2.1

A retrospective cohort of patients with acute navicular fractures who were surgically treated at a level 1 trauma center between September 1, 2010, and September 1, 2023 was analyzed. Institutional review board approval and written informed consent were obtained.

2.2

All patients who were surgically treated for acute navicular fractures were selected. Patients below the age of 16 years at the day of injury, patients with foot compartment syndrome, open fractures or injuries older than 4 weeks were excluded. All patients had at least one year of follow-up. Included patients were followed by clinical evaluation at the outpatient clinic and were sent a questionnaire (consisting of FFI, AOFAS, EQ-5D and VAS) between 2021 and 2024, at least one year after surgery. Loss to follow-up was recorded.

2.3

For each patient, a treatment strategy was chosen by three foot ankle surgeons. In general, surgical treatment (ORIF) was indicated in case of an intra-articular fracture with any displacement in a patient fit for surgery. Patients were positioned supine and a standard dorsomedial approach was used, centered over the navicular and usually in line with the second or third metatarsal (adjusted based on fracture pattern and additional injuries). Both the extensor hallucis longus and neurovascular bundle were identified and retracted. The talonavicular and/or naviculo-cuneiform joint surfaces were inspected through disruptions or dissection of the joint capsules. The fracture was debrided and small articular fragments (< 5 mm) were removed. Fracture reduction was accomplished using a mini distractor and by direct manipulation. Intra-operative reduction and alignment reconstruction were assessed with fluoroscopic anterior-posterior, oblique and lateral views. Internal fixation of fragments was usually achieved with 2.0-, 2.4- or 2.7-mm screws and/or 2.0 mm plates or other variable angle plates (2.4/2.7 mm). In case of bone defects, cancellous bone harvested from the distal tibia or allograft was used. Additional K-wires were sometimes used temporarily (6 weeks) to maintain reduction of an unstable TN joint after fracture-dislocation. Alternatively, a temporary joint spanning bridge plate was used in case of severe comminution. Primary talonavicular arthrodesis was performed in case of severe articular damage or non-reconstructable joints.

2.4

Patient-related, clinical and radiographic data were extracted from the electronic hospital database. Variables included were age at injury, gender, Body Mass Index (BMI), tobacco use, mechanism of trauma, Injury Severity Score (ISS), injury pattern, Sangeorzan classification, and concomitant ipsi- or contralateral lower extremity injuries . Data was collected on the type of treatment, follow-up, complications, functional outcome, quality of life and treatment satisfaction. Postoperative radiographs were assessed for axial realignment and joint reduction. The assessment was based on previous literature to judge reduction of navicular fractures on conventional radiographs. Criteria included less than 2 mm articular step-off, percentage of joint surface restoration and less than 3 mm of medial column length shortening . Complications were defined as delayed, mal- or non-union, fracture-related infections (FRI), and secondary arthrodesis (SA). Functional outcome was quantified using the Foot Function Index (FFI, best score 0 points), and the American Orthopedic Foot and Ankle Society midfoot score (AOFAS, best score 100 points). The AOFAS score was divided into subgroups based on arbitrary interpretation in previous literature: a score of 90–100 was graded as an excellent result; 75–89 as good; 50–74 as fair, and less than 50 points was graded as a failure or poor outcome ^, . Quality of life was measured by European Quality of Life Five Dimensions (EQ-5D). Assessment of perceived general health was done using a Visual Analog Scale (VAS) of 0–10, in which 10 represented excellent general health. Treatment satisfaction was also measured using the VAS of zero to 10, in which 10 represents the best possible satisfaction. Work status and level of activity were rated based on a modification by Arntz et al., including pre-trauma activity and work, some change in level or with limitations, and did not resume activities and work .

2.5

The statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS) version 29 (SPSS, Chicago, IL). Numeric data are expressed with means with standard deviation (SD) or median with range. Categorical data are shown as numbers with percentages. Independent sample t-tests and ANOVA with a significance level of 0.05 were used to compare means. Additionally, a multivariate linear regression was performed to identify independent predictors of functional outcome. Variables included were age, Sangeorzan classification, talonavicular joint dislocation, concomitant injuries, type of fixation, fracture reduction, implant removal, infection and secondary arthrodesis. A manual backward linear regression was performed. Variables were included into the multiple regression model if p < 0.05 ( Fig. 1 ).

Flow diagram of patient selection.

2.6

A systematic review of the literature, in adherence to the PRISMA statement, was performed of the following databases using the OVID search engine: MEDLINE, EMBASE and CENTRAL databases (January 2000 to September 2024) using the terms “navicular [tiab]” and “Chopart [tiab]” . All sources were last consulted on January 13th, 2025. Because of the advances in surgical strategies and available implants, studies prior to 2000 were excluded. Two authors (EWME and JP) performed the systematic review and consequent data extraction independently. Results from all databases were combined and duplicates removed. In case of disagreement, a third independent reviewer was consulted (TS) to provide consensus on inclusion. Criteria for the selection of articles are outlined in Table 1 . The search strategy and selection process are illustrated in Fig. 2 . Risk of bias was assessed using the ROBINS-I V2 tool and certainty of evidence was based on GRADE, according to the same principle (EWME and TS independently, complete consensus) ^, .

Flow diagram of literature selection.

2.7

Data on the year of publication, type of study, number of patients, gender, age, mechanism of injury, type of fracture (anatomy), treatment, fracture reduction, primary outcome, complications as reported by authors, functional outcome and follow-up period were extracted from the reports by EWME, collected in an Excel data sheet, and checked by JP, JH and TS independently. Only studies that applied functional outcome instruments, such as the Foot Function Index (FFI), American Orthopedic Foot & Ankle Society midfoot score (AOFAS), Weber functional outcome score or Musculoskeletal Function Assessment (MFA) were included. No additional data had to be obtained from study investigators. For each outcome, the effect measure presented in this review was the measure reported by the authors. This is a narrative systematic review as data conversions or synthesis were not considered feasible due to high heterogeneity and serious risk of bias (Appendix I).

3.1

Sixty-six patients with acute navicular fractures who were surgically treated at our level 1 trauma center between September 1, 2010, and September 1, 2023 were identified. Nine patients were excluded and questionnaires were sent to the remaining 57 patients, of whom 46 responded ( Fig. 1 ). There were 24 females and 22 males, with an overall median age at the day of trauma of 35.9 (range 16.7–72.2) years. Mean BMI was 24.8 (SD 4.1) and 7 out of 46 patients reported tobacco use. The majority of patients (n = 29) was referred from other hospitals after a median period of seven days (range 1–28) after trauma. Mean follow-up time from the day of injury was 69.0 (SD 42.6) months.

3.2

The mechanisms of trauma were fall or inversion during daily activities (n = 22), fall from height (n = 9), motor vehicle accident (MVA, n = 9) and crush (n = 6). Mean ISS was 4.0 (SD 0.15). All patients were diagnosed using both conventional radiography and CT imaging. Most patients (n = 34) sustained a Sangeorzan type 3 injury, meaning a comminuted fracture in the sagittal plane with lateral displacement of the forefoot (abduction). A quarter of patients suffered a type 2 injury, with a fracture line from dorso-lateral to plantar-medial and medial displacement (adduction) of the forefoot (n = 10). Only two patients had a type 1 injury, meaning a fracture line in the coronal plane without forefoot angulation.

Seven patients had an isolated navicular fracture whereas two thirds had additional midtarsal fractures (n = 33) and/or injuries of a tarsometatarsal joint (n = 6). The fracture distribution is illustrated in Fig. 3 . Close to half of the patients (n = 20) presented with fracture-dislocation of the talonavicular joint. None of the included patients sustained open fractures or fractures to the contralateral foot or ankle.

Fracture distribution. Radiographics 2000; 20:819–736, RSNA, 2000.

3.3

Prior to definitive surgery, six patients were temporarily treated with either percutaneous Kirschner wire (K-wire) fixation (n = 4) or external fixation (n = 2). Two patients with severely comminuted type 3 fractures with talonavicular joint displacement and destruction were consequently managed with primary talonavicular arthrodesis (n = 2). For all other patients (n = 44), the strategy in definitive fracture management was ORIF. This was mostly achieved by using an anatomical navicular plate (n = 26, of which 7 with temporary K-wire fixation of the talonavicular joint for 6–8 weeks), screws only (n = 9), joint-sparing bridge plate (n = 5), or a combination of the previous (n = 4).

Postoperative radiographs of ORIF patients were assessed for axial realignment and joint reduction. Mean articular step-off was 0.4 mm (SD 0.7). Only one patient (2.3 %) had a step-off of more than 2 mm (2.8). Mean joint surface restoration was 97 %. One patient had less than 80 % of joint surface due to lateral loss of navicular bone resulting in 60 % restoration. There was no relevant medial column shortening (0 mm in n = 40, 1–2 mm in n = 4).

3.4

After primary surgical treatment, union was achieved in 43 patients (non-union n = 3, 6.5 %). Half of the patients who were treated with ORIF (n = 23/44, 52.3 %) required more than one operation with a median of 2 (range 1–4). Implants were removed in 22 out of 46 patients (47.8 %), including both patients after primary arthrodesis (6 and 12 months) and all patients after bridge-plating (median 4 months, range 3–24). There were three patients (6.5 %) who suffered a deep infection after primary surgery. In addition to temporary fixation and implant removal, nine patients (19.6 %) underwent additional surgical intervention such as debridement and wash-out in case of infection (n = 3, 6.5 %), secondary talonavicular arthrodesis due to painful osteoarthritis or nonunion (n = 5/44, 11.4 %, mean 13 months after ORIF) and revision due to nonunion (n = 3, 6.5 %). In one other patient, union failed with signs of avascular necrosis of the navicular bone, however due to only mild complaints the patient declined to undergo secondary arthrodesis. One patient with infected non-union after PA underwent debridement, wash-out, intravenous antibiotics based on cultures during 12 weeks and revision surgery.

3.5

Overall AOFAS was good and treatment satisfaction was high ( Table 2 ). Functional outcome and patient-reported outcome measures per subgroup are shown in Table 3 . Multiple significant differences were found between the type of fixation, removal of implants and outcome. With the numbers available, no significant differences were detected in outcome scores (functional, quality of life, health and satisfaction) between patients with or without tobacco use, joint dislocation, concomitant injuries or fracture reduction.

Table 3

Functional outcome and other patient-reported outcomes per subgroup.

Subgroup	AOFAS	FFI	EQ5D	Perceived health	Treatment satisfaction
Classification (n) Type 1 (2) Type 2 (10) Type 3 (34) p	96.5 (2.1) 78.4 (18.7) 72.5 (19.0) 0.18	2 (2.8) 30.8 (28.5) 25.2 (20.0) 0.24	5 (0) 6.5 (1.7) 7.4 (1.7) 0.07	8.3 (0.4) 8.1 (1.0) 7.8 (1.3) 0.28	10 (0) 8.7 (1.7) 8.5 (1.4) 0.75
Type of fixation (n) PA (2) Screws only (9) Navicular plate (26) Bridge plate (5) Combination (4) p	48.5 (46.0) 83.1 (14.2) 79.5 (15.3) 53.4 (13.7) 66 (16.0) 0.003	50 (41.0) 23.2 (23.7) 19.2 (18.4) 40.6 (12.8) 39.5 (28.3) 0.06	9 (1.4) 6 (1.0) 6.9 (1.7) 9.2 (0.8) 7.8 (1.0) 0.003	7 (0) 8.3 (0.7) 8.1 (1.3) 6.4 (1.3) 6.9 (0.6) < 0.001	6.3 (1.1) 9.1 (1.2) 9.0 (1.0) 8.0 (1.5) 6.5 (1.8) 0.02
Implant removal (n) Yes (n = 22) No (n = 24) p	67.7 (20.2) 81.4 (15.5) 0.01	34.4 (21.8) 17.2 (19.2) 0.007	7.7 (1.5) 6.5 (1.7) 0.02	7.3 (1.1) 8.2 (1.3) 0.01	7.8 (1.5) 9.2 (1.0) < 0.001

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