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pISSN 1738-3757 eISSN 2288-8551J Korean Foot Ankle Soc 2015;19(2):69-72

http://dx.doi.org/10.14193/jkfas.2015.19.2.69

TN joint has been associated with a high non-union rate5) due to

poor visualization of the entire cartilage area, and the great chance

of avascular necrosis (AVN) of both talus and navicular. It is also

difficult to obtain a stable fixation because of the morphometric

shape, the short length and the small size of navicular bone.6)

CASE REPORT

A 37-year-old female with a history of burn injury to the right

foot was presented to our clinic with a sharp pain on the navicu-

lar bone that was aggravated with weight bearing and right foot

deformity area. The patient reported being burned by hot water at

the age of 6 months, and was operated twice at the age of 7 years

to correct the foot deformity (details not available). For the past

36 years, the patient has been doing well and walking with mini-

mal pain. However, she noted that the pain has been increasing

in severity within the last year and she was unable to walk, and

complained of pain even at rest. There was no history of recent

trauma.

Upon physical examination, the patient had an antalgic gait with

limb shortening of 3.5 cm on the right lower extremity. She also

had a valgus hindfoot, abducted midfoot and scarred skin over

The objective of arthrodesis of the foot is to correct the deformi-

ty of the involved joint and achieve a stable, pain-free plantigrade

foot.1) This provides a better functional outcome for the patient

with the increased stress in the surrounding non-fused joints.

An arthrodesis of the foot joint can be performed in situ in pa-

tients with a chief complaint of pain in the foot but has no foot

deformity, or in patients who cannot maintain gait stability after

surgery for correction of the foot deformity.2)

Double and triple arthrodesis are common procedures that are

often performed to restore and maintain the physiologic alignment

of the hindfoot. It is also performed in severely deformed rocker-

bottom foot correction surgery where we reconstruct a destroyed

midfoot joint.3) The need for an isolated talonavicular (TN) joint

fusion can arise, although rarely, in cases of navicular fracture, iso-

lated degenerative or idiopathic TN joint etiology.4)

Gross visualization of the entire cartilage area is required for

complete denudation of the cartilage. Thus, isolated fusion of the

Case Report

CC This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Copyright 2015 Korean Foot and Ankle Society. All rights reserved.ⓒ

We report on a case of post-burn contracture and right foot deformity in a 37-year-old female who underwent two surgical interventions at the age of seven years. The patient remained well without any associated problems until she presented to our hospital at the age of 37 years with severe pain and right foot deformity. A few treatment modalities have been reported, and amputation has been suggested as the best approach. However, our patient was treated with a talonavicular arthrodesis and a soft tissue procedure, which resulted in a stable, plantigrade, and pain-free foot with an unsupported, bipedal gait.

Key Words: Rocker bottom foot, Arthrodesis, Foot deformities

Isolated Talonavicular Arthrodesis as an Option for Severe Rocker Bottom Foot Deformity: A Case Report

Stephanie Stephanie*, Jun Young Choi, Abhishek Kumar, Jin Soo Suh

Department of Orthopaedic Surgery, Inje University Ilsan Paik Hospital, Goyang, Korea,

*Department of Surgery, Howard University College of Medicine, Washington, DC, USA

Received February 24, 2015 Revised April 22, 2015 Accepted April 22, 2015Corresponding Author: Jin Soo SuhDepartment of Orthopaedic Surgery, Inje University Ilsan Paik Hospital, 170 Juhwa-ro, Ilsanseo-gu, Goyang 411-706, KoreaTel: 82-31-910-7968, Fax: 82-31-910-7967, E-mail: sjs0506@paik.ac.kr

Financial support: None.Conflict of interest: None.

70 Vol. 19 No. 2, June 2015

ed cancellous screws (Fig. 5). Both peroneal tendons of the lateral

compartments were lengthened and the extensor digitorum ten-

don was transferred to the extensor hallucis longus (EHL) muscle.

Then we excised the tip of the second toe, along with the corn

and anterolateral scar of the right foot. A myocutaneous free flap

was obtained from the ipsilateral latissimus dorsiand used to cover

the defect. Postoperatively, the patient was kept on a cast stabiliza-

tion of non-weight bearing for 6 weeks, followed by 6 weeks of

gradual weight-bearing as tolerated.

Three months postoperatively, the patient obtained a planti-

grade foot and was able to walk pain free without any support (Fig.

6). Radiologically, an assessment of the AP talo-first metatarsal

angle revealed 41o with forefoot valgus and 11.8o on lateral view,

while the calcaneal pitch angle measured 5o (Fig. 7).

her right anterolateral ankle (Fig. 1). There was an anterolateral

post-burn scars and band contracture (Fig. 2) on the patient’s right

ankle, and a tender bony prominence on the surface of the medial

midfoot. The second distal toe was also amputated and the toe tip

was protruding over the skin, giving rise to a corn. There was no

evidence of previous or ongoing infection.

Radiologic examinations (Fig. 3) revealed a talo-first metatarsal

angle of 75o on weight bearing anteroposterior (AP) view and 60o

on lateral view. The angle of the calcaneal pitch was 17o while

the midfoot was abducted, pronated, and the navicular bone held

down against the floor. Scanogram showed a 3.5 cm shortening of

the right lower limb (Fig. 4).

The patient underwent the TN fusion using two partially thread-

Figure 1. Figure 1. Burn scar over extensor digitorum longus tendon (arrow). Figure 2. Figure 2. Anterolateral scar over ankle.

A B

Figure 3.Figure 3. Radiologic examinations revea-led a talo-first metatarsal angle to be 75o on weight bearing anteroposterior view (A) and 60o on lateral view (B).

www.jkfas.org

71Stephanie Stephanie, et al. Isolated Talonavicular Arthrodesis

This condition is of rare occurrence. Besides, it is very difficult to

generalize the specific treatment plan for all cases because each

case is unique and has specific conditions.7,8)

Lateral column lengthening is generally used to correct hindfoot

valgus and severe flat foot deformity. However, our patient has

a very tight soft tissue tension on the lateral aspect of the foot de-

spite previous resection, scar band release, and lateral side tendon

lengthening. It is generally believed that isolated TN fusion is not

commonly recommended for the relieve of pain or functional

restoration of the midfoot,9,10) with the great chance of AVN, non-

union, malunion and progressive posttraumatic arthritic changes.

However, in our particular case, isolated TN fusion became the

treatment of choice because the patient suffered from a severe

shortening of the lateral ray, along with an extreme valgus of the

forefoot.

A double or triple arthrodesis would require a substantial

amount of bone resection, especially at the talar neck. This is not

always a good choice because it leads to further shortening of

foot.

It would be prudent to mention here that one of the presenting

DISCUSSION

There has been very few reports published on the treatment of

rocker-bottom feet deformity complicated by burn contracture.

Figure 4.Figure 4. Scanogram showed a shortening of 3.5 cm of the right lower limb.

A B C

Figure 5.Figure 5. Postoperative radiographs showed talonavicular arthrodesis state with two cannulated screws. Anteropos-terior (A), lateral (B), and hindfoot (C) alignment view on standing.

Figure 6.Figure 6. The patient obtained a planti-grade foot and was able to walk pain free without any support at three months postoperatively.

72 Vol. 19 No. 2, June 2015

chief complaints of the patient was difficulty in managing her daily

footwear. The patient’s feet would slide off her shoes with every

step. Amputation at the level of trans-metatarsal would have ag-

gravated this problem postoperatively.

Next, we also excised the second toe tip because it was protrud-

ing out of the dorsum of the foot and producing a corn. Peronei

lengthening was done to correct the overall abduction inclination

of the foot. Transfer of the extensor digitorum longus to the EHL

had caused the force of the tendon to be diverted medially. The

anterolateral thigh flap was based on the perforator derived from

the descending branch of the lateral circumflex femoral artery.

An alternative treatment option for a patient with severe rocker

bottom deformity is to amputate the foot at the level of the trans-

metatarsal bone. The rationale is that such procedure is less

complicated and has a rapid recovery time. However, the patient

refused this treatment modality.

Therefore, we performed an isolated TN arthrodesis of the foot

and the lateral side soft tissue reconstructive surgery. This proce-

dure can be an excellent treatment option for the patients with

a severe rocket-bottom foot deformity and especially in selected

cases like this where the foot length is shortened, and this proce-

dure would result in a reduction of lever arm after fusion.

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Figure 7.Figure 7. Radiologic assessment of the anteroposterior (AP) talo-first metatarsal angle revealed 38o (A) on AP view with hindfoot valgus (B) and 12o on lateral view, while the calcaneal pitch angle measured -9.6o (C).

A B C