Calcaneonavicular Coalition Excision

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TECHNIQUE STEPS
Preoperative Patient Care
Operative Techniques
E

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.
  • explain whether or not (and why) a calcaneal osteotomy is needed
F

Room Preparation

1

Surgical instrumentation

  • osteotomes
  • rongeurs
  • Senn retractors
  • bone wax
  • straight (Keith) needles
  • sterile felt
  • button

2

Room setup and equipment

  • set up OR with a radiolucent operating table.
  • C-arm comes in from the opposite side.
  • monitor is in surgeon's direct line of site on opposite side of the OR table.

3

Patient positioning

  • supine with the foot at end of the bed.
  • bump under ipsilateral buttock.
  • tourniquet placed high on thigh with webril underneath
G

Ollier Incision

1

Make incision over the coalition along the Langer lines

  • incision is over the sinus tarsi just over the coalition
  • take the incision down to the level of EDB fascia
  • be aware of the lateral branches of the superficial peroneal nerve
H

Deep Dissection

1

Expose the EDB

2

Expose the coalition

  • release the insertion of the EDB
  • elevate from distal to proximal
I

Calcaneonavicular Coalition Identification

1

Identify the coalition

  • identify the coalition between the calcaneus and the navicular
  • identify the center of the coalition (may be cartilaginous).
  • this will mark the center of the coalition excision

2

Identify the talonavicular and calcaneocuboid joints

  • these facilitate guidance of coalition excision.
  • freer elevators may be placed here.
J

Excise the Calcaneonavicular Coalition

1

Resect calcaneonavicular coalition

  • resect the coalition with a 1.2 cm osteotome
  • be careful to avoid the surface of the cuboid and head of the talus
  • remove the bone wedge
  • complete excision
  • rongeurs may be used to complete the resection.
  • a 1cm x 1cm gap between the calcaneus and navicular is needed to minimize the risk of recurrence.

2

Confirm excision is adequate

  • confirm the adequacy of the excision with internal rotation radiographic images

3

Test range of motion

  • check hindfoot and subtalar range of motion
  • these should be significantly improved if the coalition has been excised
  • if motion is not sufficient, be wary of insufficient excision and/or the presence of other coalitions in the same foot.
  • look to see if the navicular and the calcaneus independently
K

Fat Graft Harvest

1

Identify raw bone edges of calcaneus and navicular

2

Apply bone was to raw edges

3

Remove excess bone wax.

4

Remove excess bone wax

L

EDB interposition

1

Fill the site of the excised coalition with EDB muscle.

  • place absorbable suture in distal edge of EDB
  • place straight (Keith) needle on each end of suture.
  • advance needles through site of excised coalition and bring out through medial hindfoot.
  • the needles and suture are brought through the piece of felt and button on the medial hindfoot
  • make sure that the EDB fills the gap where the coalition has been excised.

2

Secure the EDB.

  • the sutures over the medial hindfoot are tied over the felt and button
N

Wound Closure

1

Irrigation and hemostasis

  • irrigate the wound prior to closure

2

Superficial closure

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

3

Immobilization

  • A below-knee walking cast is worn for 2 weeks.
Postoperative Patient Care
 

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