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Talonavicular Arthritis

What Is Talonavicular Arthritis?

Please see foot & ankle anatomy for more information about the talonavicular joint.

Arthritis is disease (damage) of cartilage. Cartilage lines the surface of the bones where two or more bones form a joint. Cartilage allows smooth and frictionless movements. Disease of cartilage leads to roughened surfaces which causes friction and increased wear and tear in the joint. This in turn can cause inflammation, pain, and joint deformity.

Talonavicular arthritis is when arthritis involves the talonavicular joint.

A - Normal radiograph of the foot lateral view B - Talonavicular arthritis

A – Normal radiograph of the foot lateral view B – Talonavicular arthritis

What Can Cause It?

Any condition that damages the cartilage (joint surface) will cause talonavicular arthritis to develop.

The common conditions that cause subtalar arthritis are:

What Are The Symptoms?

Typical symptoms of talonavicular arthritis include:

  • Pain
    • Painful stiffness in the morning
    • Eases off with activity but later becomes constant
    • Worse in cold damp weather
    • Exacerbated by weight bearing, walking and standing
    • Limits activities (reduced walking distance, unable to do sports)
    • Limp
  • Swelling
  • Reduced movement in the joint (stiffness)
  • Change in foot shape (joint deformity)

What Investigations May Be Required?

Investigations help confirm the diagnosis, grade the severity of the condition and where applicable, aid in pre operative planning.


Plain radiograph (x-ray)

Plain radiographs are a quick and effective way of confirming arthritis in a joint. In the early stages when there is inflammation with no damage to the joint they maybe normal. Most people however present when there is some structural damage.

The following are features of arthritis on a plain radiograph:

  • Decreased joint space
  • Subchondral sclerosis
  • Subchondral cysts
  • Osteophytes
  • Deformity (change in foot shape)
A - Normal radiograph of the foot lateral view B - Talonavicular arthritis

A – Normal radiograph of the foot lateral view B – Talonavicular arthritis

Plain radiograph of the foot showing talonavicular joint arthritis (blue arrows)

Plain radiograph (x-ray) of the foot showing talonavicular joint arthritis (blue arrows)


MRI

MRI provides excellent high definition static images. It is useful in pre operative planning and to exclude any other pathology in the hindfoot. It is also useful in monitoring healing.

MRI is particularly useful in assessing:

  • Cartilage loss
  • Reactive bone changes
  • Effusion
  • Synovitis
  • Ligament damage
  • Tendon pathology (tenosynovitis, tendon tears)
  • Any other pathology
MRI of an ankle (side view) demonstrating severe talonavicular arthritis, note the presence of fluid (oedema) shown as a lighter grey colour in the talus and navicular bone, as well as the presence of a large cyst, all indicative of severe talonavicular arthritis

MRI of an ankle (side view) demonstrating severe talonavicular arthritis, note the presence of fluid (oedema) shown as a lighter grey colour in the talus and navicular bone compared to the surroudning darker bones, as well as the presence of a large cyst, all indicative of severe talonavicular arthritis

 

mri-tn

A – MRI of a normal talonavicular joint B – MRI of diseased Talonavicular joint, note darkened area representing damage to bone and cartilage


CT

CT images give excellent information on bone structure and is superior to plain radiography in that respect.

CT is particularly useful in the following cases:

  • 3D image reconstruction
  • Pre operative planning
  • Evaluating the joint in the presence of surgical hardware ie screws & plates
  • Assessing adjacent joints for presence of arthritis
  • Assessing bone healing (fusion)

Ultrasound

Ultrasound is a quick, painless and non invasive method of assessing soft tissue structures.

Ultrasound is particularly good at ascertaining:

  • Presence of inflammation in the lining of the joint (synovitis)
  • Evidence of fluid in the joint (effusion)
  • Evidence of adjacent soft tissue structure pathology such as tenosynovitis

Bone Scan

Bone scan is a non specific test. It utilises a radioactive dye, absorbed by the body and taken up by areas of high metabolic activity such as inflammation and infection. It will not tell you what the diagnosis is, but will usually tell you if an abnormality is present.

This test is done in special circumstances.

Radiograph of a bone scan showing increased uptake in the foot

Picture of a bone scan showing increased uptake in the foot

Can The Problem Get Worse?

The natural history of talonavicular arthritis is very variable, some patients describe a rapid deterioration, while others take many years to get worse.

The changes associated with arthritis are irreversible, the joint will never return to its normal healthy state. That is not to say that all patients are symptomatic, some patients describe stiff joints with mild ache and are able to manage their symptoms with activity modification. However some patients describe significant pain and functional limitation.

You should see an Orthopaedic Foot & Ankle Surgeon if one or more of the following applies to you:

  • Pain affecting your quality of life
  • Pain affecting your ability to work
  • Your pain is getting worse
  • You have night pain
  • You have rest pain
  • You can no longer exercise or participate in sports to the level you desire
  • You have started to develop deformity in your foot or ankle
  • You have a swelling of unknown cause
  • You are unsure about the underlying diagnosis (cause of your symptoms)
  • Failure of conservative measures such as rest, time, anti-inflammatories and physiotherapy
  • Problems with footwear

As the arthritis becomes more severe and any deformity becomes fixed, adjacent joints will also become involved and become arthritic.

Radiographs demonstrating how talonavicular arthritis can get worse A - normal talonavicular joint (blue line) B - severe end stage talonavicular arthritis C - in addition highlighting severe excess bone growth (shaded blue area), subtalar arthritis (yellow line)

Radiographs demonstrating how talonavicular arthritis can get worse A – normal talonavicular joint (blue line) B – severe end stage talonavicular arthritis C – in addition highlighting severe excess bone growth (shaded blue area), subtalar arthritis (yellow line)


Grading a disease in medicine is used for the following reasons:

  • Assessing the severity of a condition
  • For accurate record keeping 
  • To help monitor disease progression
  • For ease of communication between colleagues for example
  • In some cases to give information on prognosis
  • In some cases to help guide treatment

There are a number of grading systems used for arthritis. We use the following grading system based on radiographic (x-ray) features at The London Foot & Ankle Clinic:

  1. Little or no joint space narrowing
  2. Minimal joint space narrowing with small marginal osteophytes
  3. Definite joint space narrowing and osteophytes
  4. Extreme joint space narrowing (no space between the bones on x-rays)

Non-Operative Treatment Options

Non-operative management for ankle arthritis aims at relieving pain and return to full activity including sports whenever possible. It is likely to be most effective in the early stages of the condition.

It should always be the first line of treatment. Options include:

Activity modification

A period of rest from sports and exercise that bring on symptoms. Avoiding high impact activities with lots of turning and twisting.


Footwear modification

Wearing above ankle boots that give more support to the joint. The use of a shoe with a rocker bottom sole can also help as it helps spread the load away from the midfoot.


Insoles & orthotics

Custom orthotics that stiffen the mid portion of the foot can ease symptoms.


Non steroidal anti-inflammatories

The use of non-steroidal anti-inflammatory drugs (NSAIDs) can decrease discomfort in patients with talonavicular arthritis by reducing inflammation in the joint.


Analgesics

The use of paracetamol and other painkillers to help reduce pain levels.


Physiotherapy

Physiotherapy works by strengthening muscles around not only the joint but the whole kinetic chain. Calf stretches can also help reduce loads and forces going across the midfoot.

Results are variable with arthritis and depend really on the severity of the disease. In a very stiff and damaged joint, physiotherapy may make your symptoms worse. Your surgeon will guide you.


Walking aids

The use of a walking stick or cane to reduce the forces going across the damaged joint.


Weight loss

Can relieve the pressure on painful damaged joints.


Dietary supplements

These are increasingly popular with people who have arthritis. The cartilage found in joints, normally contains glucosamine and chondroitin. It is thought that taking supplements of these natural ingredients may help to improve the health of damaged cartilage.

Research has provided mixed results but on the whole suggests that glucosamine sulphate is more likely to be helpful than glucosamine hydrochloride. If you are thinking of taking glucosamine, we suggest taking 1,500 mg per day of glucosamine sulphate. If you notice no improvement in your symptoms after 3 months then you should probably discontinue it. If you do find it improves your symptoms then you ned to continue taking the supplements. There is no extra benefit in taking glucosamine and chondroitin.

Remember that supplements also have side effects and it is advisable to discuss with your GP before starting any new treatment.


Other treatment options

There is no one treatment that has a reliably successful, quick and easy cure for arthritis. Therefore researchers and doctors are constantly looking for new and better ways of treating arthritis.

Many treatments have come into fashion and then gone away over the years once results had shown that the initial promise was premature and misplaced.

At The London Foot & Ankle Clinic we do not promote or discourage new treatment options for arthritis. We would however advise a cautious approach to relatively untested treatment modalities with little or no evidence to back their use. Patients undergo these treatments at their own risk.

Injections For Talonavicular Arthritis

There are a number of treatments that involve an injection or series of injections for the treatment of talonavicular arthritis.


Image guided steroid and local anaesthetic injection

This injection serves as both a therapeutic and diagnostic intervention. Steroids reduce inflammation and can ease painful symptoms. The local anaesthetic numbs an area of the body for roughly 12 to 48 hours.

The steroid is unpredictable in its success at easing painful symptoms but has very low risk of complications and therefore is an attractive therapeutic option prior to further more invasive surgical intervention. The local anaesthetic on the other hand is very predictable in its action. If there is an area of damage it will definitely ease symptoms for 12 to 48 hours. If symptoms do not ease during this period, one has to question whether the diagnosis is correct.

Steroids reduce inflammation and ease pain when injected directly into an arthritic joint. It is most likely to be effective in the early stages of arthritis.

We carry out almost all injections under a short general anaesthetic (1 minute) as injecting into a painful joint can be quite sore. While you are asleep and lying still a small needle is inserted into the joint and the position is confirmed using an x-ray in theatre. A small amount of dye is injected first to make sure the needle is in the correct spot and then a mixture of Depomedrone (steroid) and Bupivacaine (long lasting local anaesthetic) is injected. Undertaking the injection in this manner ensures a pain free experience for the patient and the best outcome clinically as there is no doubt about the placement of the injection.

The local anaesthetic will cause numbness in the area injected for approximately 12 to 48 hours. This action is predictable. What is not predictable is the duration of action of the steroid. It may work for one month, several months or even more than a year.

Injections are not repeated less than 6 monthly intervals.

Please read here for more information regarding injections and possible complications.


Image guided viscosupplementation

Normal joints have lubrication fluid called synovial fluid. A major constituent of synovial fluid is a substance called hyaluronic acid. This helps not only lubricate the joint but also act as a shock absorber easing the load across the joint.

It has been noted that people with arthritis tend to have lower concentrations of hyaluronic acid than normal.

Viscosupplementation involves injecting hyaluronic acid into arthritic joints. The procedure would be carried out as for a steroid injection under a short general anaesthetic and x-ray control.

Please read here for more information regarding injections and possible complications.

Operative Treatment Options

Surgical management is reserved for patients who have failed to respond to non operative treatment.

Patients should understand that the decision to undergo surgery should not be taken lightly.

Any intervention is considered in a step wise manner, with the least invasive procedure carried out first.


Talonavicular fusion

This operation has excellent outcomes in terms of pain relief and return to activities of daily living.

It involves removing all remnants of the diseased joint (cartilage) and fusing the the bones so that no joint exists. With no more joint there will be no more movement and therefore no more pain. The aim is to sacrifice painful movement for pain relief.

The majority of patients when they first hear about this procedure are quite apprehensive. This is understandable, joints exist to allow movement. A fusion is the total opposite to this, and therefore most patients perceive it as unnatural. However contrary to what most people think, after a fusion you will be less likely to limp and be a lot more active including the ability to exercise and do sports. Please read this blog for more details.

The operation is usually carried out through one or more incisions on the top (dorsum) of the foot. The operation is undertaken under a general anaesthetic and patients usually require an overnight stay in hospital.

The main complication is non union (the bones not fusing together). This is reported in numerous studies to be around 5 to 10%. In the event of this complication, the operation is repeated with bone graft to stimulate the healing and given time most patients eventually heal.

Currently talonavicular fusion remains the treatment of choice for end stage talonavicular arthritis. There is no talonavicular joint replacement.

A - Lateral radiograph of a foot pre operatively demonstrating severe bone on bone talonavicular arthritis B - Post operative radiograph at 6 weeks with successful fusion at the talonavicular joint

A – Lateral radiograph of a foot pre operatively demonstrating severe bone on bone talonavicular arthritis B – Post operative radiograph at 6 weeks with successful fusion at the talonavicular joint

 

A - Oblique radiograph pre op demonstrating severe talonavicular arthritis B - Post op radiograph demonstrating successful fusion of talus and navicular bones

A – Oblique radiograph pre op demonstrating severe talonavicular arthritis B – Post op radiograph demonstrating successful fusion of talus and navicular bones


Triple fusion

In some patients who have had arthritis in the joint for a long time, adjacent joints can become damaged as well. The talonavicular, calcaneocuboid and subtalar joint in a normal foot work work in a similar fashion. Damage to one, puts increased strain on the others.

If there is evidence of damage to the other two joints, your surgeon Mr Malik may advise you to have all three joints fused to provide you with the best outcome.

A - Normal foot & ankle radiograph B - patient with severe talonavicular arthritis and subtalar joint involvment C - post triple joint fusion - made made an excellent recovery with increased range of motion, complete relief of pain and full function

A – Normal foot & ankle radiograph B – patient with severe talonavicular arthritis and subtalar joint involvment C – post triple joint fusion – made made an excellent recovery with increased range of motion, complete relief of pain and full function

 

Potential Complications

It should be borne in mind that complications can result from a condition with or without surgery.


Potential complications of non-operative treatment include:

  • Worsening pain
  • Increased stiffness
  • Increasing deformity
  • Adjacent joint disease
  • Pain elsewhere, for example in the knee, hip or lower back (due to abnormal gait and compensatory mechanisms)

Complications can occur as with any type of surgery. Please see Complications for more detailed explanation of post surgical complications.

Potential general complications of any operative treatment include:

  • Risks and complications of anaesthesia
  • Bleeding
  • Infection (superficial and deep)
  • Blood clots
  • In the case of an MIS procedure it may be necessary to proceed to open surgery if during the operation it is felt that a better outcome will be achieved using an open technique
  • Failure to fully correct deformity (particularly if longstanding deformity)
  • Need for further surgery (revision or further treatment)
  • Persistent pain
  • Complex regional pain syndrome
  • Wound healing problems

Potential specific complications of talonavicular and triple fusion include:


Note – these complications are not exhaustive and are meant as a guide

Post Operative Period & Recovery

Please read the information regarding what to expect post surgery on this website.

Remember that below is a guide to recovery and that everyone heals at different rates and some people do take longer. Use this information to help you understand your condition, possible treatment and recovery. The timeframes given below are a minimum, it is important that you appreciate this when considering surgery as your healing and recovery may take longer.


Immediate post operative period

All surgical procedures for talonavicular arthritis will be carried out under a general anaesthetic.

You will have a backslab applied post operatively for two weeks. You will spend one night in hospital after your operation and receive intravenous antibiotics the next morning.

Please do not remove your backslab until you are seen by your surgeon Mr Malik at the two week post operative clinic appointment.

You will be non weight bearing for approximately 6 to 8 weeks. The physiotherapist will guide you with the use of crutches after your operation and before your discharge from hospital.

For the first two weeks following your surgery please keep your foot elevated to the level of your heart for 95% of the time.

A picture demonstrating high elevation after foot and ankle surgery

A picture demonstrating high elevation

Naturally most people do not have a hospital bed at home. The same effect can be achieved by lying in a bed or lengthways on a sofa, with pillows behind your back and under your foot. You cannot have your leg elevated sitting in a chair. It is strongly advised that during the first two weeks you are house bound.

To minimise risk of infection keep the foot dry and cool. Avoid humid and hot environments. Keep the foot dry and when showering wear a Limbo bag.

To minimise the risk of blood clots please move your foot and ankle at regular intervals. Please ensure you are well hydrated. If you have a risk of blood clots please notify Mr Malik who may organise for you to have blood thinning injections as a precaution.


Two weeks post operatively

You will be reviewed at the clinic and your dressings removed. Your wound will be checked to see that it has healed and there are no signs of infection.

At this stage if the swelling has subsided sufficiently you will be advised to keep your foot in an elevated horizontal position whenever possible to minimise swelling.

You will be placed in another non weightbearing cast for a further 4 to 8 weeks. Short trips can be made outside, within limits of pain and swelling.


Six weeks post operatively

At this stage if your healing is progressing satisfactorily swelling and bruising should have subsided considerably, although expect some degree of swelling for at least 4 to 6 months.

Depending on the x-ray findings you will either go into a walker boot and be allowed to weight bear through the operated foot, or you will have to remain non weight bearing in plaster.

If your x-rays are encouraging and your wounds completely healed you will be given advice regarding soft tissue massage and scar desensitisation. Scar desensitisation should start as soon as the wound has completely healed. You can do this by massaging cream (E45 for example) into the scar and around the wound area. You may shower and get the area wet only if the wound has completely healed and is dry.


Three months post operatively

Check radiographs should show signs of bone healing. You will be able to start wearing normal footwear (swelling permitted), although stiff soled shoes are advisable. You will require physiotherapy for approximately 3-6 months. This will help optimise the outcome of your operation.

FAQs

How long does the operation take?

This is probably the most common question asked of surgeons. Total operation time is different from the actual total surgical time. For example a flight involves not just the flying time, but the time checking in, going through security and boarding the plane for example.

The time given below is only a guide to the actual surgical time.

For a talonavicular fusion

Up to 90 minutes.

For a triple fusion

Up to 120 minutes.


When can I drive?

Depends on the side operated on and whether you drive an automatic car. If the car is manual then regardless of the side operated on it will be roughly 3 months post surgery. If you drive an automatic and the left foot has been operated on then it will be roughly 4 weeks before you can drive short distances.

Please see guidance above and information here. Ultimately it is the responsibility of the patient to decide if they are safe to drive. A good way of knowing is if you can stamp your right foot heavily on the ground to mimic an emergency brake. If you have any hesitation or pain then it should suggest you are not safe to drive. Remember prolonged driving involves keeping your feet in a dependant position. This will worsen the post operative swelling.


When can I return to work?

This really depends on you and your job. If you have a job that involves a lot of standing, walking and is manual it may be 8 to 12 weeks. If you have a sedentary job, for example in an office and you have a reasonable commute you may be able to go back to work at 2 weeks, although this would be exceptional and not the norm.


What should the final outcome be?

Excellent pain relief and return to full activities of daily living.

Patient Feedback

“I only wish I had been referred to Mr Malik earlier. I have suffered with Rheumatoid Arthritis since 2012, and have suffered pain and swelling in the mid foot region of my left foot on and off since diagnosis.

In May this year the pain became constant, and despite 2 courses of steroids, there was no improvement. It was then I was referred to Mr Malik, who following MRI scan and X-Rays diagnosed talonavicular arthritis with severe bone marrow oedema. He suggested 6 weeks of touch weight bearing to reduce the swelling, but there was no improvement, so surgery was the only option to relieve pain, and make me mobile again.

In October Mr Malik performed a talonavicular fusion with bone graft. Mr Malik is a fantastic surgeon, extremely informative, skilled and reassuring. 2 weeks post op when the backslab was removed the wound had healed beautifully with no bruising what so ever. The anaesthetist Dr Size was amazing too. He performed the surgery under a General anaesthetic, with a popliteal nerve block.

I can honestly say I had no ill effects from the GA, and I experienced no pain post operatively at all. The nerve block lasted 36 hours.

My recovery is going very well. Thank you very much Mr Malik and Dr Size.”

Katherine Rasinksy – 18/11/2016

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