72 old Tarsal Coalition 20221.pdf

Natural History of the Pediatric Flatfoot Flexible Calcaneovalgus Hypermobile Developmental Classification of the Flatfoot Pathological Vertical Talus Severed PT Tendon Neurogenic Hypermobile with Limitations Tarsal Coalitions 3 Tarsal Coalition: Definition Congenital union of two or more tarsal bon...

Natural History of the Pediatric Flatfoot Flexible Calcaneovalgus Hypermobile Developmental Classification of the Flatfoot Pathological Vertical Talus Severed PT Tendon Neurogenic Hypermobile with Limitations Tarsal Coalitions 3 Tarsal Coalition: Definition Congenital union of two or more tarsal bones by bone, fibrous tissue, or cartilage Planovalgus deformity Decreased subtalar/midfoot motion Pain and peroneal spasm Historical Perspective 5 Etiology of Tarsal Coalition Harris BJ. Anomalous structures in the developing human foot. Anat Rec 1955; 121-399. Usually reported prevalence of 1% to 2% What is the prevalence of tarsal coalitions? Nalaboff KM, Schweitzer ME. MRI of tarsal coalition: frequency, distribution, and innovative signs. Bull NYU Hosp Jt Dis 2008;66:14–21 Prospective study of 574 individuals older than 12 years Prevalence of tarsal coalition was 11.5% Rühli FJ, Solomon LB, Henneberg M. High prevalence of tarsal coalitions andtarsal joint variants in a recent cadaver sample and its possible significance. Clin Anat 2003;16:411– 5. Study of 114 feet from 62 cadavers with no known foot disorders Prevalence of 13% 100 cadaveric feet Incidence of talocalcaneal coalition was as high as 12.7%. Joints most commonly affected are talocalcaneal and calcaneonavicular (90% of cases) Stormont DM, Peterson HA The relative incidence of tarsal coalition. Clin Orthop Relat Res 1983;181:28–36. 314 cases of tarsal coalition from 11 studies Talocalcaneal 48.1% Calcaneonavicular was 43.6% Talonavicular and Calcaneocuboid were 1.3% Unspecified group made up the remaining 5.7% Incidence of Symptomatic Pediatric Tarsal Coalition in Olmsted County. Taylor J. Jackson, et al. J Bone Joint Surg Am, 2020 Nov 11 Methods A population-based database was used to identify all new diagnoses of symptomatic tarsal coalitions 18 years old or younger between 1966 and 2018 Results Incidence of Symptomatic Pediatric Tarsal Coalition in Olmsted County. Taylor J. Jackson, et al. J Bone Joint Surg Am, 2020 Nov 11 58 patients with a total of 79 symptomatic tarsal coalitions were identified Annual incidence = 3.5 per 100,000 children 43 calcaneonavicular (CN) coalitions 27 talocalcaneal (TC) coalitions 9 other coalitions (7 talonavicular, 1 naviculocuboid, and 1 naviculocuneiform) Incidence of Symptomatic Pediatric Tarsal Coalition in Olmsted County. Taylor J. Jackson, et al. J Bone Joint Surg Am, 2020 Nov 11 Results: The overall incidence peaked between the ages of 10 and 14 years for both boys and girls Presentation Talonavicular 3-5 Y/O Calcaneonavicular 8-12 Y/O Talocalcaneal 12-16 Y/O Synostosis (osseous) Types of coalitions? Synchondrosis (cartilage) Syndesmosis (fibrous) Presentation Symptoms Pain Valgus Deformity Subtalar Stiffness Pain results from the mechanical abnormality Incomplete coalition – microfractures PathophysiologyCoalition Lack of internal rotation Reduction in subtalar glide in dorsiflexion Clinical Exam 17 Clinical Exam 18 Tarsal Coalitions 19 What are the physical exam findings? Restricted motion of the STJ and MTJ – variable!! Loss of supination of the hindfoot with heel rise – variable!! Pes planus or pes cavus Flat arch or normal arch Describe the foot type of talo-calcaneal coalitions Middle facet coali,on: Pes planus Posterior facet coalition: Pes cavus What are the radiographic findings of a coalition? C-sign or ring sign Talar beak (dorsal osteophyte arising from the head of the talus) Middle facet not visible on lateral view Anteater nose sign Narrowing of posterior sub-talar joint line Rounded lateral process of talus Short, cup-shaped talar neck Radiographic Findings Calcaneonavicular Lateur LM. Subtalar coalition: diagnosis with the C sign on lateral radiographs of the ankle. Radiology 1994;193(3):847–51. C sign Circular density composed of the talar dome and inferior margin of the sustentaculum tali 25 Advanced Imaging 27 Morphologic Variations Talus dominant Calcaneus dominant Symmetric Symmetric Talus Dominant Calcaneus Dominant Morphologic Varia-ons Focal, discreet Large, massive Indicated only for persistently painful tarsal coalitions Treatment Basics No evidence that resection of painless, incidentally identified tarsal coalitions leads to better outcomes than the natural history of the condition. It is not clear what causes some to become painful Attempts should be made to relieve symptoms by nonoperative means 34 Activity modification NSAIDs/Injections NonOpera:ve Treatments Orthotics Immobilization in walking boot or walking cast Pain is generally relieved completely within 24 to 48 hours of cast/boot application Approximately 30% of patients remain pain-free after cast removal 6 weeks 35 Results of Nonoperative Treatment for Symptomatic Tarsal Coalitions. Eric Shirley, et al. Cureus. 2018 Jul 8;10(7):e2944. Surgical Resection Predicting outcome Patient’s age Extent of the joint involved Degree of hindfoot valgus Presence of degenerative changes Indicated for those feet with persistent or recurrent disabling pain despite prolonged attempts at nonoperative management Surgery The goal of treatment is to relief pain Surgical options Resection of the coalition Deformity correction with an osteotomy Arthrodesis 38 What are the contraindications for resection? NWB splint x 1 week WBAT in Boot/ROM x 3 weeks Post-Op Recovery Shoes/PT at 4 weeks Post op RTA? Post-op: inadequate resection Post-op: good resection?? CT: Talus dominant pattern, incomplete ossification 14 year old 48 49 50 51 52 14 y/o with CN Coalition 53 54 What do the outcomes show us? 55 Operative versus nonoperative treatment in children with painful rigid flatfoot and talocalcaneal coalition. Giovanni Luigi Di Gennaro, et al. BMC Musculoskelet Disord. 2020 Mar 24;21(1):185 Methods Retrospective review medical records Children with Right Flatfoot and TC coalition Nonoperative treatment consisted of manipulation under anesthesia, cast immobilization and shoe insert Operative treatment consisted of combined TCC resection, graft interposition and subtalar arthroereisis 56 Operative versus nonoperative treatment in children with painful rigid flatfoot and talocalcaneal coalition. Giovanni Luigi Di Gennaro, et al. BMC Musculoskelet Disord. 2020 Mar 24;21(1):185 57 58 Operative versus nonoperative treatment in children with painful rigid flatfoot and talocalcaneal coalition. Giovanni Luigi Di Gennaro, et al. BMC Musculoskelet Disord. 2020 Mar 24;21(1):185 58 Comfort TK, Johnson LO. Resection for symptomatic talocalcaneal coalition. J Pediatr Orthop 1998;18(3):283–8 77% success rate with resection when the coalition involved one-third or less of the total surface area of the subtalar joint on CT Wilde PH, Torode IP, Dickens DR, et al Resecgon for symptomagc talocalcaneal coaligon. J Bone Joint Surg Br 1994;76(5):797–801 Hindfoot valgus of greater than 16 degrees and a coalition surface area greater than 50% of the posterior facet on CT were predictors of poor results after resection Gait abnormalities after resection of talocalcaneal coalitions 5 excellent, 4 good, 3 fair, and 2 poor clinical results Mean duration of 6 years after resection Good results deteriorate over time Most patients have a residual functional deficit with decreased motion of the hindfoot and the ankle Kitaoka HB et al. JBJS 1997 Functional and Radiological Outcomes After Tarsal Coalition Resections: A Minimum 5-Year Follow-Up Kadir Ilker Yildiz, et al. The Journal of Foot & Ankle Surgery 58 (2019) 1223−1228 33 patients between 12 and 35 years old Resections (24 TC and 9 CN) Functional and Radiological Outcomes After Tarsal Coalition Resections: A Minimum 5Year Follow-Up Kadir Ilker Yildiz, et al. The Journal of Foot & Ankle Surgery 58 (2019) 1223−1228 At the minimum 5-year follow-up Subtalar joint osteoarthriTs developed in all paTents with TC resecTons and most paTents with CN resecTons, but paTents did not have funcTonal impairment Functional and Radiological Outcomes After Tarsal Coalition Resections: A Minimum 5-Year Follow-Up Kadir Ilker Yildiz, et al. The Journal of Foot & Ankle Surgery 58 (2019) 1223−1228 More favorable long-term outcomes TC coalitions were