed total talus replacement for avascular necrosis of the talus. Foot Ankle Int. 2020;41(12):1529-1536. doi:10.1177/1071100720948461
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17. Kim SJ, Kim YW, Park JH, Kim GL. Comparison of osteochondral autologous transplantation and dorsiflexion closing wedge metatarsal osteotomy for late-stage Freiberg disease in adults. Foot Ankle Int. 2020;41(5):529-535. doi:10.1177/1071100720904363
18. Cracchiolo A 3rd, Kitaoka HB, Leventen EO. Silicone implant arthroplasty for second metatarsophalangeal joint disorders with and without hallux valgus deformities. Foot Ankle. 1988;9(1):10-18. doi:10.1177/107110078800900104
19. Townshend D, Magdi G. Total ceramic arthroplasty for painful, destructive disorders of the lesser metatarso-phalangeal joints. Foot. 2007; 17:73-75. 10.1016/j.foot.2006.09.006.
20. Glazebrook M, Morash J, Alhadhoud M, Daniels TR. Preliminary experience with polyvinyl alcohol hydrogel implant for pathology of the second metatarsal head. Foot Ankle Int. 2019;40(11):1304-1308. doi:10.1177/1071100719866700
21. Hetsroni I, Nyska M, Ayalon M. Plantar pressure distribution in patients with Müller-Weiss disease. Foot Ankle Int. 2007;28(2):237-241. doi:10.3113/FAI.2007.0237
22. Monteagudo M, Maceira E. Management of Müller-Weiss disease. Foot Ankle Clin. 2019;24(1):89-105. doi:10.1016/j.fcl.2018.09.006
23. Li SY, Myerson MS, Monteagudo M, Maceira E. Efficacy of calcaneus osteotomy for treatment of symptomatic Müller-Weiss disease. Foot Ankle Int. 2017;38(3):261-269. doi:10.1177/1071100716677741
24. Fornaciari P, Gilgen A, Zwicky L, Horn Lang T, Hintermann B. Isolated talonavicular fusion with tension band for Müller-Weiss syndrome. Foot Ankle Int. 2014;35(12):1316-1322. doi:10.1177/1071100714548197
25. Doyle T, Napier RJ, Wong-Chung J. Recognition and management of Müller-Weiss disease. Foot Ankle Int. 2012;33(4):275-281. doi:10.3113/FAI.2012.0275
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