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| LETTER TO EDITOR |
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| Ahead of print publication |
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Uncommon cause of progressive dorsomedial right midfoot pain
Vadivalagianambi Sivakumar1, Venkatraman Indiran2
1 Department of Radiodiagnosis, Meenakshi Medical College and Research Institute, Kancheepuram, India
2 Department of Radiodiagnosis, Sree Balaji Medical College and Hospital, Chennai, Tamil Nadu, India
| Date of Submission | 05-Mar-2022 |
| Date of Acceptance | 25-Apr-2022 |
| Date of Web Publication | 27-Aug-2022 |
Correspondence Address:
Venkatraman Indiran,
Department of Radiodiagnosis, Sree Balaji Medical College and Hospital, 7, Works Road, Chromepet, Chennai - 600 044, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/injr.injr_43_22
Dear Editor,
A 56-year-old man presented with progressive dorsomedial right midfoot pain for 6 months, which worsened with weight-bearing. There was no history of trauma/systemic disorders. There was no documented history of COVID-19 or thrombophilic episode. There were no musculoskeletal symptoms on the left foot or any other joints. Physical examination revealed tenderness over the navicular region and flattened medial arch of the foot. His white blood cell count, erythrocyte sedimentation rate, and C-reactive protein were normal. This patient did not have radiography of the foot. The magnetic resonance imaging (MRI) and computed tomography (CT) of the right foot revealed collapse of the lateral portion of the navicular bone with a consequent comma-shaped appearance of the navicular bone. Medial subluxation of the navicular bone and associated secondary talonavicular osteoarthritis were noted. Findings are consistent with a diagnosis of Mueller–Weiss syndrome [Figure 1] and [Figure 2]. | Figure 1: A 56-year-old man with progressive dorsomedial right midfoot pain. Axial CT section (a) shows the collapse of the lateral portion of the navicular bone with the consequent comma-shaped appearance of the navicular bone and medial subluxation of the navicular bone (white arrow). Sagittal reformatted CT section (b) of the mid- and hindfoot shows a collapse of the lateral portion of the navicular bone and associated secondary talonavicular osteoarthritis (white arrow). CT: Computed tomography
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 | Figure 2: A 56-year-old man with progressive dorsomedial right midfoot pain. Axial T2-weighted MR image (a) shows a collapse of the lateral portion of the navicular bone with a consequent comma-shaped appearance of the navicular bone (white arrow). Axial proton density fat-saturated images (b and c) of the mid- and hindfoot show edema in the medial aspect of the comma-shaped appearance (white arrow). MR: Magnetic resonance
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Mueller–Weiss syndrome is a rare condition that involves osteonecrosis of the navicular bone in an adult. The characteristic findings for Mueller–Weiss syndrome are a dorsomedial dislocation along with the collapse of the lateral navicular bone, resulting in a comma-shaped configuration.[1] This syndrome is distinct from Köhler's disease, the osteochondrosis of the tarsal navicular bone in children, which is self-limiting and has a favorable outcome. Possible etiologies include a combination of delayed ossification of the tarsal navicular and abnormal force and osteonecrosis. Persistent lateral loading on an inadequately ossified, ischemia-prone navicular bone may contribute to the condition. Environmental and nutritional may be possible predispositions.[2] It is commonly present in the fourth to sixth decade of life and is more common in females and is frequently bilateral. Plain weight-bearing radiographs and clinical examination may be enough to diagnose the problem.[3] The paradoxical pes planus varus deformity on radiography is characteristic.[4] Maceira radiological staging of Mueller–Weiss syndrome is based on the compression/fragmentation of the navicular bone and Meary's angle (talus-first metatarsal angle).[5] CT scan is useful for assessing bone stock and for preoperative planning. MRI is helpful to rule out other conditions such as stress fractures or infection. Differential diagnoses include osteomyelitis, Paget's disease, healing fracture of the navicular, and diabetic Charcot foot.[5] Initial nonsurgical treatment includes supportive or accommodative orthotics or nonweight bearing cast immobilization. Surgical techniques described in the literature isolated talonavicular arthrodesis, internal fixation of navicular, talonavicular-cuneiform arthrodesis, and open or arthroscopic triple fusion.[4] He was advised to undergo talonavicular arthrodesis, but he has preferred to wait. The recognition of characteristic comma-shaped configuration of navicular due to collapse of lateral aspect of navicular helps diagnose Muller–Weiss syndrome or Brailsford's disease and avoid misdiagnosis. Early recognition and management can control symptoms and delay the progression of the disease and secondary osteoarthritis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Nguyen AS, Tagoylo GH, Mote GA. Diagnostic imaging of the Mueller-Weiss syndrome: Findings of a rare condition of the foot. J Am Podiatr Med Assoc 2014;104:110-4.  |
| 2. | Samim M, Moukaddam HA, Smitaman E. Imaging of Mueller-Weiss Syndrome: A review of clinical presentations and imaging spectrum. AJR Am J Roentgenol 2016;207:W8-18. |
| 3. | Mohiuddin T, Jennison T, Damany D. Müller-Weiss disease-Review of current knowledge. Foot Ankle Surg 2014;20:79-84. |
| 4. | Hermena S, Francis M. Clinical presentation, imaging features, and management of Müller-Weiss disease. Cureus 2021;13:e18659. |
| 5. | Volpe A, Monestier L, Malara T, Riva G, Barbera G, Surace MF. Müller-Weiss disease: Four case reports. World J Orthop 2020;11:507-15. |
[Figure 1], [Figure 2]
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