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Podiatric Surgery II > 6) Tarsal Coalition > Flashcards

6) Tarsal Coalition Flashcards

1
Q

Tarsal coalition

A
  • Condition in which 2 or more bones in midfoot or rearfoot are joined (complete/incomplete osseous coalition)
  • Fibrous/Cartilaginous coalition
  • Patients usually present in adolescence with recurrent sprains, pain in midfoot with spastic for fixed flatfoot
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2
Q

Coalition proposed etiology (LeBouq)

A
  • LeBouq’s theory of failure of differentiation of embryonic mesenchymal tissue
  • Autosomal dominant inheritance
  • First trimester insult
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3
Q

Coalition proposed etiology (Pfitzner)

A
  • Pfitzner theory of ossification of accessory bones into adjacent tarsal bones
  • Disproved by Harris finding coalitions in fetus
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4
Q

Acquired tarsal coalition etiologies

A
  • Arthritis
  • Infection
  • Trauma
  • Neoplasms
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5
Q

Congenital tarsal coalition

A
  • Accessory ossicle incorporation
  • Genetic mutation to an autosomal gene, resulting in failure of differentiation and segmentation of primitive mesenchyme
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6
Q

Coalition causes restriction or absence of

A
  • Motion between two or more tarsal bones

- Can produce dramatic symptom complex, ultimately resulting in rigid peroneal spastic flatfoot

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7
Q

Tarsal coalition incidence

A
  • 0.04% (24 cases in 60,000 young military personnel)
  • 0.9% (11 in 1,232 children clinic)
  • 1.4% (28 in 2,000 army personnel)
  • On average < 1% of the general population
  • 50-80% Bilateral
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8
Q

Tarsal coalition types/occurrence

A
  • 90% Talocalcaneal (TC)
  • Calcaneonavicular (CN)
  • Talonavicular (3rd most common, <50 cases reported in literature)
  • Calcaneocuboid
  • Cubonavicular
  • Naviculocuneiform
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9
Q

Tarsal coalition associated abnormalities

A
  • Symphalangism (hands and feet)
  • Metatarsal fusions
  • Vertebral fusions
  • Sacroiliac fusions
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10
Q

Tarsal coalition pathophysiology

A
  • Normal STJ motion involves rotation and gliding

- During stance, STJ rotates from a position of 4 degrees external-valgus to 6 degrees of internal-varus

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11
Q

When the internal rotation is restricted by coalition, the tarsal joints have to compensate with

A
  • Flattening of the foot and loss of longitudinal arch
  • Leads to an adaptive shortening of the peroneal tendons, reactive peroneal spasm, and so-called peroneal spastic flatfoot
  • Prolonged restriction of motion eventually may lead to posterior facet arthrosis of the subtalar joint
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12
Q

Subtalar joint gliding motion is lost during foot dorsiflexion.
Gliding motion replaced with hinge motion instead

A
  • Widening at the plantar aspect of the midtarsal joints, narrowing at the dorsal surfaces, and overriding of the navicular on the talar head at maximum dorsiflexion
  • Creating traction effect on the ligaments and capsule of the talonavicular joint resulting in talar beaking seen in many radiographs of tarsal coalitio
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13
Q

Pain symptoms associated with tarsal coalitions

A
  • May therefore be attributed to ligament sprain, peroneal muscle spasm, sinus tarsi irritation, subtalar joint irritation, and arthritic changes
  • The variability of the symptoms in different patients may be due to the variability of subtalar restriction of the different coalitions
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14
Q

Classification of tarsal coalition based on

A
  • Etiology type
  • Anatomic type
  • Tissue type
  • Articular involvement
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15
Q

Tachdjian’s classification

A
  • Descriptive classification that suggest the importance of assessing other areas of the foot and the remainder of the body
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16
Q

Juvenile (osseous immaturity) articular classification system

A 
- Type I - Extra-articular coalition
         A- No secondary arthritis
         B- Secondary arthritis
- Type II - Intra-articular coalition
         A- No secondary arthritis
         B- Secondary arthritis
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17
Q

Adult (osseous maturity) articular classification system

A 
- Type I - Extra-articular coalition
         A- No secondary arthritis
         B- Secondary arthritis
- Type II - Intra-articular coalition
          A- No secondary arthritis
          B- Secondary arthritis
18
Q

Types of coalitions (osseous vs. non)

A
  • Synostosis - osseous union
  • Synchondrosis - cartilaginous union
  • Syndesmosis - fibrous union
  • Combo
19
Q

Bars vs. bridges

A
  • BARS = Extra-articular coalitions occur outside a normal joint
  • BRIDGES = Intra-articular coalitions occurring at normal joint sites
20
Q

Ossification/sympotmatic presentation

A
  • Talonavicular 3-5 y/o
  • Calcaneonavicular 8-12 y/o
  • Talocalcaneal 12-16 y/o
  • Pain secondary to mechanical stress arising from periosteum
21
Q

Biomoechanical findings

A
  • Middle facet talocalcaneal coalitions are associated with the greatest loss of subtalar motion and are the most likely to generate valgus
22
Q

Heel-tip test

A
  • Examiner supinates the foot of a standing patient by raising the medial border of the forefoot and keeping the heel and lateral border in contact with the floor
  • In patients with limited or decreased subtalar motion, compensatory external tibial rotation is decreased, and the patella is not observed to rotate outward as in a person without tarsal coalition
23
Q

Jack’s test

A
  • Demonstrate the fixed nature of the pes planus and the loss of hindfoot inversion
  • Also used for PTTD
24
Q

Clinical findings

A
  • Incidental finding on routine radiographs
  • Onset of pain insidious, developing after trauma or unusual activity
  • Pain aggravated by activity and relieved with rest
  • Limitation of motion (subtalar and midtarsal), and muscle spasm
  • Recurrent ankle sprains
  • Sinus tarsi syndrome
25
Q

Tonic muscle spasm (clinical finding)

A
  • Rigid peroneal spastic flatfoot
  • Biomechanical “splinting” of STJ
  • Peroneus brevis attempting to restrict painful subtalar joint motion - subconscious effort
  • NO neurological pathology (clonic spasticity)
26
Q

Causes of peroneal spastic flatfoot

A
  • Tarsal coalition
  • Arthropathies
  • Inflammation
  • Infection
  • Subchondral fractures
27
Q

Conservative treatment

A
  • Restriction of subtalar and midtarsal joint motion - shoe modifications, orthoses, padding, casting
  • PT, NSAIDs, local steroid injections, prn
28
Q

Surgical treatment

A
  • Resection or fusion
29
Q

Radiographic evaluation

A
  • TALOCALCANEAL (middle facet) -LAT
  • ”C” Signs – formed from the medial talar dome and posteroinferior border of the sustentaculum tali
  • Bony bridge between the talar dome and sustentaculum tali, in combination with a prominent inferior border of the sustentaculum tali
30
Q

Halo sign

A
  • Middle facet coalition demonstrating radiographic sclerosis of the subtalar joint and the ‘‘halo’’ effect of spherical diffusion of ankle and hindfoot forces
31
Q

Arthritic changes noted on radiographic evaluation

A
  • Secondary arthritic or adaptive changes

- Functions of supination and pronation assumed by other joint, ie. Ball-and-socket ankle joint in talocalcaneal

32
Q

Cross-sectional imaging

A
  • CT
  • MRI
  • Reserved for cases in which radiographs are inconclusive
33
Q

Talocalcaneal coalition

A
  • Intra-articular coalitions traditionally considered indication for fusion
  • Juvenile IIA, if small enough or if incomplete, may consider resection arthroplasty
  • Wilde et al found that a valgus greater than 16º and a coalition surface area greater than 50% of the posterior facet on CT were predictors of poor results after resection
  • Future arthrodesis may be indicated
34
Q

Talocalcaenal coalition middle facet arthroplasty

A
  • Linear incision from posterior-inferior medial malleolus to plantar-medial aspect of first cuneiform
  • Incision carried deeply between FDL tendon and NV bundle (Tib. Post. and FDL retracted dorsally and NV bundle retracted plantarly)
  • Middle facet coalition identified and resected (4-7mm)
  • Arthroereisis?
35
Q

Calcaneonavicular coalition radiographic evaluation

A
  • CALCANEONAVICULAR - MO
  • “comma sign” - protrusion of calcaneus toward navicular
  • “anteater nose sign”
36
Q

Calcaneonavicular coalition characteristics

A
  • Extra-articular coalition

- In younger pt. with minimal secondary arthritic changes, resection arthroplasty is procedure of choice - (Juvenile-IA)

37
Q

Calcaneonavicular coalition surgical treatment

A
  • Lateral curvilinear or Ollier type of incision
  • EDB origin reflected off calcaneus, retracted distally
  • Must preserve the TN and CC joint ligaments
  • Bar is generously resected (1 to 1.5cm)
  • EDB muscle belly may be sutured into defect?
38
Q

Calcaneonavicular coalition post-op

A
  • NWB, below the knee cast for 3-4 weeks
  • Cast may be bi-valved and subtalar and midtarsal joint ROM exercises begun
  • Begin WB after 4-6 weeks
  • Most freq. Post-op complication is recurrent bone growth
  • Must consider triple arthrodesis with failure or severe secondary arthritic changes
39
Q

Talonavicular coalition characteristics

A
  • Intra-articular coalition
  • Frequently asymptomatic
  • If symptomatic, resection then fusion, as well as fusion of TC and CC joints recommended
40
Q

Calcaneocuboid coalition

A
  • Rare, intra-articular coalition
  • Double arthrodesis of TN and TC joint may indicated
  • Extra-articular coalition
  • Similar to calcaneonavicular coalition

Podiatric Surgery II (6 decks)

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