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Talo-Calcaneal tarsal coalition takedown

    Overview

    Learn the Talo-Calcaneal tarsal coalition takedown surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Talo-Calcaneal tarsal coalition takedown surgical procedure.
    As with all coalitions the main indication for operation in a Talo-Calcaneal coalition is for pain relief. Improved joint mobility may result though this is far less predictable , especially in the adult patient, and is not an indication for operation.
    The classical features of a unilateral plano-valgus foot and a fixed subtalar joint are by no means invariably present. Some patients may demonstrate apparent subtalar mobility on examination due to compensatory ankle mobility.
    The question in adults with Tarsal coalitions is always whether to perform a simple take-down rather than to proceed directly to fusion surgery and this is a decision made with the patient fully aware of the implications of both surgical paths.

    Indications

    INDICATIONS.
    -As with all coalitions the main indication for operation is for pain relief .
    -Improved joint mobility may result though this is far less predictable , especially in the adult patient, and is not an indication for operation.
    SYMPTOMS AND EXAMINATION.
    The commonest presentation of the condition is with lateral hindfoot pain. This can occur in a previously asymptomatic adult (though it will have been longstanding) or there may be a long history of manageable symptoms which have deteriorated. On rare occasions the coalition presents co-incidentally following an ankle sprain or other unrelated injury which has failed to settle. A proportion of patients will also have associated spurring of the talo-navicular joint, which can be discreetly symptomatic. If so they will suffer dorso-medial midfoot pain and probably be locally tender here. This requires an additional approach to debride the talo-navicular joint.
    The classical features of a unilateral plano-valgus foot and subtalar stiffness are by no means invariably present. Some patients have a normally aligned hindfoot and apparently mobile Subtalar joint. The latter on accurate examination can be seen to be due to compensatory ankle mobility. Coalitions may on occasion present bilaterally.
    It is often difficult clinically to make an assessment of the presence of arthritis given the inherent stiffness in many coalitions .
    The question in adults with Tarsal coalitions is always whether to perform a simple take-down rather than to proceed directly to fusion surgery. My own preference has always been to preserve the joints initially in the absence of degenerative change and especially in the absence of any deformity of note. This is less successful in percentage terms than opting primarily to fuse (Subtalar or Triple) but is quicker to recover from and will not have the likely deteriorating effect upon the ankle observed in the longer term after fusion surgery.
    The long-term outcome of leaving asymptomatic coalitions untreated in terms of their relative risk of developing secondary arthritic change is not known. If the coalition is associated with significant stiffness that this may occur ultimately is a logical assumption (and of course arthritis is present in some at presentation). It is difficult to argue for surgically treating coalitions if they are not symptomatic.
    Though classically coalitions present from late childhood into adolescence they can first become symptomatic far later into adult life, when minor symptoms become less tolerable.
    INVESTIGATION.
    Coalitions are detectable by their direct appearance on imaging and an educated guess can be made about their presence if spurring (and sometimes dysmorphism) of the Talo-navicular joint is seen.
    A purely bony coalition can be seen with an oblique or lateral hindfoot X-Ray as can any relevant Talo-navicular pathology.
    A more objective and comprehensive assessment of all relevant joints, alignments and pathologies is more routinely made however with MRI, occasionally CT or both. Coalitions may be purely fibrous, purely bony or more often a mix.
    NON-OPERATIVE MANAGEMENT.
    In the adult an attempt at conservative management is appropriate in many patients. The nature of this may be a period in a post-operative boot , the use of an orthotic or an intra-coalition injection (or all three). One paper in the literature review of this section suggests that conservative management is highly successful in the symptomatic adult but I have never found it so.
    ALTERNATE/ADDITIONAL OPERATIVE MANAGEMENT.
    -In Adults the first question if operative treatment is required is whether there is significant inter-current arthritic change present or not. If so joint fusing surgery may be a better choice. Whether a triple fusion or simply subtalar fusion depends on the nature of the deformity and degenerative change.
    -In the presence of significant hindfoot valgus additional procedures may be considered at the time of surgery to improve the hindfoot position during joint sparing surgery. In the adult an examples would be a medialising Calcaneal osteotomy . In the child or adolescent the addition of an arthroresis implant into the sinus tarsi.
    -It there is inter-current dorsal spurring of the talo-navicular joint and the patient also localises discomfort to this area this joint should be debrided also.
    The approach described is used for access to the medial side of the subtalar joint
    The most common reasons for this are either as part of correcting a severely valgus & degenerate subtalar joint or takedown of a Talo-calcaneal tarsal coalition.

    Setup

    GA or Regional anaesthetic
    Thigh tourniquet
    Femoral & Sciatic nerve block for post-operative pain relief
    Peri-operative antibiotics
    LMW Heparin prophylaxis
    Supine position , sandbag under contra-lateral buttock.

    Operation

    The sagittal T2 image medially shows no discernible articulation between talus and calcaneus.

    The coronal slices need to be studied in this case. They show a significant over hang of the medial talus over the medial aspect of the posterior facet of the subtalar joint that will need to be extensively resected. Bone oedema is present quite extensively through both talus and calcaneus when compared to the distal tibia.

    Skin incision made in the line of the Tibialis posterior tendon , from behind the medial malleolus to its insertion into the navicular.

    The Tibialis Posterior (1) is identified after opening its sheath (2).

    There is some synovitis (1) associated with the tendon which will be removed. The deeper approach will be through the thick fibrous tissue which comprises the bed of the tendon(2).

    Prior to the deeper dissection the Flexor Digitorum Longus (2) is identified after opening its sheath (1). The interval between the two , commencing in the bed of the Tibialis Posterior , is then developed.

    As dissection commences the bony “bridge” associated with the medial aspect of the subtalar joint becomes visible between the two tendons (1 & 2).

    The deep fascia (1) , immediately beneath the Tibialis Posterior , is reflected by sharp dissection off the under-lying medial aspect of the subtalar joint (3) . The FDL tendon (2) is retracted inferiorly to optimise access.

    Further precise sub-periosteal stripping allows better definition of the area of coalition (1). It can be difficult to orientate oneself accurately here . Evidence of any visible joint line should be looked for and stressing through the subtalar joint might produce some movement between Talus and Calcaneus. If the coalition is large then a generous (CT informed) bony debridement is likely to be required before any movement at all can be identified.

    With some preliminary resection of “overhanging” coalition (1 & 3) a joint line becomes evident .This is aided by controlled distraction applied from within this initially tight space using the McDonalds (2).
    The FDL (4) will require measured retraction to gain access to the more posterior aspects of the joint.

    Closer inspection reveals more clearly a “seam” of chondral lining at the line of cleavage (1) between the closely opposed Talar (3) and Calcaneal (2) articular surfaces.

    It is key that one ensures complete resection of the coalition . The dimensions that need to be appreciated are both A-P as well as Superior to Inferior. The imaging associated with this case demonstrates an unusually large medial talo-calcaneal coalition.
    The Laminar spreader (1) is a very useful tool for aiding identification of the joint line, assisting separation of intra-articular adhesions and confirming adequate resection has been completed.

    A sagittal CT slice of what on a single slice appears to be a fairly limited talo-calcaneal coalition with associated spurring of the talo-navicular joint.

    The axial imaging suggests the pathology to be more extensive.

    Post Operative

    This obviously depends on the indication. If as part of a corrective triple fusion then see this section.
    If as for take down of a coalition the first two weeks are spent in a lightweight cast , limited weight bearing
    After two weeks into long post-operative boot and commence weight bearing using crutches.
    Usually by the end of 3 weeks post op it is comfortable to weight-bear just in the boot without the need for crutches.
    From 2 weeks , once out of cast , active and passive ankle & subtalar range of movement exercises are started .This should be under physiotherapy supervision .
    The main objective of surgery is pain relief. On occasion increased subtalar range that is achieved on table can be maintained , but only with an active program of joint mobilisation and only if this is not at the expense of pain returning.
    Of upmost importance through-out the post-operative period is that the wound is looked after . Wound infection and small areas of breakdown occur easily in a freshly healed wound that is allowed to rub on socks/shoewear.
    Any exudate from the wound which is allowed prolonged contact with the wound will further excacerbate any skin breakdown . Dressing changes may therefore need to be frequent if such a complication ensues.
    Once out of cast I advise another month of daytime dressings when in shoes and also nocturnal dressings whilst any of the wound remains unhealed
    Showering & bathing is from when out of cast.

    Recommended Reading

    Tarsal coalitions in the adult population :Does treatment differ from the adolescent ?
    Foot Ankle Clin 2012 (jun) 17 (2): 195-204 .Thorpe SW, Wukich DK
    The authors management protocol is detailed. 3 months of conservative treatment initially followed by joint sparing surgery as an initial route in the absence of significant intercurrent arthritic change is advocated. Resection is more likely to be successful in Calcaneonavicular coalitions than Talocalcaneal coalitions in the authors experience
    For patients requiring fusion if the hindfoot is neutral alignment an in-situ subtalar fusion and if valgus deformation then a Triple fusion possibly with additional calcaneal osteotomy.
    Tarsal coalition in adults.
    Foot Ankle Int 2000 ;21(8):669-72.
    Varner KE, Michelson JD.
    32 feet with 18 talocalacaneal ,14 calcaneonavicular coalitions & 1 naviculocuneiform coalition reported. Approximately 2/3rds showed decreased subtalar movement and a similar proportion had a neutral hindfoot. Conservative management was used comprising casting , analgesia & activity modification .
    5 patients proceeded to operative management (onecoalition resection and 4 subtalar fusions)
    Long term functional outcomes of resected tarsal coalitions.
    Foot Ankle Int 2013:34(10):1370-5
    Khoshbin A, Law PW, Caspi L, Wright JG.
    Mean age at surgery 12 years and at follow up 27 years
    19 calcaneonavicular coalitions reviewed and 13 Talocalcaneal coalitions .No significant difference with respect to outcome and no effect on outcome relating either to extent of coalition or degree of hindfoot valgus.

    Reference

    • orthoracle.com

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