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The response to the question below was authored by Marc Mitnick DPM

Navicular fracture shattered with bone graft

by Brandi
(Fort Lauderdale, FL, USA)

Im 3 1/2 months post-op. This thing (left foot) is still causing me nightmares. Cramping at night. Walking on it weight-bearing is tolerable but seems like Im stepping on a nail on the planter side of my foot parallel to the incision on the dorsal side of my foot. It brings me to tears. My orthopedist has cleared me to return to work now which Im still in pain, unsteady and have fallen because of lack of strength in my left foot. (which is not cool since I had a monteggia Variant Fracture (3fractures actually, 2/ulna and 1/radius head in Y shape) at the same time I injured my left foot falling 8ft when a ladder collapsed beneath me.

Anyway, is this pain normal? The feeling Im stepping on a nail with every step?

RESPONSE

Hi Brandi,

At first blush it would appear to me that the amount of pain you describe is not normal 3 1/2 months post op.

This might be easier for me to wrap my head around if I could see some x-rays but I will have to make do with the information you are supplying me. The enclosed picture reveals perhaps a little more swelling in the left foot, but other than that, it is of little help.

Suffice it to say that every one has a different pain threshold and furthermore every one heals at a different rate. Should you be completely healed at three and half months? Probably not. But, what I would have hoped you would have said is that you still have some degree of discomfort, but overall, the foot is much better.

Furthermore you are seeing improvement every week. If this is the case, then you can assume things will continue to get better and your doctor is clearing you with the understanding that you are "well on your way to being healed".

Having said that, if you still feel like you are

walking on a nail all the time and it is painful enough to bring you to tears then something is wrong, or at the very least you are healing slowly and will require more time. I have no way of knowing without seeing an x-ray. Stated another way, if your improvement has leveled off and you are not seeing further improvement then you need to be concerned.

If you have told your surgeon how the foot feels to walk on, then I am at a loss as to how he feels you are ready to be discharged.

I have no idea who your surgeon is, nor do I really care, but many times a surgeon will look at the final x-ray and if every thing appears "normal" then you are discharged, without taking into account whether or not there is any excessive pain.

I would assume at your last visit you told the doctor about the feeling of walking on a nail and would be curious as to what his response was.

As I see it, you have two choices. You can go back to your surgeon and have a candid conversation about the amount of pain you are having and let him reassess whether or not you are ready to go back to work, or perhaps more importantly whether or not there is some issue with your surgery that needs to be further addressed.

Of course, the type of work you do also comes into play. If you have a job where you are seated all day then returning to work should be no big deal, but if your job requires you to be on your feet all day, that could be a problem.

If you get no satisfaction in your answer, then the smart move here would be to seek a second opinion from another doctor in your area who can view your x-rays and actually examine you.

Marc Mitnick DPM
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Jan 26, 2016
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Thank you
by: Brandi

Thank you again FROM THE BOTTOM OF MY HEART!!

My orthopedist refuses to get involved with looking at my old CT/films or form an opinion about the prior procedure other than the current facts.

It was a Comminuted & compressed fracture involving the navicular bone with extension into the talonavicular joint and navicuneiform joints.

The final Fluroscopic images were obtained on AP & lateral views noting the navicular to be well reduced, well aligned and hardware to be extra-articular, then it goes onto to state how it was closed.

I have my surgical notes.. and locating original and second CT plus access to a physician 24/7 who is my Significant Other(SO).

Im just beyond frustrated asking how this could have happened. According to what I have read about this surgery, this could have been a non-union, which it isn't, or healed fine. There nothing about why this other than CT for causation. The only options I have are hardware removal, and fusion, or the worst.. amputation.

My orthopedist just told me there was nothing I could have done to prevent this. You seem to be the only one who is willing to answer anything...

Is this normal?
This injury has already destroyed my quality of life and I will be disabled for the rest of my life after the fusion which was caused by the hardware destroying my talus and causing severe osteoarthritis in the talonavicular joint.
I have asked about "arthoplasty" of sorts to the bones in order to keep the function and he said that wasn't possible.

Why cant anyone give me a straight answer?

As I see it, the big problem is that you suffered a comminuted fracture of the navicular which is one of the hardest types of fractures to reduce simply because it is not just one "crack" in the bone but multiple breaks. The surgeon's goal is to put the bone back together somewhat in the same manner as putting a puzzle together. He or she has to push all the pieces back together and then hold them together with fixation.

When you are dealing with trauma, every situation is different because of the different variables involved and the surgeon's first goal is to get everything back together and unfortunately in many cases "hope for the best".

Since the fracture itself affected the adjacent joints, you cannot put full blame on screw placement as the source of your present situation. In order to get the pieces of navicular bone that make up parts of the joints back into place, it is not surprising that the screws extended into the joint itself. Keep in mind you are dealing with very small bone fragments and it is difficult to get these small pieces properly aligned.

If all the fractures have clinically healed, I do not recall how long ago you suffered this injury, I would first consider having the screws removed without a fusion. Depending on how the screws are fixated, the surgeon might also be able to remove any osteophytes (bone spurs) that may be present in the joint. Along with wearing an orthotic to stabilize the talo-navicular joint, I would see how you made out. You might find you do quite well.

If that did not work out to your satisfaction then you could always opt for a fusion and I have to say, that as well might not be the end of the world for you either, as you may find, again, with the use of an orthotic, you do very well.

Keep in mind, the only drawback to my proposed strategy (and I am making this proposal from the other side of the internet without ever examining you) is that you potentially would be looking at two additional surgeries rather than one.

Good luck.

Marc Mitnick DPM

Jan 25, 2016
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ORIF
by: Brandi Smithson

I had an ORIF on my navicular as posted in the previous comment above. I have found very few articles regarding the procedure that was done. I have recently discovered the screws are protruding into my talonavicular joint. Not one screw but multiple. I read once somewhere to surgery protocol with regards to screw placement. This has destroyed my talus head with cysts, osteophytes and I have severe crippling pain with the osteoarthritis of the talonavicular joint. This was recently discovered at a University hospital with another orthopedist ordering the CT since none of this showed on CT.
So my question is where do I find the procedure protocol? I have found a little from the OAfoundation.org but nothing specific. Thank you

ORIF-open reduction internal fixation (for those who do not know what the acronym stands for) as the name implies is where the surgeon goes in, resets the broken bone (reduction) and then holds the re-positioned fracture in place by some form of internal fixation, in your case screws.

There are two issues here. The first is where and what type of fracture you had in the navicular bone. As you can imagine no two fractures are the same, and secondly the length and angle of the screws inserted.
The goal of surgery in an ideal world is to place screws that are long enough to hold the broken bone together without impinging on adjacent bones.

The problem in your case is that the screws used ended up penetrating your talus bone and doing damage to that bone as well. Now that could have been caused by the fracture being in such a position that it was impossible to miss the talus bone and the talo-navicular joint or the other possibility is that the screws used were too long and even though they closed the fracture, they did additional damage. A third possibility is that they intentionally wanted the screws to go through an adjacent bone to bring about additional stabilization. I am only guessing here and have no idea what the actual surgical strategy was.

In most cases doctors will do intra-operative fluoroscopy where they can visualize the screw placement to see if the screws are properly positioned after they are inserted.

I am not sure you will find specific answers to your questions in the literature, as you well know, surgery is more of an art then a science. This means that every surgical situation has its own set of issues that have to be addressed and it is up to the surgeon to come up with a strategy to address the specific needs of each patient.

Speak with your present orthopedist, who should be able to discern what type of navicular fracture you had and whether or not the screw placement was properly done.

Marc Mitnick DPM

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ADDITIONAL REFERENCES

Mayo Clinic

Johns Hopkins Medicine

MedlinePlus

Arthritis Foundation

University of Rochester Medical Center

Harvard Health

Drugs.com

American Academy of Pediatrics

Penn State Medical Center

National Institutes of Health

Columbia University Department of Rehabilitation

ScienceDirect

Stanford Health Care

Illinois Bone and Joint Institute

Mount Sinai Hospital

Institute for Chronic Pain

University of Florida Health

American Family Physician

Cedars-Sinai

University of Maryland Medical Center

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Wonderful advice

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location unknown

Navicular fracture shattered with bone graft

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