Muller-Weiss disease; proposed classification and treatment algorithm

R. McKenna, J. Wong, A. Tucker

Introduction: Muller-Weiss disease is an uncommon condition with unclear etiology and no gold standard treatment. The question arises; which joints to fuse? Although no consensuses prevail, one must postulate fusion should include those affected. Consequently, to establish an algorithm for its surgical management we set out to study clinical and radiographic features with use of SPECT-CT and a literature review.

Methods: 57 consecutive feet presenting with Muller-Weiss disease analysed; 15 men, 25 women, age 22-84. Condition bilateral in 17, left side 16, right in 7 patients. Specific history and examination by senior author. Radiographic series and SPECT-CT obtained with surgery performed on significantly symptomatic feet. Measurements of Meary-Tomeno angles, anteroposterior thickness of navicular at the midpoint of each naviculo-cuneiform, alongside the medial extrusion distance and percentage of compression in each case performed.

Results: Poor correlation between Meary's angle and 1) degree of compression at naviculo-cuneiform joints, 2) degree of extrusion 3) compression vs extrusion using R² coefficient of determination (invalidating Maceira et al. classification). In unilateral cases, extrusion significantly greater on affected side 94.7% (P< 0.001 Fisher exact test). Degree of extrusion significantly greater in bilateral than unilateral cases (p=0.004 unpaired T test). Valgus hindfoot and Meary's negative most common pattern with no correlation between heel alignment and Meary's R² = 0.003. SPECT-CT useful to determine subtalar involvement in 'stage 2 disease.'

ConclusionLFollowing review of cases and published literature we propose the following classification for Muller-Weiss disease with treatment algorithm. 3 Stage delineation: Stage 1 (Normal hindfoot alignment); 1A. Talonavicular disease only - Isolated Talonavicular arthrodesis 1B. Talonavicular + Subtalar; double medial or triple arthrodesis. Stage 2. Talonavicular + Naviculocuneiform; 2A. Adequate bone stock - Talo-naviculo-cuneiform arthrodesis, 2B. Inadequate bone stock +- subtalar disease; Talo-naviculo-cuneiform arthrodesis with tricortical bone graft (Mayich). Stage 3; Asymmetric ankle varus; Pantalar arthrodesis Double/triple/TNC/TAR arthrodesis with hindfoot re-alignment.