STJ arthrofibrosis as a cause of ankle pain in children

Admin2 · Oct 8, 2005

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Arthrofibrosis involving the middle facet of the talocalcaneal joint in children and adolescents.
Rassi GE, Riddle EC, Kumar SJ.
J Bone Joint Surg Am. 2005 Oct;87(10):2227-31

BACKGROUND: Pain over the anterolateral aspect of the ankle in a patient with a history of repeated ankle sprains and with restricted subtalar movement may be associated with a tarsal coalition. Nineteen patients presented with such a history, but conventional imaging did not reveal a cartilaginous or osseous coalition. Since symptoms persisted despite nonoperative treatment, the middle facet was explored surgically. The purpose of this study was to discuss the operative findings and to report the results of treatment.

METHODS: Nineteen patients (twenty-three feet) with pain over the anterolateral aspect of the ankle or a history of repeated ankle sprains had restricted subtalar joint motion and inconclusive findings on diagnostic imaging, except for bone-scanning. Their ages ranged from 9.1 to 18.5 years. The middle facet of the subtalar joint was explored surgically through a 3 to 4-cm-long incision centered over the sustentaculum tali. The results at a mean of 5.8 years were classified as good, fair, or poor on the basis of pain, talocalcaneal joint motion, and shoe wear.

RESULTS: Routine radiographs, computed tomography, and magnetic resonance imaging revealed no major abnormality, whereas technetium-99m bone scintigraphy consistently showed slightly increased isotope uptake in the middle facet. Surgical removal of a hypervascular and thickened capsule and synovium in the area of the middle facet of the subtalar joint decreased pain and improved subtalar motion. The final result was good in seventeen patients (twenty feet) and fair in two patients (three feet). There were no poor results.

CONCLUSIONS: A diagnosis of inflammatory arthrofibrosis should be considered when a patient with a painful rigid flatfoot has normal findings on radiographs and hematological studies but increased isotope uptake in the middle facet of the talocalcaneal joint on bone scintigraphy. Excision of the hypervascular capsule and synovium from this area can result in resolution of the symptoms.

LEVEL OF EVIDENCE: Therapeutic Level IV.
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NewsBot · Aug 18, 2009

Resection of Talocalcaneal Coalition in Children and Adolescents without and with Osteotomy of the Calcaneus.
Hamel J.
Oper Orthop Traumatol. 2009 Jun;21(2):180-92.

OBJECTIVE : Resection of the painful medial talocalcaneal fibrocartilaginous or bony bridge, thereby restoration of mobility of the peritalar joint complex; in case of flatfoot deformity realignment of the hindfoot and midfoot by medial sliding calcaneal osteotomy and in some cases correction of equinus contracture by intramuscular lengthening of the gastrocnemius muscle.

INDICATIONS : Before growth arrest: - Bony or fibrocartilaginous bridge at the medial or dorsomedial talocalcaneal region with or without pain. - Rigid flatfoot deformity caused by talocalcaneal coalition. After growth arrest: - Resection is indicated only in case of local pain or hindfoot deformity.

CONTRAINDICATIONS : Resection is not indicated in cases without local pain or deformity after growth arrest or in cases with marked osteoarthritis of the talonavicular or talocalcaneal joint. If the cross section of the bony bridge exceeds 20 x 30 mm, resection is not recommended.

SURGICAL TECHNIQUE : Longitudinal incision at the medial facet of the subtalar joint. Exposure of the bony bridge. Subsequent resection until the talocalcaneal joint line is clearly visible. Gentle mobilization of the contracted subtalar joint to regain inversion. After resection of the coalition the distance between the corresponding bone areas should measure at least 10 mm. Bone wax is used to prevent bleeding and the gap is filled with fatty tissue. Additionally, in some cases an intramuscular lengthening of the contracted gastrocnemius muscle is necessary. In case of flatfoot deformity alignment should be restored by calcaneal lengthening and/or medializing sliding calcaneal osteotomy.

POSTOPERATIVE MANAGEMENT : The lower leg is immobilized in a cast for at least 2 weeks postoperatively; additional procedures require an extended period of immobilization. Afterwards, range of motion exercises are useful to regain motion of the peritalar joint complex.

RESULTS : 24 resections of a talocalcaneal coalition in 22 pediatric or adolescent patients were carried out. The coalition was located at the medial joint facet in 18 cases and in the dorsomedial talocalcaneal region in seven cases (in one patient combination of both). Three patients presented with an additional calcaneonavicular coalition. A talocalcaneal bone bridge of the entire joint was found in five cases. In seven patients an intramuscular lengthening of the gastrocnemius muscle was necessary. In nine patients a calcaneal lengthening procedure, and in five patients a calcaneal sliding osteotomy were added. A lengthening in the region of a calcaneocuboid synostosis was untertaken in one case. After a mean follow-up of 21.2 months 17 patients are completely or nearly pain-free. Five patients still complain of pain, but are improved. Two patients were lost to follow-up.
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