Calcaneonavicular Coalation

Calcaneonavicular coalition or tarsal coalition is a condition that mainly affects children with severe stiff or flat feet. It is a condition where there is an abnormal connection between two or more tarsal bones. The coalitions can occur between bones that do not have joints between them. Some people with the condition do not feel any pain and others feel pain when there is any movement between the connected bones. The result is a stiff and immobile midfoot or hindfoot.

Causes of Calcaneonavicular Coalition

The condition is usually inherited. It occurs when the bones in the foot do not develop properly in the womb. Other causes include arthritis, infections, and injuries to the area.

Symptoms of Calcaneonavicular Coalition

The majority of people with a tarsal coalition are born with it. However, the symptoms do not appear until the bones start to mature. It happens when one is between 8 and 16 years. For some, they do not experience the symptoms until they get into their adult years. Here are the most common Calcaneonavicular coalition symptoms:

• Flatfoot in the feet. It could be in one or both of them.
• Pain on the top and outer part of the foot.
• Stiff ankle and foot.
• Overly tired legs.
• Muscle spasms that make the foot turn outwards when you walk.

How to Diagnose Calcaneonavicular Coalition

Tarsal coalitions diagnosis is through physical examinations of the ankle and foot. An accurate medical history also helps to identify if the condition is inherited. You can also get diagnosed through X-rays. MRI and CT scan also come in handy in verifying the diagnosis and find out the type of coalition, the location, and the joints affected. 

Treatment Options Available for Calcaneonavicular Coalition

The treatment options for this condition are numerous and includes both surgical and non-surgical options. The treatment options are determined based on the extent of the condition. 

Non-surgical treatment options include:

• Non-steroidal anti-inflammatory medications to alleviate pain and inflammation.
• Steroid injections to the joint for relief from inflammation and pain.
• Physical therapy including ultrasound therapy, massage, and numerous motion exercises.
• Immobilizing the foot in a cast boot or cast so the affected area can rest.
• Using orthotic devices that limit joint movement and provide pain relief.

Surgical Treatment- Arthroscopy

If these options do not work, surgery might be necessary.  Arthroscopy is a minimally invasive surgery to correct the condition. The technique has a quick recovery time and a follow-up for the next 12 months. The skin incision is supposed to be superficial. The incision is followed by blunt dissection of the subcutaneous tissue to prevent any nerve damage from occurring. Complications that might arise include hematoma, neuroma, and infections. 

Arthroscopy Surgical Procedure

To begin with, the patient is installed in dorsal decubitus and a cushion placed under the ipsilateral buttock. At the foot of the limb, a pneumatic tourniquet is applied. To perform the surgery, you need to have the image identification at three-quarters of the incidence. 

The steps involved in arthroscopy are as follows:

• First, you need to confirm that the portal is posterior to the anterolateral process of the calcaneus, dorsal to the angle of Gissane. After dissecting by Halsted forceps down to contact the bone, you introduce a 4mm arthroscope.
• Using a needle, insert the second visual portal. The portal is inserted distal to the calcaneal process and lateral to the extensor digitorum longus tendon. 
• The longitudinal subcutaneous dissection by Halsted forceps conserves the third peroneus tendons and the extensor digitorum longus, and the immediate dorsal cutaneous nerve that is a branch of the superficial peroneal nerve. The nerve can first be located subcutaneously when the foot is in maximum inversion.
• The surgery proceeds downwards towards the tarsal sinus. Now, you can carefully release the extensor digitorum brevis muscle with the use of a motorized knife. It will help create a work chamber around the coalition that is later completely isolated then removed using a motorized burr. Extra care must be taken while making this excision to prevent cartilage damage at the inferolater altalar head and the superior edge of the cuboid joint surface. 
• Use a curette or Smilie straight meniscus knife to remove the deepest part of the bone bridge to ensure complete rectilinear resection. After removing this part of the bone, you can perform cauterization followed by fulguration. Check for complete resection at the lower side of the talonavicular and calcaneocuboid joints. 
• Make sure that there is a coalition and a calcaneonavicular joint space of at least 1 cm, the palpation hook will serve as a landmark. You can check for joint ROMs after completing the surgery on the varus-valgus maneuvers and flexion-extension. 
• While the surgery seems complicated, it is effective for treating the condition. When the space is less than 10mm, there is a 30% chance of the condition reoccurring. It is recommended that the space during resection to be equal or more than 1 cm.

For children between 11 and 15 years, the surgery takes between 63 to 94 minutes, and full recovery is attained after 12 months of follow-up treatment. It is recommended that the condition is treated early enough when one is still a child to aid in quick recovery.

Recovery After Surgery

After surgery, there is follow-up care for the next 12 months. After surgery, you can start postoperative active and passive foot mobilization procedures. This should be followed by gradual resumption to weight-bearing based on the pain tolerance of the individual. All this is done during physiotherapy until there is full recovery. 

Final Thoughts on Calcaneonavicular Coalition

Calcaneonavicular coalition pain in children can reduce their movements and lead to stiff ankle and foot movements. The condition can be treated by the use of non-invasive methods if not severe. If non-invasive treatments do not work, the only option is to undergo surgery.  If you or your loved ones have Calcaneonavicualar Coalition, you can contact Gurnee Podiatry & Sports Medicine and get help from Dr. Schoene and his team. Also if you have additional information about the condition, you can mention it in the comment section below.