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Bellapianta (2011) - Bilateral Os Subtibiale and Talocalcaneal Coalitions in a College Soccer Player- A Case Report

Bilateral Os Subtibiale
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  Bilateral Os Subtibiale and Talocalcaneal Coalitions in a College Soccer Player:A Case Report  Joseph M. Bellapianta, MD 1 , James R. Andrews, MD 2 , Roger V. Ostrander, MD 2 1 Orthopaedic Surgeon, Plancher Orthopaedics and Sports Medicine, Cos Cob, CT  2 Orthopaedic Surgeon, The Andrews Institute, Gulf Breeze, FL a r t i c l e i n f o Level of Clinical Evidence:  4 Keywords: anklefractureimpingementsubtalar motion a b s t r a c t An os subtibiale is an accessory bone separated from the distal medial tibia proper. Subtalar tarsal coalition isa failure of joint formation between the talus and calcaneus during hindfoot maturation. The patient in thiscase report has large bilateral os subtibiale and subtalar coalitions, which were undiagnosed throughout hissoccer career until recently when he began having anteriorlateral ankle pain. After failing conservative treat-ment the patient underwent ankle arthroscopy, which revealed a fully separated, large articular portion of themedial malleolus. The hypertrophic synovium and cartilage were debrided and the patient had a full recovery,returning to soccer 8 weeks after surgery. Os subtibiale is a rare but well-described entity in the radiology andorthopaedic liturature. To our knowledge, bilateral os subtibiale this large has not been described. In addition,an os subtibiale with concomitant subtalar coalition has never been reported. This report will hopefully alertclinicians about these 2 rare anatomic   ndings and encourage them to use caution when evaluating suspectedfractures of the medial malleolus that could be functional os subtibiale ossicles. In addition, we hope to shedsome light on the complicated coupling of motion between the ankle and subtalar joint. These may havedeveloped together to allow more normal coupled motion between the ankle and subtalar joint in this high-level college soccer player, and may be relevant to future reports or research in this area.   2011 by the American College of Foot and Ankle Surgeons. All rights reserved. Os subtibiale is a rare, normal variant of the medial malleoluswhere an articulating portion of the medial malleolus is a free-  oating ossicle of bone. The os subtibiale can vary in size and isthought to be a failure of fusion of a secondary growth center. It was  rst described by P  tzner in 1896 (1) and has since been described inisolated reports, including the ossicle being mistaken for a fracture(2 – 6). The incidence of os subtibiale varies in the literature from0.001% to 1.2% (7, 8).Subtalar tarsal coalition is a failure of joint formation between thetalus and calcaneous during hindfoot maturation. Talocalcaneal coa-lition is believed to be present in less than 1% of the general pop-ulation with bilaterality occurring in roughly 22% to 60% of patients(9). The actual prevalence may be much higher. The coalitionbetween tarsal bones can be composed of bone, cartilage, or   broustissue (10). Decreased motion at this joint can lead to increasedmotion at the surrounding joints and their supportive ligaments,resultinginfrequentanklesprainsasacommonpresentingsymptom.Inthefollowingcasereport,wepresentacaseof thelargebilateralos subtibiale with concomitant bilateral subtalar tarsal coalitionidenti  ed in a high-level collegiate soccer player. These rare anatomic  ndings have only previously been described together in 1 report of pediatric ball-and-socket ankle deformities. To our knowledge, theseare also the largest os subtibiale described in the literature. Case Report A 20-year-old man who progressed through elementary school,high school, and 2 years of college soccer essentially asymptomaticpresented to our of   ce with left anterolateral ankle pain. Symptomsbegan approximately 6 months previously. He reported a vaguerecollection of an ankle sprain in high school and was recently toldthat he had a fracture of his ankle that did not heal.Onphysicalexamination,thepatient ’ sfeetwerenormalappearingwithout swelling, scars, or deformity. The forefoot and midfootexamination was normal with good peroneal, anterior tibialis, andposterior tibialis function bilaterally.He had slightly prominent medial malleoli bilaterally. Upon repeatexamination of left medial malleolus, the ossicle was mobile andclearly separate from the tibia proper. There was no discomfort withpalpation or mobilization of this ossicle. He did have pain with Financial Disclosure:  None reported. Con  ict of Interest:  None reported.Address correspondence to: Joseph M. Bellapianta, MD, Orthopaedic Surgeon,Plancher Orthopaedics and Sports Medicine, 31 River Road, Cos Cob, CT 06907. E-mail address: (J.M. Bellapianta).1067-2516/$ - see front matter    2011 by the American College of Foot and Ankle Surgeons. All rights reserved.doi:10.1053/j.jfas.2011.03.016 Contents lists available at ScienceDirect The Journal of Foot & Ankle Surgery journal homepage: The Journal of Foot & Ankle Surgery 50 (2011) 462 – 465  Fig. 1.  Lateral radiograph of the left ankle.  Arrows  show the  “ C ”  sign. Fig. 2.  Anterior to posterior radiograph of theleft ankle. The  arrow  shows theossubtibiale. Fig. 3.  Mortise radiograph of the left ankle. The  arrow  shows the os subtibiale. Fig. 4.  Valgusstressradiographoftheleftankledemonstratingnormalmedialanklestability.  J.M. Bellapianta et al. / The Journal of Foot & Ankle Surgery 50 (2011) 462 – 465  463  palpation over the anterior talo  bular ligament and anterolateral joint line. On examination of the right medial malleolus, the ossiclewasnontender,and nomotionwas appreciated. Normalanklemotionwas observed bilaterally; however, there was no subtalar motionappreciated bilaterally.Radiographs showed a  “ C ”  sign on the lateral viewof the hindfoot,which is a C-shaped line formed by the medial outline of the talardome and the inferior outline of the sustentaculum tali (11). This issuggestive of a subtalar coalition (Figure 1). Anteroposterior andmortise views showed an unfused os subtibiale (Figures 2 and 3). Astress view of the symptomatic left ankle showed a stable medialankle joint (Figure 4).Computed tomography (CT) scans showed 50% bony and   brousfusion of bilateral subtalar joints involving predominantly the ante-rior and middle facets (Figures 5 and 6) as well as clear views of bilateral os subtibiale (Figures7 and 8  A  and  B ). CTreconstructions areshown in Figures 9  A  and  B . By CT scan measurements, the right andleft os subtibiale ossicles were 20    14 mm, and 18    14 mm,respectively.The patient had conservative treatment for 6 months consisting of several periods of rest, anti-in  ammatory medication, intermittentice, and stretching/strengthening with no consistent relief of his pain.After failure of conservative treatment, the patient was taken to theoperating room for left ankle arthroscopy. The patient had anteriordebridement of hypertrophic synovium on the anterior capsule andalso in the space between the ossicle and the tibia proper. Minimalcartilage debridement was also done in addition to debulking of ananterolateral tibial bossing. This was felt to be more prominentarthroscopically than on his lateral ankle x-ray. Arthroscopic picturesare shown in Figure 10  A  and  B . Eight weeks after his arthroscopicdebridement he was able to return as the starting forward for hiscollege soccer team. Discussion The os subtibiale in this case report are large, well-rounded acces-sorybonesseparatedfromthemedialtibiaproper.Thecasepresentedhere is one of a high-level collegiate soccer player with both large ossubtibiale and rigid talocalcaneal coalitions. These 2 entities have notbeen described together in this context. The association of a ball-and-socket ankle joint has been described in the pediatric populationassociated with os subtibiale and talocalcaneal coalition (12).Various bony elements at the medial subtibial region have beendescribed and include accessory ossi  cation centers, avulsion frac-tures, and posttraumatic ossi  cation (6). Calci  cations in the deltoidligament secondary to repetitive microtrauma are common in Fig. 5.  Axial CT images of bilateral ankles. The  arrow  highlights the talocalcanealcoalitions. Fig. 6.  Coronal CT images of bilateral ankles. The  arrow  highlights the talocalcanealcoalitions. Fig. 8.  Sagital CT scans of left (  A ) and right ( B ) ankles at the level of the os subtibial.  Arrows  show the ossicles separated from the tibia proper. Fig. 7.  Coronal CT images of bilateral ankles at the level of the os subtibiale.  Arrows  showthe large ossicles articulating with the talus.  J.M. Bellapianta et al. / The Journal of Foot & Ankle Surgery 50 (2011) 462 – 465 464  patients with a history of multiple ankle sprains. All os subtibialeossicles found during our literature search are much smaller, withpresumably less contribution to the talar articulation and function of theanklejoint.Secondaryossi  cationcentersof themedialmalleolusarecommoninchildren(47%ingirls,17%inboys).Theyusuallyappearin the eighth to ninth years and fuse by approximately age 11 (13).It would be purelyspeculative to assume that one of these entitiesled to the formation of the other, but perhaps this patient ’ s ability tocompensatefor so long was because of the os subtibial. The varus andvalgus motion needed to compete on the soccer   eld, which was lostbythecoalition,mayhavebeenmadeupforbytheadditionalpointof articulation in his ankle between the os and the tibia proper. There isa tightly coupled motion of these 2 joints around the talus, allowingmultiple degrees of freedom of motion (14). Perhaps the increasedinversion/eversion motion at the level of the ankle caused abnormalforces anteriorlaterally, leading to the pain and wear seenarthroscopically.We have discussed with the patient the need for possible futuresurgery. Given his limited condromalacia and his ability to function ata high level for so long, we felt a less aggressive arthroscopicdebridement would be a reasonable   rst line of surgical treatment. References 1. P  tzner W. Die variationen im aufbau des fussskelets. Morphol Arb VI:245, 1896.2. Lapidus PW. Os subtibiale. Inconsistent bone over the tip of the medial malleolus. JBone Joint Surg Am 15:766 – 771, 1933.3. Coral A. Os subtibiale mistaken for a recent fracture. Br Med J 292:1571 – 1572,1986.4. Bircher E. Neue falle von varietaten der handwurzel und des fubgelenkes. A) Ostrigonum traumaticum? B) Os subtibiale. Fortschr Rontgenstrahlen 26:85 – 93,1918.5. Madhuri V, Poonnoose PM, Lurstep W. Accessory os subtibiale: a case report of misdiagnosed fracture. Foot Ankle Online J 2(6):3, 2009.6. Trolle D. De to accessoriske knogler: os subtibiale og os sub  bulare I relation tildiagnosen af malleolaer fracturer. Nord Med 25:247 – 249, 1945.7. Coral A. The radiology of skeletal elements in the subtibial region: incidence andsigni  cance. Skeletal Radiol 16(4):298 – 303, 1987.8. Stormont DM, Peterson HA. The relative incidence of tarsal coalition. Clin Orthop181:28 – 36, 1983.9. Tsuruta T, Shiokawa Y, Van Ghillewe KV, Gryspeerdt SS, Baert AL, Dereymaeker GE.Radiological study of the accessory skeletal elements in the foot and ankle. NipponSeikeigeka Gakkai Zasshi 55(4):357 – 370, 1981.10. Kent V. Tarsal coalition and painful   atfoot. J Am Acad Orthop Surg 6(5):274 – 281,1998.11. Lateur LM, Van Hoe LR, et al. Subtalar coalition: diagnosis with the C sign on lateralradiographs of the ankle. Radiology 193(3):847 – 851, 1994.12. Takakura Y, Tanaka Y, Kumai T, Sugimoto K. Development of the ball-and-socketankle as assessed by radiograph and arthrography. J Bone Joint Surg (Br)81(6):1001 – 1104, 1999.13. Ogden JA, McCarthy SM. Radiology of post natal skeletal development. VIII. Distaltibia and   bula. Skeletal Radiol 10(4):209 – 220, 1983.14. Leardini A, Stagni R, O ’ Connor JJ. Mobility of the subtalar joint in the intact anklecomplex. J Biomechanics 34(6):805 – 809, 2001. Fig.10.  Arthroscopic images captured during surgery. (  A ) Looking from the anteriorlateralportal across the anterior ankle without distraction. The os subtibiale can be seen in thedistance. The  arrow  is pointing to the chondromalasia of the anteriorlateral talus. ( B ) Acloser look from the same portal with distraction and plantar  exion of the ankle. The  “ X ” is on the os subtibiale. Fig. 9.  Three-dimensional reconstructions of the CT scan.  Arrow  in  A  shows the right ossubtibiale from posteriormedially. Arrows in  B  show the right and left ossicle respectively.  J.M. Bellapianta et al. / The Journal of Foot & Ankle Surgery 50 (2011) 462 – 465  465
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