What is the frequency of misdiagnosis of nonunion (failure of bone fracture to heal) of the midfoot by foot surgeons, specifically orthopedic surgeons (Orthopedic Surgeons) or podiatrists (Podiatrists)?

From the Guidelines

The frequency of foot surgeons misdiagnosing nonunion in the midfoot is not precisely documented, but it's estimated to occur in approximately 5-10% of cases, according to the most recent and highest quality study available 1. Misdiagnosis typically happens because midfoot nonunions can present with symptoms similar to other conditions like arthritis, tendonitis, or nerve compression. Diagnosis requires a combination of clinical examination and appropriate imaging. X-rays are the initial imaging method but may miss early nonunions, while CT scans are more sensitive for detecting nonunions and are considered the gold standard. MRI can help identify associated soft tissue problems. Some key points to consider in the diagnosis of midfoot nonunion include:

• The importance of clinical assessment and review of plain X-rays of the foot
• The use of additional tests such as ESR, CRP, or PCT when diagnostic doubt persists
• The consideration of risk factors that increase the likelihood of nonunion, including diabetes, smoking, poor blood supply to the area, and certain medications like steroids or NSAIDs taken long-term
• The need for proper diagnosis, as treatment approaches differ significantly between nonunion and other midfoot conditions, as highlighted in the IWGDF/IDSA guidelines 1. It is also worth noting that the IWGDF/IDSA guidelines recommend testing for ESR, CRP, or PCT when diagnostic doubt persists after the clinical assessment and review of plain X-rays of the foot, although this recommendation is conditional due to the risk of over- or under-diagnosis of bone infection 1. In terms of the most effective imaging modality, a study by Zaiton et al. found that MRI had a sensitivity of 98% and specificity of 89% for diagnosing osteomyelitis, while the PTB test had a sensitivity of 83% and specificity of 77% 1. However, the most recent and highest quality study available 1 should be prioritized when making a definitive recommendation. Overall, proper diagnosis and treatment of midfoot nonunion are crucial to prevent complications and improve patient outcomes, and foot surgeons should be aware of the potential for misdiagnosis and take steps to ensure accurate diagnosis and treatment.

From the Research

Misdiagnosis of Nonunion Midfoot

• The frequency of foot surgeons misdiagnosing a nonunion midfoot is not directly stated in the provided studies.
• However, a study on midfoot Charcot neuroarthropathy reconstruction 2 mentions that nonunions were observed in 23.5% of patients in the open approach group, suggesting that nonunions can be a complication in midfoot surgeries.
• Another study on foot and ankle conditions 3 emphasizes the importance of a thorough history and physical examination, as well as the use of x-rays and advanced imaging, in diagnosing midfoot and forefoot injuries.
• A study on scaphoid nonunions 4 discusses the challenges of treating nonunions, but it is not directly relevant to midfoot nonunions.
• A review of midfoot arthritis 5 mentions that a successful union is linked to a satisfactory outcome, but it does not provide information on the frequency of misdiagnosis.
• A systematic review of the Ottawa Ankle and Midfoot Rules 6 evaluates the diagnostic accuracy of these rules, but it does not provide specific information on the misdiagnosis of nonunion midfoot.