Reconstruction of the orbital floor with lyophilized tensor fascia lata

Outcome of Reconstruction of Advanced Brown's Maxillary Defect with Free Tissue Transfer: Our Early Experience in a Tertiary Cancer Centre in North-East of India

Reconstructions of the maxillary defect after tumor resection are challenging surgeries. Maxillary reconstructions are done using obturators, locoregional flaps and free tissue transfers. Free flap options available for maxillary reconstruction are radial forearm, anterolateral thigh free flap, free fibular osteocutaneous flap, rectus abdominis myocutaneous flap, scapular, and iliac crest osteomyocutanous free flap etc. This is a single institutional observational study conducted at a tertiary cancer centre in North East India from May 2018 to April 2019. All the reconstructions are done with free tissue transfer. Post-operative outcome was assessed with University of Washington Quality of Life Questionnaire (UW-QOL v4.1). Data was collected from patient records and hospital online reporting system. All data were analysed using SPSS (statistical package for social sciences) version 21. Brown's classification was used to classify maxillary defects in this study. A p value ≤ 0.05 was considered statistically significant. In our study, we included fourteen patients (n = 14), of which anterolateral thigh free flap was used for reconstruction in thirteen cases and in one case free fibular osteocutaneous flap was done. Mean age is 33.36 ± 14 years; there was two flap failure. Flap failure is associated with a statistically significant low swallowing and appearance score (p value is 0.036 for both). The orbital exenteration is associated with low appearance score but it is not statistically significant (p value 0.70), probably due to small sample size in the series. Our early experience of free tissue transfer in maxillary reconstruction is satisfactory in terms of quality of life of the patient as well as the oncological outcome. With positive initial experience in maxillary reconstruction with free flaps large study population will be considered in near future.

Resorbable Material for Pediatric Orbital Floor Reconstruction

INTRODUCTION

The use of resorbable materials is becoming more popular for pediatric orbital floor reconstruction. The purpose of this systematic review is to evaluate the effectiveness and safety of the various materials used in pediatric orbital floor reconstruction.

METHODS

A systematic literature search was performed to identify all relevant articles reporting complications following pediatric orbital floor reconstruction. The search included published articles in three electronic databases-Ovid MEDLINE, EMBASE, and PubMed starting from database establishment to July 2017. Primary endpoints were enophthalmos, diplopia, and infection. Resorbable material was compared to autologous grafts and nonresorbable material.

RESULTS

A total of 14 studies containing 248 patients were included in this review. Fifty-four (21.8%) patients had reconstruction performed with autologous grafts, 72 (29.0%) patients with resorbable material, and 122 (49.2%) patients with nonresorbable material. Resorbable materials had the lowest rate of postoperative enophthalmos (3/52; 5.8%) and the highest rate of postoperative diplopia (19/72; 26.4%). In contrast, nonresorbable materials had the lowest rate of postoperative diplopia (5/122; 4.1%), the highest rate of postoperative enophthalmos (14/102; 13.7%). Autologous reconstruction was associated with an 11.1% (4/36) rate of postoperative enophthalmos and a 22.2% (12/54) rate of postoperative diplopia. Nine cases (8.8%) of postoperative infection were documented with nonresorbable materials. No cases of infection were reported with autologous grafts or resorbable materials.

CONCLUSION

Newer resorbable implants are safe and have a similar complication profile as traditional autologous grafts in pediatric orbital floor reconstruction.

[Bone cement implant as an alternative for orbital floor reconstruction: A case report]

BACKGROUND

The management of orbitary fractures is one of the most challenging in facial trauma; the variety of reconstruction materials for its treatment is broad and is constantly improving, but despite this there is no consensus for its use or literature that sustains it.

OBJECTIVE

To present the use and design of a preformed bone implant as an alternative for the reconstruction of orbital floor fractures in the pediatric age group.

CLINICAL CASE

A 7-year old male who suffered a right hemifacial contusion trauma with clinical and tomographic diagnosis of right pure blowout type orbital floor fracture with inferior rectus muscle entrapment and right post-traumatic palpebral ptosis. Successful surgical reconstruction was performed 7 days later with a pre-constructed bone cement implant. Eight weeks after surgery the patient presented with mild residual palpebral ptosis, no ocular movement limitations and no diplopia.

CONCLUSIONS

The use of a bone cement implant can be considered appropriate for the reconstruction of these fractures, as another alternative to be used by the ophthalmologist among the variety of all the other materials used for this purpose. We consider that our optimism based on the results obtained in this case obligates us to increase the number of patients treated in order to gather more evidence and do larger follow up.

Reconstruction of Orbital Floor Fractures with Porous Polyethylene Implants: A Prospective Study

PURPOSE

The main aim of our study was to assess and evaluate the efficacy, long standing outcome and infection of porous polyethylene implants in treatment of orbital floor fractures.

PATIENT AND METHODS

Twelve patients with fractures of orbital floor were included in the study. The cause of fracture was road traffic accident, self fall and cow hit respectively. They also complained of enophthalmos (n = 9), diplopia (n = 3), restricted eye movement (n = 2), impairment of infraorbital nerve (n = 3) and dystopia (n = 6). All the fractures were reconstructed with thin porous polyethylene sheets.

RESULTS

No implants were extruded and there were no signs of inflammatory reactions against porous polyethylene implant. In all nine patients with pre-op enophthalmos it was corrected post-operatively with p value = 0.000 and was statistically significant; diplopia in one patient was corrected; persistence of double vision was noted in two patients. Restricted eye movement was corrected in all patients, dystopia was corrected in four patients and in two patients have persisting dystopia. Paresthesia persisted in all three patients.

CONCLUSION

Our experience was that reconstruction of orbital floor fracture using porous polyethylene implant is reliable, safe and effective and may be used for reconstruction of the orbital floor fracture with no donor site morbidity.

A review of materials currently used in orbital floor reconstruction

Orbital fractures are common fractures of the midface. As such, numerous techniques and materials exist for the repair of this region, each with inherent advantages and disadvantages. But does the ideal implant material exist? Should we stop and simply use readily available materials, or should the cycle of need and discovery continue? A comprehensive review of materials used in orbital reconstruction and possible new directions in orbital floor reconstruction are presented.

Biomaterials for reconstruction of the internal orbit

Orbital floor injuries, alone or combination with other facial fractures, are one of the most commonly encountered midface fractures. Techniques for orbital reconstruction have migrated away from autogenous bone grafts to well-tolerated alloplasts, such as titanium and Medpor. Material for reconstructing the orbit can then be selected based on requirements of the defect matched to the mechanical properties of the material. Material selection is largely and ultimately dependent upon surgeon preference.

Mucociliary clearance impairment after zygomaticomaxillary-orbital fractures

OBJECTIVE

The purpose of this study was to examine the influence of zygomaticomaxillo-orbitalis (ZMO) fracture and its symptoms on mucociliary transport (MCT).

STUDY DESIGN

The study encompassed 144 patients who sustained ZMO fracture. A saccharine test was conducted in every patient both on the side of fracture and on the unaffected side. The results were analyzed in connection with the patients' age, sex, degree of injury, method of treatment, time since fracture, and duration of surgery.

RESULTS

It was shown that MCT was considerably impaired on the affected side compared with the control side. However, the degree of impairment did not vary significantly in the patients regardless of the analyzed parameters.

CONCLUSIONS

ZMO fracture induces the disorder of MCT. Balloon Foley catheter in the open reduction of ZMO fracture impairs MCT. The analyzed parameters do not affect the disorders of MCT.

Biomaterials and implants for orbital floor repair

Treatment of orbital floor fractures and defects is often a complex issue. Repair of these injuries essentially aims to restore the continuity of the orbital floor and to provide an adequate support to the orbital content. Several materials and implants have been proposed over the years for orbital floor reconstruction, in the hope of achieving the best clinical outcome for the patient. Autografts have been traditionally considered as the "gold standard" choice due to the absence of an adverse immunological response, but they are available in limited amounts and carry the need for extra surgery. In order to overcome the drawbacks related to autografts, researchers' and surgeons' attention has been progressively attracted by alloplastic materials, which can be commercially produced and easily tailored to fit a wide range of specific clinical needs. In this review the advantages and limitations of the various biomaterials proposed and tested for orbital floor repair are critically examined and discussed. Criteria and guidelines for optimal material/implant choice, as well as future research directions, are also presented, in an attempt to understand whether an ideal biomaterial already exists or a truly functional implant will eventually materialise in the next few years.

Comparison of collagen membranes and polydioxanone for reconstruction of the orbital floor after fractures

Orbital floor fractures, often combined with zygomatic fractures, are common fractures of the midface. Surgery of orbital fractures is done to free incarcerated or prolapsed orbital tissue and to restore the anatomic skeletal size of the orbit. Lyodura was a standard for the reconstruction of the orbital floor until cases of Creutzfeldt-Jakob disease were reported, so that polydioxanone (PDS) is widely used today. However, infections around the implant are reported. In a randomized controlled clinical study on 24 patients with orbital floor defects of approximately 1 cm, we evaluated the use of a collagen membrane compared with a PDS foil. Computed tomography controls and ophthalmologic examinations were performed after 6 months in 10 patients per group.Intraoperative complications occurred neither in the collagen membrane group nor in the PDS group. In case of orbital rim fractures, the collagen membrane could additionally cover these defects. Perioperatively and postoperatively, no complications such as infections were observed. After 6 months, computed tomography controls revealed a complete reposition of orbital tissue and even bone regeneration in both groups. Diplopia and hypoesthesia were completely reversed after half a year.Smaller defects (up to 1 cm) of the orbital floor can be restored with a PDS foil or a collagen membrane. However, for larger defects, stability may not be sufficient.

Efficacy of Iliac Crest vs. Medpor in Orbital Floor Reconstruction

AIM

The present study is to compare the effectiveness of iliac crest graft and medpor implant, for repairing traumatic orbital floor defects.

MATERIALS AND METHODS

A total of 20 patients were included in the study. Autogenous iliac crest graft and medpor implant was used in 10 patients of the each group. Patients were evaluated for the presence or absence of diplopia, enophthalmos, infraorbital nerve paresthesia, and ocular motility disorders. Surgical indications for orbital exploration included entrapment of orbital tissues, large orbital defect (greater than 50% of the orbital floor or more than 8 mm), or orbital floor defects with involvement of other zygomaticofrontal complex fractures.

RESULTS

All patients were successfully treated by restoration of the orbital wall continuity. Follow-up was done at 1-12 weeks. One patient had postoperative infection. There was no graft extrusion.

CONCLUSIONS

Both the groups showed satisfactory results, but group II was better than group I, as there was no donor site morbidity. Porous polyethylene (Medpor) is a biocompatible and high-density polyethylene implant. It is well tolerated by surrounding tissue, and its porous structure is rapidly infiltrated by host tissue. It is a highly stable and somewhat flexible porous alloplast that has rapid tissue in growth into its pores.

Reconstruction of orbital floor fractures using autologous nasal septal bone graft

We describe herein a new technique for reconstruction of the orbital floor, using autologous nasal septal bone and report the surgical results achieved in maxillofacial trauma patients.Prior to its clinical surgical application, a cadaver practice was carried out on 5 formalin-fixed adult human cadavers to establish the feasibility and efficacy of the method. Fifteen patients with orbital floor fractures, operated between 2005 and 2008, using this technique, were included in the current study.Cadaveric practice revealed that an adequate and appropriate size of septal bone graft can be harvested for reconstruction of the orbital floor. All patients except one had satisfactory clinical and radiologic late results. One patient experienced persistent enophthalmos, possibly due to delayed repair and associated displaced zygomatic bone fracture.Autologous nasal septal bone as an orbital floor bone graft has many advantages, including low donor site morbidity, adequacy and appropriateness of size, and similarity of its bicortical morphology and histologic nature compared with the orbital floor bone. Our clinical results strongly support that this technique can become a satisfactory alternative to existing reconstruction methods.

Bone graft application from anterior sinus maxillary wall in orbital floor reconstruction

To analyze the reconstruction of inferior orbital wall with the use of bone graft harvested from anterior maxillary wall. Medical University of Silesia, Chair of Maxillofacial Surgery. Eighteen patients, aged between 16 and 64 years (15 men and 3 women), with posttraumatic orbital floor defects were treated. The technique was applied in 18 patients with defect in orbital inferior wall. In 11 patients, it was "blowout" fracture, and in 7 cases, the orbital wall fracture accompanied the zygomatico-orbital fracture. Bone transplant after fracture revision covered the orbital floor. Primary outcomes were scored during the operation for passive eyeball movement. Secondary outcomes were estimated (i.e., radiograms, healing of the wound, correct sight, and eyeball mobility). In all cases, full improvement was affirmed, and there was no postoperative complication of any type. Our study indicates that the maxillary bone graft technique is a good and simple orbital floor reconstruction method. Shortening of surgery time and limitation of operative procedures are advantages of this method.

MOC-PSSM CME article: Zygomatic fractures

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand the common signs, symptoms, and treatment options for zygomatic fractures. 2. Answer basic questions on therapy for zygomatic fractures.

SUMMARY

This maintenance of certification article on zygomatic fractures attempts to review the current approaches to the treatment of these fractures. Although the article does not deal with extended approaches to treatment, it does in a general sense present the preoperative, intraoperative, and postoperative thinking for the plastic surgeon approaching these patients in general practice. A further in-depth review can be obtained through the references at the end of the article.

Diagnosis and management of enophthalmos

Enophthalmos is a relatively frequent and misdiagnosed clinical sign in orbital diseases. The knowledge of the different etiologies of enophthalmos and its adequate management are important, because in some cases, it could be the first sign revealing a life-threatening disease. This article provides a comprehensive review of the pathophysiology, evaluation, and management of enophthalmos. The main etiologies, such as trauma, chronic maxillary atelectasis (silent sinus syndrome), breast cancer metastasis, and orbital varix, will be discussed. Its objective is to enable the reader to recognize, assess, and treat the spectrum of disorders causing enophthalmos.

Solvent-dehydrated fascia lata allograft for covering intraoral defects: Our experience

Mucosal defects in the oral cavity as a result of tumors, preprosthetic surgical procedure, or trauma are always a concern for surgeons. The aim of this study is to present our experience and discuss the advantages and problems arising with the use of solvent-dried human fascia lata allografts in oral mucosal defects, thus evaluating its clinical efficacy. Sixteen intraoral lesions were removed from 15 patients. The rehabilitation of the mucosal defects was achieved using solvent-dehydrated human fascia lata allografts. No graft rejection or infections were detected. The material was effective for enhancing the hemostasis, relieving the pain, and inducing rapid epithelization. The final result was excellent, even though in 2 cases complications were experienced. Hence, the use of the material proved to be reliable, practical, and safe.

Repair of Traumatic Orbital Wall Defects Using Conchal Cartilage

BACKGROUND

The authors' aim was to investigate the efficiency of conchal cartilage grafts in defective orbital wall fractures, which are encountered isolated or in combination with other orbitozygomatic fractures. The authors assessed, for this purpose, the follow-up results of patients treated by using conchal cartilage grafts.

METHODS

Ten patients who had defective orbital wall fractures and were treated by using conchal cartilage graft among those treated for facial fractures in the authors' clinic were included in the study. The wall defects in the patients were detected either with preoperative radiologic images or with orbital exploration performed to look for a possible defect accompanying the fracture with orbital extension during the operation. In all patients (four isolated and six combined orbital fractures), who had defects varying from 100 to 400 mm, conchal cartilage grafts were adapted to the defect. In the postoperative follow-up, Hertel exophthalmometry was also performed together with clinical examination so that enophthalmos that might develop as a complication could be assessed.

RESULTS

In the postoperative period, cartilage graft was palpated slightly in two patients at the edge of the infraorbital rim. Limitation in eye movement, diplopia, and enophthalmos did not occur in our patients, except for one who reported to us 1 year after the primary trauma. No complication in the donor area was observed.

CONCLUSIONS

Conchal cartilage could be considered one of the autogenous materials among those materials suitable for the repair of defective orbital wall fractures that are not oversized. It has the advantages of being adequate for reconstruction of the fracture, easy to obtain, easily adaptable to the orbital walls, and having minimum morbidity at the donor site.

Another use of the Foley catheter: retraction for operations on the floor of mouth and ventral aspect of the tongue

A Foley catheter that is passed through the nose and sutured to the tip of the tongue can be used to facilitate retraction for operations on lesions on the ventral aspect of the tongue and the floor of the mouth. It provides excellent access and is simple, inexpensive, atraumatic, minimises frustration, reduces the operating time, and eliminates some of the difficulties associated with the use of metal retractors.

Reconstruction of Orbital Floor Fracture Using Solvent-Preserved Bone Graft

The orbital floor is one of the most frequently damaged parts of the maxillofacial skeleton during facial trauma. Unfavorable aesthetic and functional outcomes are frequent when it is treated inadequately. The treatment consists of spanning the floor defect with a material that can provide structural support and restore the orbital volume. This material should also be biocompatible with the surrounding tissues and easily reshaped to fit the orbital floor. Although various autografts or synthetic materials have been used, there is still no consensus on the ideal reconstruction method of orbital floor defects. This study evaluated the applicability of solvent-preserved cadaveric cranial bone graft and its preliminary results in the reconstruction of the orbital floor fractures. Twenty-five orbital floor fractures of 21 patients who underwent surgical repair with cadaveric bone graft during a 2-year period were included in this study. Pure blowout fractures were determined in nine patients, whereas 12 patients had other accompanying maxillofacial fractures. Of the 21 patients, 14 had clinically evident diplopia (66.7 percent), 12 of them had enophthalmos (57.1 percent), and two of them had gaze restriction preoperatively. Reconstruction of the floor of the orbit was performed following either the subciliary or the transconjunctival approach. A cranial allograft was placed over the defect after sufficient exposure. The mean follow-up period was 9 months. Postoperative diplopia, enophthalmos, eye motility, cosmetic appearance, and complications were documented. None of the patients had any evidence of diplopia, limited eye movement, inflammatory reactions in soft tissues, infection, or graft extrusion in the postoperative period. Providing sufficient orbital volume, no graft resorption was detected in computed tomography scan controls. None of the implants required removal for any reason. Enophthalmos was seen in one patient, and temporary scleral show lasting up to 3 to 6 weeks was detected in another three patients. Satisfactory cosmetic results were obtained in all patients. This study showed that solvent-preserved bone, which is a nonsynthetic, human-originated, processed bioimplant, can be safely used in orbital floor repair and can be considered as another reliable treatment alternative.

Naturally occurring scaffolds for soft tissue repair and regeneration

Cell growth supports (i.e., scaffolds) that provide a conducive environment for normal cellular growth, differentiation, and angiogenesis are important components of tissue engineered grafts because rapid integration with the host is essential for long-term graft viability. While many of these scaffold materials are synthetic biodegradable polymers, others are naturally derived from mammalian tissue sources. Naturally occurring scaffold materials include small intestinal submucosa, acellular dermis, amniotic membrane tissue, cadaveric fascia, and the bladder acellular matrix graft. Upon implantation, these materials elicit a host-tissue response that initiates angiogenesis, encourages tissue deposition and culminates in restoration of structure and function specific to the grafted site. The sources, the methods of procurement and processing, and the effects of these naturally occurring materials on angiogenesis and tissue deposition are reviewed.

A comparison of parietal and iliac crest bone grafts for orbital reconstruction

PURPOSE

This study evaluated the results of cranial (membranous) versus iliac crest (endochondral) bone grafts as implants to correct post-traumatic globe malposition and/or diplopia.

PATIENTS AND METHODS

Twenty-two patients underwent 25 orbital reconstructions with bone for enophthalmos, hypophthalmos, and diplopia after trauma to the orbit. Inclusion criteria consisted of at least 4 months postsurgical follow-up, pre- and postsurgical quantitative orbital measurements, photographic documentation, and complete medical records regarding inpatient and outpatient data.

RESULTS

Nine cranial bone grafts and 16 iliac crest grafts were placed. Ages were similar in both groups. The average follow-up was 24 months for the cranial graft group (range, 4 to 54 months) and 18 months for the iliac crest graft group (range, 4 to 51 months). Preoperative enophthalmos averaged 4.11 and 5.06 mm in the cranial and iliac crest groups, respectively, and postoperatively the measurements were 1.78 and 1.37 mm, respectively. Changes in hypophthalmos generally reflected changes in the enophthalmos correction. In 10 patients diplopia was corrected by the procedure. There was a statistically significant change in the enophthalmos of patients when comparing pre- and postoperative status, but no statistically significant difference between the results of the cranial and iliac crest graft groups.

CONCLUSION

There is no difference in the ability of cranial and iliac crest bone grafts to correct post-traumatic enophthalmos.

Resorbable Mesh in the Treatment of Orbital Floor Fractures

A variety of materials have been used to reconstruct defects of the orbital floor. Autogenous materials such as bone and cartilage have the obvious drawback of the necessary donor site, whereas alloplastic implants carry the potential risk of infection, particularly when in communication with the maxillary sinus. Consequently, there has been interest in the use of resorbable alloplastic material that acts as a barrier until completely degraded. In this series, a total of 12 patients with orbital defects larger than 1 cm2 were treated by the placement of a resorbable mesh plate of polyglycolic and polylactic acid (Lactosorb). Of the total of 12 patients treated, 3 were lost to follow-up. Of the remaining 9 patients, the mean follow-up was 6 months, with the longest follow-up being 15 months and the shortest 1 month. Two patients developed enophthalmos. In each case, this measured 2 mm using Hertel exophthalmometry, and was present in the early postoperative period (less than 1 month). The cause of the enophthalmos in both patients was found to be a technical error in placement of the mesh. One patient developed an inflammatory reaction along the infraorbital rim requiring implant removal. This occurred at 7 months. From the above series, it is concluded that resorbable mesh is an acceptable material for reconstruction of the orbital floor in selected patients. It is believed that larger floor defects are better suited for nonresorbable alloplastic reconstruction, and that placement of the mesh over the infraorbital rim is unnecessary and places the patient at risk for a local inflammatory reaction.

Effectiveness of a new perforated 0.15 mm poly-p-dioxanon-foil versus titanium-dynamic mesh in reconstruction of the orbital floor

INTRODUCTION

In recent years a new perforated PDS (poly-p-dioxanon) foil (0.15 mm) has become available and has not yet been proven to be successful in reconstruction of the orbital floor after blow-out-fractures in randomized studies. The main aim of this clinical trial is to compare this new PDS foil with titanium dynamic mesh (0.3 mm) (TD), which is well established in reconstruction of the orbital floor.

PATIENTS AND METHODS

In a prospective multicentre randomized trial, conducted between 1997 and 1998, out of 42 patients with fractures of the orbital floor, 28 patients needing material for reconstruction were randomized to receive either PDS foil or TD. In a comprehensive preoperative and postoperative protocol patients were monitored by the surgeon, radiologist and ophthalmologist with a postoperative follow-up of least 6 months.

RESULTS

Maximum defects of the orbital floor were comparable in both groups (PDS group: 13.3 mm, TD group: 13.9 mm). In both groups the surgical procedure was well tolerated, and functional and cosmetic results were evaluated as satisfactory by all patients. Ophthalmological evaluation, performed up to 6 months postoperatively, revealed double vision or vertical strabismus in nine patients (five PDS group, four titanium group). This was not confirmed subjectively in each single patient. Also ex- or enophthalmos, registered in seven patients of the PDS and four of the TD group (mainly + /- 1 mm) were not considered as relevant by the patients.

CONCLUSION

The new 0.15 mm perforated PDS foil was comparable to 0.3 mm titanium mesh concerning functional and cosmetic outcome. Obviously, persisting ophthalmometric disorders were compensated very well in both groups. PDS foil is felt to be the preferred material since it is bioresorbable and more convenient to handle.

Reconstruction of orbital fractures with dehydrated human dura mater

PURPOSE

The best method for reconstructing the fractured orbital floor remains controversial. This article evaluates the usefulness of dehydrated human dura mater for orbital floor reconstruction after facial trauma.

PATIENTS AND METHODS

A retrospective analysis of 55 patients who had undergone surgical repair of orbital fractures was performed. The dura mater was used when the disruption was less than 2 cm in diameter. Fractures were divided into 3 types: type I (blow-out), type II (orbitozygomatic fracture), and type III (midfacial fracture). The patients were followed-up at least 1 year after surgery, and the cosmetic and functional results were reviewed.

RESULTS

A 7% complication rate was noted. No implant migration or infection resulted. One year postsurgery, all patients showed a complete resolution of their diplopia.

CONCLUSION

The safety and biocompatibility of dehydrated human dura mater support its use in orbital defects less than 2 cm in diameter.

Resection of talocalcaneal middle facet coalition. Interposition with a tensor fascia lata allograft: a case report

Tensor fascia lata is utilized in the management of complex soft-tissue injuries and defects, but has not been described in the literature in the use of tissue interposition with resection of talocalcaneal middle facet coalitions. This article is a case presentation of a resection of a middle facet coalition with interposition of an allograft of tensor fascia lata. At 14 months postoperative follow-up, range of motion of the subtalar joint was noted to be 20 degrees, and without pain or crepitus. There was no radiographic evidence of degenerative changes in Chopart's joint. The patient returned to all routine and sports activities without pain. He was satisfied with the outcome of the procedure.