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Calcaneonavicular Coalition Excision

Preoperative Patient Care

A

Intermediate Evaluation and Management

1

Perform focused history

  • ask about onset, frequency, intensity and duration of pain
  • find out about factors which worsen and lessen the pain
  • elicit history of ankle sprains
  • question about flatfoot deformity

2

Perform focused physical exam

  • test ankle and subtalar range of motion
  • examine for other potential causes of pain

3

Interprets basic imaging studies

  • imaging studies
  • plain radiographs, including oblique
  • advanced imaging (CT or MRI) to look for other coalitions

4

Makes informed decision to proceed with operative treatment

  • makes sure appropriate conservative measures have been tried
  • describes accepted indications and contraindications for surgical intervention

5

Provides post-operative management and rehabilitation

  • postop:2 week postoperative visit
  • cast is removed
  • felt and button are removed from medial hindfoot
  • foot orthotic (over-the counter or custom) is used when wearing shoes
  • begin range of motion exercises
  • increase activity: walking, biking, jogging, swimming
  • diagnose and manage early complications
  • postop:4 week postoperative visit
  • increase activity as tolerated
  • may need physical therapy if range and strength are significantly limited at this time
  • remind patient and family that resumption of complete, full activity usually occurs 3 months post-op
  • postop:3 months postoperative visit
  • check to make sure activities are back to near normal
  • tell the patient and family, the patient should follow-up in another 3 months if not back to normal by that time

6

Capable of diagnosis and early management of complications

  • appropriate evaluation for wound complications and infection
  • complex regional pain syndrome is rare, but can occur after foot surgery in children with chronic pain
B

Advanced Evaluation and Management

1

Appropriately orders and interprets advanced imaging studies

  • CT or MRI 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
C

Preoperative H & P

1

Obtains history and performs basic physical exam

  • identify medical co-morbidities that might impact surgical treatment

2

Order appropriate imaging studies

  • triplanar radiographs of the foot
  • advanced imaging to assess for other coalitions and their extent

3

Prescribe nonoperative treatments

  • activity modification
  • foot orthotic
  • immobilization with a cast or walking boot

4

Perform operative consent

  • describe complications of surgery including
  • recurrent coalition
  • presence of other, unidentified, coalitions
  • stiffness
  • deformity
  • ongoing pain
  • infection
  • wound complications

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

O

Perioperative Outpatient Management

1

Discharge patient appropriately

  • pain meds
  • weight-bearing as tolerated
  • cast care instructions
  • schedule follow-up in 2 weeks
R

Complex Patient Care

1

Develops unique, complex post-operative management plans

 

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