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An Incidental Finding of a Talonavicular and Talocalcaneal Joint Coalition After a Tibial Pilon Fracture: A Case Report
The Journal of Foot & Ankle Surgery xxx (2017) 1–3
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Case Reports and Series
An Incidental Finding of a Talonavicular and Talocalcaneal Joint Coalition After a Tibial Pilon Fracture: A Case Report Heidi M. Godoy, DPM 1, Mark J. Micciche, DPM 2 1 2
Resident Physician, Postgraduate Year II, Geisinger Community Medical Center, Scranton, PA Associate, LaPorta & Associates, Dunmore, PA
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
It has been proposed that patients with talocalcaneal and talonavicular coalitions have decreased ankle joint range of motion. It has also been reported that rotational forces regularly absorbed by the talocalcaneal joint are transferred to the ankle joint in patients with coalitions, increasing the stress on the ankle joint after trauma. To the best of our knowledge, only 1 reported study has detailed the increased stress placed on the ankle joint secondary to a coalition. We present a case study of a 53-year-old female who experienced a traumatic fall and subsequent right ankle fracture. Advanced imaging studies revealed a comminuted tibial pilon fracture and talocalcaneal and talonavicular joint coalitions. She underwent open reduction and internal fixation for treatment of the fracture, and the coalitions were not treated because they were asymptomatic. She was kept non-weightbearing for 6 weeks postoperatively and was returned to a regular sneaker at 10 weeks postoperatively. The postoperative films revealed stable intact fixation and pain-free gait with no increased restriction in her ankle joint range of motion. The hardware was removed at 13 months postoperatively. She had not experienced increased pain or arthritic changes at 15 months postoperatively. Ó 2017 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: pilon subtalar joint talocalcaneal talocrural talonavicular tarsal coalition
A tarsal coalition is a union between 2 tarsal bones that limits the range of motion of the involved joint. The etiology of tarsal coalitions is uncertain; however, evidence has shown that they can be either congenital or acquired. Congenital tarsal coalitions are more common, occur in the adolescent population, and result from failure of mesenchymal segmentation of 2 tarsal bones. Acquired tarsal coalitions are rare, occur mostly in the adult population, and can result from trauma, surgery, arthritis, or neoplasms (1). The 2 most common types of tarsal coalitions are calcaneonavicular and talocalcaneal (TC) coalitions (1,2). A TC coalition is characterized by nonspecific symptoms such as vague hindfoot pain, which often occurs after minor injuries such as recurrent ankle sprains. Most patients with TC coalitions are asymptomatic; however, several investigators have reported that restriction of the subtalar joint increases the mechanical stress on the ankle joint (1–5). A case of an unusual pilon fracture with a TC and talonavicular (TN) coalition is presented, in which abnormal force might have been applied to the ankle mortise owing to restriction of the subtalar joint motion and might have increased the fracture severity.
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Heidi M. Godoy, DPM, Geisinger Community Medical Center, 1800 Mulberry Street, Scranton, PA 18510. E-mail address: [email protected] (H.M. Godoy).
Case Report We present a case report of a 53-year-old female. The patient was walking on her porch when her right leg slipped through a loose plank and she suffered a right ankle fracture. She was brought to the emergency department where the physical examination revealed significant edema and tenderness to the right ankle with noted deformity but no open fractures and an intact neurovascular status. Plain radiography revealed an isolated intraarticular tibial plafond fracture, with intact medial and lateral malleoli and no widening of the syndesmosis (Fig. 1). A TN osseous coalition and a ball and socket ankle joint were incidentally discovered as well. Computed tomography confirmed a pilon fracture, the TN coalition, and a middle facet TC coalition (Fig. 2). The patient was placed in a splint and compressive dressing, admitted to the hospital, and taken to the operating room the next day for open reduction and internal fixation. The patient was placed on the operating table in the supine position, and general anesthesia was administered. A well-padded thigh tourniquet was applied, the limb was prepared sterilely, the limb was exsanguinated using a esmarch, and the tourniquet was inflated to 350 mm Hg. A longitudinal incision was made at the anterior aspect of the ankle, and dissection was carried down to the fracture site. Manual reduction of the fracture fragments was performed and temporarily stabilized with Kirschner wires. Open reduction and internal fixation using a 123-mm distal tibial plate and a smaller 6-hole
1067-2516/$ - see front matter Ó 2017 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2017.06.005
2
H.M. Godoy, M.J. Micciche / The Journal of Foot & Ankle Surgery xxx (2017) 1–3
Fig. 1. Plain radiographs revealing an isolated intraarticular tibial plafond fracture. (A) Frontal view. (B) Lateral view.
hand plate was performed. After the hardware had been secured, the syndesmosis was stressed, and no widening was appreciated. The postoperative films showed excellent reduction of the fracture with no ankle joint incongruity (Fig. 3A, 3B). The patient was placed in a well-padded posterior splint and was kept non-weightbearing for 6 weeks postoperatively. She began partial weightbearing in a controlled ankle motion boot at 8 weeks postoperatively and was in a regular sneaker by 10 weeks. The patient was able to walk without discomfort when she transitioned to sneakers. At 3 months postoperatively, she had returned to running and performing activities of daily living pain free. At 1 year after surgery, the hardware was removed to prevent stress shielding, and the patient healed uneventfully 1 year post-hardware removal. The patient never experienced symptoms associated with either of her tarsal coalitions. Contralateral foot radiographs taken at her last postoperative visit revealed identical coalitions to her left lower extremity. She did have significant restriction of range of motion of the subtalar joint; however, this did not cause her pain, and her ankle joint range of motion was pain free. She was asymptomatic at her 16-month follow-up examination.
Discussion Zuckerkandl (6) first described talocalcaneal coalitions in 1877. The main symptoms associated with this condition are foot fatigue and vague pain at the hindfoot with increased activity. Patients with talocalcaneal coalitions have restricted or absent motion of the subtalar joint. Many investigators have reported the mechanical characteristics of the ankle complex (7–12). The ankle joint complex is composed of the talocrural and subtalar joints. The subtalar joint has motion mainly in the frontal plane and the talocrural joint has motion mainly in the sagittal plane. In patients with subtalar joint coalitions, a noted restriction in subtalar joint inversion will be present. An adaptation to this is the development of a ball and socket ankle joint, which allows for increased inversion and eversion at the talocrural joint. Siegler et al (11) observed the respective range of motion of the ankle complex in inversion. According to their findings, if the subtalar joint motion has been lost, either completely or incompletely, an excessive rotational force will be loaded onto the talocrural joint in inversion.
Fig. 2. Computed tomography reconstructions revealing (A) and (B) a pilon fracture, (C) the talonavicular coalition.
H.M. Godoy, M.J. Micciche / The Journal of Foot & Ankle Surgery xxx (2017) 1–3
3
Fig. 3. (A to C) Postoperative radiographs revealing intact fixation with no signs of hardware loosening.
In addition, Leardini et al (9) reported that the range of motion of the subtalar joint accounts for >70% to 90% of the overall range of motion of the ankle complex. Hamel et al (13) reported that isolated TN synostosis results in marked impairment of the subtalar range of motion. In our review of the published data, we found only 1 study that appreciated an abnormal fracture pattern to the talocrural joint in a patient with a subtalar joint coalition. Imade et al (7) reported a case study of a 16-year-old male who experienced an ankle fracture after playing tennis. His radiographs revealed an unusual fracture mechanism that the investigators believed was secondary to his talocalcaneal coalition (7). To the best of our knowledge, no other reported studies have described the increased fracture mechanism at the ankle secondary to restriction of the hindfoot in patients with coalitions. We also were unable to appreciate any published data that showed a correlation between patients with coalitions versus subtalar joint fusions and their altered biomechanics. One could postulate that the decreased or absent range of motion seen in a subtalar arthrodesis could also increase the risk of a traumatic pilon fracture, such as we are proposing occurs with coalitions. We are in the process of performing a cadaveric study whereby we would fuse the TC and TN joints and load the ankle joint in a supination-adduction force. We will evaluate the fracture mechanism at the ankle joint and will be able to appreciate whether or not a more severe fracture pattern will occur with fused TN or TC joints. Although our patient’s fracture mechanism was severe, minimal comminution was appreciated intraoperatively. Computed tomography did reveal a posterior malleolar fracture, and reduction of the posterior malleolar fracture was attempted intraoperatively. However, secondary to the decreased range of motion at the subtalar joint and fused talonavicular joint, surgical reduction and restoration of the anatomic alignment was difficult. After several attempts, it was decided to forego reduction of the posterior malleolus. We did explain to her that her subsequent risk of arthritis would be increased secondary to her fracture mechanism; however, at 2 years postoperatively, she had no complaints of arthritis or increased pain to her ankle joint. The rationale behind the type of internal fixation used was that our patient was a young, healthy female with no other comorbidities. We believed it was not necessary to use larger plates secondary to this.
Another reason the specific construct was chosen was secondary to its low profile and ability to use 2 separate plates on the distal tibia. The hardware was removed approximately 1 year postoperatively to prevent future stress shielding (Fig. 3C). In conclusion, we believe that patients with tarsal coalitions should undergo a more thorough perioperative decision-making process in the presence of any traumatic fracture secondary to their altered biomechanics. It is also important to explain to patients with TN or TC coalitions that they might be at increased risk of sustaining a more significant injury to the ankle in a trauma, secondary to the amount of force that is dampened by the subtalar and talonavicular joints. Treatment of asymptomatic talocalcaneal coalition is not necessarily needed; however, it is important to provide patients with information regarding their increased level of risk. References 1. Mosier KM, Asher MA. Tarsal coalitions and peroneal spastic flatfoot. A review. J Bone Joint Surg Am 66A:976–984, 1984. 2. Jayakumar S, Cowell HR. Rigid flatfoot. Clin Orthop 122:77–84, 1977. 3. Leonard MA. The inheritance of tarsal coalition and its relationship to spastic flat foot. J Bone Joint Surg Br 56B:520–526, 1974. 4. Scranton PE. Treatment of symptomatic talocalcaneal coalition. J Bone Joint Surg Am 69:533–539, 1987. 5. Takakura Y, Tanaka Y, Kumai T. Development of the ball-and-socket ankle as assessed by radiography and arthrography. J Bone Joint Surg Br 81B:1001–1004, 1999. 6. Zuckerkandl E. Ueber einen fall von synostose zwischen talus und calcaneus. Allg Weiner Med Zeitung 22:293–294, 1877. 7. Imade S, Takao M, Nishi H, Uchio Y. Unusual malleolar fracture of the ankle with talocalcaneal coalition treated by arthroscopy-assisted reduction and percutaneous fixation. Arch Orthop Trauma Surg 127:277–280, 2007. 8. Konradsen L, Voigt M. Inversion injury biomechanics in functional ankle instability: a cadaver study of simulated gait. Scand J Med Sci Sports 12:329– 336, 2002. 9. Leardini A, Stagni R, O’Connor JJ. Mobility of the subtalar joint in the intact ankle complex. J Biomech 34:805–809, 2001. 10. Michelson JD. Ankle fractures resulting from rotational injuries. J Am Orthop Surg 11:403–412, 2003. 11. Siegler S, Udupa JK, Ringleb IS. Mechanics of the ankle and subtalar joints revealed through a 3D quasi-static stress MRI technique. J Biomech 38:567–578, 2005. 12. Stagni R, Leardini A, O’Connor JJ. Role of passive structures in the mobility and stability of human subtalar joint: a literature review. Foot Ankle Int 24:402–409, 2003. € ller G, Becker W. A case of bilateral isolated talonavicular synostosis in 13. Hamel J, Mu childhooddobservations of tarsal joint function and functional adaptation of the proximal ankle joint. Z Orthop Ihre Grenzgeb 131:275–277, 1993.
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Case Reports and Series
An Incidental Finding of a Talonavicular and Talocalcaneal Joint Coalition After a Tibial Pilon Fracture: A Case Report Heidi M. Godoy, DPM 1, Mark J. Micciche, DPM 2 1 2
Resident Physician, Postgraduate Year II, Geisinger Community Medical Center, Scranton, PA Associate, LaPorta & Associates, Dunmore, PA
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
It has been proposed that patients with talocalcaneal and talonavicular coalitions have decreased ankle joint range of motion. It has also been reported that rotational forces regularly absorbed by the talocalcaneal joint are transferred to the ankle joint in patients with coalitions, increasing the stress on the ankle joint after trauma. To the best of our knowledge, only 1 reported study has detailed the increased stress placed on the ankle joint secondary to a coalition. We present a case study of a 53-year-old female who experienced a traumatic fall and subsequent right ankle fracture. Advanced imaging studies revealed a comminuted tibial pilon fracture and talocalcaneal and talonavicular joint coalitions. She underwent open reduction and internal fixation for treatment of the fracture, and the coalitions were not treated because they were asymptomatic. She was kept non-weightbearing for 6 weeks postoperatively and was returned to a regular sneaker at 10 weeks postoperatively. The postoperative films revealed stable intact fixation and pain-free gait with no increased restriction in her ankle joint range of motion. The hardware was removed at 13 months postoperatively. She had not experienced increased pain or arthritic changes at 15 months postoperatively. Ó 2017 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: pilon subtalar joint talocalcaneal talocrural talonavicular tarsal coalition
A tarsal coalition is a union between 2 tarsal bones that limits the range of motion of the involved joint. The etiology of tarsal coalitions is uncertain; however, evidence has shown that they can be either congenital or acquired. Congenital tarsal coalitions are more common, occur in the adolescent population, and result from failure of mesenchymal segmentation of 2 tarsal bones. Acquired tarsal coalitions are rare, occur mostly in the adult population, and can result from trauma, surgery, arthritis, or neoplasms (1). The 2 most common types of tarsal coalitions are calcaneonavicular and talocalcaneal (TC) coalitions (1,2). A TC coalition is characterized by nonspecific symptoms such as vague hindfoot pain, which often occurs after minor injuries such as recurrent ankle sprains. Most patients with TC coalitions are asymptomatic; however, several investigators have reported that restriction of the subtalar joint increases the mechanical stress on the ankle joint (1–5). A case of an unusual pilon fracture with a TC and talonavicular (TN) coalition is presented, in which abnormal force might have been applied to the ankle mortise owing to restriction of the subtalar joint motion and might have increased the fracture severity.
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Heidi M. Godoy, DPM, Geisinger Community Medical Center, 1800 Mulberry Street, Scranton, PA 18510. E-mail address: [email protected] (H.M. Godoy).
Case Report We present a case report of a 53-year-old female. The patient was walking on her porch when her right leg slipped through a loose plank and she suffered a right ankle fracture. She was brought to the emergency department where the physical examination revealed significant edema and tenderness to the right ankle with noted deformity but no open fractures and an intact neurovascular status. Plain radiography revealed an isolated intraarticular tibial plafond fracture, with intact medial and lateral malleoli and no widening of the syndesmosis (Fig. 1). A TN osseous coalition and a ball and socket ankle joint were incidentally discovered as well. Computed tomography confirmed a pilon fracture, the TN coalition, and a middle facet TC coalition (Fig. 2). The patient was placed in a splint and compressive dressing, admitted to the hospital, and taken to the operating room the next day for open reduction and internal fixation. The patient was placed on the operating table in the supine position, and general anesthesia was administered. A well-padded thigh tourniquet was applied, the limb was prepared sterilely, the limb was exsanguinated using a esmarch, and the tourniquet was inflated to 350 mm Hg. A longitudinal incision was made at the anterior aspect of the ankle, and dissection was carried down to the fracture site. Manual reduction of the fracture fragments was performed and temporarily stabilized with Kirschner wires. Open reduction and internal fixation using a 123-mm distal tibial plate and a smaller 6-hole
1067-2516/$ - see front matter Ó 2017 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2017.06.005
2
H.M. Godoy, M.J. Micciche / The Journal of Foot & Ankle Surgery xxx (2017) 1–3
Fig. 1. Plain radiographs revealing an isolated intraarticular tibial plafond fracture. (A) Frontal view. (B) Lateral view.
hand plate was performed. After the hardware had been secured, the syndesmosis was stressed, and no widening was appreciated. The postoperative films showed excellent reduction of the fracture with no ankle joint incongruity (Fig. 3A, 3B). The patient was placed in a well-padded posterior splint and was kept non-weightbearing for 6 weeks postoperatively. She began partial weightbearing in a controlled ankle motion boot at 8 weeks postoperatively and was in a regular sneaker by 10 weeks. The patient was able to walk without discomfort when she transitioned to sneakers. At 3 months postoperatively, she had returned to running and performing activities of daily living pain free. At 1 year after surgery, the hardware was removed to prevent stress shielding, and the patient healed uneventfully 1 year post-hardware removal. The patient never experienced symptoms associated with either of her tarsal coalitions. Contralateral foot radiographs taken at her last postoperative visit revealed identical coalitions to her left lower extremity. She did have significant restriction of range of motion of the subtalar joint; however, this did not cause her pain, and her ankle joint range of motion was pain free. She was asymptomatic at her 16-month follow-up examination.
Discussion Zuckerkandl (6) first described talocalcaneal coalitions in 1877. The main symptoms associated with this condition are foot fatigue and vague pain at the hindfoot with increased activity. Patients with talocalcaneal coalitions have restricted or absent motion of the subtalar joint. Many investigators have reported the mechanical characteristics of the ankle complex (7–12). The ankle joint complex is composed of the talocrural and subtalar joints. The subtalar joint has motion mainly in the frontal plane and the talocrural joint has motion mainly in the sagittal plane. In patients with subtalar joint coalitions, a noted restriction in subtalar joint inversion will be present. An adaptation to this is the development of a ball and socket ankle joint, which allows for increased inversion and eversion at the talocrural joint. Siegler et al (11) observed the respective range of motion of the ankle complex in inversion. According to their findings, if the subtalar joint motion has been lost, either completely or incompletely, an excessive rotational force will be loaded onto the talocrural joint in inversion.
Fig. 2. Computed tomography reconstructions revealing (A) and (B) a pilon fracture, (C) the talonavicular coalition.
H.M. Godoy, M.J. Micciche / The Journal of Foot & Ankle Surgery xxx (2017) 1–3
3
Fig. 3. (A to C) Postoperative radiographs revealing intact fixation with no signs of hardware loosening.
In addition, Leardini et al (9) reported that the range of motion of the subtalar joint accounts for >70% to 90% of the overall range of motion of the ankle complex. Hamel et al (13) reported that isolated TN synostosis results in marked impairment of the subtalar range of motion. In our review of the published data, we found only 1 study that appreciated an abnormal fracture pattern to the talocrural joint in a patient with a subtalar joint coalition. Imade et al (7) reported a case study of a 16-year-old male who experienced an ankle fracture after playing tennis. His radiographs revealed an unusual fracture mechanism that the investigators believed was secondary to his talocalcaneal coalition (7). To the best of our knowledge, no other reported studies have described the increased fracture mechanism at the ankle secondary to restriction of the hindfoot in patients with coalitions. We also were unable to appreciate any published data that showed a correlation between patients with coalitions versus subtalar joint fusions and their altered biomechanics. One could postulate that the decreased or absent range of motion seen in a subtalar arthrodesis could also increase the risk of a traumatic pilon fracture, such as we are proposing occurs with coalitions. We are in the process of performing a cadaveric study whereby we would fuse the TC and TN joints and load the ankle joint in a supination-adduction force. We will evaluate the fracture mechanism at the ankle joint and will be able to appreciate whether or not a more severe fracture pattern will occur with fused TN or TC joints. Although our patient’s fracture mechanism was severe, minimal comminution was appreciated intraoperatively. Computed tomography did reveal a posterior malleolar fracture, and reduction of the posterior malleolar fracture was attempted intraoperatively. However, secondary to the decreased range of motion at the subtalar joint and fused talonavicular joint, surgical reduction and restoration of the anatomic alignment was difficult. After several attempts, it was decided to forego reduction of the posterior malleolus. We did explain to her that her subsequent risk of arthritis would be increased secondary to her fracture mechanism; however, at 2 years postoperatively, she had no complaints of arthritis or increased pain to her ankle joint. The rationale behind the type of internal fixation used was that our patient was a young, healthy female with no other comorbidities. We believed it was not necessary to use larger plates secondary to this.
Another reason the specific construct was chosen was secondary to its low profile and ability to use 2 separate plates on the distal tibia. The hardware was removed approximately 1 year postoperatively to prevent future stress shielding (Fig. 3C). In conclusion, we believe that patients with tarsal coalitions should undergo a more thorough perioperative decision-making process in the presence of any traumatic fracture secondary to their altered biomechanics. It is also important to explain to patients with TN or TC coalitions that they might be at increased risk of sustaining a more significant injury to the ankle in a trauma, secondary to the amount of force that is dampened by the subtalar and talonavicular joints. Treatment of asymptomatic talocalcaneal coalition is not necessarily needed; however, it is important to provide patients with information regarding their increased level of risk. References 1. Mosier KM, Asher MA. Tarsal coalitions and peroneal spastic flatfoot. A review. J Bone Joint Surg Am 66A:976–984, 1984. 2. Jayakumar S, Cowell HR. Rigid flatfoot. Clin Orthop 122:77–84, 1977. 3. Leonard MA. The inheritance of tarsal coalition and its relationship to spastic flat foot. J Bone Joint Surg Br 56B:520–526, 1974. 4. Scranton PE. Treatment of symptomatic talocalcaneal coalition. J Bone Joint Surg Am 69:533–539, 1987. 5. Takakura Y, Tanaka Y, Kumai T. Development of the ball-and-socket ankle as assessed by radiography and arthrography. J Bone Joint Surg Br 81B:1001–1004, 1999. 6. Zuckerkandl E. Ueber einen fall von synostose zwischen talus und calcaneus. Allg Weiner Med Zeitung 22:293–294, 1877. 7. Imade S, Takao M, Nishi H, Uchio Y. Unusual malleolar fracture of the ankle with talocalcaneal coalition treated by arthroscopy-assisted reduction and percutaneous fixation. Arch Orthop Trauma Surg 127:277–280, 2007. 8. Konradsen L, Voigt M. Inversion injury biomechanics in functional ankle instability: a cadaver study of simulated gait. Scand J Med Sci Sports 12:329– 336, 2002. 9. Leardini A, Stagni R, O’Connor JJ. Mobility of the subtalar joint in the intact ankle complex. J Biomech 34:805–809, 2001. 10. Michelson JD. Ankle fractures resulting from rotational injuries. J Am Orthop Surg 11:403–412, 2003. 11. Siegler S, Udupa JK, Ringleb IS. Mechanics of the ankle and subtalar joints revealed through a 3D quasi-static stress MRI technique. J Biomech 38:567–578, 2005. 12. Stagni R, Leardini A, O’Connor JJ. Role of passive structures in the mobility and stability of human subtalar joint: a literature review. Foot Ankle Int 24:402–409, 2003. € ller G, Becker W. A case of bilateral isolated talonavicular synostosis in 13. Hamel J, Mu childhooddobservations of tarsal joint function and functional adaptation of the proximal ankle joint. Z Orthop Ihre Grenzgeb 131:275–277, 1993.