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Calcaneonavicular Coalition

James Kutchback, DPM
Senior Resident
Northwest Medical Center

Tarsal coalition is a condition where two tarsal bones are bridged and adversely affects the motion of the foot. The etiology is most commonly congenital of unknown mechanism. This can be intra-articular or extra-articular and may include talocalcaneal, talonavicular, calcaneocuboid, naviculocuneiform, calcaneonavicular, and cubonavicular coalitions.

Dr. Michael Downey described a classification system that is based on age, articular involvement, and arthritic changes which can be used as a surgical management tool. Osseous immature patients with an extra-articular coalition and no arthritic changes tend to have better surgical outcomes and are able to attain a more normal foot function. Osseous mature patients with an intra-articular coalition and arthritic changes seem are a greater challenge to manage and typically result in fusion and restricted foot function.

The various procedures described include resections, fusions, and osteotomies. These have been performed in combination and with other adjunctive procedures with the goal of pain relief while attaining the best possible function.

CASE PRESENTATION

A 13-year-old male presented to the clinic with a history of severe pain in the right foot following extended periods of weight bearing. He had pain in the planter arch, lateral foot and ankle and fatigue in the leg muscles. The pain was relieved with rest. His parents have noticed that he is “flat footed” and his right foot is “angled out” significantly.

Past Medical History: asthma
Past Surgical History: n/a
Medications: albuterol prn
Allergies: Penicillin
Social History: aspires to spend a whole day at Disney World pain free and keeping up with the guys
Family History: unremarkable

Orthopedic Exam: NWB appearance - pes planovalgus B/L, R>L; R foot is severely abducted; talar head protrusion R>L. ROM – decreased dorsiflexion at the ankle joints with the knees extended, improved dorsiflexion with the knees flexed; restricted ROM at the subtalar and midtarsal joints of the R foot. Gait analysis – no supination of the R foot with heel raise; antalgic gait; abductory twist of the R foot. Pain on palpation of the sinus tarsi and the talonavicular area.

Xrays, AP, lateral, MO B/L feet – R foot exhibits calcaneonavicular coalition; increased talocalcaneal and calcaneocuboid angles; anterior advancement of the Cyma line; no overt arthridities noted.

Normal left foot

Calcaneal Navicular Coalition Right

Coalition seen on lateral view

CT Scan demonstrating coalition

Neurovascular status is WNL B/L.
Skin color, texture and turgor are WNL B/L.

Impression: Calcaneonavicular coalition R; Collapsing pes planovalgus B/L with peroneal spasm on the R foot; Gastroc-equinus B/L.

Plan: Surgical and non-surgical treatment options were discussed. The patient and his family requested surgical intervention. Resection of the calcaneonavicular coalition was performed and augmented with a MBA subtalar joint implant and gastrocnemius recession.

Opening Paratenon

Gastroc Recession

Gastroc Recession

Insertion of arthroeresis

Placement of implant seen on flouroscopy

A pseudoarthrosis was noted intra-operatively. A significant increase in subtalar and midtarsal joint ROM was appreciated. The MBA implant improved the planovalgus deformity while helping to maintain space at the resection site. A bivalved below knee cast was applied and he will remain NWB for 3-4 weeks.

Resected Coalition with arthroeresis in place