770625
research-article2018
FAIXXX10.1177/1071100718770625Foot & Ankle InternationalAldahshan et al
Article
Endoscopic Resection of Different Types of Talocalcaneal Coalition
Foot & Ankle International® 1–7 © The Author(s) 2018 Reprints and permissions: sagepub.com/journalsPermissions.nav https://doi.org/10.1177/1071100718770625 DOI: 10.1177/1071100718770625 journals.sagepub.com/home/fai
Wael Aldahshan, MD1, Adel Hamed, MD1, Faisal Elsherief, MD1, and Ashraf Mohamed Abdelaziz, MD1
Abstract Background: The purpose of this study was to describe the technique of endoscopic resection of talocalcaneal coalition (TCC) by using 2 posterior portals and to report the outcomes of endoscopic resection of different types and sites of TCC. Methods: An interventional prospective study was conducted on 20 feet in 18 consecutive patients who were diagnosed by computed tomography to have TCC for which nonoperative treatment had failed and endoscopic resection was performed. The patients were divided into groups according to the site of the coalition (middle facet or posterior facet) and according to type (fibrous, cartilage, or bony). The mean follow-up period was 26 months (range, 6-36). Results: The average preoperative American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score was 57.7 (range, 40-65), and the average preoperative visual analog scale (VAS) score was 7.8 (range, 6-8). The average postoperative AOFAS hindfoot score was 92.4 (range, 85-98; P < .01). The average postoperative VAS score was 2.4 (range, 1-4). All patients showed no recurrence on postoperative lateral and Harris-Beath X-ray until the end of the study. Conclusions: Endoscopic resection of TCC was an effective and useful method for the treatment of talocalcaneal coalition. It provided excellent outcomes with no recurrence in this short-term study. Resection of the fibrous type had a better outcome than resection of cartilage and bony types. Endoscopic resection of the posterior coalition had a better outcome than resection of the middle coalition. Level of Evidence: Level III, comparative study. Keywords: talocalcaneal coalition, endoscopic resection Talocalcaneal coalition (TCC) is the most common type of tarsal coalition that causes hindfoot pain. The incidence of TCC has been reported to be between 1% and 6%.5,8,13 TCC is best detected with a Harris-Beath view or ski-jump view.4 Computed tomography (CT) scanning remains the standard imaging technique in diagnosis and classification.2,5 Operative treatment is indicated after failure of conservative treatment. The operative options for tarsal coalition are either resection or arthrodesis. Resection is indicated in symptomatic patients with less than 50% involvement of the joint, and no arthritic changes of the subtalar joint are involved.1,9,13 Many open techniques have been described for TCC excision with or without interposition material, but none has shown superior results.2,6,7 Open surgery has many disadvantages, such as risk of wound dehiscence, unsatisfactory results, infection and delayed wound healing9 with increased risk of incisional neuroma formation,10 and prolonged hospitalizations.12 The most important
technical issue is inadequate exposure of the posteromedial aspect. The purpose of this study was to describe the technique of endoscopic resection of TCC by using 2 posterior portals and to report the outcomes of endoscopic resection of different types and sites of TCC. Our hypothesis was that by using 2 posterior portals, with retraction of the flexor hallucis longus (FHL), it would be possible to approach and visualize the medial aspect of the subtalar joint (Figure 1). TCC has different pathologies and sites of coalition; therefore, endoscopic resection of different types and sites of coalition would lead to different results. 1
Alzahraa University Hospital, Faculty of Medicine for Girls, Al-azhar University, Cairo, Egypt
Corresponding Author: Wael Aldahshan, MD, Alzahraa University Hospital, Al-azhar University, 6th district, Naser City, Cairo, 1356, Egypt. Email:
[email protected]
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Foot & Ankle International 00(0) Table 1. General Characteristics of Studied Patients. Items
Figure 1. Schematic view for the arthroscopic approach to the posterior facet and middle facet of the subtalar joint using 2 posterior portals. Note the retraction of the flexor hallucis longus (FHL) and use of the posteromedial portal as a viewing portal and the posterolateral portal as a working portal. FDL, flexor digitorum longus.
Methods After approval by the ethical review board, a prospective study was conducted between June 2012 and December 2014 on 20 feet in 18 consecutive patients diagnosed with TCC who did not respond to conservative treatment such as activity modification, foot orthoses, nonsteroidal antiinflammatory drugs, physical therapy, and cast immobilization. The patients underwent endoscopic excision of the bar through 2 posterior portals. One patient with unilateral coalition was lost to follow-up at the sixth month. Inclusion criteria were symptomatic patients with TCC involving less than 50% of the joint. Exclusion criteria were arthritic changes of the subtalar joint, association with another coalition, and hindfoot valgus causing lateral impingement. The average age at the time of operation was 21.8 ± 3.1 (range, 18-29) years. Two (10%) cases were bilateral and 16 (90%) cases were unilateral. Thirteen (65%) patients were male, and 5 (35%) patients were female; operations were performed on the right foot in 13 (65%) cases and on the left foot in 7 (35%) cases. The mean follow-up period was 26 ± 7.1 (range, 6-36) months. One patient with unilateral coalition stopped follow-up at the sixth month (Table 1). Preoperative evaluation of all patients included history, physical examination, American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, maximum standing time (MST), maximum walking distance (MWD), visual analog pain scale (VAS) score, examination of subtalar mobility, X-ray of both lateral and Harris-Beath views, and CT to determine the site, size, shape, and types of coalition. To measure MST, we had the patient record it during daily activity. MWD was measured from the treadmill during
Sex, No. (%) Male Female Type, No. (%) Fibrous Cartilage Bony Mixed Site, No. (%) Middle Posterior Unilateral/bilateral, No. (%) Unilateral Bilateral Feet, No. (%) Right Left Age at the time of operation Mean ± SD, y Range, y Follow-up period Mean ± SD, mo Range, mo Average time to return to normal daily activity Mean ± SD, wk Range, wk
Studied Group (n = 20) 13 (65.0) 7 (35.0) 5 (25.0) 6 (30.0) 8 (40.0) 1 (5.0) 13 (65.0) 7 (35.0) 18 (90.0) 2 (10.0) 13 (65.0) 7 (35.0) 21.8 ± 3.1 18-29 26 ± 7.1 6-36 4.8 ± 1.3 3-7
sport activity. Both MST and MWD are not validated tests, but they roughly describe the changes in daily activity of the patient. The patients were divided according to site of coalition into a posterior-facet group and a middle-facet group and according to type of coalition: bony, cartilaginous, and fibrous groups. All patients underwent endoscopic resection for TCC through 2 posterior portals under general or spinal anesthesia with a thigh tourniquet. A 30-degree 4.5-mm optic and 5-mm shaver (full radius and acromionizer) were used. In the prone position, the affected foot was at the very end of the table, and the distal tibia rested over a roll or sandbag for easy manipulation without conflict with the other foot. Then, external rotation was controlled using a sandbag ipsilaterally under the iliac bone, and the table was tilted to the contralateral side with a post. Routine posterolateral (PL) and posteromedial (PM) portals were used, and the posterior joint lines of the ankle and subtalar joints with FHL were identified. The os trigonum or Stieda process (if present) was excised. Complete release of the FHL retinaculum with mobilization of the FHL tendon was done to identify the
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Aldahshan et al
Figure 2. Arthroscopic view of posterior ankle after removal of the Stieda process and release of the flexor hallucis longus (FHL) retinaculum.
Figure 4. Arthroscopic view showing the posterior aspect of subtalar used as a guide during the shaving of the coalition.
Figure 3. An arthroscopic view showing the posterior aspect of the subtalar joint with a nylon tab used to retract the flexor hallucis longus (FHL) tendon.
posterior aspect of the subtalar joint, which made it easy to retract the FHL (Figure 2). The FHL tendon was retracted and separated using a nylon tape from the PM portal (Figure 3). The PM corner of the subtalar joint was shaved to make working room and evaluate the extent of the coalition. The portals were then switched. The scope then was rested over the FHL, protecting the neurovascular bundle, and the shaver was directed laterally. We used the posterior aspect of the subtalar joint as a direction guide during the shaving and checked it occasionally (Figure 4). The portals were switched again to confirm that the very anterior end of the coalition now had healthy cartilage and to check the movement of the subtalar joint (Figure 5). We shaved off subarticular bone more than the articular surface by 2 mm (cartilage lipping) and then used a radiofrequency blade over the subarticular bone to prevent recurrence (Figure 6). Postoperative evaluation included the AOFAS hindfoot score, MST, MWD, VAS, examination of subtalar mobility, and time of return to normal daily activity. X-ray, lateral, and Harris-Beath views were done immediately after surgery and then at 6, 12, and 24 months (Figures 7 and 8).
Figure 5. Arthroscopic view showing that there is a movement in the subtalar joint. FHL, flexor hallucis longus.
Figure 6. Arthroscopic view shows the forming of a lipping of the cartilage by shaving the subarticular bone more than the articular surface by 2 mm.
One day after surgery, full weightbearing as tolerated was allowed, with full range of motion (ROM). Active and
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Foot & Ankle International 00(0) variance (ANOVA) test for comparison between more than 2 mean values; and unpaired t test to compare preoperative and postoperative data. Qualitative data were expressed as number and percentage. The value of significance was taken at P ≤ .05.
Results
Figure 7. Preoperative X-ray lateral view of the right ankle of a male patient with bony talocalcaneal coalition (TCC).
Figure 8. Immediate postoperative X-ray lateral view of the right ankle of the same patient after arthroscopic resection of talocalcaneal coalition (TCC).
At surgery, 5 (24%) feet had fibrous coalition, 6 (30%) feet had a cartilaginous bar, and 8 (40%) feet had a purely bony bar. One (5%) foot had mixed coalitions. Coalitions were located at the middle facet in 13 (65%) feet and at the posterior facet in 7 (35%) feet. Preoperatively, all patients had diffuse pain while standing and walking. The average preoperative maximum standing time was 23 (range, 15-35) minutes, and the average postoperative maximum standing time was 148 (range, 120-180) minutes (P < .01) (Table 2). The average preoperative maximum walking distance was 130 (range, 90-150) m, and the average postoperative maximum walking distance was 1200 (range, 850-2000) m (P < .01) (Table 2). The average preoperative AOFAS hindfoot score was 57.7 (range, 40-65), and the average postoperative AOFAS hindfoot score was 92.4 (range, 85-98; P < .01). The average preoperative VAS score was 7.8 (range, 6- 8), and the average postoperative VAS score was 2.4 (range, 1-4). The average time to return to normal daily activity was 4.8 ± 1.3 (range, 3-7) weeks (Table 2). According to types, the results of comparisons between fibrous, cartilaginous, and bony coalitions are shown in Table 3. According to site, the results of comparisons between posterior- and middle-facet coalitions are shown in Table 4. Preoperatively, no subtalar mobility could be detected in any of the patients; postoperatively, all patients showed clinical subtalar mobility without stiffness. X-ray (lateral and Harris-Beath views) series through the end of study showed no recurrence.
Complications
passive ROM and strengthening exercises were started after suture removal (2 weeks). Six weeks after surgery, the patient was allowed to return to normal daily and sport activity.
One patient (5%) had hyperesthesia over the medial aspect of the calcaneus for 3 months but improved completely after 6 months.
Statistics
Discussion
Coding of data was carried out manually, and the analysis was conducted through Statistical Package for Social Science (SPSS), version 16 (SPSS, Inc, an IBM Company, Chicago, IL). Quantitative data were presented as mean ± standard deviation (SD), using an unpaired t test for comparison between 2 independent variables; 1-way analysis of
Resection of TCC is indicated in symptomatic patients with no arthritic changes and less than 50% involvement of the joint. The technique has advantages over fusion because it preserves hindfoot mobility and offers earlier return to normal daily and sport activity than fusion does. Endoscopic resection of TCC is a new method that permits
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Aldahshan et al Table 2. Comparison Between Preoperative and Postoperative AOFAS, MST, and MWT for All Patients. Items AOFAS Range Mean ± SD MST Range Mean ± SD MWD Range Mean ± SD VAS Range Mean ± SD
Preoperative
Postoperative
40-55 48 ± 4.7 15-35 24.5 ± 6.7
85-98 90.1 ± 4.7 1 20-180 146 ± 22.3
100-150 127.5 ± 20.7
1000-2000 1485 ± 370.3
6-8 7 ± 0.6
1-4 2±1
Paired t Test
P Value
20.5
