Open reduction and internal fixation of navicular stress fracture with or without bone graft

This injury is usually seen in participants in running sports. They develop a running-related mid-foot pain, which starts off relatively mild and some athletes can continue to train for weeks to months, which contributes to the delay in diagnosis. Eventually the pain reaches a stage that the athlete is unable to run.

On examination the navicular bone is tender to touch and often patients are unable to hop due to the pain.

An x-ray may show a fracture, especially if the presentation is late. Otherwise it is diagnosed with a combination of a regional bone scan and CT scan, or an MRI. However the CT scan is often the best as it shows the best bone detail.

If the imaging and clinical features are suggestive of delayed healing, or risk of not-healing, the surgery may be recommended. The non-operative treatment is strict non-weight bearing for at least 2 months, and sometimes longer.

If the fracture is an established non-union, then a bone graft will be required and this may be sourced from the pelvis or leg. The surgeon performs the operation with the patient under a general anaesthetic.

Through an incision over the dorsum (or top) of the foot, the fracture is exposed, the fibrous tissue and / non-healed bone excised, and the fracture packed with bone graft. The fracture line is then compressed together with one or two screws which are placed across the bone under x-ray control, in a manner that pushes the edges of the fracture together and supports the healing bone.

Although the patient is allowed to move the foot, no weight bearing is permitted until 2 months post surgery. After this partial weight bearing can be progressed to full weight bearing as long as pain free. A check CT scan at 3 months post surgery is performed, and if there is sufficient healing the patient can slowly return to full activities.

Immediately post-surgery

• You will wake up in recovery with your operated leg in a short (below knee) cast or a heavy bandage only
• The cast is may be used to both protect the surgical site and control your pain. The cast bandage should be left intact until seen in surgeon’s rooms for your first post-operative review
• The wound will be closed with dissolving sutures which do not require removal
• The nurses will administer pain killers as required
• You will be encouraged to move the knee and hip on the operated side
• When you have recovered from the anesthetic, you will be allowed to mobilize with the assistance of crutches
• You are not allowed to bear any weight on the operated side
• The surgeon will see you before you leave and explain the surgical findings and the procedure performed

From discharge until 2 weeks post surgery

• Although you are allowed to mobilize as indicated above, when not moving around try tokeep the ankle above the level of the heart to reduce the amount of swelling and pain.
• You are encouraged to move the operated knee and hip often, and for at least 10 minutes every 3-4 hours during waking hours.
• You will also be encouraged to move the toes, and ankle if not placed in a cast
• You may notice some bruising appearing in your toes, days to weeks following your surgery. This is bleeding from the operation site that has tracked distally under the influence of gravity and should not cause alarm.

Phase 1: first 6-8 weeks following surgery

• No weight bearing is allowed for the first 6 weeks post surgery
• Immediately following surgery, simple ankle and toe movements are allowed, while non-weight bearing.
• Following the first post-operative review, 10 days post-surgery, active range of motion (ROM) exercises are permitted and should be supervised by a physiotherapist, as well as foot intrinsic muscle exercises
• These exercises should be delayed until the wounds have healed well ROM, quadriceps exercises and co-contractions while non-weight bearing are performed for the knee
• Partial weight bearing with crutches may be allowed at 6-8 weeks post surgery
• The ankle may be placed in a fracture boot which is removed for exercise sessions, but in most cases is only in a heavy bandage until the first post-operative review, and nothing thereafter.