Kohler Disease Treatment & Management

  • Author: Bernardo Vargas; Chief Editor: Jason H Calhoun, MD, FACS   more...
 
Updated: Feb 17, 2012
 

Medical Therapy

A weight-bearing, below-the-knee cast is recommended. Total cast time is approximately 6-8 weeks. The cast is better in moderate varus (10-15º) that is associated with moderate equinus (10-20º). In this position, the navicula is relaxed from posterior tibialis strain. Arch supports can be prescribed following the cast period and used for an average of 6 months. In mild cases, soft arch supports may be the only treatment necessary.

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Follow-up

Symptoms in treated patients can last for less than 3 months.[6] In untreated patients, symptoms may be present for 15 months. As immobilization in a short leg cast decreases the duration of symptoms, treating all patients for at least 6 weeks is recommended. If pain is persistent after a 6-week period of casting, a new cast must be applied for 6 supplementary weeks. Ippolito et al performed a long-term follow-up of 12 cases.[9] Other causes of foot pain, including talar coalition or an accessory navicular, should be investigated if the pain does not disappear after the cast period.

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Complications

In 1984, Ertel and O'Connell reported a case of acquired talonavicular coalition that followed avascular necrosis of the tarsal navicular bone.[10] This complication is very rare.

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Outcome and Prognosis

The evolution of the x-ray appearance in Köhler disease is variable. Normal x-rays may be obtained 6-18 months following onset. At adulthood, the navicular bone is expected to be normal. Patients recover excellent function.[11]

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Contributor Information and Disclosures
Author

Bernardo Vargas  MD, Consulting Staff, Department of Orthopedic Surgery, University Hospital of Geneva, Switzerland

Disclosure: Nothing to disclose.

Specialty Editor Board

Heidi M Stephens, MD, MBA  Associate Professor, Department of Surgery, Division of Orthopedic Surgery, University of South Florida College of Medicine; Courtesy Joint Associate Professor, Department of Environmental and Occupational Health, University of South Florida College of Public Health

Heidi M Stephens, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, and Florida Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Shepard R Hurwitz, MD  Executive Director, American Board of Orthopaedic Surgery

Shepard R Hurwitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for the Advancement of Science, American College of Rheumatology, American College of Sports Medicine, American College of Surgeons, American Diabetes Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Association for the Advancement of Automotive Medicine, Eastern Orthopaedic Association, Orthopaedic Research Society, Orthopaedic Trauma Association, and Southern Orthopaedic Association

Disclosure: Nothing to disclose.

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Jason H Calhoun, MD, FACS  Frank J Kloenne Chair in Orthopedic Surgery, Professor and Chair, Department of Orthopedics, The Ohio State University Medical Center

Jason H Calhoun, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Diabetes Association, American Medical Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Missouri State Medical Association, Musculoskeletal Infection Society, Southern Medical Association, Southern Orthopaedic Association, Texas Medical Association, and Texas Orthopaedic Association

Disclosure: Nothing to disclose.

Additional Contributors

Dr. Mark Clayer, MD, MBBS, FRACS, FAOrthA, is gratefully acknowledged for the contributions made to this article.

References

  1. Kohler A. Uben eine häubige bisher ansheinend unbekannte Erkrankung einzelner kindlicher Knochen Verh deutsch Röntg-Ges 1908;4:110.

  2. DiGiovanni CW, Patel A, Calfee R, Nickisch F. Osteonecrosis in the foot. J Am Acad Orthop Surg. Apr 2007;15(4):208-17. [Medline].

  3. Khan AQ, Sherwani MA, Gupta K, Siddiqui YS, Hali NZ. Kohler's disease. Saudi Med J. Sep 2008;29(9):1357-8. [Medline].

  4. Waugh W. The ossification and vascularisation of the tarsal navicular and their relation to Köhler's disease. J Bone Joint Surg Br. Nov 1958;40-B(4):765-77. [Medline]. [Full Text].

  5. Berard J, Fournet-Fayard J. [Idiopathic ostonecrosis of the scaphoid tarsal bone (Köhler's second disease)] [French]. Rev Rhum Mal Osteoartic. Feb 1983;50(2):163-5. [Medline].

  6. Williams GA, Cowell HR. Köhler's disease of the tarsal navicular. Clin Orthop Relat Res. Jul-Aug 1981;158:53-8. [Medline].

  7. Khoury J, Jerushalmi J, Loberant N, Shtarker H, Militianu D, Keidar Z. Kohler disease: diagnoses and assessment by bone scintigraphy. Clin Nucl Med. Mar 2007;32(3):179-81. [Medline].

  8. Gips S, Ruchman RB, Groshar D. Bone imaging in Kohler's disease. Clin Nucl Med. Sep 1997;22(9):636-7. [Medline].

  9. Ippolito E, Ricciardi Pollini PT, Falez F. Köhler's disease of the tarsal navicular: long-term follow-up of 12 cases. J Pediatr Orthop. Aug 1984;4(4):416-7. [Medline].

  10. Ertel AN, O'Connell FD. Talonavicular coalition following avascular necrosis of the tarsal navicular. J Pediatr Orthop. Aug 1984;4(4):482-4. [Medline].

  11. Borges JL, Guille JT, Bowen JR. Köhler's bone disease of the tarsal navicular. J Pediatr Orthop. Sep-Oct 1995;15(5):596-8. [Medline].

  12. Khan AQ, Sherwani MA, Gupta K, Siddiqui YS, Hali NZ. Kohler's disease. Saudi Med J. Sep 2008;29(9):1357-8. [Medline].

 
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Radiograph from a 16-year-old patient who had Köhler disease. Normal x-rays at adulthood are the rule for Köhler disease.
Radiograph from a patient with Köhler disease. This image is typical for Köhler disease. Note the flat aspect of the tarsal scaphoid.
 
 
 
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