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Introduction
  • Structural anomaly between two or three tarsal bones causing a rigid flatfoot 
    • two types
      • congenital
        • most common
      • acquired
        • less common and caused by
          • trauma
          • degenerative 
          • infections
  • Epidemiology 
    • demographics
      • age of onset
        • calcaneonavicular usually 8-12 years old 
        • talocalcaneal usually 12-15 years old
    • prevalence 
      • varies from 1%-2%
    • location
      • calcaneonavicular (most common)
      • talocalcaneus 
  • Pathophysiology  
    • embryology
      • failure of mesenchymal segmentation leading to coalition between two or three tarsal bones
        • develops into a fibrous coalition, or undergoes metaplasia to cartilage +/-  bone
    • pathoanatomy
      • gait mechanics
        • subtalar joint will normally rotate 10 degrees internally during stance phase
          • in presence of coalition, internal rotation does not occur
      • deformity
        • flattening of longitudinal arch
        • abduction of forefoot
        • valgus hindfoot
        • peroneal spasticity (also known as peroneal spastic flatfoot)
      • pain generator theories
        • ossification of previously fibrous or cartilaginous coalition
        • microfracture at coalition bone interface
        • secondary chondral damage or degenerative changes
        • increased stress on other hindfoot joints
  • Associated conditions
    • nonsyndromic
      • autosomal dominant 
    • syndromic
      • fibular hemimelia
      • carpal coalition
      • FGFR-associated craniosynostosis (FGFR-1, FGFR-2, FGFR-3)
      • Apert syndrome, Pfeiffer, Crouzon, Jackson-Weiss and Muenke
Classification
  • Anatomic classification
    • calcaneonavicular 
      • between calcaneus and navicular bones (most common)
    • talocalcaneal            
      • middle facet of talocalcaneal joint
  • Pathoanatomic classification
    • 3 types
      • fibrous coalition (syndesmosis)
      • cartilagenous coalition (synchondrosis)
      • osseous coalition (synostosis)
Presentation
  • History
    • history of prior recurrent ankle sprains 
  • Symptoms
    • asymptomatic
      • most coalitions are found incidentally
      • 75% of people are asymptomatic
    • pain
      • location of pain
        • sinus tarsi and inferior fibula suggests calcaneonavicular 
        • distal to medial malleolus or medial foot suggests talocalcaneal 
      • pain worsened by activity
        • onset of symptoms correlates with age of ossification of coalition
      • calf pain
        • secondary to peroneal spasticity
  • Physical exam
    • inspection
      • hindfoot valgus
      • forefoot abduction
      • pes planus
    • range of motion
      • limited subtalar motion
      • heel cord contractures
      • arch of foot does not reconstitute upon toe-standing   
        • hindfoot remains in valgus (does not swing into varus) upon toe-standing
    • special tests
      • reverse Coleman block test
        • evaluate for subtalar rigidity
Imaging
  • Radiographs
    • recommended views
      • required
        • anteroposterior view
        • standing lateral foot view
        • 45-degree internal oblique view
          • most useful for calcaneonavicular coalition
        • Harris view of heel
    • findings
      • calcaneonavicular coalition
        • "anteater" sign
          • elongated anterior process of calcaneus
      • talocalcaneal coalition
        • talar beaking on lateral radiograph
          • occurs as a result of limited motion of the subtalar joint
          • irregular middle facet joint on Harris axial view
        • c-sign  
          • c-shaped arc formed by the medial outline of the talar dome and posteroinferior aspect of the sustentaculum tali
        • dysmorphic sustentaculum
          • appears enlarged and rounded
  • CT scan 
    • Has been suggested as part of the preoperative workup to
      • rule-out additional coalitions
        • incidence approx. 5%
      • determine size, location and extent of coalition  
        • size of talocalcaneal coalition based on size of posterior facet using coronal slices  
  • MRI
    • may be helpful to visualize a fibrous or cartilaginous coalition
    • STIR sequences help to differentiate inflammatory changes (e.g. tendinitis) in local structures 
Treatment
  • Nonoperative
    • observation, shoe inserts
      • indications
        •  unclear. 
      • techniques
        • medial arch support and preserved hindfoot alignment
      • outcomes
        • In rigid flat feet shoe inserts may be the cause of discomfort.
    • immobilization with casting, analgesics
      • indications
        • initial treatment for symptomatic cases   
      • techniques
        • below-knee walking cast for six-weeks
      • outcomes
        • up to 30% of symptomatic patients will become pain-free with a short period of immobilization
  • Operative
    • coalition resection with interposition graft, +/- correction of associated foot deformity  
      • indications
        • persistent symptoms despite nonoperative management  
        • coalition involves <50% of joint surface area
      • techniques
        • open vs arthroscopic coalition resection
        • interposition material 
          • extensor digitorum brevis (calcaneonavicular coalition)
          • split flexor hallucis longus tendon (talocalcaneal coalition)
          • interposed fat graft
          • bone wax
        • correction of associated hindfoot, midfoot or forefoot deformities
          • calcaneal osteotomy for hindfoot valgus
          • calcaneal lengthening to create arch after resection
          • heel cord lengthening if intraoperative ankle dorsiflexion is not past neutral
      • outcomes 
        • 80-85% will experience pain relief
        • poor outcomes
          • coalition resection >50% size of joint surface area
          • uncorrected hindfoot valgus 
          • associated degenerative changes 
    • subtalar arthrodesis
      • indications
        • role has not been well established
        • consider if coalition involves >50 % of the joint surface of a talocalcaneal coalition
      • technique
        • open vs. arthroscopic 
        • consider an associated calcaneal osteotomy with severe hindfoot malalignment
    • triple arthrodesis (subtalar, calcaneocuboid, and talonavicular)
      • indications 
        • advanced coalitions that fail resection
        • diffuse associated degenerative changes affecting calcaneocuboid and talonavicular joints
      • technique
        • open vs. arthroscopic
Surgical Techniques
  • Calcaneonavicular coalition resection  
    • approach
      • lateral or sloppy lateral position
      • anterolateral approach over coalition
    • incision
      • oblique incision just distal to subtalar joint
      • between extensor tendons and peroneal tendons
    • technique
      • protect branches of superficial peroneal and sural nerves
      • reflect fibrofatty tissues in sinus tarsi anterior and extensor digitorum brevis distally
      • identify coalition between anterior process of calcaneus and navicular bones and confirm with fluorscopy
      • excise bar with saw or osteotomes, which leaves defect ~1cm in size
      • interpose fat, bone wax or portion of extensor digitorum brevis muscle into defect
    • post-operative
      • short-leg, non-weight bearing cast for 3-4 weeks
  • Talocalcaneal coalition resection  
    • approach
      • positioned supine
      • medial approach to hindfoot
    • incision
      • horizontal or curved incision centered over sustentaculum tali
      • between flexor digitorum longus and neurovascular bundle
    • technique
      • sustentaculum tali usually just plantar to the talocalcaneal coalition
      • identify normal subtalar joint cartilage by dissecting out the anterior and posterior facets
        • this will help determine location and size of coalition resection
        • confirm with two needles immediately anterior and posterior to coalition clinically and confirm with fluorscopy
      • resect coalition with high speed-burr, ronguers and curettes
      • invert and evert subtalar joint to demonstrate improvement in subtalar motion
      • interpose fat, bone wax or portion of flexor hallucis longus tendon into defect
    • post-operative
      • short-leg non-weight bearing cast for three weeks
Complications
  • Incomplete resection
  • Recurrence of the coalition
  • Residual pain or stiffness 
    • due to malalignment or associated arthritis
    • due to unrecognized 2nd coalition - this should be identified by a preoperative CT scan
 

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(OBQ07.124) A 10-year-old girl complains of foot pain for the past 4 weeks while playing basketball for her school team. A radiograph is shown in Figure A. What is the most appropriate treatment? Review Topic

QID: 785
FIGURES:
1

coalition excision with fat interposition

16%

(429/2638)

2

coalition excision with extensor digitorum brevis interposition

8%

(203/2638)

3

subtalar arthrodesis

0%

(8/2638)

4

4 weeks of immobilization in a short leg cast

74%

(1939/2638)

5

excision of accessory navicular

2%

(42/2638)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(OBQ04.81) A 14-year-old female presents with 6 months of bilateral foot pain at the tarsal sinus. Clinical images of standing examination and heel rise are shown in Figures A and B, respectively. Radiographs of the left foot are shown in Figure C and D. Which of the following findings most likely is associated with this patient's condition? Review Topic

QID: 1186
FIGURES:
1

Dynamic supination during swing phase of gait

1%

(14/1260)

2

Limited push-off power, limited forefoot contact, and excessive heel contact during stance phase of gait

15%

(185/1260)

3

Recurrent ankle sprains

54%

(675/1260)

4

Posterior tibial tendon insufficiency

27%

(345/1260)

5

Weak tibialis anterior relative to the peroneus longus resulting in first ray plantar flexion

3%

(32/1260)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ05.156) A 10-year-old girl has had recurrent left ankle sprains for the past 9-months. She has tried immobilization in a cast for 5-weeks which has failed to provide relief. She is tender to palpation at the tarsal sinus. Radiographs and CT scan of the left foot show an isolated calcaneonavicular coalition and physical exam revealed a neutral hind foot. What is the next best step in management? Review Topic

QID: 1042
1

Resection of coalition at the middle facet if <20° hindfoot valgus is present

8%

(37/447)

2

Coalition resection and interposition of extensor digitorum brevis

81%

(363/447)

3

Complete excision of sustentaculum tali

1%

(6/447)

4

Resection of coalition with concomitant calcaneal neck lengthening or medial slide

7%

(33/447)

5

Triple arthrodesis

1%

(6/447)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(OBQ09.203) A 13-year-old girl presents to the office for the first time with a history of occasional ankle sprains while playing soccer. A history reveals activity-related pain localized to the sinus tarsi. Clinical exam demonstrates pes planus without instability. A radiograph is shown in figure A. What is the most appropriate next step in treatment? Review Topic

QID: 3016
FIGURES:
1

Triple arthrodesis

0%

(7/1687)

2

Coalition excision

43%

(727/1687)

3

Subtalar arthrodesis

1%

(14/1687)

4

Plantar fascia repair

0%

(4/1687)

5

Cast immobilization

55%

(933/1687)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(OBQ10.22) A 13-year-old female complains of a year long history of anterior and lateral foot and ankle pain. Physical exam demonstrates limited subtalar motion compared to her contralateral foot. A lateral radiograph is shown in Figure A. A selected CT image of the hindfoot is shown in Figure B. What foot deformity is commonly associated with this condition? Review Topic

QID: 3110
FIGURES:
1

Hindfoot varus

13%

(393/3123)

2

Rigid pes planus

78%

(2440/3123)

3

Pes Cavus

4%

(116/3123)

4

Equino-cavovarus

4%

(112/3123)

5

Rocker bottom foot

2%

(49/3123)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(OBQ05.140) A 14 year-old girl has chronic foot pain which has failed to respond to previous surgical coalition resection and soft tissue interposition. A radiograph of her foot is shown in Figure A. A CT scan demonstrates a talocalcaneal coalition with almost complete involvement of the subtalar joint. What is the treatment of choice? Review Topic

QID: 1026
FIGURES:
1

revision coalition resection and extensor digitorum brevis interposition

16%

(150/957)

2

revision coalition resection and fat interposition

9%

(83/957)

3

tibiotalocalcaneal arthrodesis

6%

(56/957)

4

talonavicular arthrodesis

5%

(48/957)

5

triple arthrodesis

64%

(616/957)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5
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