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ACCESSORY NAVICULAR BONE: NOT SUCH A NORMAL VARIANT


A. Bernaerts1, F Vanhoenacker1, 2, S. Van de Perre1,2, A.M. De Schepper1, P .M. .M. Parizel1 The accessory navicular is often erroneously considered as a normal anatomic and roentgenographic variant. Three distinct types of accessory navicular bones have been described.The type 2 and 3 variants have been associated with pathologic conditions such as posterior tibial tendon tear and painful navicular syndrome and therefore should not be arbitrarily dismissed as a roentgenologic variant in a symptomatic patient. The pathogenesis and radiologic findings are discussed and illustrated.
Key-word: Ankle, anatomy.

The accessory navicular, of which three variants have been described, is often considered as a normal anatomic and roentgenographic variant. However, the type 2 and 3 variants have been associated with pathologic conditions such as posterior tibial tendon (PTT) tear and painful navicular syndrome. This is caused by an altered insertion of the PTT by the accessory navicular. This can be better understood when one has notion of the normal anatomy and function of the posterior tibial muscle. Anatomy

ed at the medial malleolus are oriented at the magic angle resulting , in a higher signal on short TE images. The magic angle artefact fades on T2-weighted images, so these should always be obtained. Secondly, the distal aspect of the tendon broadens and has interposed connective tissue and therefore is heterogeneous in signal over the distal 2 to 3 cm before its insertion onto the medial navicular (2). The posterior tibialis muscle acts to plantarflex the ankle and the foot. Furthermore it locks the tarsal bones by traction during normal gait creating a rigid midfoot (1).

Posterior tibialis tendon


The posterior tibialis muscle originates from the interosseous membrane and the adjacent tibial posterior surface in the proximal third of the leg. The tendon prolongs the muscle belly in the distal third of the leg and curves around the medial malleolus beneath the flexor retinaculum. The tendon has a complex insertion into the tarsal and metatarsal bones. From the clinical point of view, the most important is the insertion onto the medial navicular bone (1). The posterior tibialis tendon is normally about twice the diameter of the adjacent flexor digitorum longus tendon. It is of low signal on all pulse sequences. However, there are two exceptions to this lack of signal intensity. The first factor that influences the signal intensity of the tendon is the magic angle artefact. If the ankle is imaged with the foot at 90 degrees to the leg, the collagen fibres within the tendon locat-

Accessory navicular bone


Three distinct types of accessory navicular bones have been described (Fig. 1): (1) a small, round separate ossicle imbedded within the posterior tibial tendon (type 1); (2) a larger, triangular ossification centre adjacent to the navicular tuberosity and connected by a synchondrosis (type 2); and (3) an enlarged medial horn of the navicular itself, called a cornuate navicular (type 3). These three types have a collective incidence of 4 to 21% (3). Pathology

Fig. 1. Schematic drawing of the three types of accessory navicular bone.

Posterior tibialis tendinopathy


The presence of either an accessory navicular type 2 or type 3 (cornuate navicular) is a risk factor for PTT tendinopathy, since the accessory navicular acts as it were a native navicular with the bulk of the posterior tibialis tendon inserting onto the accessory navicular. This
Fig. 2. Functional repercussion of accessory navicular bone.The accessory navicular acts as it were a native navicular with the bulk of the posterior tibialis tendon inserting onto the accessory navicular. This leads to a more proximal insertion of the PTT (dashed line). Hereby, the leverage of the malleolus on the PTT is reduced and therefore the stress on the tendon increases.

From: 1. Department of Radiology, Universitair Ziekenhuis Antwerpen (University of Antwerp), Edegem; 2. Department of Radiology, AZ St-Maarten, Campus Duffel, Duffel, Belgium. Address for correspondence: Dr F .M. Vanhoenacker, M.D., Department of Radiology, Universitair Ziekenhuis Antwerpen (University of Antwerp), Wilrijkstraat 10, B-2650 Edegem, Belgium.

leads to a more proximal insertion of the PTT. Hereby, the leverage of the malleolus on the PTT is reduced and therefore the stress on the tendon increases (Fig. 2).

PROCEEDINGS OF THE SRBR-KBVR OSTEOARTICULAR SECTION OCTOBER MEETING

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A
Fig. 3. PTT tendinopathy associated with accessory navicular type 2. AP radiograph of the foot (A) demonstrating a type 2 accessory navicular (small arrows). Coronal T1- (B) and fat-suppressed T2- (C) weighted MR images reveal thickening of the PTT with a central area of high signal intensity consistent with tendinopathy (arrow).

B C

Fig. 4. PTT tendinopathy associated with cornuate navicular. AP radiograph (A) shows a type 3 accessory navicular. Axial T1- (B) and T2- (C) weighted MR images reveal an enlarged PTT with multifocal speckled internal signal intensity (white arrow). Also note edema in the adjacent cornuate navicular (black arrow).

Fig. 5. Symptomatic accessory navicular. AP radiograph (A) shows a type 2 accessory navicular. Axial T1- (B) and T2- (C) weighted MR images demonstrate cortical irregularity at the synchondrosis and kissing marrow edema on either side of the pseudarthrosis.

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Clinically, patients can present with a flat foot deformity and associated hindfoot valgus. On MR imaging, tendinopathy is characterised by a contour deformity with intrasubstance signal intensity alterations (Fig. 3, 4) (1).

Symptomatic accessory navicular


A type 2 accessory navicular may become symptomatic for another reason. The repetitive contractions of the PTT as it inserts onto the accessory ossicle can produce shearing stress forces at the synchondrosis, and generate pain and tenderness along the medial aspect of the midfoot. CT examination easily reveals cortical irregularity and fragmentation of the accessory

navicular. Sclerosis involving both sides across the synchondrosis can also be observed (4). MR imaging demonstrates bone marrow edema within the accessory bone and occasionally the adjacent navicular (Fig. 5). It may show high signal intensity within the synchondrosis on T2-weighted images. Bone scintigraphy may be of value when the significance of the ossicle is uncertain (3). Conclusion In conclusion, patients with an accessory navicular bone type 2 or 3 and medial foot pain or flatfoot should be examined by MRI for insertion abnormalities of the PTT or painful accessory navicular.

Conversely, look for an accessory navicular bone on MRI in patients with flatfoot or PTT abnormalities. References
1. Schweitzer M.E., Karasick D.: MR Imaging of Disorders of the Posterior Tibialis Tendon. Am J Roentgenol, 2000, 175: 627-635. 2. Tuite M.J.: MR imaging of the Tendons of the foot and ankle. Semin Musculoskelet Radiol, 2002, 6: 119131. 3. Miller T.T.: Painful accessory bones of the foot. Semin Musculoskelet Radiol, 2002, 6: 153-161. 4. Bencardino J.T., Rosenberg Z.S.: MR imaging and CT in the assessment of osseous abnormalities of the ankle and foot. Magn Reson Imaging Clin N Am, 2001, 9: 567-578.

IMAGING OF TUMOURS OF THE FOOT AND ANKLE


P Van Dyck1, F Vanhoenacker2, J.L. Gielen1, A.M. De Schepper1, P . .M. .M. Parizel1 The general presentation of osseous and soft-tissue neoplasms of the foot and ankle is not different from lesions encountered in other parts of the body and imaging features may be nonspecific. Some lesions, however, have a predilection for the foot and ankle and may have typical imaging features, such as plantar fibromatosis or intraosseous lipoma. This presentation aims to give an overview of bone and soft-tissue tumours of the foot and ankle and to discuss the strength of each imaging modality in the diagnosis.
Key-word: Bone neoplasms.

Bone tumours

Bone-forming bone tumours


Osteoid osteoma (Fig. 1) is one of the most common benign tumours of the foot and ankle, with the majority found in the talus. Most patients present in the second decade. Clinical symptoms are a dull, constant bone pain that is worse at night and, typically, relieved by salicylates. Most talar lesions are subperiosteal and located at the superior aspect of the talar neck. In cortical lesions, radiography usually reveals a lucent or mineralised nidus with surrounding sclerosis. CT-scan is more sensitive to depict the nidus and is used , in our

institution, to guide thermal ablation of the lesion. Bone scintigraphy may reveal the double density sign, where the central nidus shows greater uptake than the inflammatory response in the surrounding bone. MR imaging is less accurate than CT to depict the nidus, but can be used to evaluate the extent of accompanying bone marrow and soft-tissue oedema. Osteoblastoma, histologically and radiologically similar to osteoid osteoma, is an uncommon bone tumour which has a predilection for the foot and ankle. A nidus greater than 1.5 cm is, by convention, consistent with osteoblastoma. Osteosarcoma is one of the most common bony malignancies of the

foot and ankle. Most lesions in the foot and ankle are intraosseous, osteoblastic and high grade. 66% are located in the distal tibia. Metastatic disease is common and results in a poor prognosis. The patients mean age is around 35 years. Radiographically, there is an aggressive moth-eaten or permeative pattern of bone destruction and usually soft-tissue extension. Amorphous or cloud-like mineralisation is common, and a spiculated periosteal reaction is often present. MR imaging characteristics are nonspecific: low to intermediate signal intensity on T1-weighting and inhomogeneous high signal intensity on T2-weighting. Mineralised foci display low signal on all pulse sequences.

Cartilage-forming bone tumours


From: 1. Dpt of Radiology, University Hospital Antwerp, Edegem; 2 Dpt of Radiology, AZ Sint-Maarten, Duffel. Address for correspondence: Dr. F .M. Vanhoenacker, M.D., Dept. of Radiology, University Hospital Antwerp, Wilrijkstraat 10, B-2650 Edegem., Belgium.

Enchondroma is a benign bony neoplasm that is much more found in the hand than in the foot and ankle. In the forefoot, it is one of the most common benign bone lesions,

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