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

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.

Clinical applications of allografts in foot and ankle surgery

PURPOSE

The purpose of this review is to systematically analyse current literature on the use of allografts in the surgical treatment of foot and ankle disorders in adult patients. Based on this study, we propose evidence-based recommendations.

METHODS

The database for PubMed was searched for all published articles. No timeframe restrictions were applied. Clinical studies eligible for inclusion met the following criteria: performed on patients over 18 years old; subject to surgical treatment of foot and ankle disorders; with report on the outcome of the use of allografts; with a report and assessment of pain and function, or equivalent; minimum follow-up of 1 year was required. Two reviewers independently screened and selected studies for full-text analysis from title and abstract. 107 studies were included from 1113 records. Studies were grouped according to surgical indications into ten categories: musculoskeletal tumours (n = 16), chronic ankle instability (n = 15), ankle arthritis (n = 14), osteochondral lesions of the talus (n = 12), Achilles tendon defects (n = 11), other tendon defects (n = 9), fusions (n = 9), fractures (n = 8), hallux rigidus (n = 3) and other indications (n = 10).

RESULTS

Most studies displayed evidence level of IV (n = 57) and V (n = 39). There was one level I, one level II and nine level III studies. Most studies reported allografting as a good option (n = 99; 92.5%). Overall complication rate was 17% (n = 202).

CONCLUSIONS

Fair evidence (Grade B) was found in favour of the use of allografts in lateral ankle ligament reconstruction or treatment of intra-articular calcaneal fracture. Fair evidence (Grade B) was found against the use of allogeneic MSCs in tibiotalar fusions.

LEVEL OF EVIDENCE

V.

Resection of Medial Talocalcaneal Coalition With Interposition of a Pediculated Flap of Tibialis Posterior Tendon Sheath

BACKGROUND

The purpose of the study was to present a novel operative technique in the management of medial talocalcaneal coalition (TC) and to report our clinical and radiologic results after interposition of a pediculated flap (PF) of the tibialis posterior tendon sheath.

METHODS

Twelve feet of 10 patients with a medial TC were treated with the interposition of PF of the tibialis posterior tendon sheath following resection. Pre- and postoperative clinical examinations were performed to evaluate the range of motion and the function of the tibialis posterior muscle of the affected foot. Pain was registered by visual analog scale (VAS) and the function of the foot by the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score. The mean follow-up duration was 57.2 months (SD ±37.2 range 12-128) after surgery. Magnetic resonance imaging (MRI) was carried out to assess the outcome.

RESULTS

All patients reported a significant reduction of pain ( P = .002) at the final follow-up. The activity level had improved since the operation, and the subtalar joint motion was increased, but no weakness of the tibialis posterior muscle could be observed. The AOFAS hindfoot score was significantly improved ( P = .002). MRI did not reveal any migration of the tibialis posterior tendon sheath, and the interposed PF was confirmed at the resection zone. Furthermore, no TC relapse or ruptures of the functional anatomical structures could be observed.

CONCLUSION

The resection combined with the interposition of a PF of the tendon sheath seems to avoid relapse of TC and improves symptoms and the function of the foot.

LEVEL OF EVIDENCE

Level IV, case series.

Talocalcaneal Joint Middle Facet Coalition Resection With Interposition of a Juvenile Hyaline Cartilage Graft

Talocalcaneal joint middle facet coalition is the most common tarsal coalition, occurring in ≤2% of the population. Fewer than 50% of involved feet obtain lasting relief of symptoms after nonoperative treatment, and surgical intervention is commonly used to relieve symptoms, increase the range of motion, improve function, reconstruct concomitant pes planovalgus, and prevent future arthrosis from occurring at the surrounding joints. Several approaches to surgical intervention are available for patients with middle facet coalitions, ranging from resection to hindfoot arthrodesis. We present a series of 4 cases, in 3 adolescent patients, of talocalcaneal joint middle facet coalition resection with interposition of a particulate juvenile hyaline cartilaginous allograft (DeNovo(®) NT Natural Tissue Graft, Zimmer, Inc., Warsaw, IN). With a mean follow-up period of 42.8 ± 2.9 (range 41 to 47) months, the 3 adolescent patients in the present series were doing well with improved subtalar joint motion and decreased pain, and 1 foot showed no bony regrowth on a follow-up computed tomography scan. The use of a particulate juvenile hyaline cartilaginous allograft as interposition material after talocalcaneal middle facet coalition resection combined with adjunct procedures to address concomitant pes planovalgus resulted in good short-term outcomes in 4 feet in 3 adolescent patients.

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.

Preliminary report: resection and interposition of a deepithelialized skin flap graft in tarsal coalition in children

Six tarsal coalitions in children were managed surgically using a deepithelialized skin flap for interposition after resection of the bony, fibrous or cartilaginous coalition. The advantage of this technique is that due to positioning the skin flap, joint motion can be preserved. The clinical results using the Ankle Hindfoot Scale of the American Orthopedic Foot and Ankle Society were excellent in two and good in four cases. The radiographs at follow-up showed no recurrences of the resected coalitions. This study shows that the use of deepithelialized skin flap interposition is effective in providing pain relief for the patients in symptomatic coalitions.

Bilateral single-stage middle facet talocalcaneal coalition resection combined with flatfoot reconstruction: a report of 3 cases and review of the literature. Investigations involving middle facet coalitions--part 1

Talocalcaneal middle facet coalitions are associated with rigid pes planovalgus that often requires surgical intervention. Simple resection of the coalition is preferred for symptomatic cases in the absence of rearfoot arthritis. While resection of the coalition will remove the osseous restriction of motion and may eliminate pain, the procedure does not specifically correct the concomitant pes planovalgus. In this report of 6 feet in 3 patients, we advocate combining resection of the coalition with concomitant flatfoot reconstruction in a single-stage operation. The patients in this series averaged 13.67 (range 12-17) years of age at the time of their foot surgeries, and their follow-up averaged 30 (range 16-54) months. All of the patients displayed bilateral middle facet talocalcaneal coalitions and underwent bilateral resection combined with flatfoot reconstruction. Each patient had 1 foot corrected followed by a period of at least 6 months before the contralateral foot was corrected. The mean postoperative American Orthopaedic Foot and Ankle Society ankle-hindfoot score was excellent (94.33+/-2.81 points) overall. The median radiographic values for calcaneal inclination, Meary's, and anteroposterior talar-first metatarsal angles demonstrated statistically significant improvements: 9 degrees (3 degrees, 13 degrees) (P= .0273), 4 degrees (2 degrees, 7 degrees) (P= .0269), and 6 degrees (3 degrees, 11 degrees ) (P= .0277), respectively, and all feet demonstrated improved subtalar joint motion without pain. Although long-term results remain to be determined in a larger cohort, it is hoped that this combined approach to talocalcaneal coalition will delay or obviate future rearfoot arthrosis and the need for arthrodesis.

LEVEL OF CLINICAL EVIDENCE

4.