Tarsal Coalition

Tarsal coalition (TC) is an abnormal connection between two or more bones that is present at birth. The connection may be made of fibrous tissue, cartilage, or bone. Most people with TC do not have symptoms. Occasionally, patients experience decreased motion in their foot joints, which can be painful. As one joint loses motion, surrounding joints can develop arthritis. TC usually affects children and teens but can appear in adults also. The condition affects 1-6% of the population and about half of patients have problems with both feet.

Symptoms

While TC may be present at birth, symptoms usually are delayed until the bone matures. This explains why most patients experience pain gradually. The typical patient is a child or teen with foot stiffness and pain with activity. Other symptoms may include discomfort when walking on uneven surfaces, frequent ankle sprains, limited side-to-side joint motion, and flat feet.

Causes

Tarsal coalition is caused by a gene mutation. The bones of the feet are divided into three parts: the hindfoot (back of the foot), midfoot (middle of the foot), and forefoot (front of the foot). Tarsal coalition involves the bones in the midfoot and hindfoot.

Of these bones, the calcaneus (heel bone), talus (lower bone of the ankle), and navicular (boat-shaped bone in the middle of the foot) are most commonly involved. Most tarsal coalitions are one of two types:

• Talo-calcaneal coalition: In this case the talus and the calcaneus have not fully separated.
• Calcaneo-navicular coalition: In this case the front part (beak) of the calcaneus is attached to the outside and lower part of the navicular bone.

Diagnosis

Your foot and ankle orthopedic surgeon will typically diagnose TC with X-rays of the foot and ankle. In some cases, a CT scan or MRI can help in the diagnosis. A CT scan will best determine the extent of a bony coalition while an MRI will be more useful in diagnosing small, fibrous, or cartilage coalitions.

Treatments

In asymptomatic coalitions, observation is all that is needed. In almost all symptomatic cases, non-surgical treatment is the first option.

Non-surgical Treatment

Your surgeon may suggest the following treatments to relieve symptoms:

• Avoiding aggravating activities or walking on uneven ground
• A supportive shoe, orthotic, or ankle brace
• Anti-inflammatory medications
• Immobilization with a cast or walking boot
• Local corticosteroid injection

Surgical Treatment

When conservative management has been exhausted, surgical options should be considered. The type of surgery will depend on the location and size of the coalition, the presence of any arthritis at the joints near the coalition, and the expectations and activity level of the patient.

Resection of the coalition is performed to decrease pain and improve motion between the affected bones. Younger patients tend to do better with resection of a coalition. If the coalition is large or if arthritis is present, your surgeon may suggest a fusion of the affected joints. This improves pain but does not improve motion.

Recovery

A walking cast or boot is used to protect the surgical site. If a fusion procedure is performed, a longer period of immobilization and non-weightbearing is necessary. This is followed by physical therapy to restore range of motion and strength. Arch supports or orthotics also can be helpful in stabilizing the joint, even after surgery. Although it may take up to a year to fully recover, most patients have pain relief and improved motion after surgery.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots. In fusion surgery there is a small risk that the bones will not fuse together.

Talus Fracture

A talus fracture is a broken ankle bone. The talus is the bone in the back of the foot that connects the leg and the foot. It joins with the two leg bones (tibia and fibula) to form the ankle joint and allows for upward and downward motion of the ankle. The talus (ankle bone) sits within the ankle mortise or hinge, which is made up of the two leg bones, the tibia and fibula. There are three joints:

• the ankle, which allows the up-and-down motion of the foot with the leg
• the subtalar joint, which allows for side-to-side movement
• the talonavicular joint, which has a complicated biomechanical function that controls flexibility of the foot and the arch of the foot.

The talus has no muscular attachments and is mostly covered with cartilage, which makes injuries difficult to heal.

Symptoms

Most patients present with pain and swelling around the ankle. They also experience severe ankle pain and difficulty walking due to bruising and swelling.

Causes

Ankle fractures often are the result of high-energy injuries. Falls from ladders and automobile accidents result in the most severe injuries. However, these fractures also may occur from twisting the ankle, which can result in small chips or fragments that are broken off the edges of the ankle.

Diagnosis

In many cases the diagnosis can be made by your physician on physical examination alone. He or she will examine your foot for evidence of swelling or bruising around the ankle. X-rays help visualize the extent of joint involvement and show the location and size of bone fragments. Oftentimes a CT scan is ordered to provide the physician with more information about the fracture. Due to the high energy that is commonly associated with these injuries, your physician also may examine you for other injuries involving the back, neck, head and other extremities.

Treatments

Talus fractures may be treated in a cast or surgery may be recommended.

Non-surgical Treatment

Non-surgical treatment is recommended for fractures in which the pieces of bones remain close together and the joint surfaces are well-aligned. Patients who smoke or have diabetes or poor circulation may be treated without surgery due to the very high risk of developing complications if surgery is performed.

Surgical Treatment

For a majority of patients, surgical treatment is the correct form of treatment. The goal of surgery is to restore the size and shape of the talus. Sometimes this is a problem as the multiple fragments of bone are like putting together the pieces of a difficult puzzle. If the bone has several large pieces, your foot and ankle orthopedic surgeon may perform open reduction and internal fixation (ORIF). The procedure involves making a cut(s) on your foot and placing a metal plate and/or screws to hold the bones together until healing occurs. The procedure aids in restoring the function of your foot.

Recovery

Recovery can be prolonged. No weight or walking on the leg will be allowed for 8-12 weeks. Once the bone is healed, exercise and physical therapy is started to maximize the function of the ankle. You should expect some swelling around the foot for several months after the procedure.

This injury can be very debilitating with persistent pain, stiffness and swelling even after an excellent non-surgical or surgical treatment. However, most people, depending on the type and severity of the fracture, are able to return to most work and recreational activities.

Risks and Complications

Talus fractures are quite severe injuries and can lead to longstanding problems with the foot and ankle. There are early and late complications.

Early complications most often are related to the significant swelling that can occur after these injuries, which can cause wound problems and infection. People who smoke, diabetics, and those with poor circulation are at greatest risk for these complications.

Late complications typically are related to the severity of the initial injury. Most people experience a certain degree of stiffness within the foot and ankle. When the blood supply to the ankle is damaged it can lead to death of the bone, a condition called avascular necrosis (AVN). This condition can lead to significant deformity and arthritis and require additional surgery.

FAQs

How long will I be out of work?

This is a severe injury. Depending on the type of work performed, most people are unable to return to work for at least two weeks after the injury. Those with active jobs may not be able to return for six months to a year.

Do the plates and screws need to be removed?

Plates and screws hold the bones together so that they can heal. Once the bones are healed the hardware serves no purpose. However, most orthopedic surgeons do not recommend removal of the plate and screws unless there are problems with pain or infection.

Stress Fracture

A stress fracture is a small crack in a bone. These fractures most often result from overuse and can occur with an increase in activity. Stress fractures most commonly occur in the weightbearing bones of the legs. When a bone is subjected to a new stress, such as a new exercise routine, it may not be prepared for the increased workload, and as a result, may develop a stress fracture.

Symptoms

The symptoms of stress fractures vary widely. The most common complaint is pain. The pain may develop gradually and often is relieved by rest. Pain usually becomes more intense with physical activity and can be associated with swelling. It is rare to see bruising or discoloration.

Causes

Overuse is the most common cause of a stress fracture. An increase in exercise, athletics, job duties, or even a change in shoes can cause a stress fracture. Other risk factors include repetitive and high-impact activities, such as running, gymnastics, and dance. Osteoporosis also may increase the risk of a stress fracture. Weaker bones may be more susceptible to changes in activity. Any bone of the foot can develop a stress fracture.

Diagnosis

After learning your medical history, your foot and ankle orthopedic surgeon will examine your foot for areas of tenderness and take X-rays. A stress fracture typically is painful directly over the affected bone. If the X-rays are normal, but there is still a high suspicion for a stress fracture based on your history and exam, your surgeon may order additional imaging such as a CT scan, bone scan, or MRI.

Treatments

Since stress fractures most often occur as a result of overuse, initial treatment includes stopping the activity that brought on the fracture. A period of rest typically is needed. If a low impact type of exercise such as biking does not recreate the pain, it may be permitted.

If pain continues with rest from activity, your surgeon may recommend additional treatment. This can include wearing a stiff-soled shoe, a rigid insert/orthotic, or a walking boot. In some cases, your doctor may recommend limited weightbearing with crutches, or even a cast. Calcium and vitamin D supplements may be prescribed to supplement bone health.

Most stress fractures will heal with conservative treatment. If the bone fails to heal, surgery may be necessary. Surgery often involves placing metal plates and screws to secure the bone. Alternatively, your surgeon may inject a bone substitute through a small incision.

Risks and Complications

The most common complication that occurs with a stress fracture involves the bone not healing, called a nonunion. Other complications include malunion, in which the bone heals but in an abnormal position, or recurrent fractures. Recurrent fractures occur more often if the patient has osteoporosis. Patients with osteoporosis should speak with their doctor regarding treatment options.

FAQs

How can I prevent stress fractures?

There are precautions you can take to reduce your risk of stress fractures:

• Start slowly when beginning an exercise program. You should walk and stretch to warm up before progressing to running.
• Make sure your shoes fit properly and have adequate cushioning.
• Make sure you take the time to cool down properly after exercise.
• If you notice discomfort, avoid higher-impact exercise and activity.

Bone Grafts

A bone graft takes bone from one area of the body and puts it in another area to provide support and/or fill in areas where bone is missing. Bone grafts are either taken from the patient (autograft) or taken from a bone donor (allograft). The best bone graft provides enough bone and healing with minimal problems for the patient.

Proximal tibial bone graft (PTBG) is a type of autograft. The proximal tibia is the upper portion of the leg or shin bone that is just below the knee joint. Getting bone from this body part usually is less painful than from other areas like the pelvis.

Diagnosis

PTBG is done when there is not enough bone to allow healing or when your foot and ankle orthopedic surgeon is trying to improve the chances of your bones healing. This typically includes certain fractures or fractures that have not healed and any fusions (forcing two or more separate bones to grow together) of foot/ankle joints.

The main reason to not have a PTBG is if you have hardware in the upper leg. Such devices include knee replacements, plates, and screws and rods. Other reasons to avoid a PTBG include skin problems or infection at the upper leg. Also, some orthopedic procedures require a specifically shaped graft that the proximal tibia cannot provide. This kind of graft may need to be taken from the pelvis.

Treatment

The graft usually is taken from the leg above the foot/ankle being operated on. Your surgeon will make an incision over an area of the upper leg. The incision may be small or large depending on how much graft is needed for your foot/ankle.

Two types of bone can be taken from the proximal tibia. The first is a harder, outer shell of bone that can be removed as a strip. The second is the spongier bone within the proximal tibia. Tools such as drills, chisels, and scoops are used for a PTBG. At times, the surgeon may leave a drain in the leg at the bone for a short time to prevent excessive blood collection. The skin incision typically is closed with sutures or skin staples.

Recovery

Recovery from a PTBG is related to healing of the wound. This usually takes a couple of weeks. You may bear weight on the leg from which the bone was taken if the foot/ankle surgeries done at the same time allow for it. Bending the knee is usually allowed immediately after a PTBG.

Risks and Complications

Potential problems after a PTBG include infection, fracture of the proximal tibia, and pain related to the procedure.

FAQs

If proximal tibial bone graft is taken from my knee, will this prevent me from being able to have other procedures in this area, such as knee replacement?

No. Most surgeries to treat knee problems can be done safely in the future.

Does harvesting tibial bone grafting damage the knee joint?

No. The graft is taken just below the actual joint with great care taken to protect the knee at all times.

Platelet-rich Plasma (PRP)

Platelets are small cells in the blood that help form clots to stop bleeding. Platelet-rich plasma (PRP) is a patient’s own concentrated platelets. PRP contains a large number of growth factors, which are thought to stimulate healing.

When PRP is injected, it can aid the body’s natural healing of injuries. The goal is not only to relieve symptoms but also to create actual healing. In some cases, PRP injections may reduce the need for medication and/or surgery.

PRP injections have been used to treat tendon, ligament, cartilage and bone injuries, as well as arthritis. Around the foot and ankle, PRP is used for treatment of tendon and ligament injuries such as plantar fasciitis and Achilles tendinitis.

PRP injections are not recommended for the treatment of infections or cancer.

Treatment

A small amount of a patient’s blood is drawn and then spun at high speed. The platelets are concentrated to contain 3-5 times the concentration of growth factors compared to normal human blood. Your foot and ankle orthopedic surgeon will then inject this liquid around or near the area being treated. They may use ultrasound or an X-ray as a guide for placing the injection.

Your surgeon may recommend a single injection or a series of injections based on the injury being treated and your initial response to the therapy.

Recovery

You may experience mild pain and irritation of the area for several days following the injection. Some doctors may ask patients to limit motion or weightbearing activity immediately following the injection. The use of a brace, boot, or cast may be recommended during the early post-injection course.

Three to seven days after the injection, you may gradually return to normal physical activities. The return to full activity is determined based on your response to the therapy and the recommendation of your surgeon.

Risks and Complications

As PRP is obtained from your own blood, the risk of reaction is low. As with any injection, there is a small risk of injury to any structures in the area as well as a very small risk of infection.

FAQs

How many PRP injections can I have?

A treatment may require a series of injections, perhaps 3-5. However, multiple injections often are not recommended if there is no improvement in symptoms following the first or second treatment.