Talocalcaneal Coalitions

Morphological characteristics of talocalcaneal coalitions: Anatomical observation, finite element analysis and clinical application

BACKGROUND

The intricate anatomical structure of talocalcaneal coalitions (TCCs) presents significant challenges for clinicians in both diagnosis and treatment. This study aimed to investigate the anatomy, imaging characteristics, and biomechanical properties of TCCs, providing essential references for contemporary clinical diagnosis, treatment, scientific research, and education regarding TCCs.

METHODS

The morphologies of TCCs were examined and classified in intact dry osseous specimens from 131 Asian adults. The imaging characteristics of TCCs were summarized by carefully observing the X-rays and CT scans. Additionally, finite element models of TCCs were established and validated, allowing for the simulation and analysis of stress and strain.

RESULTS

The TCCs were primarily located in the region between the posterior end of sustentaculum tali (ST), the medial port of the tarsal canal, and the medial edge of the posterior talar articular surface (PTF). In comparison to specimens with cartilage and ligament connections, the medial tubercle of osseous connections exhibited significant inward and downward protrusion, while the ST was longer and thicker. Statistically significant differences were noted in the widths of the calcaneus and talus, as well as in the thickness and length of the ST (P < 0.05). CT imaging provided an accurate determination of TCCs' locations, while X-rays revealed the presence of the "C sign" and "duck beak sign" in all osseous connection specimens. Finite element model analysis indicated that stress was primarily concentrated at the osseous connection, which also reduced displacement of the subtalar joint.

CONCLUSIONS

The comprehension of the precise location, anatomical morphological characteristics, imaging features and finite element mechanical properties of TCCs is instrumental in enhancing the diagnosis and treatment of TCCs.

Massive tarsal coalition with extended tarsometatarsal coalition in a child: a case report

Tarsal coalition refers to the union of two or more tarsal bones, which mostly involves the calcaneonavicular and talocalcaneal joints; it is rarely found in multiple unions or unions extended to the metatarsal bones. Nearly 50% of cases occur bilaterally and can be either symmetrical or asymmetrical. We described a rare case of symmetrically bilateral tarsal coalitions involving all the tarsal bones, except for the medial cuneiform, and extending to the fourth metatarsal bones in a 5-year-old boy. This patient exhibited no obvious symptoms and had not received any further intervention, only regular follow-up. To our knowledge, this is the first report of this type of massive coalition involving the union of six tarsals and one tarsometatarsal bilaterally.

Tarsal coalition in adults

Adult tarsal coalition consists in abnormal union of two or more tarsal bones. Reported incidence ranges between 1 and 13%. It is generally a congenital condition, due to dominant autosomal chromosome disorder, but with some acquired forms following trauma or inflammatory pathology. Poorly specific clinical signs and the difficulty of screening on conventional X-ray may lead to diagnostic failure. The present review of tarsal coalition addresses the following questions: how to define tarsal coalition? How to diagnose it? How to treat it? And what results can be expected? There are 3 types of tarsal coalition, according to the type of tissue between the united bones: bony in pure synostosis, cartilaginous in synchondrosis, and fibrous in syndesmosis. Location varies; the most frequent forms are talocalcaneal (TC) and calcaneonavicular (CN), accounting for more than 90% of cases. Cuneonavicular, intercuneal and cuboideonavicular locations are much rarer, at less than 10%. Tarsal coalition is classically painful, often with valgus spastic flatfoot in young adults. The pain is caused by the biomechanical disturbance induced by the bone, cartilage or fibrous bridges which partially or completely hinder hindfoot and/or midfoot motion. Conventional imaging, with weight-bearing X-ray and CT, is standard practice. Weight-bearing CT is increasingly the gold standard, displaying abnormalities in 3 dimensions. Functional imaging on MRI and tomoscintigraphy assess direct and indirect joint impact at the affected and neighboring joint lines. Non-operative treatment can be proposed, with orthoses, rehabilitation and/or injections. But surgery is the most frequent option: either resection of the bony, cartilaginous or fibrous constructs to restore optimally normal anatomy, or arthrodesis in the affected joint line or the entire joint. Surgery can be open, arthroscopic or percutaneous, depending on the severity of the biomechanical impact on the affected and neighboring joints. Resecting the abnormality is the standard practice in all locations if it affects less than 50% of the talocalcaneal joint line and there is no osteoarthritis to impair the functional outcome. Otherwise, fusion is required. Level of evidence: V; expert opinion.

Resection of Calcaneonavicular and Talocalcaneal Coalitions With Surgical Correction of the Hindfoot Valgus Deformity in One Step

Background

Calcaneonavicular (CNC) and talocalcaneal (TCC) coalitions are the most common cause of rigid flatfoot in children. After resection, correction of the most frequent valgus-hindfoot deformity usually requires a second-step surgery. We report results of a retrospective study of patients treated with a one-step correction.

Methods

Between 2008 and 2019, data were collected on 26 patients (19 male, 7 female) affected by CNC (n = 18) and TCC (n = 13), all with rigid symptomatic flatfeet. Average age at surgery was 12.5 ± 1.1 (SD) years (range, 9.8-15.2). All patients (26/26) underwent resection, 20 of 26 underwent at the same time subtalar extraarticular screw arthroereisis (SESA) for correction of residual hindfoot valgus deformity. Pre- and postoperative talocalcaneal angle according to Costa Bartani and Talar inclination angle in weightbearing were measured. Twenty-five of 26 patients had postoperative American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score.

Results

Pre- and postoperative talocalcaneal average angle for CNC was respectively 141.5 ± 7.7 degrees and 130.5 ± 5.2 degrees (P < .0001) and 143.7 ± 7.7 degrees and 129.7 ± 7.0 degrees (P < .0001) for TCC. Talar inclination average angle for CNC was 29.2 ± 5.3 degrees and 19.3 ± 1.6 degrees (P < .0001) and 31.2 ± 6.4 degrees and 21.4 ± 3.4 degrees (P < .0001) for TCC. Average follow-up (FU) was 4.7 ± 3.0 years (range, 6 months-11.9 years, median 4.9 years), with a mean age at FU of 17.2 ± 5.8 (SD) years (min 12.1, max 25.3, median 16.8 years). The mean AOFAS ankle-hindfoot score for CNC and for TCC was 96.6 (range 83-100) for resection and valgus correction as one-step procedure with no statistical difference (P = .5) between CNC and TCC. No patients had additional surgery for complications or recurrence.

Conclusion

Symptomatic rigid flatfeet affected by CNC and TCC treated with coalition resection and minimally invasive subtalar arthroereisis (SESA) for residual hindfoot valgus correction in one step in adolescent age achieved good to excellent results in all cases. Further surgery to correct malalignment was avoided.

Level of Evidence

Level IV, retrospective study.

Nonneurologic Cavovarus Feet in Skeletally Immature Patients: Main Causes and Principles of Treatment

The foot resembles a tripod. The 3 legs consist of (1) the tip of the heel, (2) the first metatarsal, and (3) the fifth metatarsal. This concept is useful to explain cavus or flat feet. When the tips of the tripod move closer, the arch becomes higher. The leg of the tripod that moves the most will determine the type of cavus feet, which can be hindfoot cavus, forefoot cavus, or first metatarsal cavus. Cavovarus foot denotes the presence of a three-dimensional deformity of the foot, but it is much more a descriptive feature than a diagnosis.

Talus bone: normal anatomy, anatomical variations and clinical correlations

Talus is a pivotal bone that assists in easy and correct locomotion and transfers body weight from the shin to the foot. Despite its small size, it is implicated in many clinical disorders. Familiarity with the anatomy of the talus and its anatomical variations is essential for the diagnosis of any disorder related to these variations. Furthermore, orthopedic surgeons must be fully aware by this anatomy during podiatry procedures. In this review, we attempt to present its anatomy in a simple, updated and comprehensive manner. We have also added the anatomical variations and some clinical points relevant to the unique and complex anatomy of talus. The talus has no muscle attachment. However, it does have many ligaments attached to it and others around it to keep it in place. Moreover, the bone plays a pig role in movements due to its involvement in many joints. Most of its surface is covered with articular cartilage. Therefore, its blood supply is relatively poor. This puts the talus at greater risk for poor healing as well as more complications in the event of injury than any other bone. We hope this review will make it easier for clinicians to pursue and understand the updated essential knowledge of one of the most complex bone anatomies that they need in their clinical practice.

Surgical Treatment of Calcaneonavicular and Talocalcaneal Coalitions

Tarsal coalition is determined by an absence of segmentation between one or more foot bones. The main symptom is activity-related foot pain, usually dorsolateral for calcaneonavicular coalitions and medial for talocalcaneal ones. At presentation, a symptomatic tarsal coalition must be treated conservatively for at least 6 months. If the conservative treatment fails and the foot is still painful, resection is the treatment of choice. Advantage of surgery is to restore mobility and reduce the risk of subsequent degenerative arthritis. Common pitfalls of surgery include failure to recognize associated coalitions, inadequate or extensive resection, and injury of adjoining bones.

A new classification of talocalcaneal coalitions based on computed tomography for operative planning

BACKGROUND

Current classifications emphasize the morphology of the coalition, however, subtalar joint facets involved should also be emphasized.

OBJECTIVE

The objective of this study was to develop a new classification system based on the articular facets involved to cover all coalitions and guide operative planning.

METHODS

Patients were diagnosed with talocalcaneal coalition using a CT scan, between January 2009 and February 2021. The coalition was classified into four main types according to the shape and nature of the coalition: I, inferiorly overgrown talus or superiorly overgrown calcaneus; II, both talus and calcaneus overgrew; III, coalition with an accessory ossicle; IV, complete osseous coalition (I-III types are non-osseous coalition). Then each type was further divided into three subtypes according to the articular facets involved. A, the coalition involving the anterior facets; M, the coalition involving the middle facets, and P, the coalition involving the posterior facets. Interobserver reliability was measured at the main type (based on nature and shape) and subtype (articular facet involved) using weighted Kappa. Results There were 106 patients (108 ft) included in this study. Overall, 8 ft (7.5%) were classified as type I, 75 ft (69.4%) as type II, 7 ft (6.5%) as type III, and 18 ft (16.7%) as type IV. Twenty-nine coalitions (26.9%) involved the posterior facets only (subtype-P), 74 coalitions (68.5%) involved both the middle and posterior facets (subtype-MP), and five coalitions (4.6%) simultaneously involved the anterior, middle, and posterior facets (subtype-AMP). Type II-MP coalition was the most common. The value of weighted Kappa for the main type was 0.93 (95%CI 0.86-0.99) (p<0.001), and the value for the subtype was 0.78 (95%CI 0.66-0.91) (p<0.001).

CONCLUSION

A new classification system of the talocalcaneal coalition to facilitate operative planning was developed.

The C-sign in normal feet: a prospective study and novel imaging algorithm for subtalar joint tarsal coalition

OBJECTIVE

The C-sign on lateral radiographs has been subject to considerable debate with respect to its reliable association to subtalar joint tarsal coalition. The purpose of this study was to determine to what degree subtalar joint pronation factors into (a) the appearance of both complete and incomplete type A C-signs and (b) the conspicuity of the middle facet in both flatfeet and rectus feet.

STUDY DESIGN

Forty-seven normal adult volunteers were enrolled into the study with a total of 92 feet, of which 42 were flexible flatfeet and 50 were rectus feet with normal subtalar joint range of motion. Lateral weight-bearing radiographs were taken of each foot in a position of (a) standing and (b) maximum subtalar joint pronation. Investigators evaluated images for the visibility of the middle facet, and the presence or absence of a continuous or interrupted type A C-sign.

PRINCIPAL RESULTS

No continuous C-signs were produced with extreme pronation in either the rectus/normal or flatfoot populations. Three incomplete type A C-signs were produced with pronation, two of which were in rectus feet. Two absent middle facet signs were also produced with pronation. Absent visualization of the facet had high positive and negative predictive values (1.00 and 0.99 respectively) for the presence of an incomplete C-Sign.

MAJOR CONCLUSIONS

The standard, routine lateral foot/ankle radiographic image protocol for suspected talocalcaneal coalition should be modified routinely positioning the foot maximally supinated, thereby minimizing the possibility of producing C-signs (complete or type A incomplete) and/or absent middle facet signs with pronation in either normal or flatfeet. A novel algorithmic approach can then be simply applied to determine when ancillary CT scanning is warranted for suspected posterior facet coalition.

Operative versus nonoperative treatment in children with painful rigid flatfoot and talocalcaneal coalition

Background

The management of painful rigid flatfoot (RFF) with talocalcaneal coalition (TCC) is controversial. We aimed to compare operative and nonoperative treatment in children with RFF and TCC.

Methods

We retrospectively reviewed medical records and radiographs of children with RFF and TTC treated between 2005 and 2015. The nonoperative treatment consisted of manipulation under anesthesia, cast immobilization and shoe insert after cast removal. The operative treatment consisted of combined TCC resection, graft interposition and subtalar arthroereisis.

Results

Thirty-four children (47 ft) in the nonoperative group and twenty-one children (34 ft) in the operative group were included. No differences were found between groups, concerning baseline characteristics. The mean age at treatment was 11.8 years (9–17): 11.6 (9–17) for the nonoperative group, 12.2 (10–15) for the operative group. The mean follow-up averaged 6.6 (3–12) years and was significantly longer in the nonoperative group (7.8 versus 4.7 years; p < 0.0005), since the operative procedure was increasingly practiced in the latest years.

There were no complications in either groups, but 6 patients (7 ft) in the nonoperative group were unsatisfied and required surgery. At the latest follow-up, the AOFAS-AHS improved in both groups, although the operative group showed significantly better improvement. The operative group reported also significantly better FADI score, after adjustment for follow-up and baseline variables.

Conclusion

The operative treatment showed better results compared to the nonoperative treatment. Symptomatic RFF with TCC in children can be effectively treated in one step with resection, graft interposition and subtalar arthroereisis. Further prospective randomized studies are needed to confirm our findings and to identify the best operative strategy in this condition.

Surgical treatment of tarsal coalitions in children and adolescents

A tarsal coalition is an abnormal connection between two or more tarsal bones caused by failure of mesenchymal segmentation.

The two most common tarsal coalitions are calcaneonavicular coalition (CNC) and talocalcaneal coalition (TCC). Both CNC and TCC can be associated with significant foot and ankle pain and impaired quality of life; there may also be concomitant foot and ankle deformity.

Initial, non-operative management for symptomatic tarsal coalition commonly fails, leaving surgical intervention as the only recourse.

The focus of this article is to critically describe the variety of methods used to surgically manage CNC and TCC. In review of the pertinent literature we highlight the ongoing treatment controversies in this field and discuss new innovations.

The evidence-based algorithmic approach used by the authors in the management of tarsal coalitions is illustrated alongside some clinical pearls that should help surgeons treating this common, and at times complex, condition.

Cite this article: EFORT Open Rev 2020;5:80-89. DOI: 10.1302/2058-5241.5.180106

[Evans lateral lengthening calcaneal osteotomy in treatment of talocalcaneal coalition with hindfoot valgus deformity]

OBJECTIVE

To investigate the effectiveness of the Evans lateral lengthening calcaneal osteotomy (E-LLCOT) in treatment of talocalcaneal coalition (TCC) with hindfoot valgus deformity.

METHODS

Between January 2014 and October 2017, 10 patients (13 feet) of TCC with hindfoot valgus deformities underwent E-LLCOTs. There were 6 males (8 feet) and 4 females (5 feet) with an age of 13-18 years (mean, 15.8 years). The disease duration was 10-14 months (mean, 11.5 months). The foot deformity was characterized by hindfoot valgus, forefoot abduction, and collapse of the medial arch. Pain site was the tarsal sinus in 4 feet, TCC in 5 feet, and ankle joint in 4 feet. There were tightness of the gastrocnemius in 3 cases (4 feet) and Achilles tendon in 7 cases (9 feet) on Silverskiold test. The preoperative American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was 46.54±9.08 and visual analogue scale (VAS) score was 6.54±0.88 after walking 1 kilometer. The AOFAS ankle-hindfoot score and VAS score were adopted to evaluate the postoperative function of the foot. The talar-first metatarsal angle (T1MT), talonavicular coverage angle (TCA), talar-horizontal angle (TH), calcaneal pitch angle (CP), and heel valgus angle (HV) were measured after operation.

RESULTS

All incisions healed by first intention. All patients were followed up 12-30 months (mean, 18 months). At last follow-up, the AOFAS ankle-hindfoot score and VAS score were 90.70±6.75 and 1.85±0.90, respectively, showing significant differences when compared with preoperative scores ( t=-23.380, P=0.000; t=35.218, P=0.000). X-ray films showed that the osteotomy healed at 2-4 months (mean, 3 months) after operation. At last follow-up, the T1MT, TCA, TH, and HV were significantly lower than preoperative ones ( P<0.05), and the CP was significantly higher than preoperative one ( P<0.05). During the follow-up, the pain did not relieve obviously in 1 patient (1 foot), and the cutaneous branch of the sural nerve injured in 1 patient (1 foot).

CONCLUSION

For TCC with severe hindfoot valgus deformity, E-LLCOT can effectively correct deformity and relieve pain.

Tarsal coalition

PURPOSE OF REVIEW

Tarsal coalitions may cause painful pes planovalgus and recurrent sprains, and can lead to arthrosis if improperly managed. In this review, we discuss the current topics related to talocalcaneal and calcaneonavicular coalitions.

RECENT FINDINGS

Tarsal coalitions are initially managed with conservative therapy, and when this approach fails, surgery is performed. Treatment of calcaneonavicular coalitions involves resection of the coalition and interposition of the extensor digitorum brevis muscle or fat, and in cases of marked valgus deformity, correction of the deformity. In talocalcaneal coalitions, recommendations include coalition resection for those affecting less than 50% of the area of the posterior facet and with a less than 16° valgus, coalition resection and valgus correction for those affecting less than 50% of the area and valgus greater than 16°, and isolated valgus correction for those affecting more than 50% of the area and with a more than or less than 16° valgus. Arthrodesis is reserved as a salvage procedure.

SUMMARY

Talocalcaneal and calcaneonavicular coalitions can cause painful pes planovalgus. Their diagnoses are confirmed by plain radiograph, computed tomography, and, in cases of fibrous or cartilaginous coalitions, MRI. Initial treatment is conservative, and when symptoms persist, resection of the coalition is recommended along with tissue graft interposition with or without associated valgus correction. Arthrodesis is indicated as a salvage procedure whenever treatment fails or with advanced arthrosis.

[Effectiveness of a modified posterior approach for arthroscopic resection on painful talocalcaneal coalition in adults]

OBJECTIVE

To investigate the effectiveness of arthroscopic talocalcaneal coalition resection in painful adults via a modified posterior approach.

METHODS

Between January 2015 and December 2017, 9 patients with painful talocalcaneal coalition accepted arthroscopic resection via the posterior malleolus high lateral observation approach combined with the lower medial operation approach. Of them, 6 were male and 3 were female, aged from 19 to 30 years (mean, 24 years). Among them, 2 cases had no definite local trauma and 7 cases had a history of sprain of foot and ankle. The disease duration ranged from 6 to 30 months, with a median of 12 months. Rozansky classification of talocalcaneal coalition for the 9 patients: 5 cases (5 feet) were type Ⅰ, 2 cases (2 feet) type Ⅱ, and 2 cases (2 feet) type Ⅲ. The patients had no sequelae of limb dysfunction and no limb joint surgery in the past. All the patients received anteroposterior and lateral X-ray films and CT scans of the ankle joint during follow-up. The visual analogue scale (VAS) score and American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hind foot score were used to evaluate the effectiveness.

RESULTS

The operation time was 60-90 minutes (mean, 76 minutes). All patients were followed up 12-24 months (mean, 18 months). All the incisions healed by first intention, without infection, skin necrosis, lower extremity deep vein thrombosis, vascular nerve and tendon injury, bone bridge recurrence, and other complications. The ankle function recovered well and the pain was relieved obviously after operation, and the patients returned to work at 3-5 months after operation, with an average of 3.9 months. At last follow-up, the VAS score was 0.7±0.5, which was significantly improved ( t=20.239, P=0.000) when compared with preoperative score (4.2±0.5); the AOFAS ankle-hind foot score was 94±4, which was significantly improved ( t=-27.424, P=0.000) when compared with preoperative score (62±2). According to AOFAS ankle-hindfoot scoring system, the results were excellent in 7 cases and good in 2 cases at last follow-up.

CONCLUSION

It is more intuitive, more space, and more flexibility for operation via the modified posterior malleolus high lateral observation approach combined with the lower medial operation approach in talocalcaneal coalition. It is feasible to remove talocalcaneal coalition programmatically according to the specific anatomic signs during the operation.

Tarsal coalition in paediatric patients

Tarsal coalition is due to failure of segmentation between two or more foot bones during embryological development at a site where the joint cleft fails to develop. Depending on the nature of the tissue connecting the bones, the abnormality is a syndesmosis, synchondrosis, or synostosis. Although the coalition exists at birth, synostosis usually develops only late during growth. Talo-calcaneal and calcaneo-navicular coalitions account for over 90% of all cases of tarsal coalition. The joint at the site of the coalition is stiff. Pain during physical activity is the main symptom, although recurrent ankle sprain is another possible presenting manifestation. During the physical examination, range-of-motion limitation at the hindfoot or midfoot should be sought, as well as varus or valgus malalignment of the hindfoot. Either pes planus or pes cavus may be seen. Calcaneo-navicular coalition may be visible on the standard radiograph, whereas talo-calcaneal coalition is best visualised by computed tomography or magnetic resonance imaging. As growth proceeds, the coalition becomes ossified and range-of-motion diminishes. Onset of the pain is often in the second decade of life or later. In patients with symptomatic tarsal coalition, the initial management should always consist in non-operative treatment for at least 6 months. A consensus exists that surgery should be offered when non-operative treatment fails. Open resection of the coalition is the treatment of choice, although endoscopic resection is also an option. Sound evidence exists that resection of the coalition can produce favourable outcomes even in the long-term. Fusion should be reserved for failure of resection, extensive coalitions, multiple coalitions, and patients with advanced osteoarthritis.

Treatment of isolated talonavicular coalition: Case report and literature review

Tarsal coalition refers to an abnormal fibrous, cartilaginous, or bony connection that develops between two or more tarsal bones. Talocalcaneal coalition and calcaneonavicular coalition account for more than 90% of all cases of tarsal coalition. Coalition exists early at birth, but bony connection usually develops during the patient's late growth period. Isolated cases of talonavicular coalition have rarely been reported. We herein report a case involving an 11-year-old patient with an isolated talonavicular coalition from a soft tissue to bony connection who was treated with arthroscopy for ankle arthritis. To our knowledge, this is the first case in which the whole formation of the talonavicular coalition was observed with a series of radiographic and magnetic resonance imaging examinations. The pain caused by the talonavicular coalition was managed by nonoperative treatment, while the ankle pain caused by the arthritis was relieved after ankle arthroscopy. At 6 years postoperatively, the patient remained pain-free while walking for 30 minutes and was satisfied with the operative outcome. Continuous follow-up confirmed that after the formation of talonavicular coalition, the coalition can continue to progress, forming bony talocalcaneal coalition and calcaneocuboid coalition.

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.

Massive Osteochondral Lesion of the Talus in a Skeletally Immature Patient Associated With a Tarsal Coalition and Valgus Hindfoot

Rarely, osteochondral lesions of the talus occur without a history of trauma. Accurate interpretation of the mechanical load distributions onto the ankle leading to potential atraumatic cartilage damage must always be studied. The published data on the optimal treatment of talar osteochondral lesions in skeletally immature patients are scarce, especially when the lesions are associated with hindfoot malalignment. We describe the case of a pediatric female with an atraumatic osteochondral lesion of the talus associated with a talocalcaneal coalition and a valgus hindfoot, which we consider the first case to be reported. She presented with prolonged bilateral ankle pain and catching during gait of approximately 2 years' duration with a restricted range of motion, with the pain more excruciating in the right ankle. Radiographs revealed a large osteochondral lesion located at the lateral talar dome. The patient underwent partial osteochondral allograft transplantation, together with hindfoot realignment and coalition resection with a fat graft interposition. At the 2-year follow-up examination, the patient was free of pain in her right foot and ankle, with no signs of radiologic failure.

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.

Treatment of hindfoot and ankle pathologies with posterior arthroscopic techniques

The two-portal hindfoot arthroscopy is an effective procedure enabling direct visualisation of posterior ankle pathology with low invasiveness.

An important stage of the hindfoot endoscopy is localisation of the flexor hallucis longus (FHL) tendon to protect the neurovascular bundle which is located just medial to it.

Posterior ankle impingement syndrome and FHL tenosynovitis are common causes of posterior ankle pain and frequently occur together.

Posteriorly localised talar osteochondral lesions, Achilles tendon disorders, osteoarthritis, talar bone cysts and talar fractures are among the other pathologies that can be treated with hindfoot arthroscopy.

Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160055. Originally published online at www.efortopenreviews.org