How To Conquer The Accessory Navicular Bone
- Volume 15 - Issue 1 - January 2002
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Be aware that the two-drill hole method is an alternative to using an anchor to tenodese the posterior tibial tendon to the navicular bone. Employing a .062 K-wire or small drill bit, make a hole from dorsal to plantar at the medial edge of the navicular bone. Create a second drill hole just proximal to this drill hole. Then thread a 2-0 non-absorbable suture through the proximal drill hole from plantar to dorsal with a Swanson wire passer loop or similar instrument.
The free end of the suture is now on the dorsal aspect of the navicular bone and the needle is at the plantar aspect of the navicular bone. Pass a Bunnell type suture repeatedly through the posterior tibial tendon from distal to proximal and then back proximally. Then cut the needle from the suture. Again, using the Swanson wire passer loop, thread the free end up through the distal hole from plantar to dorsal.
Then pull the suture and tendon tight towards the distal hole. Tie the ends of the suture dorsally by hand while holding the foot in subtalar joint neutral or a mildly inverted position. You may perform additional reinforcing sutures with a 2-0 absorbable, tightening the posterior tibial tendon to plantar soft tissues, including the plantar talo-navicular spring ligament.
Final Notes
Closure includes realigning the periosteum over the navicular bone and suturing with a 3-0 dexon. Reunite the tendon sheath and close with a 5-0 absorbable suture in a continuous baseball suturing technique. Close subcutaneous tissues with a 4-0 absorbable suture. Perform skin closure with a 5-0 absorbable suture in subcuticular suturing technique. Dress the surgical site in typical fashion.
Proceed to apply a well-padded, below knee fiberglass cast with the foot held in STJ neutral or a mildly inverted position. You should have the patient wear the non-weightbearing cast for approximately three weeks and then progress to partial weightbearing with a cast boot walker. In about four weeks, your patient should start physical rehabilitation and be ambulatory in sneakers. In about three months, he or she should be able to resume exercise activities.
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Be aware that the two-drill hole method is an alternative to using an anchor to tenodese the posterior tibial tendon to the navicular bone. Employing a .062 K-wire or small drill bit, make a hole from dorsal to plantar at the medial edge of the navicular bone. Create a second drill hole just proximal to this drill hole. Then thread a 2-0 non-absorbable suture through the proximal drill hole from plantar to dorsal with a Swanson wire passer loop or similar instrument.
The free end of the suture is now on the dorsal aspect of the navicular bone and the needle is at the plantar aspect of the navicular bone. Pass a Bunnell type suture repeatedly through the posterior tibial tendon from distal to proximal and then back proximally. Then cut the needle from the suture. Again, using the Swanson wire passer loop, thread the free end up through the distal hole from plantar to dorsal.
Then pull the suture and tendon tight towards the distal hole. Tie the ends of the suture dorsally by hand while holding the foot in subtalar joint neutral or a mildly inverted position. You may perform additional reinforcing sutures with a 2-0 absorbable, tightening the posterior tibial tendon to plantar soft tissues, including the plantar talo-navicular spring ligament.
Final Notes
Closure includes realigning the periosteum over the navicular bone and suturing with a 3-0 dexon. Reunite the tendon sheath and close with a 5-0 absorbable suture in a continuous baseball suturing technique. Close subcutaneous tissues with a 4-0 absorbable suture. Perform skin closure with a 5-0 absorbable suture in subcuticular suturing technique. Dress the surgical site in typical fashion.
Proceed to apply a well-padded, below knee fiberglass cast with the foot held in STJ neutral or a mildly inverted position. You should have the patient wear the non-weightbearing cast for approximately three weeks and then progress to partial weightbearing with a cast boot walker. In about four weeks, your patient should start physical rehabilitation and be ambulatory in sneakers. In about three months, he or she should be able to resume exercise activities.
References:
References
1. Macnicol, M.F., Voutsinas S.; Surgical Treatment of the Symptomatic Accessory Navicular, J.B.J.S. Journal of Bone and Joint Surgery, Volume 66-B, Pp. 218-226 March 1984.
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