Treatment Pearls For Mueller-Weiss Syndrome

William Fishco DPM FACFAS

Mueller-Weiss syndrome is an adult onset spontaneous avascular necrosis condition of the navicular bone. This condition is distinctly different from Kohler’s disease, which is a pediatric osteochondritis.

I have seen a couple cases of Mueller-Weiss Syndrome in the past 15 years so I am sure you have had cases as well.

Mueller-Weiss syndrome more commonly occurs in women and favors a bilateral distribution. Kohler’s disease, on the contrary, tends to be unilateral in presentation. For Mueller-Weiss syndrome, X-rays reveal a comma-shaped or wedge-shaped navicular bone on the anteroposterior view. Fragmentation of bone may be visible in advanced cases. The lateral view typically reveals narrowing and sclerosis of the bone.

When one makes the diagnosis early, in addition to immobilization, authors have described surgical treatment via decompression of the bone with drilling.1 In more advanced cases of bone destruction, authors have recommended fusion with or without bone grafting.2

The first case that I will share with you is a 42-year-old female with bilateral foot pain. She related stiffness and pain for years. Her past medical history was remarkable for gastroesophageal reflux disease, depression, chronic pain and a history of drug abuse (methamphetamine). Her social history was remarkable for tobacco abuse, drug abuse and alcohol abuse, and she was medically disabled.

Her examination revealed normal vascular, neurological and dermatological findings. The patient’s orthopedic exam revealed a stiff hindfoot with limited subtalar/midtarsal joint motion. Pain occurred with attempted motion of the hindfoot and with palpation of the talonavicular joint. Her X-rays revealed medial extrusion of the navicular (wedge-shaped) and loss of width of the bone on the lateral view. She had similar X-ray findings on both feet (see Figures 1-3).

She underwent surgery on her left foot, which included debridement of necrotic bone and arthrodesis of the talonavicular joint. I used autogenous bone graft from the calcaneus and applied an external fixator (see Figure 4). She ultimately went on to a non-union. After removing her external fixator, I fitted her for a brace (see Figures 5-6).

She was incarcerated for a drug-related crime(s) and I lost her to follow up. Certainly, she was never a good surgical candidate as she was a smoker and had drug abuse problems, but she pushed my hand to do surgery. She had legitimate chronic foot pain and there was nothing other than surgery that I could do for her.

The second case is a 62-year-old male who had a year and a half history of left foot pain. Prior to seeing me, he had multiple opinions regarding his condition, indicating to him that he had a “chip” fracture on the top of his foot. His pain was localized to the dorsal and medial aspect of the midfoot. The patient was wearing a fracture boot at the time of his first visit with me. His past medical history was remarkable for diabetes, hypercholesterolemia, depression, hypertension, and a prior history of a gastrointestinal ulcer. The patient’s social history was remarkable for being married, a non-smoker, a non-drinker, and he was retired. He was a professional baseball pitcher for a short period of time.

The patient’s physical exam revealed strong pedal pulses. He had a loss of epicritic sensation to both feet. The dermatologic exam revealed mild edema to the medial aspect of the hindfoot. The orthopedic exam revealed pain to palpation along the course of the medial column. He had stiff motion of the hindfoot. X-rays revealed collapse of the navicular bone with fragmentation (see Figures 6-7). The talonavicular joint and naviculocuneiform joints were arthritic.

Surgery involved arthrodesis of the talonavicular and naviculocuneiform joints. The patient went on to complete consolidation of the fusion (see Figures 8-9) and was discharged after six months. He was pain-free upon discharge.

In summary, Mueller-Weiss Syndrome is a relatively rare condition that is a spontaneous avascular necrosis of the navicular bone in skeletally mature feet. I have presented two patients and their treatment courses.

References

1. Janositz G, Sisák K, Tóth K. Percutaneous decompression for the treatment of Mueller-Weiss syndrome. Knee Surg Sports Traumatol Arthrosc. 2011; 19(4):688-90.
2. Tosun B, Al F, Tosun A. Spontaneous osteonecrosis of the tarsal navicular in an adult: Mueller-Weiss syndrome. J Foot Ankle Surg. 2011; 50(2):221-4.

Comments

Interesting PEARL to know about spontaneous avascular necrosis of the navicular in terms of onset:

1) Pediatric Onset: Kohler's Disease
2) Adult Onset: Meuller Weiss Syndrome

This PEARL should be taught in all podiatry schools from now to third-year podiatry students after their white coat ceremonies.

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