What is the recommended treatment for a dorsal cuneonavicular ligament tear?

Treatment of Dorsal Cuneonavicular Ligament Tear

For a dorsal cuneonavicular ligament tear, pursue early anatomic reduction with stable fixation and ligament reconstruction, as failure to repair the disrupted ligaments leads to subluxation, posttraumatic arthritis, and disabling pain requiring salvage arthrodesis. 1

Initial Diagnostic Approach

MRI is the preferred imaging modality for evaluating midfoot ligamentous injuries, with 83% sensitivity for diagnosing traumatic tendon and ligament injuries about the foot and ankle in surgically confirmed cases. 2

• Begin with standard radiographs of the foot, including weightbearing views when the patient can tolerate them, as these are the appropriate initial imaging for acute foot trauma. 2
• Proceed to MRI when ligamentous injury is suspected but radiographs appear normal or equivocal, as advanced imaging is supported for midfoot injuries. 2
• Ultrasound may serve as an alternative for direct evaluation of the dorsal cuneonavicular ligament, though normative data and proper positioning are critical for accurate assessment. 2

Acute Management Strategy

Primary surgical repair with ligament reconstruction is essential when a complete dorsal cuneonavicular ligament tear is identified. 1

• Perform early anatomic reduction and stable fixation of any associated joint dislocations or fractures, as delayed or suboptimal reduction results in persistent subluxation and arthralgia. 1
• Repair the disrupted dorsal cuneonavicular ligaments primarily rather than leaving them unrepaired, as the case literature demonstrates that unrepaired ligaments lead to joint subluxation requiring secondary procedures. 1
• Use percutaneous or open fixation techniques to maintain reduction while ligaments heal, ensuring anatomic alignment of the cuneonavicular joint. 1

When Conservative Management Fails

Salvage arthrodesis of the cuneonavicular joint is indicated when subluxation and posttraumatic arthritis develop following inadequate initial treatment. 1

• Consider arthrodesis at 6 months post-injury if persistent subluxation causes disabling pain despite attempted conservative management. 1
• Primary arthrodesis may be a viable option for severe midfoot fracture-dislocations with extensive ligamentous disruption, as it facilitates rehabilitation and obviates the need for secondary arthrodesis when arthritis inevitably develops. 1
• Fusion of the cuneonavicular joint provides pain relief and allows return to work, with good functional outcomes at 24-month follow-up. 1

Critical Pitfalls to Avoid

The most common error is leaving disrupted dorsal cuneonavicular ligaments unrepaired, which invariably leads to joint subluxation, chronic pain, and the need for salvage procedures. 1

• Do not rely solely on percutaneous fixation without addressing the ligamentous injury, as this results in suboptimal reduction. 1
• Recognize that the dorsal cuneonavicular ligament, while amenable to ultrasound evaluation, requires direct surgical repair when completely torn to prevent long-term instability. 2, 1
• Early anatomic reduction, stable fixation, and ligament reconstruction together are essential for good outcomes—omitting any component compromises the result. 1