Use of a Cannulated Guide in Talocalcaneal Coalition Resection

The optimal operative management of symptomatic talocalcaneal coalitions is debated, and there is no clear consensus on the operative criteria that leads to long-term successful outcomes. Operative options include coalition resection, osteotomies, and arthrodesis. With the advent of routine CT scans, the indications for middle facet coalition resection evolved. Herzenberg et al recommended resection of middle facet coalitions if the articular cartilage of the anterior and posterior facet joints could be preserved. Comfort and Johnson found the outcome correlated with the size of the coalition, with less extensive coalitions demonstrating improved outcomes. Other authors observed poor outcomes in patients treated with middle facet coalition resection where the preoperative CT scan demonstrated a coalition greater than 50% of the surface area of the posterior facet. A more recent study has called this recommendation into question. Khoshbin et al found favorable results with coalition resection, including talocalcaneal coalitions composing greater than 50% of the posterior facet, more than a decade after treatment. Furthermore, when compared with nonoperative management, talocalcaneal coalition resection results in a greater level of activity and return to sports. Failure to fully resect a talocalcaneal coalition may lead to worse operative outcomes. In their series of 9 patients, Olney and Asher had 2 patients with fair or poor results; in both cases, an incomplete coalition resection was found at the second surgery. Wilde et al also found inadequate resection to be a factor in unsatisfactory results following coalition resection. Middle facet coalitions are approached medially with an incision distal to the medial malleolus and plantar to the tibialis posterior tendon. The middle facet of the talocalcaneal joint is located in the interval between the flexor digitorum longus and the flexor hallucis longus tendons, dorsal to the sustentaculum tali. To identify the coalition, some authors advocate using Keith needles and radiography prior to making the incision. Others recommend use of Keith needles intraoperatively to identify the coalition as needed. Alternatively, a flat instrument can be inserted anterior or posterior to the coalition to mark the extent of the coalition. Authors recommend using osteotomes, rongeurs, curettes, or a power burr to resect the coalition. Alternatively, one can use an onion skin technique, as described by Salomao et al. In this technique, the periosteum over the bar is reflected and the anterior and posterior margins of the subtalar joint are identified, followed by slicing off the bar in “onion skin” layers. To verify complete resection, subtalar joint motion should be present and articular cartilage should be visible around the resected area. While all of these techniques work theoretically, in practice it is often difficult to find, identify, and resect the middle facet coalition. The sustentaculum tali is encased in bone, and it is difficult for the surgeon to determine where to begin the resection to identify the plane of the coalition. In less extensive coalitions, the planes may be more apparent, but even in these cases it is challenging to determine if resection has been completed until the anterior edge of the posterior facet is visible. We present a novel technique for the intraoperative identification and resection of talocalcaneal coalitions by using a cannulated guide introduced from the sinus tarsi.