Tarsal coalitions in the adult population: does treatment differ from the adolescent?

Cubonavicular Coalition in a Middle-Aged Woman: A Case Report

Cubonavicular coalition is a rare type of tarsal coalition that can be described as osseous or nonosseous (fibrous, cartilaginous, or fibrocartilaginous). Typically, it manifests symptoms during adolescence, as it presents with pain at the Mid-hindfoot and with decreased range of motion at the midtarsal joints, hindfoot valgus deformity, or peroneal spasm. Here, we present a rare case of cubonavicular coalition in a middle-aged woman with atypical presentation and a review of the literature. We conclude that this abnormality should be taken into account in the differential diagnosis of mid-hindfoot pain, even in middle-aged adults.

Talocalcaneal Coalition Resection in the Adult Population: A Systematic Review

Tarsal coalition is a congenital malformation of the tarsal bones of the foot that typically presents with features such as pain, recurrent sprains, and flat foot in childhood. In a small number of patients, a delayed presentation may be apparent, with symptoms instead presenting in adulthood. The most commonly accepted hypothesis is that the tarsal coalition becomes more symptomatic as the coalition progressively ossifies. To this date, no author has systematically evaluated the literature to identify the best approach when surgically managing these patients, in particular concerning the resection of the coalition. This study aims to systematically review the literature, searching EMBASE, MEDLINE, Web of Science, Google Scholar, and the Cochrane Library to identify and evaluate studies that presented an outcome for resection of the adult talocalcaneal coalition. Alongside overall outcomes, details on the extent of the coalition, surgical method, post-operative regimen, and presenting symptoms were extracted for each patient studied. This was conducted in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. With 72 patients, this is the largest evaluation of an adult tarsal coalition population to date. Our findings indicate that talocalcaneal coalition in adulthood presents differently from the classical peroneal spasm found in childhood. Better scores were reported for coalitions either managed with an endoscopic approach or with interposition of the flexor hallucis longus tendon. Despite some reported benefits in the literature, a trial of conservative management or the use of a rehabilitation regimen had a limited impact on the overall patient outcome. Tarsal coalition in adulthood requires rigorous clinical evaluation to identify appropriate management options. Resection of the coalition is a safe approach to definitively managing these patients, but consideration should be given to the surgical method to ensure each patient has the best outcomes. In particular, consideration should be given to using an endoscopic approach or interposition of the flexor hallucis longus tendon in order to achieve the best patient outcomes. However, there remains a paucity of literature evaluating this demographic and further high-impact studies are required to comprehensively evaluate this population.

Lateral Arthroscopic Subtalar Arthrodesis for Talocalcaneal Coalition: Surgical Technique

Resection of symptomatic talocalcaneal coalitions (TCCs) has been performed for patients with normal tarsal joints and <50% involvement of the subtalar joint. For those with TCCs >50% of subtalar articulation or/and subtalar arthritis, a subtalar arthrodesis is done. The purpose of this Technical Note is to describe the arthroscopic resection of TCC and talocalcaneal arthrodesis during the same procedure by using a 2 lateral portal technique. With the patient in lateral decubitus under general or locoregional anaesthesia, the foot and ankle are extended beyond the edge of the surgical table. A lateral portal is created 1 cm anterior to the tip of the lateral malleolus in which the arthroscope is introduced. The anterolateral portal is created 1 cm inferior and 2 cm anterior to the tip of the lateral malleolus. The posterior subtalar surface is prepared progressively. The TCC resection is completed. The fixation is obtained with 2 cannulated screws. The arthroscopic resection of TCC and subtalar arthrodesis during the same procedure by using 2 lateral portals can be done for correctly selected patients.

Outcomes of Posterior Arthroscopic Subtalar Arthrodesis for Medial Facet Talocalcaneal Coalition

BACKGROUND

Medial facet talocalcaneal coalition can be a painful condition. This study aimed to determine clinical and radiographic outcomes of posterior arthroscopic subtalar arthrodesis (PASTA) for adult patients presenting with symptomatic medial facet talocalcaneal coalition and normal hindfoot alignment, with a minimal follow-up of 18 months.

METHODS

Between June 2017 and July 2019, this procedure was performed on 8 feet (8 patients; mean age, 55 [42-70] years; mean BMI, 29.8 [24.4-45.0] kg/m²). Clinical assessment was performed using Visual Analog Scale for Pain (VAS-P), Foot and Ankle Outcome Score (FAOS) and the 36-Item Short-Form Health Survey (SF-36). Patient satisfaction was assessed at the last available follow-up as "very satisfied", "satisfied" or "unsatisfied". Radiographic analysis was performed using plain radiography, computed tomography (CT) scan and magnetic resonance imaging (MRI). The primary outcome was to determine both clinical and radiographic outcomes.

RESULTS

The mean follow-up was 25.1 (18.2-34.2) months. The authors found statistically significant improvement on all clinical scores (VASP-P, FAOS and SF-36). They registered 6 "very satisfied" patients, 2 "satisfied" patients and no "unsatisfied" patient. Fusion of the subtalar joint was observed in all patients by 12 weeks and in 5 of them as soon as 8 weeks postoperatively (mean, 9.5 [8-12] weeks). There were no cases of delayed fusion or nonunion of the subtalar joint, superficial or deep infection, neurovascular damage, thromboembolic event, screw breakage, need for hardware removal or revision surgery.

CONCLUSION

This study found that PASTA is a safe and reliable technique for adult patients presenting with symptomatic medial facet talocalcaneal coalition and normal hindfoot alignment, demonstrating and maintaining clinical improvement at an average follow-up of 2 years.

LEVEL OF EVIDENCE

Level IV, case series.

Excision of a Middle Facet Tarsal Coalition

Middle facet tarsal coalition is one of the commonly seen tarsal coalitions in clinical practice that can cause pain and associated flatfoot deformity. Excision of the coalition is one of the treatment options for symptomatic cases. Although symptoms may subside in children following a period of immobilization, resection should be considered as a treatment alternative for children and adolescents because of the potential for restoration of subtalar joint movement. The indications for excision of the coalition are not consistently reported in the literature, and the procedure is not always easy to perform. In this article, we describe the steps for a successful excision of a middle facet tarsal coalition.

Description

The incision is marked from 1 cm inferior to the medial malleolus, extending distally to the navicular tuberosity and inferior to the level of the posterior tibial tendon. The coalition is first located by retracting the flexor tendons and the neurovascular bundle. The bone on the surface of the coalition is gradually removed to expose the middle facet. A 2-mm guide pin and a cannulated dilator probe inserted through the sinus tarsi into the tarsal canal that exits anterior to the posterior facet help with identifying the margins of the coalition. The middle facet is then removed either partially or totally, depending on the size, shape, and location of the coalition, until the posterior facet is visualized. Following excision, bone wax is used on the exposed surfaces or fat is inserted to prevent adhesion and recurrent bone formation. If there is an associated flatfoot deformity, additional surgeries, including a medial translational osteotomy or a lateral column lengthening of the calcaneus, a Cotton osteotomy, an arthroereisis, or a calcaneus stop procedure, may be necessary.

Alternatives

The alternative treatment for managing a middle facet coalition is immobilization of the foot in a boot or cast for 6 to 8 weeks to decrease pain. This will not improve the function of the hindfoot, which remains stiff, but may alleviate pain temporarily. Excision of the coalition in combination with other procedures for correction of the flatfoot is an alternative to an arthrodesis of the subtalar joint and works well in children and adolescents, particularly in those with reasonable subtalar joint flexibility. A triple arthrodesis is rarely performed for an isolated middle facet coalition, even in adults, unless there is peritalar arthritis and more severe abduction of the talonavicular joint with associated stiffness.

Rationale

The rationale for excision of a middle facet tarsal coalition is to maximize the mobility of the hindfoot, in particular, the subtalar joint. The success of excision of the coalition is associated with the rigidity of the hindfoot and the presence of a flatfoot deformity. The stiffer the hindfoot and the flatter the foot, the less likely is excision of the coalition to be successful. Since the alternative to resection of a middle facet coalition is arthrodesis of the subtalar joint, one must distinguish between feet in which there is mobility, and excision is more likely to be successful, and those that are rigid, for which arthrodesis is preferable. In many feet, however, the size of the coalition is not associated with the flexibility of the hindfoot, and in an extremely rigid hindfoot, we recommend an arthrodesis, even in an adolescent patient. Rigidity increases with increasing age, and it is uncommon to excise the middle facet coalition in adult patients or in a patient in whom subtalar arthritis is evident.

[Imaging diagnostics of the foot : What the orthopaedic surgeon expects from the radiologist]

CLINICAL/METHODICAL ISSUE

Foot pain is in the case of long-term congenital, acquired or posttraumatic foot deformities a relevant clinical problem.

STANDARD RADIOLOGICAL METHODS

On the basis of the clinical findings and the orthopaedic question, radiographs of the foot while standing in two planes are supplemented by radiographs of the ankle in an anterior-posterior plane. The imaging diagnostics of the foot are based on the conventional X‑ray diagnostic workup and becomes even more precise and differentiated by the possibility of intersecting imaging procedures.

PERFORMANCE

The diagnostic significance of imaging methods is discussed in this overview by means of clinical examples. In this context, cross-sectional imaging procedures can serve the clinician in the further decision-making process and clarify the question whether surgical treatment, for example, in the case osteoarthrosis is indicated.

PRACTICAL RECOMMENDATIONS

Primarily, prior to any imaging procedure the appropriate medical history, inspection, clinical examination and the gait analysis in patients with foot pain are necessary. Interdisciplinary communication between orthopaedic/trauma surgeons and radiologists is necessary in order to provide the right imaging modality for difficult questions, to correctly interpret the resulting imaging findings, and to derive a therapeutic consequence from this. The decision whether conservative therapy or a surgical procedure is recommended will be made depending on the patients' prior therapies and the restriction of quality of life.

Bilateral Triple Talocalcaneal, Calcaneonavicular, and Talonavicular Tarsal Coalition: A Case Report

We report a rare case of a female, aged 42 years, with symptomatic bilateral triple tarsal coalition, that is, talocalcaneal, calcaneonavicular, and talonavicular tarsal coalition. The patient was treated conservatively by adjusting her activities. At the 12-month follow-up, the patient was asymptomatic. Bilateral triple tarsal coalition is a rare disorder, especially in nonsyndromic patients. The purpose of this case report was to highlight this rare type of multiple bilateral tarsal coalitions and to discuss the relevant existing literature.

Rare Combination of a Cuboid-navicular Tarsal Coalition with a Closed Tibialis Anterior Tendon Rupture: A Case Report and Review of the Literature

Introduction

Tibialis anterior tendon (TAT) rupture and cuboid-navicular coalition (CNC) are rare, to the best of our knowledge, only 238 cases of TAT rupture and 34 cases of CNC are described in the past century.

Case Report

A 47-year-old man came with a sudden onset of foot pain including drop foot to our department. We diagnosed a TAT rupture, which was fixed through suture. The pathologist testified degenerative changes in the tendon. In addition, a CNC was diagnosed. No extra treatment was necessary for the CNC. At the 6-year follow-up examination, the patient had no pain and went back to normal day activities (AOFAS 95/100 points).

Conclusion

We presume that, in our case, the long-term stress at the TAT through the foot deformity, caused by the CNC, may have supported the tendon rupture. CNC normally is symptom free. Therapy of a painful CNC should start with a conservative therapy. When this fails, an operation can be considered.

Coalitions of the Tarsal Bones

Tarsal coalitions are the result of impaired mesenchymal separation of the tarsal bones. The most common types include calcaneonavicular or talocalcaneal coalitions. Subtalar stiffness results in pathologic kinematics with increased risk of ankle sprains, planovalgus foot deformity, and progressive joint degeneration. Resection of the coalition yields good results. Tissue interposition may reduce the risk of reossification, and concomitant deformity should be addressed in the same surgical setting.

Combined Osseous Medial Cuneonavicular Coalition and Nonosseous Naviculocuboid Coalition Presenting as First Metatarsophalangeal Joint Pain

Tarsal coalitions of the lesser tarsus are relatively rare congenital anomalies. A case report of a 54-year-old man with an osseous medial cuneonavicular coalition and a nonosseous naviculocuboid coalition that presented as first metatarsophalangeal joint pain is described.

Results of Nonoperative Treatment for Symptomatic Tarsal Coalitions

INTRODUCTION

Recommendations for the initial treatment (nonoperative measures to surgical excision) of symptomatic tarsal coalitions vary. Because nonoperative outcomes are poorly established, we retrospectively evaluated their success in preventing surgery and achieving pain relief for pediatric patients with symptomatic tarsal coalitions.

MATERIALS AND METHODS

 A retrospective study of pediatric patients with symptomatic tarsal coalitions treated at a single institution was undertaken. Clinical notes were examined for treatment methods, response to treatment, and need for additional procedures. A statistical analysis was performed using the chi-square and Mann-Whitney U tests.

RESULTS

 Fifty symptomatic tarsal coalitions (mean patient age, 11.4 years; range, 8.1-17.9) were treated with nonoperative measures. Surgery was not required in 79% of calcaneonavicular and 62% of talocalcaneal coalitions. Pain relief was achieved in 53% of 81 nonoperative treatment trials. Continuous immobilization via casting, intermittent immobilization via walking boot, and supportive measures were not significantly different in pain relief (p = 0.35) or preventing surgery (p = 0.62).

CONCLUSION

 Nonoperative treatment methods have the potential to achieve pain relief and prevent or delay surgery for symptomatic tarsal coalitions. However, some families may elect to forgo nonoperative measures knowing that surgery may eventually be required.

Diagnostics in tarsal fusion: The theory and practise in The Netherlands

BACKGROUND

This study compares the preferences of Dutch orthopaedic surgeons for different diagnostic modalities in performing tarsal fusions versus consensus, evidence or expert opinion reported in the literature.

METHODS

A literature search of Medline was performed to obtain evidence-based information on various diagnostic tools. In addition, 89 registered Dutch foot and ankle surgeons were sent a questionnaire concerning the diagnostic modalities use in tarsal fusion.

RESULTS

Fifty-eight (65%) questionnaires were returned. The experienced surgeons measured outcomes significantly more often than other surgeons. Diagnostic injections were often used, although scant evidence exists in the literature. Postoperative diagnostics mainly consist of X-ray examination, although there is consensus in the literature that computed tomography is more accurate.

CONCLUSIONS

The study revealed some surprising discrepancies concerning the use of diagnostic imaging in tarsal fusion. More clinical research is needed to identify the most effective diagnostic imaging modalities so as to encourage their wider adoption.

A pictorial review of reconstructive foot and ankle surgery: evaluation and intervention of the flatfoot deformity

This pictorial review focuses on basic procedures performed within the field of podiatric surgery, specifically for elective reconstruction of the midfoot and rearfoot with focus on the flatfoot deformity. Our goal is to demonstrate objective radiographic parameters that surgeons utilize to initially define the deformity, lead to procedure selection, and judge post-operative outcomes. We hope that radiologists will employ this information to improve their assessment of post-operative radiographs following reconstructive foot surgeries. First, relevant radiographic measurements are defined and their role in procedure selection explained. Second, the specific surgical procedures of the Evans calcaneal osteotomy, medial calcaneal slide osteotomy, Cotton osteotomy, subtalar joint arthroeresis, and arthrodeses of the rearfoot are described. Finally, specific plain film radiographic findings that judge post-operative outcomes for each procedure are detailed.

A Different Type of Talocalcaneal Coalition With Os Sustentaculum: The Continued Necessity of Revision of Classification

OBJECTIVE

The objective of our study was to retrospectively determine the prevalence and image findings of extraarticular talocalcaneal coalition with os sustentaculum, a type of talocalcaneal coalition that does not appear in current classification systems, in patients with an imaging diagnosis of foot coalition.

MATERIALS AND METHODS

This study was performed using a database query of radiology reports of ankle and foot CT or MRI examinations performed from August 2001 to November 2013. Eighty-one patients were identified through a keyword search of the database for "talocalcaneal coalition," "tarsal coalition," "coalition," or "os sustentaculum." Imaging features of CT or MRI findings were evaluated. Chart review was used to identify demographic information.

RESULTS

Extraarticular talocalcaneal coalition with os sustentaculum was diagnosed in 13 patients (nine men, four women), which represents a prevalence of 16.0% (13/81) in all foot coalitions and 24.1% (13/54) in all talocalcaneal coalitions. Four of 13 patients underwent surgical resection, and histology was obtained in three patients. Nine patients who had no history of trauma were symptomatic and all patients with bone marrow edema at the coalition sites on MRI (n = 5) were also symptomatic. Coexisting extraarticular talocalcaneal coalition with os sustentaculum and intraarticular talocalcaneal coalition were observed in 11 of 13 patients.

CONCLUSION

The os sustentaculum is a component of extraarticular talocalcaneal coalitions and as such is usually related to the presence of symptoms. If a patient with an os sustentaculum has symptoms in the medial talocalcaneal joint area, an extraarticular talocalcaneal coalition related to the os sustentaculum should be considered.

Posterior Arthroscopic Subtalar Arthrodesis

Introduction

Although subtalar joint arthrodesis may be achieved through open or arthroscopic approaches, we have found that posterior arthroscopic subtalar arthrodesis has technical advantages compared with other approaches.

Step 1 Preoperative Assessment and Planning

Clinically assess the foot and ankle with regard to remaining motion, previous scarring, and associated deformities, ensuring that no concomitant procedure will be needed in the supine position.

Step 2 Positioning of the Patient

Use spinal or general anesthesia.

Step 3 Placement of the Posterolateral Portal Lateral to the Achilles Tendon

Place the posterolateral portal lateral to the Achilles tendon at the level of the tip of the lateral malleolus, according to the original technique described by van Dijk et al.

Step 4 Placement of the Posteromedial Portal Medial to the Achilles Tendon

Place the posteromedial portal medial to the Achilles tendon at the level of the tip of the lateral malleolus.

Step 5 Exposure of the Subtalar Joint by Removing the Fatty Tissue and Part of the Posterior Joint Capsule

With the help of the shaver, look for the landmarks of the posterior arthroscopy, going from the posterolateral part of the subtalar joint toward the flexor hallucis longus tendon, which is medially located, while exposing the tibiotalar joint.

Step 6 Debridement and Microfracturing of the Posterior Facet of the Subtalar Joint

Sometimes an accessory portal, just anterior to the tip of the external malleolus, may be needed to achieve a distraction of the anterior part of the subtalar posterior facet.

Step 7 Use of Bone Graft

To perform this concomitant step, which generally is not necessary, use an arthroscopic forceps to insert a 5 by 20-mm autograft or allograft in the subtalar joint.

Step 8 Fixation of the Subtalar Joint Using Two Cannulated Screws and Fluoroscopy

Use two cannulated screws with a 7.3-mm diameter; we prefer stabilization screws to compression screws.

Step 9 Additional Surgical Procedures

Always clean out the posterior compartment of the ankle during the PASTA procedure, as is done during surgical treatment for posterior impingement syndrome, and note that both posterior impingement syndrome and subtalar degenerative changes may thereby be easily addressed through this procedure.

Step 10 Postoperative Care

A short posterior leg splint is worn for three to ten days, followed by another non-weight-bearing cast for another three weeks.

Results

Since the appearance of the original article, a total of forty-one unilateral subtalar joints in twenty-five men and sixteen women, seen between May 2007 and December 2012, with isolated subtalar arthritis or talocalcaneal coalition without any other major hindfoot arthritis were treated by posterior arthroscopic subtalar arthrodesis, and all subtalar joints except for two were considered radiographically fused at the first attempt after an average of 6.7 weeks (range, six to ten weeks).IndicationsContraindicationsPitfalls & Challenges.

Total Bilateral Tarsal Coalition: A Case Report

A 35-year-old male presented with pain and swelling of his right foot and ankle. His pain developed gradually and without overt pedal deformity. The radiologic examination revealed complete fusion of all tarsal bones of his right foot. Comparative radiographs of his left foot also showed complete tarsal coalition. Ankle osteoarthritis was diagnosed, and supportive treatment enabled the patient to return to an asymptomatic status and continue the duties of his employment. This case is presented to describe an adult patient with bilateral, massive tarsal coalition who was essentially asymptomatic until degenerative arthritic changes developed in one of his ankles.

Subtalar coalitions in the adult

Tarsal coalitions, while relatively uncommon, are typically identified in adult patients during an evaluation for ankle instability, sinus tarsus pain, and/or pes planovalgus. The true incidence of tarsal coalition is unknown with estimates ranging from 1% to 12% of the overall population. The most common area of involvement of the subtalar joint is the middle facet, and heightened awareness should be present in adult patients with limited motion of the subtalar joint. Standard radiographic imaging, to include a Harris heel view, is recommended initially, although computerized tomography scan and MRI are often necessary to confirm the diagnosis.

Talocalcaneal coalition combined with flatfoot in children: diagnosis and treatment: a review

Talocalcaneal coalition often leads to a flatfoot deformity in children. Previous reports have uncovered many aspects of tarsal coalition and flatfoot respectively, including the etiology, clinical presentation, and diagnostic imaging, as well as treatment. However, the optimum surgical procedure for talocalcaneal coalition combined with flatfoot has not been definitively determined. The nonconformity of treatment options is due to our incomplete knowledge of biomechanics, diagnosis, and indication of treatment for talocalcaneal coalition with flatfoot. The objectives of this review are to provide an overview of the current knowledge about etiology, biomechanics, classification, diagnosis, and treatment options for talocalcaneal coalitions with flatfoot and highlight its therapies in children.

Taking out the tarsal coalition was easy: but now the foot is even flatter. What now?

Patients with a preexisting hindfoot deformity, who undergo resection (with or without soft tissue interposition) of a tarsal coalition, may present with recurrent pain and worsening planovalgus deformity. This is due to the secondary effect of soft tissue contractures (lateral ligaments, peroneal tendons, calf muscles) "pulling" the foot into more valgus. Physiotherapy and insoles may help some patients. Depending on the flexibility of the hindfoot and the presence or otherwise of joint degeneration, joint-preserving corrective procedures or corrective joint fusions may be needed. Gastrocnemius, Achilles, and/or peroneal tendon releases may be required, to avoid equinus or further recurrence.

Joint-preserving surgery of valgus ankle osteoarthritis

Patients with posttraumatic ankle osteoarthritis (OA) typically present with asymmetric involvement of the tibiotalar joint, resulting in valgus or varus deformity of the ankle and hindfoot. Without appropriate treatment, patients with asymmetric ankle OA typically develop full end-stage ankle OA. Ankles with valgus deformities suffer from a lateral joint overload with subsequent lateral tibiotalar joint degeneration, which causes further lateral load shift. In these cases patients may benefit from joint-preserving realignment surgery to unload the degenerated lateral area and normalize joint biomechanics. This article describes the authors' algorithm for the treatment of patients with asymmetric valgus ankle OA.