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

Comparison of different interposition techniques after surgical resection of tarsal coalitions in children: a systematic review

In the surgical treatment of tarsal coalitions, it is unclear whether interposition material should be used to prevent recurrence. The aim of this review was to systematically examine the results of different interposition tissues after surgical resection of tarsal coalitions in children. A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Two independent investigators systematically searched electronic databases (PubMed, Embase, Cochrane) and included original articles reporting outcomes of tarsal coalition resection. The quality of included studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. Out of 294 articles, 21 studies examining 436 patients (581 feet), were included. The mean age was 12.2 years (range 7-18). There were 153 talocalcaneal, 425 calcaneonavicular, 2 naviculocuboidal, and 1 naviculocuneiform coalitions. The mean follow-up time was 58 months (range 12-276). In 96 feet, solely resection was performed. Resection and interposition were performed with muscle/tendon (n = 178), fat graft (n = 176), other material (n = 36), or a combination of interposition techniques (n = 95). Eighteen studies reported on recurrence, which was found in 45 of 485 feet (9%). The highest recurrence (17%) was described after muscle/tendon interposition for calcaneonavicular coalitions. However, a statistical comparison could not be performed. The included studies were diverse and the scientific quality was generally low (MINORS mean 7, range 3-20). Coalition resection with various interposition techniques results in low recurrence rates. It is unclear which interposition material shows the best results.

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.

8 out of 10 patients do well after surgery for tarsal coalitions: A systematic review on 1284 coalitions

BACKGROUND

The primary aim was to determine the clinical success rate after treatment for talocalcaneal (TCC) and calcaneonavicular coalitions (CNC). The secondary aim was to evaluate the complication, recurrence and revision rate.

METHODS

A search was carried out in MEDLINE, EMBASE and Cochrane Library. Methodological quality was assessed using the Methodological Index for Non-Randomised Studies (MINORS) criteria. The primary outcome was the clinical success rate and was pooled per type of coalition and treatment modality. 95% Confidence Intervals (CI) of the success rates were calculated. Secondary outcomes included complication rates, coalition recurrence rates, revision rates and pain improvement using the Visual Analogue Scale (VAS). A sub-analysis on interposition material was performed.

RESULTS

43 articles comprising of 1284 coalitions were included, with a pooled mean follow-up of 51 months. Methodological quality was fair. The overall pooled success rate for TCCs was 79% (95% CI, 75%-83%). Conservative treatment, open resection and arthroscopic resection of TCCs resulted in success rates of 58% (95% CI, 42%-73%), 80% (95% CI, 76%-84%) and 86% (95% CI, 71%-94%), respectively. CNCs have an overall success rate of 81% (95% CI, 75%-85%), with 100% (95% CI, 34%-100%), 80% (95% CI, 74%-85%) and 100% (95% CI, 65%-100%) for conservative treatment, open resection and arthroscopic resection, respectively. Pooled complication rates of 4% (95% CI, 3%-7%) for TCCs and 6% (95% CI, 4%-11%) for CNCs were found. The success rates of resection with and without interposition material for TCCs were 83% (95% CI, 78%-87%) and 79% (95% CI, 65%-88%), and for CNCs 81% (95% CI, 76%-86%) and 69% (95% CI, 44%-85%), respectively.

CONCLUSION

Treatment of tarsal coalitions can be considered good to excellent as well as safe, with an overall clinical success rate of 79% for TCCs and 81% for CNCs. Arthroscopic resection of the coalition appears to be non-inferior to open resection of TCCs and CNCs.

LEVEL OF EVIDENCE

Level IV, Systematic Review.

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.

Radiographic characteristics and outcomes of simple resection for naviculo-medial cuneiform coalition in adults

BACKGROUND

This study aimed to report the outcomes of coalition resection in adults with naviculo-medial cuneiform (NC) coalition.

METHODS

Seventeen adults (20 feet) who underwent NC coalition resection were identified. The location and morphology of coalitions and five angular parameters, including medial arch sag angle (MASA), were assessed on weightbearing radiographs. Pre- and postoperative visual analogue scale and foot function index were evaluated for clinical outcomes.

RESULTS

Most feet (19 out of 20) had a coalition at the plantar-medial aspect, and there was no radiographic evidence of residual NC joint space compromise. There was no radiographic evidence of medial arch sag (MASA, p = 0.749) or recurrence at the final follow-up (21.7 months, range 12 to 48). Clinical scores improved significantly in all patients.

CONCLUSIONS

Resection of NC coalition in adults can be successful and provides an option to arthrodesis when conservative treatments have failed.

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.

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

Endoscopic Resection of Different Types of Talocalcaneal Coalition

BACKGROUND

The purpose of this study was to describe the technique of endoscopic resection of talocalcaneal coalition (TCC) by using 2 posterior portals and to report the outcomes of endoscopic resection of different types and sites of TCC.

METHODS

An interventional prospective study was conducted on 20 feet in 18 consecutive patients who were diagnosed by computed tomography to have TCC for which nonoperative treatment had failed and endoscopic resection was performed. The patients were divided into groups according to the site of the coalition (middle facet or posterior facet) and according to type (fibrous, cartilage, or bony). The mean follow-up period was 26 months (range, 6-36).

RESULTS

The average preoperative American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score was 57.7 (range, 40-65), and the average preoperative visual analog scale (VAS) score was 7.8 (range, 6-8). The average postoperative AOFAS hindfoot score was 92.4 (range, 85-98; P < .01). The average postoperative VAS score was 2.4 (range, 1-4). All patients showed no recurrence on postoperative lateral and Harris-Beath X-ray until the end of the study.

CONCLUSIONS

Endoscopic resection of TCC was an effective and useful method for the treatment of talocalcaneal coalition. It provided excellent outcomes with no recurrence in this short-term study. Resection of the fibrous type had a better outcome than resection of cartilage and bony types. Endoscopic resection of the posterior coalition had a better outcome than resection of the middle coalition.

LEVEL OF EVIDENCE

Level III, comparative study.

Percutaneous resection of calcaneo-navicular coalition with interposition of synthetic graft

BACKGROUND

Surgical resection of calcaneo-navicular coalition (CNC) with interposition of fat or muscle graft is indicated when there is failure of conservative treatment.

OBJECTIVES

to evaluate the clinical and functional of outcome of a new mini-invasive technique for resection of CNC and interposition of synthetic graft.

METHODS

This is a prospective case series study on 9 patients (12 feet) with symptomatic CNC. Percutaneous resection of the CNC was done using a motorized bone burr through a small incision in the sinus tarsi under image intensifier control. After complete resection a synthetic graft of Teflon or Dacron measuring 15 mm × 30 mm was interposed to prevent re-union of the bone bar.

RESULTS

The mean follow up period was 26.44 months (±1.5 SD). There was statistically significant improvement in the mean total AOFAS score from 47.89 (±8.49 SD) preoperatively to 90.22 (± 5.26 SD) at two years follow up (P<0.05). The mean time to return to full daily activity was 7.44 weeks (±0.88 SD) CONCLUSION: Percutaneous resection of calcaneo-navicular bar with interposition of synthetic graft is an effective mini-invasive method for treatment of calcaneo-navicular coalition with good results in 44.4% of patients and excellent results in 55.6% of patients.

Arthroscopic treatment of calcaneonavicular coalition in children

Calcaneonavicular coalition is a common source of pain and more or less severe flat and stiff foot in children. Classically, treatment consists in resecting the coalition using a dorsolateral approach. Good quality resection and interposition can prevent recurrence. The most common complications are infection, hematoma and neuroma. Arthroscopy offers a minimally invasive alternative, but the optimal approach remains undetermined. We describe a surgical technique with an approach based on the anterolateral process of the calcaneus, in three cases with 12 months' follow-up. Arthroscopic resection has certain advantages: recovery is quicker, and the esthetic result is better. For the instrumental portal, skin incision should be superficial, followed by blunt dissection of subcutaneous tissue to avoid superficial peroneal nerve injury. Although longer term follow-up is needed, arthroscopy seems to be an attractive minimally invasive technique in this kind of pathology.

Arthroscopic resection of talocalcaneal coalitions

Excision of symptomatic talocalcaneal coalitions, after failure of an adequate conservative treatment, is a widely accepted surgical treatment when less than 50% of the subtalar joint is involved and in the absence of degenerative changes to the subtalar or surrounding tarsal joints. Favorable results have been reported in 80% to 100% of patients with open resection. The traditional medial incision to the subtalar joint provides excellent exposure of the middle facet but inadequate visualization of the posterior facet. Other common disadvantages of the traditional open technique include (1) risk of incisional neuroma formation, (2) risk of superficial wound infection and delayed wound healing, and (3) prolonged hospitalization for wound management and pain control. Prone ankle/subtalar arthroscopy has been reported to yield excellent results in the treatment of numerous hindfoot pathologies, with the advantage of reducing postoperative pain, hospital stay, infection rates, wound complications, and recovery time. A posterior arthroscopic technique for posterior-facet talocalcaneal coalition excision has been developed in an attempt to reduce the complications of the traditional open resection. Possible disadvantages of the arthroscopic procedure may include (1) longer learning curve, (2) increased surgical time, (3) possible tibial neurovascular bundle damage, and (4) difficulties in using interposition material.