surgical treatment of the symptomatic accessory navicular€¦ · navicular (figs 6,7and...

© 1984 British Editorial Society ofBone and Joint Surgery0301 -620X/84/2027 $2.00

218 THE JOURNAL OF BONE AND JOINT SURGERY

SURGICAL TREATMENT OF THE SYMPTOMATIC ACCESSORY

NAVICULAR

M. F. MACNICOL, S. VOUTSINAS

From Princess Margaret Rose Orthopaedic Hospital, Edinburgh

The accessory navicular is occasionally the source of pain and local tenderness over the instep. If

conservative measures fail, surgical treatment may be required and the results of 62 operations to one or bothfeet in 47 patients are reported. Twenty-six patients were treated by the Kidner operation, in which the main

insertion of the tibialis posterior is re-routed; in the remaining 21 the ossicle was merely excised. Excisionwas as effective as the Kidner technique, provided that the medial surface of the main navicular bone was

contoured to prevent any residual prominence. Both procedures were successful in relieving symptoms in the

majority of cases and failures resulted from errors in the selection of patients or in the surgical technique.Correction of any associated fiat foot was secondary to growth and maturation of the foot rather than to theoperation; hence the Kidner procedure does not confer any particular advantages over simple excision.

Pain and tenderness in relation to the medial arch of the

foot may be produced by an accessory navicular bone

(synonyms : os tibiale externum ; navicular secundum;

prehallux) which was first clearly described by Bauhin in

1605 (Froelich 1909). Whether this minor anomaly alters

the suspensory mechanism of the medial arch of the foot

has been a subject of some controversy, for although it is

often associated with pes planus, it may also present in

feet that are relatively normal apart from the character-

istic medial prominence (Giannestras 1973; Sullivan and

Miller 1979).Froelich (1909) considered that the accessory navi-

cular produced a flattened medial arch but recommended

no more than simple excision of the ossicle when it wassymptomatic. Subsequently, Kidner (1929, 1933) sug-

gested that the bony anomaly resulted in medial displace-

ment of the tendon of tibialis posterior, thus

compromising its action as an elevator of the tarsus. He

considered that adduction of the foot became pro-

nounced, and if impingement upon the deltoid ligament

or medial malleolus occurred then the peroneal muscleswould become reflexly overactive. He hypothesised that

this imbalance produced pronation of the foot, and

indeed might even lead to subluxation ofthe talonavicular

joint.

Kidner therefore advocated a more complex opera-tion in which not only was the accessory navicular shelled

M. F. Macnicol, BSc, MCh Orth, FRCS Ed(Orth) Consultant Ortho-paedic Surgeon, Part-time Senior LecturerPrincess Margaret Rose Orthopaedic Hospital, Fairmilehead, Edin-burgh EH 10 7ED, Scotland.

S. Voutsinas. MD, Research FellowI 2 Thiras, Keratsini, Piraeus, Greece.

Requests for reprints should be sent to Mr M. F. Macnicol.

out from the tibialis posterior, but the main portion ofthe tendon was also re-routed under the navicular, withthe intention of restoring the normal line of pull of the

tendon. Occasionally, a limited fusion of the cuneiform-

metatarsal or talonavicularjoints also was recommended.

The rationale and efficacy of this operation have beenquestioned(Giannestras 1973; Veitch 1978; Sullivan and

Miller 1979) although the procedure is still described in anumber of orthopaedic textbooks. Leonard et a!. (1965)

supported the use of the operation, and Chater (1962)recommended the Kidner procedure for adults, reservingsimple excision for the child.

Both the Kidner procedure and simple excision havebeen used in Edinburgh in patients whose symptomshave not responded to conservative measures. The

indications for the two operations have been comparable,

although in general the Kidner procedure has beenreserved for the more severe flat foot. In all patients the

source of symptoms was considered to be the result of aprominent accessory navicular, though flat foot was an

associated feature in a significant proportion of cases.

The results of the two operations have been reviewedand certain radiographic features will be discussed.

CLINICAL MATERIAL

Between 1962 and 1978, 76 patients with a symptomatic

accessory navicular in one or both feet were treated

surgically. Patients with a fused accessory navicular or a

prominent navicular tuberosity were not included. Thecase notes were reviewed retrospectively and 29 patients

excluded from the study as the pre-operative clinicaldetails, radiographs and photographs were considered to

be incomplete. The remaining 47 patients were all

examined at a special clinic. In 26 the Kidner procedurewas performed ; the remaining 21 were treated by excision

Localised tenderness

Fig. I

Fig. 2

SURGICAL TREATMENT OF THE SYMPTOMATIC ACCESSORY NAVICULAR 219

VOl.. 66-B. No. 2. MAR(H 984

Pain

Pain interfering with sport

Pain atthe end ofan ordinary day

Rest pain

Pain since trauma

Prominence

Shoe pressure

Frequency and characteristics of the symptoms reported by both groups of patients. Pain has been subdivided into fourcategories.

Plantar view of weight-hearing feet with bilateral Type IIaccessory naviculars. The medial prominences are clearly

seen. particularly on the right fot.

of the accessory bone and trimming of any residual

medial prominence of the main navicular bone. Table I

shows the composition ofeach group; females presented

approximately twice as often as males, and the Kidner

procedure was recommended bilaterally in half of the

cases operated upon, unlike simple excision where the

procedure was usually limited to one or other foot.

Figure 1 shows the symptoms in each operative

group. Pain and local tenderness over the medial

prominence (Fig. 2) was present in nearly all cases;

difficulty with shoes was less common and occurred

chiefly in women. The pain was usually described as an

ache felt over the instep or the medial prominence

towards the end of the day, although occasionally rest

pain was also present. In approximately 15 per cent of

cases a sprain of the foot was considered to be the

precipitating cause of symptoms. Other members of the

family are sometimes found to have the same condition

Mild Moderate Severe

Medial arch Slight Major (ompletc

depression

Navicular Slight Moderate Scvcrctuherositvprominence

Heel eversion 0 10 0 15 dcgrccs > I 5 degreesdegrees

Calcaneal tendon Central Slight lateral Considerabledeviation lateral des ation

Ankle Neutral Mild tilt Moderate tilt

Forefoot Neutral Mild abduction Abduction andhut no rotation pronation

Fig. 3

Three right feet : a mother (centre). her son (left) and her daughter, all of whom had bilateral accessory naviculars. The son had beensuccessfully treated for persisting foot pain by simple excision of the ossicle and surgical contouring of the main navicular.

220 M. F. MACNICOL, S. VOUTSINAS

THE JOURNAL OF BONE AND JOINT SURGERY

(Fig. 3), and McKusick (1968) considers that the

accessory navicular manifests as an autosomal dominant

trait.

The mean duration of symptoms was 33 months in

each group, ranging from 3 months to 19 years for

patients treated by the Kidner procedure, and from 6

months to I 5 years for the group treated by simpleexcision. The age at operation and the age at presentation

for the two groups are shown in Figures 4 and 5. Mostpatients presented between the ages of 10 and 1 5 years

but a few were under 5 years of. age, and some were

middle-aged.

Clinical appearances. Of the 26 patients treated by theKidner procedure, 22 (85 per cent) presented with mobileflat feet, of similar severity bilaterally. Flat feet were

classified as mild, moderate or severe according to the

criteria in Table II. Two patients had severe flat feet, 12

moderate flat feet and 8 mild flat feet. Of the remaining

four patients, three presented with clinically normal feetand one with rigid spastic flat feet secondary to

calcaneonavicular bars. In none ofthe patients was there

clinical evidence of a neuromuscular disorder.

In the group of 21 patients treated by excision of the

accessory navicular, the majority had normally shaped

medial arches apart from the medial prominence.

However, five were classified as having bilateral mobileflat foot (one severe, three moderate and one mild), and

one further case had a severe, more rigid flat foot. None

was found to have tarsal coalition or neuromuscular

abnormalities.

Radiographic appearances. At the time of operationradiographs showed that 1 3 out of the 26 patients

admitted for the Kidner procedure had bilateral accessorynavicular bones, whereas only 2 of the 21 treated by

simple excision had bilateral ossicles. The accessory

navicular has been classified into two types (Dwight

1907) both of which may present in the same patient.

Type I is small, round and discrete from the main

navicular (Figs 6, 7 and 8); it should be distinguished

from the posterior tibial sesamoid which is rarely visible

radiographically (Wood l949� O’Rahilly 1953). Type II,

originally described by Geist (1925), is closely related to

the body of the navicular but separated by an irregular

plate of dense fibrocartilage (Figs 9 and 10). Various

stages of bony union may be apparent, and traumatic or

degenerative features are known to develop both macro-

Table I. A comparison of the two groups

Operation Total M F Bilateral 1. RTotal numberof operations

Kidner 26 8 IS I) S S 39

Excision 21 8 13 2 5 14 23

scopically (Fig. 1 1 ) and microscopically (Zadek and Gold

1948). There were three Type I and 36 Type II accessory

naviculars in the Kidner group and two and 21

respectively in the group treated by excision alone.

Although pre-operative radiographs were retrieved

forall patients, only standinglateral views were considered

to be ofdiagnostic value; 17 were available in the Kidner

group and five in the group treated by simple excision.

Table II. Clinical grading of hat toot. tccording to the appcaranccswhen weight-hearing

15

U)

C

0.

0

.0

E

2

of

15 15-

1o�

5

2

19191tflc5’l


VOL. 66-B, No. 2, MARCH 1984

age 1l� l6� 21� 26� 31% 36 61. 46.. age O� 6. 11� l6�. ?1. 31% 3� 1.1�15202530351.04550 5 1O�52Ol5 1351.045

age at operation Kidner age at presentation

Fig. 4

Age at operation (left) compared with the age at presentation of the 26 patients treated by the Kidner procedure. Theproportion of male and female patients in each age group is shown.

U)

C

0.

0

.0

E

Z5

�ki�i [�111% 16� 2l� 26� 31 36 6�. 66� 0� 6 11� � � 26 � 35� 61�

age � � � 30 35 1.0 65 50 age � �o 15 20 25 30 35 60 45

at operation Simple Excision at presentation

Fig. 5

Age at operation (left) compared with the age at presentation of the 21 patients treated by simple excision of the accessorynavicular. The proportion of male and female patients in each age group is shown.

Fig. I I

Degenerative changes can be seen on thelateral (articulating) surface of this accessory

navicular.

Fig. 12



Fig. 6

Figure 6 Radiographic appearance ofa Type I accessorynavicularofthe left foot and a Type II accessory navicularof the right foot. Figures 7 and 8--Two views of the TypeI accessory navicular. Figures 9 and 10 Two views of the

Type II accessory navicular.

These radiographs were compared to the postoperative

standing lateral radiographs using three measurements:

the medial arch index or navicular index (Stewart 1970)with a normal range in Caucasians of 1 3. 1 to 17.8 (mean:

14.5); the lateral arch or cuboid index (Stewart 1970) with

a normal range in Caucasians of 3.3 to 7.3 (mean: 5.6);

and the calcaneometatarsal angle (Sullivan and Miller

1979) with a normal mean in Caucasians of 134.7 and a

standard deviation of7.7 (Fig. 12).

RESULTS

Clinical data. Surgical exploration revealed that thetendon of tibialis posterior did not invariably adopt anabnormal route to its insertion. When the Kidner

operation was used (Kidner 1929, 1933), non-absorbable

7�s�j�

Fig. 9 Fig. 10

sutures were inserted into the re-routed tendon to secure

it inferior to the main navicular, which was contouredmedially when necessary (Figs 13 and 14). To some

extent the severity of the symptoms influenced thedecision to carry out the Kidner procedure, as did the

presence of an obviously flat foot. However, the prefer-ence of the surgeon for one or other procedure appeared

to be the major factor in deciding which technique shouldbe used; hence, although the two groups can be

contrasted, they are not strictly comparable.

The patients treated by the Kidner procedure werereviewed 3 to 19 years after operation (mean 10 years);

Radiographic measurements of the weight-bearing foot.I. The medial arch or navicular index = (NN’ x I00)/AB: where NN’

is the vertical projection from the inferior tip of the navicular to theline AB: and AB is the distance between the most posterior projectionof the calcaneum and the distal end of the longest metatarsal,regardless of its number.

2. The lateral arch or cuboid index = (CC x l00)/AB: where C(’ isthe height of the cuboid above the line AB.

3. The calcaneometatarsal angle = CMT.

Fig. 13 Fig. 14

Figure 13 Anteroposterior radiograph before the Kidner procedure. Figure 14--After operation: the medial portion of the mainnavicular bone has been contoured.

Symptoms Shape

Shape after operation Number of patients Improved Unchanged Improved Unchanged

Kidnerprocedure Normal 3 3 0 0 3

Flat 23* 19 4* 14 9t

Excision Normal 15 15 0 0 15

Flat 6 5 l� 4 2�


VOl.. 66-8. No. 2. MARCH 984

those treated by simple excision of the ossicle, with or

without contouring of the main navicular bone, were

reviewed 3 to 20 years after operation (mean 12 years).

Table III shows the results.

Kidner procedure. Most of the patients treated by the

Kidner operation presented with flat foot of varyingdegree as defined by the criteria in Table II. Rather than

reporting the results in terms of the number of feet they

are presented in terms of patients, since in the bilateral

cases a similar postoperative outcome was invariably

recorded. For the three patients with normally shaped

feet, pain and tenderness were relieved although there

was no alteration in the height of the medial arch. The

patient with tarsal coalition and accessory naviculars

was relieved of neither her symptoms nor the abnormal

posture of her feet after bilateral Kidner procedures

combined with excision of the calcaneonavicular bars.

Of the 22 patients with mobile flat foot, 19 (86 percent) reported that their symptoms had been relieved by

operation ; three complained that symptoms persisted.Of these three, one had a unilateral severe mobile flatfoot in which the accessory navicular was bipartite andthis may have compromised the outcome. In another case

re-routing the tibialis posterior tendon appears to have

failed, as shown radiographically by broken wire sutures.

Lastly, unilateral recurrence of the accessory navicular

was evident on radiographs of four feet; in three of these

patients symptoms had been relieved, but pain had

persisted in one foot suggesting that the tibialis posterior

tendon was still the site of an irritative process.The shape of the mobile flat feet appeared to

improve after the Kidner operation in 14 of the 22patients (64 per cent). However, the feet whose shape

after operation was unaltered were equally dividedbetween those with mild, moderate and severe flatteningpre-operatively; hence it was impossible to predict which

feet would respond to the Kidner procedure by anincrease in the height of the medial arch. The age of the

Table Ill. The efrect ofthe two procedures upon the shape ofthe foot and the symptoms

* Includes the single case of rigid spastic flat foot (with tarsal coalition) where symptoms were probably worsened by surgery

t 3 severe. 3 moderate. 3 mild

�: Includes a rigid spastic flat foot without tarsal coalition

Calcaneometatarsal angle Navicular index Cuboid index

Right left Right left Right Left

Aulnt’r operations

Number 17 17 15 IS 15 15

Pre-operative value 141.0±4.8 140.8±4.6 10.8± 1.4 10.8± 1.4 2.9±0.5 2.9±0.5

Postoperative value 136.2±3.3 136.2±3.4 13.7±2.9 13.6± 1.5 3.4±0.5 3.4±0.5

t-test P < 0.01 P< 0.01 P < 0.01 P < 0.01 P < 0.0 I P <0.01

O.5.sl(l(’ e.vci.sion.s

Number 5 5 3 3 3 3

Pre-operativevalue 141.6±5.5 142.4±7.0 10.7± 1.8 10.7± 1.6 2.2±0.1 2.2±0.2

Postoperative value 135.4± 7.6 1 35.8 ± 7.5 12.6 ± 2. 1 I 2.6 ± 2.0 3.4 ±11.8 3.2 ± 0.9

t-test P<0.01 P<0.Ol NS NS NS

ond

- Slip to sustentacuLumtaLl

Fig. 15

The multiple insertions of the tibialis posterior tendon into the tarsalbones are shown. The principal lamina is attached to the navicular

tuberositv.


TI-IF JOURNAL OF BONE AND JOINT SURGERY

Table IV. Changes in the radiographic measurements with time. Although significant differences between pre-operative and post-operative values were observed, these cannot be attributed to the operation as growth ofthe foot alters the indices

NS. not significant since numbers too small to compare

patient at the time of operation had a more convincing

effect upon the outcome, suggesting that growth of the

foot influences to a major extent the ultimate height ofthe medial arch.

Excision of the accessory navicular. Simple excision, withor without trimming of the medial border of the main

navicular, relieved symptoms in all 15 patients with

normally shaped feet and resulted in asymptomatic feet

with a normal appearance in four out of the five patients

with mobile flat feet pre-operatively. These patients were1 1 or 12 years of age at the time of operation and only

one patient had bilateral operations. In three patients the

accessory naviculars were present bilaterally but opera-

tion was confined to the symptomatic foot ; it wasnoteworthy that in each case both feet subsequentlydeveloped normal medial arches.

The only patient in this group with persisting pain

has a rigid, spastic form offlat foot, without radiographic

evidence of tarsal coalition. Symptoms are still trouble-

some I I years after bilateral operations. In three cases a

noticeable prominence is present at the site ofthe surgical

excision, presumably because the medial border of the

main navicular had not been contoured. Although these

feet are asymptomatic, in one instance an accessory

navicular has reappeared radiographically, possibly the

result of continuing friction between the tendon and the

navicular tuberosity.

Postoperative morbidity after the Kidner procedure

could be attributed in part to the splintage required to

protect the tendon in its re-routed position. In two

patients superficial skin pressure lesions at the site of the

operation developed as a result of pressure from the

plaster cast. Twenty-three patients (88.5 per cent)

complained of pain, particularly medially, for three to

four months after the Kidner operation. Protracted

symptoms of this sort were not recorded after the

accessory navicular alone had been excised.

Radiographic data. Table IV shows the radiographic data

obtained by measuring the calcaneometatarsal angle, thenavicular index and the cuboid index. Only those patients

with clinically defined (Table II) pes planus and satisfac-


VOL. 66-B. No. 2. MARCH 1984

tory pre-operative standing radiographs are included and

hence the numbers are small. Irrespective of the nature

of the operation, or whether the surgical procedure was

bilateral or unilateral, the same changes in the various

indices were evident in both feet at review.

If these radiographic measurements of the arch of

the foot are accepted as valid, they show that re-routing

the tibialis posterior tendon has no effect upon the

radiographic indices; similar changes occur after simple

excision. Changes in the navicular index were most

marked when there was an obvious flat foot before

operation, but this effect was no different from that seenin the few such cases subjected to simple excision.

DISCUSSION

The multiple insertions of the tibialis posterior tendoninto the tarsal bones (Fig. 15) suggests that the action of

the muscle is to elevate the medial arch. A major portion

of the tendon is inserted into the body and tuberosity of

the navicular and it has often been observed that

flattening of the foot follows traumatic severance or

attrition rupture. Kidner presumed that any deviation in

the insertion of tibialis posterior would diminish its

suspensory action, although it can equally be argued that

the accessory navicular may enhance the tendon function

by a pivot effect. The theory that an accessory navicular

produces reflex overactivity of the peroneal muscles was

also not substantiated from this review.

Recurrence ofthe ossicle after excision only occurredwith Type I ossicles and suggests that this variant mayresult from stress applied to the tibialis posterior tendon

as it passes over the medial surface of the navicular. It

was notable that recurrence of the ossicle occurred only

when the prominence of the medial border of the main

navicular had not been trimmed.

A symptomatic accessory navicular presents as

commonly in flat feet as in feet with a normal medial

arch ; hence it is unproven whether the appearance of the

accessory navicular causes flat foot or is produced by it.

Probably the ossicle is part ofthe configuration of certain

pronated feet thereby contributing to any symptoms; butit is also clear that after simple excision of the accessory

navicular alone, a foot may be left with an entirely

normal medial arch radiographically.

Symptoms from the accessory navicular develop in

approximately one per thousand of the population

according to Harris and Beath (1947), being more

common in women (Specht 1973) and sometimes mani-

festing quite late in life. The ossicle is probably the most

common accessory bone in the foot, becoming radio-

graphically apparent between the ages of 9 and 1 1 years

in approximately 19 per cent of the population (Geist

1925). It persists as a distinct, separate bone in two per

cent (Zadek and Gold 1948), normally fusing completely

or incompletely to the navicular. Trauma may precipitatesymptoms and was felt to be contributory in 1 5 per cent

of cases in this review. Pain is produced by friction or

pressure over the medial prominence, by degenerative

changes in the synchondrosis, or by an associated foot

strain in cases with pes planus. Women present twice as

commonly as men, possibly because the type of shoe

worn and the greater incidence of ligamentous laxitypredispose towards the onset of symptoms.

Operation is advised only if symptoms persist after

conservative measures have been tried. Alterations to

footwear, and exercises for the intrinsic foot muscles and

lateral thigh rotators may prevent or delay the need foroperation, but once symptoms have become establishedoperation was felt to be justified. The Kidner procedure

did not confer any advantages when compared to simple

excision of the ossicle although the two series are not

strictly comparable, as the radiographic incidence of flat

foot pre-operatively was greater in the former group.Simple excision was highly successful as long as it was

combined with contouring the navicular tuberosity;

patients could be encouraged to take weight without

splintage as soon as the wound had healed, whereas after

the Kidner procedure a plaster cast for six weeks isrecommended.

Although the effects of the two procedures upon theshape of the foot was assessed radiographically the

interpretation of these results was hampered by several

factors. Pre-operative standing lateral radiographs were

not always available, and alterations in lower limbrotation and the degree of weight-bearing affected theaccuracy ofthe assessment. Furthermore, ifthe sesamoid

underlying the first metatarsophalangeal joint was not

ossified, measurement ofthe medial arch by the navicular

index proved impossible and therefore the calcaneo-

metatarsal angle (Sullivan and Miller 1979) became the

only assessment possible. Nevertheless it was clear that

the few cases of radiographically flat foot treated by

simple excision responded with an increase in the

navicular index similar to the larger number of cases of

pes planus treated by the Kidner procedure (Fig. 14).

The outcome was unpredictable, however, and Veitch(1978), who reviewed 15 patients with clinical pes planus

before the Kidner procedure, did not find any withpostoperative improvement in the arch. On the other

hand, Leonard et al. (1965) reported satisfactory results

in 25 feet subjected to the Kidner procedure, with the

postoperative production of a good medial arch. In this

present series an improvement in the navicular indexwas evident in virtually all cases.

Significantly, half of the non-operated feet, particu-

larly in the younger patients, improved with time. Thus,

12 out of 22 Kidner procedures produced a normal pair

of feet radiographically, but in five of these I 2 patients

operation had been performed on only one foot. This

confirms the well-established fact that the growing foot

develops a higher medial arch as it matures (Jones 1975)

and casts further doubt on the validity of altering the

tibialis posterior tendon insertion. The Kidner procedure

does not appear to offer any advantages over simple



excision of the ossicle, and the postoperative care is and the parent bone. Contouring of any residual medialcertainly more elaborate. While the two series in this prominence is an important addition to either operationreview are not strictly comparable, symptoms were as it not only improves the shape of the medial border ofrelieved equally by either procedure, suggesting that pain the foot but decreases both the likelihood of recurrent

is produced by pressure over the prominent accessory symptoms and the radiographic reappearance of annavicular and the resultant friction between the ossicle ossicle within the tibialis posterior tendon.

REFERENCES

Chater EH. Foot pain and the accessory navicular bone. IrJ MedSci 1962:422:471-5.

Dwight T. Variations of the hones o/the hands andj#{232}et: a c/mica/atlas. Philadelphia : JB Lippincott Co., 1907.

Froelich R. Des osselets surnum#{233}raires du tarse et de leur importance pratique. Ret’ Med de lEst I 909 : 41 : 433-6.

Geist ES. The accessory scaphoid bone. J Bone Joint Surg 1925 : 7 : 570-4.

Giannestras NJ. Foot disorders: medicalandsurgicalmanagement. 2nd ed. Philadelphia : Lea and Febiger. 1973.

Harris RI, Beath T. Army foot survey: an investigation offoot ailments in Canadian soldiers. Ottawa : National Research Council. 1947.

Jones BS. Flat-foot : a preliminary report of an operation for severe cases. J Bone Joint Surg [Br] 1975 : 57-B : 279-82.

Kidner FC. The prehallux (accessory scaphoid) in its relation to flat-foot. J Bone Joint Surg 1929 : II : 831 7.Kidner FC. Pre-hallux in relation to flatfoot. JAMA 1933; 101 : 1539-42.

Leonard MH, Gonzales S, Breck 1W, Basom C, Palafox M, Kosicki ZW. Lateral transfer of the posterior tibial tendon in certain selected cases ofpes pIano valgus (Kidner operation). C/in Orthop 1965 :40: 139-44.

McKusick VA. Mende/ian inheritance in man : catalogs o/autosomaldominant. autosoma/recessire and X-/inkedphenotipe.s. 2nd ed. Baltimore : JohnsHopkins Press, 1968.

O’Rahilly R. A survey ofcarpal and tarsal anomalies. J Bone Joint Surg [Am] 1953 : 35-A : 626-42.

Specht EE. Minor congenital deformities and anomalies of the foot. In : Inman VT, ed. Du Vries’ surger� ofthe/#{243}ot, 3rd ed. St Louis : CV Mosby1973: 54-8.

Stewart SF. Human gait and the human foot : an ethnological study of the flatfoot. Part I. C/in Orthop 1970: 70: 1 I 1-23.

Sullivan JA, Miller WA. The relationship ofthe accessory navicular to the development ofthe flat foot. C/in Orthop 1979: 144: 233-7.

Veitch JM. Evaluation ofthe Kidner procedure in the treatment of symptomatic accessory tarsal scaphoid. C/in Orthop 1978 :131 : 2 10-3.

Wood JF. Structure andfunction as seen in thefbot. 2nd ed. London : Balli#{234}re,Tindall & Cox, 1949.

Zadek I, Gold AM. The accessory tarsal scaphoid. J Bone Joint Surg [Am] 1948 : 30-A : 957-68.

surgical treatment of the symptomatic accessory navicular€¦ · navicular (figs 6,7and...

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