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BACKGROUND: Symptomatic calcaneonavicular coalitions treated with resection and interposition of the extensor digitorum brevis (EDB) muscle often have unpredictable improvement of symptoms. Concerns with regard to skin cosmesis from a bony prominence on the lateral aspect of the foot and inadequate filling of the resection gap potentially causing reossification have motivated us to use fat graft interposition instead. The purpose of this study was to describe our surgical technique and report our clinical and radiographic outcomes for fat graft interposition after resection of a calcaneonavicular coalition.
METHODS: A retrospective review of all pediatric patients surgically treated with a calcaneonavicular coalition resection from January 1999 to December 2006, was performed. Presenting symptoms and examination findings were recorded. Postoperative examinations and imaging studies were evaluated to grade reossification, and functional outcomes were assessed for all patients with minimum 1-year postoperative follow-up. In addition, a cadaveric study was performed to compare the efficacy of EDB and fat graft interposition in terms of filling the postresection gap.
RESULTS: Foot pain was the most common presenting complaint, though limitation of activities, stiffness, preoperative hindfoot malalignment, and associated injuries were also frequently observed. One year after resection, 87% of the patients returned to sport or their past activities, whereas 5% had symptomatic regrowth requiring repeat resection. Seventy-four percent had improvement of subtalar motion and 82% had improvement of plantarflexion; which was identified as an additional clinical sign of a calcaneonavicular bar. Preoperative pain averaged 7 of 10, whereas postoperative pain averaged less than 1 of 10 at rest, while walking, and with activities. The cadaveric study showed that the EDB was able to fill on average only 64% of the resected gap, leaving approximately 10 mm of the plantar gap unfilled.
CONCLUSIONS: Reossification and reoperation rates with fat graft interposition in our series were lower than in most published reports of EDB interposition. Ankle and subtalar motion improved in a vast majority of the patients, and most patients returned to sport without requiring further surgery. Resection of a calcaneonavicular coalition with interposition of fat graft, when meticulously performed, is an effective way to relieve symptoms, restore subtalar motion, and return patients to activities, while preventing reossification.
INTRODUCTION: In case of hindfoot pain, diagnosis of calcaneonavicular tarsal coalition may be missed on X-ray due to the absence of any visible synostosis. All other possible etiologies (too-long anterior process (TLAP) of the calcaneum, synchondrosis, syndesmosis) must be investigated. The literature tends to recommend imaging associating standard X-ray and CT, and possibly bone scintigraphy. MRI is, however, also worth assessing, due to the many non-osseous forms calcaneonavicular pain may take.
MATERIAL AND METHODS: Thirty-two cases of surgically treated calcaneonavicular tarsal coalition were studied. Nineteen cases, in 14 children, over a 10-year period, showed no visible synostosis on initial standard X-ray. In seven cases, bone scintigraphy was performed, CT in seven and MRI in 12. On the basis of the literature, our attitude was in favor of X-ray associated to CT in our early experience. Repeated diagnostic difficulties, however, led us to replace CT by MRI in case of foot pain combined to symptomatology suggestive of coalition.
RESULTS: The series comprised four cartilaginous forms, four fibrous forms and eight TLAPs. In 10 of the 19 feet, radiology was strictly normal, the others showing indirect osseous signs. Only three of the seven scintigraphies showed hyperfixation. CT-scan enabled diagnosis in seven cases (two synchondroses and five rudimentary forms), and missed diagnosis in four (two cartilaginous and two fibrous forms). Second intention MRI showed two synchondroses and two syndesmoses. In the light of these 11 cases, a subsequent series of eight feet was assessed by MRI in first intention, obtaining systematic diagnosis. In all the feet of the series, the symptomatic coalition was treated by surgery, allowing peroperative findings to be compared with the imaging data.
DISCUSSION: Given a rigid and painful foot syndrome suggestive of tarsal coalition, two diagnostic situations arise: (a) the clinical aspect is suggestive and standard X-ray enables diagnosis; (b) the clinical aspect is suggestive, but radiography proves non-contributive, in which case we recommend MRI with sagittal, frontal and axial slices in gadolinium-enhanced T1-weighted and fat-sat T2-weighted sequences, revealing direct (cartilaginous or fibrous coalition) or indirect signs (peripheral inflammation, osteomedullary edema, chondral lesion) unobtainable on CT scans. MRI is particularly effective in as much as most of the children concerned will not have reached bone maturity.
CONCLUSION: We consider MRI to be the most effective means of precise diagnosis (causes and consequences) of tarsal coalition, especially for calcaneonavicular locations. It entails minimal invasion and irradiation, at a lower cost than CT associated to scintigraphy.
Resection of calcaneonavicular bar with interposition of extensor digitorum brevis. A questionnaire review.
Van Renterghem D, De Ridder K. Acta Orthop Belg. 2011 Feb;77(1):83-7.
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The purpose of this study was to review the clinical outcome of teenagers who had a resection of a symptomatic calcaneonavicular bar with interposition of the extensor digitorum brevis muscle. After a mean follow-up of almost 5 years, 22 patients were assessed symptomatically and functionally by means of a questionnaire. More than 95% were satisfied with the operation.
Calcaneonavicular coalition is a common source of pain and more or less severe flat and stiff foot in children. Classically, treatment consists in resecting the coalition using a dorsolateral approach. Good quality resection and interposition can prevent recurrence. The most common complications are infection, hematoma and neuroma. Arthroscopy offers a minimally invasive alternative, but the optimal approach remains undetermined. We describe a surgical technique with an approach based on the anterolateral process of the calcaneus, in three cases with 12months' follow-up. Arthroscopic resection has certain advantages: recovery is quicker, and the esthetic result is better. For the instrumental portal, skin incision should be superficial, followed by blunt dissection of subcutaneous tissue to avoid superficial peroneal nerve injury. Although longer term follow-up is needed, arthroscopy seems to be an attractive minimally invasive technique in this kind of pathology.
Background
Surgical resection of calcaneo-navicular coalition (CNC) with interposition of fat or muscle graft is indicated when there is failure of conservative treatment.
Objectives
to evaluate the clinical and functional of outcome of a new mini-invasive technique for resection of CNC and interposition of synthetic graft.
Methods
This is a prospective case series study on 9 patients (12 feet) with symptomatic CNC. Percutaneous resection of the CNC was done using a motorized bone burr through a small incision in the sinus tarsi under image intensifier control. After complete resection a synthetic graft of Teflon or Dacron measuring 15 mm × 30 mm was interposed to prevent re-union of the bone bar.
Results
The mean follow up period was 26.44 months (±1.5 SD). There was statistically significant improvement in the mean total AOFAS score from 47.89 (±8.49 SD) preoperatively to 90.22 (± 5.26 SD) at two years follow up (P < 0.05). The mean time to return to full daily activity was 7.44 weeks (±0.88 SD)
Conclusion
Percutaneous resection of calcaneo-navicular bar with interposition of synthetic graft is an effective mini-invasive method for treatment of calcaneo-navicular coalition with good results in 44.4% of patients and excellent results in 55.6% of patients.
Arthroscopic resection of calcaneonavicular coalition/malunion via a modified sinus tarsi approach: An early case series
Ashok K. Singh, Stephen W. Parsons Foot and Ankle Surgery; Available online 8 May 2012
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Background
Calcaneonavicular coalition represents abnormal coalescence between calcaneus and navicular bone. It is a congenital anomaly, sometimes becoming symptomatic in young adolescent. This is managed conservatively initially, failing which surgical excision, open or arthroscopic, is considered. We present our arthroscopic technique via a modified sinus tarsi approach, with early results in two adolescent and two young adult patients.
Method
The patient is placed in a 45° “saggy” lateral position, and entry points for portals are marked around sinus tarsi area. The adequacy of resection is checked with image intensifier at the end of procedure. Patients complete subjective scoring forms, Manchester–Oxford Foot Questionnaire and Visual Analogue Scale, pre operatively and at follow-ups. Paired t test was performed to assess statistical significance.
Results
The results of early follow-up of these patients have confirmed complete excision, non-recurrence and symptomatic improvement. The mean difference in MOXFQ scores pre and post surgery is 39.33, with a two-tailed p value of 0.0187. Similarly, the mean difference in VAS score is 5.67 with a two-tailed p value of 0.0034. These are statistically significant and confirm symptomatic improvement at an early follow-up.
Conclusion
The arthroscopic technique provides better access allowing wide excision and causes minimal soft tissue trauma leading to early recovery and mobilisation.
Calcaneonavicular coalition
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