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#5 Surg > 75 - Tarsal Coalition > Flashcards

75 - Tarsal Coalition Flashcards

1
Q

Tarsal coalition

A
  • Tarsal coalition exists when a union causes restricted motion or absence of motion between two or more tarsal bones
  • Bars vs. Bridges
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2
Q

Bar coalition

A
  • Extraarticular coalition that occurs outside a normal joint
  • Example: Calcaneonavicular Bar
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3
Q

Bridge coalition

A
  • Intraarticular coalition that occurs at a normal joint site
  • Example: Talocalcaneal Bridge
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4
Q

Division of tarsal coalitions into extraarticular and intraarticular coalitions

A

Extraarticular coalitions (BARS)
o Calcaneonavicular
o Cubonavicular

Intraarticular coalitions (BRIDGES) 
o	Talocalcaneal (middle, posterior, anterior, combination)
o	Talonavicular
o	Calcaneocuboid 
o	Naviculocuneiform
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5
Q

History

A
  • Pre-Columbian Indian skeleton 1000AD
  • Buffon 1769 – First written description
  • Sir Robert Jones 1897 – Peroneal Spastic Flatfoot: Did not associate it with tarsal coalition
  • Kirmission 1898 – First radiographic description
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6
Q

Classifications

A
  • Etiology
  • Anatomic
  • Tissue Type
  • Articular Involvement
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7
Q

Etiology

A
  • Congenital = Most common cause of tarsal coalition in pediatric patients
  • Acquired = Most common cause of tarsal coalition in adult patients
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8
Q

Congenital etiologies

A
  • Pfitzner theory

- Leboucq theory

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9
Q

Pfitzner

A

o Incorporation of accessory ossicles into the normal tarsal bones on either side of a joint or in close approximation with one another

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10
Q

Leboucq

A

o Failure of differentiation and segmentation of primitive mesenchyme
o Heritable defect (autosomal dominant)
o Insult is detected in first trimester
o THIS IS THE PREVAILING THEORY = AUTOSOMAL DOMINANT
o If something is something is autosomal dominant, it should show up in 75% of offspring

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11
Q

Aqcuired etiologies

A
  • Arthritis
  • Infection
  • Trauma
  • Neoplasm
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12
Q

Tissue type classification

A
  • Syndesmosis: Fibrous union = Incomplete union with motion
  • Synchondrosis: Cartilaginous union = Incomplete union with motion
  • Synostosis: Osseous union = Complete union without motion
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13
Q

Articular involvement (Downey Classification) – KNOW THIS***

A
  • Juvenile (Osseous Immaturity)

- Adult (Osseous Maturity)

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14
Q

Juvenile (Osseous Immaturity)

A

Type I: Extraarticular Coalition
A: No Secondary Arthritis
B: Secondary Arthritis

Type II: Intraarticular Coalition
A: No Secondary Arthritis
B: Secondary Arthritis

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15
Q

Adult (Osseous Maturity)

A

Type I: Extraarticular Coalition
A: No Secondary Arthritis
B: Secondary Arthritis

Type II: Intraarticular Coalition
A: No Secondary Arthritis
B: Secondary Arthritis

SAME AS JUVENILE

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16
Q

Incidence – KNOW THIS

A
  • 0.04% - 1.4% in overall population
  • No racial preference
  • 50% Bilateral
  • 4:1 male/female? – These could just be bad studies, so not confident on this
  • Talocalcaneal Coalition – 48.1% = HIGHEST INCIDENCE
  • ***Calcaneonavicular Coalition – 43.6%
  • ***Other – 8.3%
17
Q

Clinical Findings

A
  • Pain
  • Limitation of motion and rigid flatfoot – most likely cause of unilateral pediatric flatfoot
  • Muscle spasm
  • No symptoms in 22% of patients – Patients often mistreated for ankle sprains and sinus tarsi syndrome
18
Q

Pain

A
  • Deep aching pain in area of coalition
  • Often localized to sinus tarsi or entire rearfoot
  • Pain with walking over rough uneven terrain (this is something that can cause pain initially)
  • May occur with secondary arthritis (a lot of times a complication of a surgical fusion is arthritis in neighboring joints – these patients have congenital fusion leading to the same thing)
  • Onset is insidious after activity or trauma and relieved with rest
  • May begin with ossification, rarely neuritic
19
Q

**Ossification ** KNOW THIS

A
  • Talonavicular Coalition: 3-5 years
  • Calcaneonavicular Coalition: 8-12 years
  • Talocalcaneal Coalition: 12-16 years
20
Q

Limitation of motion of STJ & MTJ

A
  • Most obvious clinical finding
  • STJ exhibits limited inversion - As ossification increases, motion decreases
  • Hubscher Maneuver
21
Q

Hubscher maneuver

A

o Dorsiflexion of the hallux with patient standing
o Medial band of plantar fascia is tightened
o If deformity is FLEXIBLE – Arch height will increase and rearfoot will supinate
o If deformity is RIGID – No change in arch height

22
Q

Muscle spasm

A
  • Tonic muscle spasm of the peroneal tendon – Not clonic (neurological)
  • Due to painful subtalar joint motion, the peroneal tendons guard to restrict motion and immobilize the joint
    o It hurts to invert so peroneals over-fire to prevent inversion, so eventually they spasm
    o Comfortable foot position is in valgus (EVERTED)
    o Common peroneal nerve block – May need to do this with lidocaine in order to check ROM if the peroneals are spastic
  • Peroneal spastic flatfoot does NOT always develop in a tarsal coalition
  • NOTE: there are other etiologies of peroneal spasm, so it is not always tarsal coalitions
23
Q

Radiographic evaluation – Calcaneonavicular bar

A

Demonstrated on an oblique radiograph
o Comma sign or Anteater sign

Osseous easier to diagnose
o Soft tissue coalitions
o Close proximity of Calcaneus and Navicular
o Irregular lateral Navicular cortical surface
o Flattening of Navicular laterally
o Hypoplasia of head of Talus

24
Q

Radiographic evaluation of talocalcaneal coalition

A

Demonstrated on a lateral radiograph
o Diminished posterior or middle facet
o Halo sign (sclerosis of sustentaculum tali)
o Narrowing of posterior facet
o Talonavicular beaking (secondary arthritic change)
o Flattening of lateral talar process

Calcaneal Axial (Ski-jump, Harris and Beath view)
o Looking for facet obliquity
o Parallel or less than 25 degrees

25
Q

Halo sign

A
  • Sclerotic enhancement of the sustentaculum tali

- Left: Halo sign and can also see beaking

26
Q

Facet obliquity

A
  • Greater than 25 degree obliquity on left
27
Q

Talonavicular coalition

A
  • Demonstrated on AP and lateral radiograph
  • If the talar neck looks long, it is actually a talonavicular
    coalition
28
Q

Ancillary studies

A
  • Used when radiographs are inconclusive or to assist with
    surgical planning
  • MRI – can show fibrous or cartilaginous coalitions
  • CT Scan – can show osseous coalitions
29
Q

Secondary arthritic changes

A
  • Ball in socket ankle joint = COMMON SECONDARY CHANGE
  • The dome of the talus is usually square – should NOT be rounded like a ball-in socked
  • When we have a coalition and lose frontal plane motion (inversion/eversion) so the ankle starts to remodel and take up the frontal plane motion that is lost due to the coalition
30
Q

Treatment

A
  • “Not all tarsal coalitions cause symptoms. Not all coalitions that are symptomatic necessarily remain so.”
  • You NEED to do conservative treatment, it may not be successful but you NEED to try
31
Q

Conservative treatment

A
  • NSAIDS
  • Physical Therapy
  • Shoe Modifications
  • Padding
  • ***Orthotics – Restrict subtalar and midtarsal joint motion reducing pain and muscle spasm (we already know the everted foot position is the most comfortable, so we do NOT correct the eversion in the orthotic – we allow the foot to STAY everted to avoid excess pain)
  • Casting
32
Q

Surgical treatment of tarsal coalition in juveniles

A
  • These are the possible surgical procedures based on the articular classification system (Downey classification system)
    o Juvenile IA = Resection with interposition of EDB muscle
    o Juvenile IB = Triple arthrodesis
    o Juvenile IIA = Resection with interposition of arthrodesis, Isolated/single arthrodesis, Triple arthrodesis
    o Juvenile IIB = Triple arthrodesis
  • NOTE: the bolded surgical treatment options are the recommended procedures from the longer list of options
  • ANY TIME there is secondary arthritis, the recommendation is to do an arthrodesis
33
Q

Surgical treatment of tarsal coalition in adults

A
  • Adult: IA = Resection with interposition of EDB muscle, Triple arthrodesis
  • Adult: IB = Resection with isolated/single arthrodesis, Triple arthrodesis
  • Adult: IIA = Isolated or single arthrodesis, Triple arthrodesis
  • Adult: IIB = Triple arthrodesis
  • NOTE: pretty much an arthrodesis is the procedure of choice
34
Q

Resection/interposition with EDB = BADGLEY PROCEDURE

A
  • Badgley first described this procedure in 1927
  • Ollier Incision is used in this procedure
  • EDB dissected from calcaneus and reflected distally
  • Resection of coalition is done
  • Extensor digitorum brevis muscle belly (EDB) is then placed into defect (put it into the hole you’ve created) – Other options include silicone or bone wax
  • Silicone or fat may also be used
  • Bone Wax (can use this as a hemostatic agent, but also decreases bone healing)
  • NOTE: often you want gauze or padding under the button so there is not necrosis of the skin
  • You know how much bone to resect by resecting some, check STJ ROM, resect more, check again, etc. until you have normal STJ ROM
35
Q

STUDY: Khoshbin, A., Law, P.W., Caspi, L., & Wright, J.G. (2013). Long-term functional outcomes of resected tarsal coalition

A
  • Level 3 – retrospective comparative study
  • 24 patients with 32 coalitions younger than 18y/o (SMALL SAMPLE) - Juvenile cases
  • 19 CN, 13, TC (majority were extraarticular)
  • No difference in outcomes scores when resected
  • Did not address secondary arthritis in this study
  • Resection is often preferred in juvenile patients – you are giving them the chance to regenerate/restore

#5 Surg (12 decks)

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