Fibrous Coalition of the Middle Facet
Peroneal Spastic Flatfoot
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Jay Lieberman,
DPM, FACFAS
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Tarsal coalitions are comparatively rare abnormalities. Often, symptoms appear later in life. There are many theories regarding the cause. The first is a failure of differentiation and segmentation of primitive mesenchyme during fetal development. Incorporation of accessory ossicles into the normal tarsal bone on either side of the joint is another theory. The os sustentaculum proprium may play a role in middle facet fusions as well. Intra-articular coalitions are most commonly treated with arthrodesis procedures. In some instances, however, an attempt can be made to resect the coalition if secondary degenerative changes are not advanced. Younger patients with incomplete non-osseous coalitions are better candidates for these procedures.
CASE PRESENTATION
This is an 18-year-old male who presented to our office with chief complaint of sharp pain along the posterior aspect of the calf. The pain was particularly evident in the early morning and to some extent the afternoon. The patient was not involved in many sporting activities. At the age of 9, he wore his first pair of orthotics in a depth shoe. Most recently, he tried a new pair of orthotics. This provided only marginal control of his symptoms. The left foot was more symptomatic than the right.
Figure 1: Fibrous Coalition Middle Facet |
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PAST MEDICAL HISTORY: This is essentially unremarkable.
MEDICATIONS: None
ALLERGIES: NKA
SOCIAL HISTORY: The patient was not a smoker, nor did he consume alcohol. He did not use recreational drugs. He did not drink coffee or tea.
PAST FOOT/ANKLE HISTORY: The patient has had no surgery or hospitalizations related to the foot.
REVIEW OF SYSTEMS: This was essentially unremarkable.
LOWER EXTREMITY PHIYSICAL EXAMINATION: The patient’s neurovascular status was intact. Pedal pulses were graded +2/+4 bilateral. Proprioceptive sensoriums were intact. The skin was supple and well hydrated. The nails were normal.
Clinically noted was palpable tenderness along the posterior facet of the subtalar joint bilateral. The discomfort the patient described in the posterior aspect of the left foot appeared to be more closely related to the subtalar joint than the Achilles tendon. ROM in the mid tarsal and first MPJ was fluid and unrestricted. Ankle dorsiflexion was limited in both the knee flexed and knee extended position. It was difficult at the time of the initial examination to determine whether any motion on the frontal plane was emanating from the subtalar joint or from the ankle. On gait analysis, a virtual collapse of the medial column was noted on mid stance of gait. There was a valgus position of the heel noted as well. When the patient was asked to rise to a toe-raised position, we saw no change in the longitudinal arch of the left foot. The right foot was more flexible.
X-rays taken preoperatively demonstrated obscurity of the posterior facet. There was anterior advancement of the cyma line and increased talocalcaneal angle.
Figure 2:
Obscured Middle and Posterior Facet |
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Figure 3:
Medial Subluxation Talar Head |
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ASSESSMENT: High suspicion for subtalar joint coalition.
PLAN: The patient was sent for a MRI. The imaging revealed that the patient had a fibrous coalition in the subtalar joint.
Figure 4: Fibrous Coalition Middle Facet |
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Figure 5: MRI Axial Fibrous Coalition |
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The patient was fitted for a Ritchie brace. He wore the brace for two to three months, but, ultimately, found it too cumbersome and stopped wearing it. The patient was given a diagnostic/therapeutic Marcaine injection into the subtalar joint. He responded quite favorably. This indicated that addressing the coalition/flatfoot would be beneficial to the patient.
The patient and his family engaged in discussions regarding the expectations and possible complications associated with biplane calcaneal osteotomy. The goal of the procedure was to better align the rearfoot, address pronation, and lessen pain associated with the coalition.
Intraoperatively, the fibrous coalition was identified and resected. A percutaneous Achilles tendon lengthening was performed .
Figure 6: Excessive Pronation |
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Figure 8: Identification of Middle Facet and Posterior Tibial Tendon |
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Figure 9: Portion of Talus for Resection |
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An BioArch® subtalar arthroereisis was put into place to maintain the separated segments of the coalesced site. A Koutsogiannis anterior medial calcaneal osteotomy was performed using two Darco® 7.0 Headless Screws.
Figure 10: Koutsogiannis Placement |
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Figure 11:
Screw Placement |
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Figure 12:
Darco 7-0 headless compression screws |
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Figure 13:
Axial View with Arthroereisis in
Place - Joint Space is now opened |
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