Rheumatoid Arthritis – Talonavicular Joint

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Figure 1: Normal vs Arthritic Talonavicular Joint
Figure-1-Talonavicular-Arthritis_thumb

Rheumatoid Arthritis is a common cause of talonavicular arthritis (along with stress fractures of the navicular).

Physical Exam and Symptoms

Patients usually complain of an aching pain in the midfoot that is aggravated by standing and walking, especially walking on uneven terrain. Upon physical exam, motion is severely limited through the midfoot. There may be swelling in the foot just in front of the ankle. Sometimes the swelling is caused by “RA tissue”.

Imaging Studies

X-rays are helpful in diagnosing this condition. Arthritic changes can be noted through the talonavicular joint (Figure 1). Sometimes, the affected joint “disappears” or autofuses. This can increase motion on nearby joints and can also result in pain.

Treatment

Non-Operative Treatment

  • Comfort shoes can be helpful in the treatment of this condition. A stiff sole or shank will prevent painful motion
  • Activity modification will also be helpful. A stretching program to the back of the calf can decrease excessive stress through overworked joints.
  • Weight loss to decrease the force going through this area of the foot will be beneficial.
  • Management of Rheumatoid Arthritis: An appropriate physician needs to be involved in the management of the disease process; Orthopedists are better suited for treatment of specific structural issues.

Operative Treatment

Fusion of the talonavicular joint with screws can be done in patients who have failed non-operative treatment. A bone graft can be done in conjunction with this procedure to increase the fusion rate (decrease the rate of non-union). Sometimes it may be necessary to fuse adjacent joints to improve surgical outcomes (e.g. subtalar, calcaneocuboid or cuneiform-navicular joint)

Additionally, bone quality in often diminished in patients with RA and may require preoperative “bone treatment”.

Recovery

6-12 weeks (or more) in a cast is required to allow the bones to heal. After this initial time period, the patient can gradually begin walking in a boot, such as a CAM walker. At this point, physical therapy should begin to work on strengthening and gait retraining. Patients are often dramatically better at the 10-12 week mark. It generally takes over a year to reach a point of maximal recovery.

Complications

In addition to the common surgical complications, there are specific complications with a talonavicular fusion. Non-union is the most common complication of this procedure, due to the poor blood supply in that region and the amount of force applied to that area when walking.


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