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Calcaneonavicular coalition with naviculocuneiform and cuneiform-first metatarsal coalitions: a case report.

A 15-year-old female with a history of cerebral palsy (GMFCS 1) presented with pain in her left ankle and foot. She was a high school sophomore. She had increasing pain in her left ankle and foot over the last few years. She had a history of recurrent left ankle sprains that initially occurred while playing sports (including volleyball) or walking on uneven surfaces. More recently, however, she stated that the instability occurs while walking on level ground. She had a past surgical history of a left tendino-Achilles lengthening when she was an infant with revision 11 years later and left third toe arthrodesis. On physical exam, her left ankle dorsiflexed to neutral with limited subtalar motion. The patient was neurovascularly intact throughout her left foot and ankle. X-rays and CT showed a fibrocartilaginous coalition of the calcaneonavicular joint along with partial osseous fusion of the naviculocuneiform (Chopart's joint) and medial cuneiform-first metatarsal joints (Figs. 1 and 2).

The patient was initially treated conservatively with immobilization in a short leg cast for 2 months followed by gradual return to activity in an Arizona ankle brace. The patient continued to have symptoms and 1 year after presentation underwent resection of the coalitions with interposition of fibrin glue. The calcaneonavicular coalition was addressed first using an oblique Ollier incision over the lateral aspect of the foot. After excision of the calcaneonavicular coalition, there was persistent limitation of hindfoot and midfoot motion. Because of this persistent limitation in motion, the navicular-medial cuneiform and medial cuneiform-first metatarsal coalitions were subsequently resected through a second incision along the medial aspect of the foot. The coalitions were found to affect approximately one-third of the joints, respectively. After the coalitions were excised, there was improved mobility of the hindfoot and midfoot. Four milliliters of fibrin glue were injected into the involved joints. Postoperative images are shown in Figure 3.

Postoperatively, she was non-weightbearing for the first 6 weeks followed by partial weightbearing for 4 weeks with a CAM boot full-time. Subsequently, she was made weightbearing as tolerated with CAM boot on an as needed basis along with initiation of physical therapy program. At 3-month follow-up, the patient continued to have pain at lateral aspect of midfoot and was given UCBL for symptomatic treatment. She was able to perform ADLs and school activities.

Discussion

Failure to identify when multiple joints are involved in tarsal coalition can result in persistent symptoms and failure of operative management. Although the exact incidence is unknown, between 3.8% to 20% of patients who present with tarsal coalition have multiple joints involved. (1) Tarsal coalition can be either complete or incomplete and can be congenital or secondary to trauma, infection, surgery, or other joint disorders of the foot. Multiple coalitions can be associated with syndromes, such as Apert syndrome, or disorders such as fibular hemimelia. Typically, the average age of presentation for tarsal coalition is 12 years secondary to progressive ossification of the coalition, leading to stiffening hindfoot and reduction in subtalar motion.

Patients can present with foot pain; fractures, including 5th metatarsal and distal tibia; sprains; stiffness; or activity limitations. (2) Obtaining x-rays is routine in the evaluation of these symptoms, but coalitions can be hard to visualize using conventional radiograph because of bone overlap, obliquity of the coalition, and coalitions of fibrocartilaginous origin. (3) In addition to AP and lateral views, 45[degrees] oblique weight-bearing view is necessary to visualize a calcaneonavicular coalition. (4) Computed tomography is the standard imaging technique to evaluate tarsal coalitions. (4) It is useful not only to confirm diagnosis but also to define size and location for preoperative planning.

Nonoperative therapy is usually the first line of treatment, which includes decreased activity, functional orthoses, and NSAIDs. Initial treatment of calcaneonavicular coalition includes a soft shoe insert or walking-cast immobilization. Surgery is indicated when conservative management fails to provide symptom relief. Success of surgical treatment depends on the ability to completely excise the coalition while limiting damage to adjacent structures. (2) The two options are arthrodesis or coalition resection. For coalition resection, interposition graft may be used, with extensor digitorum brevis (EDB), bone wax, fibrin glue, or fat as options. Bone wax or gel form is as efficacious as EDB transfer but with less wound complications such as dehiscence. (5)

Non-osseus coalitions are commonly seen at the talocalcaneal joint or calcaneonavicular joint. (6,7) There are also reports of third metatarsal and lateral cuneiform (8,9) and medial cuneiform-first metatarsal joints. (10) However, cases of multiple coalitions involving three joints below the talus, as described in this study, are rare. Solely resecting one will not resolve symptoms, and medial column pain can persist. Furthermore, addressing all coalitions in a patient can still lead to persistent debilitating pain, making these types of pathology difficult to manage.

Conclusion

Coalitions involving three joints of the midfoot are rare. To our knowledge, this is the first report of a patient having fibrocartilaginous coalition of the calcaneonavicular joint along with partial osseous fusion of the naviculocuneiform (Chopart's joint) and medial cuneiform-first metatarsal joints. Failing to adequately evaluate and address all coalitions in a patient can result in persistent pain and stiffness. Persistent midfoot pain in cerebral palsy patients should be evaluated for potential coalitions. These multi-coalition pathologies are challenging to address operatively as pain can persist even after recognizing and surgically addressing each coalition in a patient.

Disclosure Statement

None of the authors have a financial or proprietary interest in the subject matter or materials discussed, including, but not limited to, employment, consultancies, stock ownership, honoraria, and paid expert testimony.

Shaleen Vira, M.D., Gabriel J. Felder, M.D., and Norman Y Otsuka, M.D., Center for Children, NYU Hospital for Joint Diseases, New York, New York. Richard McCormack, M.D., Total Orthopaedics and Sports Medicine, Massapequa, New York.

Correspondence: Shaleen Vira, M.D., Resident Physician, NYU Hospital for Joint Diseases, 301 East 17th Street, New York, New York 10003; shaleen.vira@nyumc.org.

References

(1.) Masquijo JJ, Jarvis J. Associated talocalcaneal and calcaneonavicular coalitions in the same foot. J Pediatr Orthop B. 2010 Nov; 19(6):507-10.

(2.) Mubarak SJ, Patel PN, Upasani VV, et al. Calcaneonavicular coalition: treatment by excision and fat graft. J Pediatr Orthop. 2009 Jul-Aug; 29(5):418-26.

(3.) Mosier KM, Asher M. Tarsal coalitions and peroneal spastic flat foot. A review. J Bone Joint Surg Am. 1984 Sep; 66(7):9768-4.

(4.) Zaw H, Calder JD.Tarsal coalitions. Foot Ankle Clin. 2010 Jun; 15(2):349-64.

(5.) Cohen BE, Davis WH, Anderson RB. Success of calcaneonavicular coalition resection in the adult population. Foot Ankle Int. 1996 Sep; 17(9):569-72.

(6.) Conway JJ, Cowell HR. Tarsal coalition: clinical significance and roentgenographic demonstration. Radiology. 1969 Mar; 92(4):799-811.

(7.) Stormont DM, Peterson HA. The relative incidence of tarsal coalition. Clin Orthop Relat Res. 1983 Dec;(181):28-36.

(8.) Day FN 3rd, Naples JJ, White J. Metatarsocuneiform coalition. J Am Podiatr Med Assoc. 1994 Apr; 84(4):197-9.

(9.) Stevens BW, Kolodziej P. Non-osseous tarsal coalition of the lateral cuneiform-third metatarsal joint. Foot Ankle Int. 2008 Aug; 29(8):867-70.

(10.) Tanaka Y, Takaura Y, Sugimoto K, Kumai T. Non-osseous coalition of the medial cuneiform-first metatarsal joint: a case report. Foot Ankle Int. 2000 Dec; 21(12):1043-6.

Caption: Figure 1 Oblique and AP x-rays demonstrating calcaneonavicular coalition with naviculocuneiform and cuneiform-first metatarsal coalition.

Caption: Figure 2 Axial CT scan demonstrating calcaneonavicular coalition with naviculocuneiform and cuneiform-first metatarsal coalition.

Caption: Figure 3 Postoperative oblique and AP x-rays after surgical intervention.

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Article Details
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Author:Vira, Shaleen; McCormack, Richard; Felder, Gabriel J.; Otsuka, Norman Y.
Publication:Bulletin of the NYU Hospital for Joint Diseases
Article Type:Clinical report
Date:Apr 1, 2016
Words:1263
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