www.mkfac.

com
Mid-term outcomes in patients with symptomatic
type II accessory navicular bone and flexible pes
plano-valgus treated with osteosynthesis and medial
displacement calcaneal osteotomy

Dr Pradeep Moonot
FRCS (Orth)(UK), MS (Orth),
DNB (Orth), MD (Res)(Lond)

Foot and Ankle Specialist

Mumbai/Hyderabad/Surat/Pune
 www.mkfac.com

• The accessory navicular bone (ANB) results due to incomplete fusion of the secondary
ossification center leading to synchondrosis around the navicular bone.
• Geist classification system divides ANB into three types depending on its shape, size,
and its position in relation to the navicular tuberosity.
• Type I (30%) is a 2-3mm sesamoid bone present within the substance of the PTT.
• Type II (50-60%) is triangular or heart-shaped 8-12mm bone that is attached to the
navicular tuberosity by 1-3mm synchondrosis
Sella and Lawson Subclassification
• Type IIa --superior in position to the navicular with less acute synchondrosis-
ossicle-talar angle
• Type IIb --inferior to the navicular with more acute synchondrosis-ossicle-
talar angle
• type III is a cornuate navicular
 www.mkfac.com

• Five symptomatic adult patients with a failed conservative management for

ANB and associated flexible pes planovalgus were operated .
• Preoperative Assessment : Radiographic
1.Calcaneal pitch (inclination) angle
2.Talocalcaneal angle
3.Talo-first metatarsal angle (Meary’s angle)
4.Synchondrosis-ossicle-talar angle on lateral weight bearing radiographs
5.Talonavicular angle on antero-posterior weight bearing radiographs.
 Operative Steps www.mkfac.com

• All the cases were operated under spinal anaesthesia and tourniquet coverage.
• Medial Calcaneal displacement osteotomy (MDCO) performed first.
• An osteotomy was then performed from infero-lateral to supero-medial direction
with the help of an oscillating saw.
• The osteotomy was then fixed using a single 6.5 mm partially threaded cannulated
cancellous screw
 www.mkfac.com

• Osteosynthesis of the ANB done thenafter.

• ANB was identified and exposed along with the synchondrosis which
was thoroughly debrided along with the adjacent subchondral bone.
• ANB was fixed with either a 3.5 mm fully threaded headless screw
(Arthrex 2021, Naples, USA) in three cases or a 3.5 mm short thread
cannulated cancellous screw with washer (DePuy Synthes, USA) was
used in two cases (Case 1 and 3).
 www.mkfac.com

• The primary forces acting on type IIa ANB by the PTT are tensile forces which may lead to
its avulsion . Thus, the direction of the screw in such cases should be more horizontal
which can be better achieved using a short threaded cannulated cancellous screw.
• On the other hand, the shear forces in type IIb can lead to future arthritis. Moreover, the
direction of screw in such cases is from postero-inferior to antero-superior direction. A
headless screw prevents the abutment and irritation of the PTT while fixing these types.
Post Operative Xrays www.mkfac.com
 Results www.mkfac.com

• Mean duration of follow-up was 59.6±14.87 months

• Mean age of the patients was 28.6±7.16
• Mean synchondrosis-ossicle-talar angle was 34.65±18.49 degrees.
• All the patients were given a conservative trial
• One patient in the present study had sural nerve neuroma which resolved
completely within 6 months post-operatively
• None of the patient had recurrence in deformity at final follow-up.
• There was a 100% union rate in the present study
• AOFAS scores improved from 64.41±4.16 to 98.89±2.62 at the end of 36 months
• Improvement in the VAS scores from 7.30±1.70 to 0.41±0.18 by the end of 36
months
 Radiographic Improvement www.mkfac.com

• Gradual increase in calcaneal pitch (inclination) angle from 15.50±0.73 degrees

preoperatively to 20.39±0.79 degrees (P=0.0005).
• Significant improvement in Meary’s angle which decreased from 14.41±0.50
degrees preoperatively to 10.33±0.97 degrees (P=0.0020).
• The talocalcaneal angle decreased from 40.34±2.21 degrees preoperatively to
38.43±3.21 degrees (P=0.1160)
• The talonavicular angle decreased from 21.43±0.88 to 19.42±1.37 (P=0.0449).
www.mkfac.com