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Talocalcaneal Coalition Resection

Planning

B

Preoperative Plan

1

Template coalitions

  • template the extent and number of coalitions present

2

Execute surgical walkthrough

  • describe key steps of the operation verbally to attending prior to beginning of case.
  • describe potential complications and the steps to avoid them
C

Room Preparation

1

Surgical instrumentation

  • Kerrison rongeurs
  • osteotomes
  • high speed burr
  • Freer elevators
  • small Hoffman retractors
  • Allis clamp

2

Room setup and equipment

  • setup OR with standard operating table
  • C-arm at the foot of bed
  • monitor in surgeon's direct line of site on opposite side of OR table

3

Patient positioning

  • supine with the foot at edge of the bed
  • tourniquet placed high on upper thigh with webril underneath

Technique

D

Approach

1

Mark out the incision over the sustentaculum tali

  • incision is over the sinus tarsi just over the coalition
  • this should be approximately 1.5 to 2cm distal to the medial malleolus

2

Make the incision

  • identify and coagulate the crossing branches of the saphenous vein
E

Deep Dissection

1

Identify the tendons of the tarsal tunnel

2

Expose the coalition

  • free the posterior tibial tendon from its sheath
  • retract to the tibialis posterior dorsally
  • identify the FDL
  • extend the toes and look for movement within the sheath
  • incise the sheath in line with its fibers
  • retract the FDL plantarly
  • incise the deep sheath to expose the coalition
F

Identify Talocalcaneal Coalition

1

Identify the synchondrosis

  • identify the synchondrosis between the talus and calcaneus
  • use a curette or rongeur to unroof the periosteum
  • look for a cartilaginous interface
  • this should be the center of the resection
G

Excise Talocalcaneal Coalition

1

Resect talocalcaneal coalition

  • start the resection of the coalition with a 1 cm osteotome
  • remove the bone wedge
  • complete excision
  • complete the resection with a 3-4 mm kerrison rongeur
  • a gap of 1cm X 1cm is usually needed to complete the excision
  • place bone wax on the surface of the newly exposed bone

2

Test hindfoot range of motion

  • place a freer elevator into the middle facet defect to the posterior facet
  • free up the joint by removing capsular adhesions

3

Confirm excision is adequate

  • resection is complete when range of motion is improved and the entire posterior facet is visualized
  • confirm excision with internal rotation radiographs
H

Harvest Fat Graft

1

Identify gluteal crease on ipsilateral leg

2

Make skin incision

  • make 4 cm incision at the gluteal crease on the ipsilateral leg
  • take incision through the dermis only

3

Excise the fat graft

  • elevate the dermis proximally off the buttock
  • this should be done 1 cm on each side of the wound
  • place an Allis clamp on the fat pad
  • excise a 3cm long x 1cm wide x 1 cm deep fat pad

4

Prepare wound for closure

  • pack of the area until the foot wound is closed

5

Close wound after foot closure

  • close the subcutaneous tissue with 0 and 3-0 vicryl
  • close the skin with 3-0 monocryl
I

Fat Graft Placement

1

Fill the coalition with harvest graft

  • place harvest graft
  • hold in place with freer elevator

2

Secure the fat graft

  • place the tendon sheath over the fat graft
  • secure with a 1-vicryl suture
J

Wound Closure

1

Irrigation and hemostasis

  • copiously irrigate the wound

2

Superficial closure

  • close subcutaneous tissue with 2-0 vicryl
  • close skin with 3-0 monocryl

3

Immobilization

  • place a short leg fiberglass cast

Patient Care

K

Preoperative H & P

1

Obtains history and performs basic physical exam

  • identify medical co-morbidities that might impact surgical treatment
  • significant valgus of the calcaneus may need to addressed with a osteotomy at the same time as the coalition resection

2

Order basic imaging studies

  • Triplanar radiographs of the foot
  • May need CT to fully visualize coalition
  • Need CT to rule out any coexistent coalitions

3

Prescribe nonoperative treatments

  • place in short leg cast

4

Perform operative consent

  • describe complications of surgery including
  • infection
  • wound dehiscence
  • continued pain
  • stiffness
L

Perioperative Inpatient Management

1

Discharge patient appropriately

  • pain meds
  • cast care
  • non weightbearing
  • manage swelling
  • monitor neurological and vascular status
  • schedule follow up in 2 weeks
M

Intermediate Evaluation and Management

1

Perform focused physical exam

  • test ankle range of motion
  • test subtalar range of motion
  • take a thorough history on causes of pain
  • identify factors that worsen and better the pain

2

Interprets basic imaging studies

  • radiographs
  • look for C-sign on lateral radiograph
  • indicative of talocalcaneal coalition

3

Makes informed decision to proceed with operative treatment

  • describes accepted indications and contraindications for surgical intervention

4

Provides post-operative management and rehabilitation

  • postop:1 week postoperative visit
  • Continue cast and continue non-weight bearing
  • check radiographs
  • diagnose and management of early complications
  • postop:2-3 week postoperative visit
  • remove the cast
  • start active range of motion exercises
  • postop:6 week postoperative visit
  • cleared for activity as tolerated
  • tell patients that the ankle will not feel normal for about 6 months
  • postop:1 year postoperative visit

5

Capable of diagnosis and early management of complications

N

Advanced Evaluation and Management

1

Appropriately orders and interprets advanced imaging studies

  • CT scan
  • useful to delineate the extent of the coalition and presence of multiple coalitions

2

Completes comprehensive pre-operative planning with alternatives

3

Modifies and adjusts post-operative treatment plan as needed

  • recognize deviations from typical postoperative course
O

Complex Patient Care

1

Develops unique, complex post-operative management plans

 

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