0:00

<v ->And here, in this last case,

0:05

it is the case about a male patient,

0:08

66 years old, with chronic ankle pain

0:13

that have intensified over the last two months.

0:16

And, right out of the gate,

0:19

we can see complete boney tallow calcaneal coalition

0:24

right here,

0:26

And this

0:28

coalition is causing a secondary flat foot

0:32

and hind foot valgus as we can see here,

0:35

the hind foot valgus

0:37

and it is described that the normal angle

0:40

between the tibia and the medial wall of the calcaneum,

0:45

it should be six degrees or

0:49

less in this case here.

0:52

Let me just calculate here.

0:54

Very, very

0:56

it's look that it's 30 degree between 30 and

1:03

oh yeah, it's between 30 to 40 degrees here

1:07

this angle between the axis of the tibia and the

1:13

medial wall of the calcaneum.

1:16

So it's a prominent

1:19

hind foot valgus that we have in this case right here.

1:23

And with this hind foot valgus,

1:27

what happens is that the calcaneum rotates

1:30

laterally and superiorly and it get close

1:34

to the lateral malleus and it can cause

1:38

sup-fibular impingement.

1:40

This is an extra articular impingement,

1:43

a lateral extra articular impingement of the ankle.

1:46

In the lateral side,

1:47

we have two extra articular impingement.

1:50

We can have a talial calcaneal extra articular impingement

1:53

and also a sub-tailar,

1:58

a sub-fibular, sub-fibular impingement right here.

2:01

And notice how this area here, the fat,

2:05

the fat is blurred and it's in the area

2:09

of the peritoneal tendon.

2:11

So we can see a little bit of fluid

2:14

in the peritoneal tendons.

2:16

We can see that the peritoneal tends,

2:18

they are in this area of the sub-fibular impingement

2:23

and we can notice that the lateral,

2:27

the peritonealis longus standum, it's subluxed laterally

2:32

and that's described in cases of

2:35

advanced sub-fibular impingement.

2:39

Look that, look here the peritoneal longus standum,

2:44

it's subluxed laterally because of this

2:49

sub-fibular impingement right here.

2:52

And sometimes in case of sub-fibular impingement,

2:56

we can see bone marrow edema,

3:00

cystic bone formations.

3:01

Sometimes you can see a formation

3:03

of an extra facet, an articular facet

3:06

in this region right here.

3:08

The mechanism of trauma of the sub-fibular impingement

3:12

basically are the mechanisms that can cause high hind foot.

3:19

Hind, let me get the name here.

3:21

Hind foot valgus or some kind,

3:25

some type of calcaneum deformation

3:27

that will close this space right here.

3:30

For example, for hind foot valgus,

3:33

you can have posterior tibial tendon dysfunction,

3:38

neuropath arthropathy, inflammatory arthritis,

3:42

and for lesions

3:45

that can close this space to deformity of the calcaneus.

3:49

We can have previous trauma, healed fractures

3:54

that they don't heal in the right way.

3:56

And we can have a sub-fibular impingement

4:00

in this region right here.

4:02

And in this case, we can also see,

4:07

let me, let me get here.

4:09

The images.

4:17

Yeah.

4:18

In this case, we can see all these lesions here.

4:23

And yeah.

4:23

And that's the main point that I'd like to make

4:26

in the case.

4:27

In this patient, we don't have the tibular

4:30

calcaneum impingement right here

4:32

because the case came from calcaneal coalition.

4:37

But in cases of gradual hind foot valgus deformity

4:43

like

4:45

tibialis posterior tendinopathy,

4:48

we can have a gradual increase of this valgus deformity

4:53

and first we can have talus calcaneal impingement.

4:57

And just after that, we have this sub-fibular impingement.

5:01

Okay.

5:02

Don, any comments?

5:05

<v ->The only comment.

5:06

And it's just a basic comment

5:08

that some of my associates and even one

5:12

of our fellows this year has been particularly interested

5:15

in talal-calcaneal coalitions and they've come up

5:19

with a few interesting observations of things to look for.

5:23

One of them is the fact

5:26

that if you have a coalition in the sub-talar joint

5:29

which affects subtalar motion,

5:32

you end up with more motion at the ankle joint,

5:35

so there's a higher frequency

5:37

of osteochondral injuries of the talas

5:41

and you should always look

5:42

for that in patients who have coalitions.

5:44

I didn't see that here.

5:46

And the second is

5:47

although it's not present in all of these cases,

5:49

I don't know if you can go on your sagittal

5:51

to the lateral aspect of the talas,

5:54

they sometimes have arterial-lateral talar facet,

5:58

which is a prominent...

6:00

Yeah, plate.

6:00

Yeah, maybe about there.

6:01

<v ->Now, I don't know if that is,

6:02

but there's a developmental arterial-lateral talar facet

6:06

that has a higher frequency in patients who have coalition.

6:10

And it's very hard to tell

6:11

from an acquired, you know, effect producing it.

6:16

So there are measurements that are made,

6:20

but you wonder here it's very prominent in any case

6:23

and that is associated with coalition.

6:27

<v ->Okay, great.