Treatment of talocalcaneal coalitions

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.

Outcomes of surgical management for tarsal coalitions: a systematic review

PURPOSE

To analyze the outcome of surgical treatment of tarsal coalition, assess the role of the surgical technique, as well as of coalition size and type on outcomes.

METHODS

The search followed the Preferred Reporting Items of Systematic Review and Meta-Analysis and was performed in four databases: MEDLINE, Central, Scopus and Web of Science. The protocol has been registered in the international prospective register of systematic reviews. Patient-reported outcomes (PROMs), complications, revisions and radiographic recurrence were collected. Risk of bias was assessed using MINORS criteria. A random-effects model for meta-analysis was applied for analysis of data heterogeneity.

RESULTS

Twenty-five studies including 760 tarsal coalitions were included and had a weighted average follow-up of 44 months. Studies scored fair to poor on the risk of bias assessment with a mean MINORS score of 67% (44-81%). In 77.8% (37.5-100%) of surgically treated tarsal coalitions, good/excellent/non-limiting or improved PROMs were reported. Calculated data heterogeneity was moderate (I2 = 57%). Open bar resection with material interposition had a clinical success rate of 78.8% (50-100%). Complications occurred in 4.96% of cases. Coalition size did not prove to be a determining factor in postoperative outcome. The influence of the coalition type was not investigated by any of the studies.

CONCLUSION

Data on outcomes of surgical management for tarsal coalitions is limited to retrospective case series with high risk of bias and moderate data heterogeneity. In about ¾ of cases, open resection and interposition of material results in improved PROMs. The arbitrary margin of ≥ 50% of TC coalition size in relation to the posterior facet has little importance in surgical decision-making. None of the studies reported on the influence of the coalition type on postoperative clinical success.

Decision-Making and Management of Tarsal Coalition in the Young Adult Patient: A Critical Analysis Review

» Tarsal coalitions most commonly affect the calcaneonavicular and talocalcaneal joints in up to 13% of the general population. They alter the mechanics of the subtalar joint, limiting inversion and eversion, and place excessive stress on neighboring joints causing pain, recurrent ankle sprains, and/or progressive pes planus during the adolescent growth spurt.» While many coalitions are identified on radiographs, advanced imaging with computed tomography or magnetic resonance imaging is sometimes required. These advanced imaging modalities also serve an essential role for surgical planning to quantify coalition involvement, identify fibrous or cartilaginous coalitions, and aid in determining the degree of deformity within the foot.» Surgical treatment is reserved for feet with persistent activity-related pain not relieved by prolonged attempts at nonoperative management, which include nonsteroidal anti-inflammatory drugs, shoe orthotics, and periods of non-weight-bearing in a cast. These conservative modalities may be successful in up to 85% of cases.» For adolescent patients, recent surgical options attempt to avoid arthrodesis and focus on coalition resection and interposition grafting with or without deformity correction. The ultimate decision is based on the location of the pain, the size and histology of the coalition, the health of the posterior subtalar facet, the degree of flatfoot deformity, and the presence of degenerative changes in the subtalar and/or adjacent joints.» While many studies focus on subtalar motion and gait kinematics, the critical outcomes remain pain relief and future need for arthrodesis, which may be related not only to resection of the coalition but assessment of deformity, including after the resection has been performed.

Application of mixed reality technology in talocalcaneal coalition resection

Objectives

With positive outcomes recorded, the mixed reality (MR) technology has lately become popular in orthopedic surgery. However, there are few studies that specifically address the utility of MR in talocalcaneal coalitions (TCC) resection. Our goal in this retrospective study is to assess certain data while examining the viability of using MR to treat TCC resection.

Methods

Six consecutive patients with TCC diagnosed by computed tomography (CT) for which nonoperative therapy had failed and MR system assisted TCC resection were included in this study from March 2021 to December 2021. The feasibility and accuracy of TCC resection were assessed by post-operation radiography. The American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score and visual analog scale (VAS) score were used to assess the recovery condition and pain level pre- and post-operation.

Results

The surgeon can accurately resect the TCC according to the preoperatively determined range by superimposing the holographic model with the actual anatomy of the TCC using an MR system. Additionally, no additional x-ray was necessary while operating. Mean follow-up was 10.3 months, with a minimum of 6 months. There is a significant difference between the preoperative AOFAS score of 53.4 ± 3.8 and the 6-month follow-up AOFAS score of 97.3 ± 2.2 (p < 0.05). There is also a significant difference between the preoperative VAS score of 8.1 ± 0.7 and the 6-month follow-up VAS score of 1.7 ± 0.4 (p < 0.05). All individuals had clinical subtalar mobility without stiffness following surgery.

Conclusion

While the TCC resection operation is being performed, the application of MR technology is practicable, effective, and radiation-free, giving surgeons satisfactory support.

Tarsal coalition resections: a long-term retrospective analysis of 97 resections in 78 patients

Background

Resection of tarsal coalitions provides good patient satisfaction scores, reduced pain, and improved long-term function in both athletic and non-athletic populations. This study aimed to determine when athletic patients undergoing resection of a tarsal coalition were able to return to their desired activity, and whether they experienced a decreased desired activity level (DDA).

Methods

Data on a total of 78 patients who underwent 97 tarsal coalition resections (49 talocalcaneal coalitions, 47 calcaneo-navicular, 14 cuboid-navicular, and three cuneo-navicular; some patients had more than one coalition) operated between January 2001 and June 2020 were prospectively collected. To subjectively assess outcomes, the Roles and Maudsley score (RM) was utilized.

Results

At an average follow-up from the index procedure of 33.6 ± 41.5 months, return to activity for the entire cohort was 18.3 ± 9.6 weeks. Post-RM was 1.3 ± 0.6.

Conclusion

Surgical excision of tarsal coalitions produced favorable results, with most patients able to return to their desired activity level.

Level of evidence

IV.

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.

Evaluation and Management of Adolescents With a Stiff Flatfoot

While flatfeet are normal in children, persistence into adolescence with associated pain or asymmetry warrants additional evaluation. Rigidity of a flatfoot deformity, whether a clinical report or evident on examination, should raise suspicion for pathology. The differential diagnosis includes tarsal coalition, neurogenic planovalgus, and peroneal spasticity. History must include pointed inquiry into birth and neurologic histories to probe for a source of central spasticity. Examination must include standing assessment of hindfoot and midfoot alignment. Hindfoot rigidity may be assessed by the double limb heel rise test and manual examination. Radiographs should include standing ankle (anterior-posterior and mortise) and whole foot (anterior-posterior, external rotation oblique, and lateral) images. Magnetic resonance imaging is more sensitive for identifying coalitions and better characterizes adjacent cartilage, subchondral edema, and tendon pathology, yet CT better characterizes the anatomy of a bony coalition. Conservative treatments are pathology-dependent and play a more prominent role in neurogenic or peroneal spastic flatfoot. Surgical management of coalitions is centered on coalition resection coupled with arthrodesis in the case of a talocalcaneal coalition with a dysplastic subtalar joint; concomitant planovalgus reconstruction is considered on a case-by-case basis.

Midterm Outcomes of Talocalcaneal Coalition Arthroscopic Resection in Adults

BACKGROUND

Arthroscopic resection of the talocalcaneal coalition (TCC) has been reported to be associated with good short-term outcomes. However, the midterm outcomes of this approach remain uncertain.

METHODS

We performed a retrospective study of patients who underwent arthroscopic resection for symptomatic TCC. The patients were divided into 2 groups (group P, patients with isolated posterior facet coalition; and group MP, patients with both middle and posterior facet coalition). The preoperative and postoperative visual analog scale (VAS) scores for pain and American Orthopaedic Foot & Ankle Society (AOFAS) scale scores were calculated. The postoperative AOFAS and VAS scores between the 2 groups were analyzed. Patient satisfaction was also assessed.

RESULTS

Thirty-two patients were included in this study. The mean age at the time of surgery was 26.0±8.5 years, and the mean follow-up period was 56.9±18.0 months. Thirteen (41%) patients were in group P, whereas 19 (59%) patients were in group MP. Postoperative VAS and AOFAS scores improved more significantly than preoperative scores. At the final follow-up, excellent and good subjective outcomes were attained in 26 patients (81%), fair and poor outcomes in 6 patients (19%). There were no statistical differences in the postoperative AOFAS (91.0±7.0 vs 85.8±10.8, P = .532) and VAS score (2.1±1.7 vs 4.0±2.6, P = .537) between patients with the ratio of coalition/posterior facet more than or less than 50%. There were no statistical differences in postoperative VAS score (1.8±1.3 vs 2.6±2.2, P = .236) and AOFAS score (92.5±5.6 vs 89.2±8.7, P = .297) between group P (n=13) and group MP (n=19), either. Three patients (9.4%) had complications, including these notable findings: 1 patient complained of restricted dorsal flexion, 1 with computed tomography-proven coalition recurrence, and 1 with partial tibial nerve injury.

CONCLUSION

We found that TCC arthroscopic resection was generally associated with reasonable outcomes at midterm follow-up.

LEVEL OF EVIDENCE

Level IV, case series.

Tarsal Coalitions

Tarsal coalitions are recognized as a congenital anomaly whereby the two or more bones of the hindfoot and midfoot are fused resulting in limitation of foot motion and pain. Tarsal coalitions were found to be the cause of painful flatfeet in adolescents and young adults. Developing a clinical understanding of tarsal coalitions as well as developing a step-wise conservative and surgical approach for their treatment can alleviate patient symptomatology and provide excellent long-term benefits. Conservative treatment consists of immobilization, NSAIDs, and casting for symptomatic patients, and surgical treatment for symptomatic tarsal coalition consists of resection and/or arthrodesis.

Tarsal coalition: Systematic review of arthroscopic management

INTRODUCTION

The standard of care in the treatment of symptomatic tarsal coalitions is open surgery. However, certain limitations exist with open surgery, which include limited visualization leading to an incomplete resection and possible recurrence of the tarsal coalition. Arthroscopic tarsal coalition resection (TCR) is an alternative that is gaining traction, primarily as the safety profile of posterior ankle and subtalar arthroscopy is more well understood. This study provides a systematic review of the outcomes of arthroscopic TCR.

METHODS

PubMed and Embase were searched independently by 2 reviewers for relevant articles based on predetermined criteria. The subject heading "tarsal coalition" and its related key terms were used.

RESULTS

A total of 416 studies were revealed by the initial search, out of which only 6 met our predetermined inclusion criteria. A total of 42 patients (average age: 17.6 years) were treated with arthroscopic TCR. Thirty-three (78.6%) and 9 (21.4%) patients had talocalcaneal and calcaneonavicular coalitions, respectively. The follow-up period ranged from 6 to 60 months (mean: 26 months), and no recurrence of the tarsal coalition was detected (0.0%). Complications occurred in two (4.8%) patients only, with one developing complex regional pain syndrome (CRPS), and another patient developing hyperesthesia on the medial aspect of the calcaneus.

CONCLUSION

Arthroscopic TCR is a feasible and effective surgery for both CNC and TCC with minimal complications and no disease recurrence at an average of 26 months follow-up. Future high-level of evidence studies are needed to compare the outcomes of open versus arthroscopic TCR.

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.

Prospective Evaluation of Tarsal Coalition Excision Show Significant Improvements in Pain and Function

BACKGROUND

Excision of pediatric tarsal coalition has been successful in most patients. However, some patients have ongoing pain after coalition excision. This study prospectively assessed patient-based clinical outcomes before and after surgical excision of tarsal coalition, with particular emphasis on comparison to radiologic imaging.

METHODS

We prospectively studied 55 patients who had symptomatic coalition excision for 2 years postoperatively. Patients filled out the modified American Orthopaedic Foot and Ankle Society score, the University of California Los Angeles activity score, and the simple question "does foot pain limit your activity" at 4 different time points: preoperative, 6 months postoperative, 12 months postoperative, and 24 months postoperative. Comparisons were done utilizing patient demographics, imaging parameters, and patient-reported outcomes.

RESULTS

Compared with preoperative levels, patients showed improvements in all outcome parameters. Patients with calcaneonavicular coalitions showed initial rapid improvement with later slight decline, while patients with talocalcaneal coalitions showed more steady improvement; both were similar at 2 years postoperatively.

CONCLUSIONS

This prospective study demonstrated remarkable clinical improvements after tarsal coalition excision regardless coalition type, though postoperative courses differed between calcaneonavicular and talocalcaneal types. Finally, a subset of patients has ongoing activity limiting foot pain after coalition excision which could not be explained by the data in this study.

LEVEL OF EVIDENCE

Level II-prospective cohort study.

One-Bone Tarsus: A Case Report

Tarsal coalition is a condition characterized by abnormal connections between ≥2 tarsi. Although tarsal coalition is not rare, tarsal coalitions involving >2 tarsi are very unusual. In this report, we describe a case of multiple tarsal coalitions in a 24-year-old male who experienced progressively worsening pain for 3 to 4 months before presenting for care. This case was unique in that all the tarsal and tarsometatarsal bones in the foot were fused and formed 1 integrated tarsal. All of the metatarsals were fused as well, and the patient had no joints or ranges of motion in the hindfoot or midfoot. The patient's pain was responsive to anti-inflammatory medications, and no surgical intervention was necessary. To the best of our knowledge, this is the most extensive case of multiple tarsal coalitions described in the literature to date.

Characteristics and reoperation rates of paediatric tarsal coalitions: a population-based study

PURPOSE

Tarsal coalitions are congenital fusions of two or more tarsal bones and can lead to foot pain and stiffness. Few studies examine the long-term reoperation rates following paediatric tarsal coalition surgery.

METHODS

A population-based database, linking medical records at all medical centres to capture the entire medical history of the full population of a Midwest county, was used to identify tarsal coalitions in children between 1966 and 2018. Records were reviewed for clinical data, surgical records and followed up to identify any subsequent surgical interventions.

RESULTS

A total of 58 patients (85 coalitions) were identified; 46 calcaneonavicular (CN) coalitions, 30 talocalcaneal (TC) coalitions and nine other coalitions (seven talonavicular, one naviculocuboid, one naviculocuneiform). In all, 46 coalitions were treated surgically (43 coalition resections, three arthrodeses) and 39 were treated nonoperatively. Patients treated surgically were less likely to report ongoing symptoms at final follow-up compared with patients managed nonoperatively (33% versus 67%; p = 0.0017). With a median 14.4 years (interquartile range 9.3 to 19.7) follow-up, there was an overall re-operation rate of 8.7% (4/46). Differences in reoperation rates by initial surgery (resection versus arthrodesis; p = 0.2936), coalition type (CN versus TC versus Other; p = 0.6487) or composition (osseous versus fibrocartilaginous; p = 0.29) did not reach statistical significance.

CONCLUSION

This is the first population-based study demonstrating the durability of surgical management of tarsal coalitions in a paediatric population. At final follow-up, patients treated surgically are less likely to report persistent symptoms compared with patients managed nonoperatively. Long-term reoperation rates appear to be low (8.7%).

LEVEL OF EVIDENCE

III.

Ankle Ganglion Associated with Tarsal Coalition: A Case Report with a 5-Year Follow-up

CASE

Talocalcaneal coalition (TCC) is a common type of coalition, often neglected. This case is of a 10-year-old girl with a painful ankle mass, diagnosed with TCC and a ganglion cyst. Examination revealed stiff subtalar motion, a submalleolar prominence, and well-circumscribed, tender mass at the posteromedial ankle. Treatment options include short period of casting/observation, excision vs. aspiration of the cyst, resection of the TC coalition, or a combination of the above. She underwent TCC resection with cyst aspiration.

CONCLUSION

At the 5-year follow-up, the patient's examination and imaging revealed normal motion without cyst recurrence, indicating resolution of the cyst with coalition resection.

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

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.

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.

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.

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.

Fibulocalcaneal Impingement in a Growing Child With Otherwise Asymptomatic Talocalcaneal Coalition

Subfibular impingement has been described in patients with flatfoot. It possibly occurs with valgus deformity associated with talocalcaneal coalition. We observed symptomatic unilateral fibular impingement initially on the left foot of an 11-year-old female with an otherwise asymptomatic bilateral talocalcaneal coalition. From the age of 8 years, she had complained of pain around the left fibular tip. Magnetic resonance imaging showed a partial talocalcaneal coalition. At 10 years of age, it was questioned whether the pain was related to the coalition. However, imaging of the asymptomatic right foot also showed a talocalcaneal coalition, with the coalition in both feet appearing equal. Additionally, the peroneal trochlea appeared particularly prominent, more so on the left than on the right foot. Therefore, the symptoms were suspected to have been caused only by fibulocalcaneal impingement owing to a relatively long fibula. Subperiosteal shortening of the fibula was performed at when she was 11 years old. A bed for the peroneal tendons was created around the remaining epiphysis of the fibula, and the fibular ligaments were reattached with Arthrex^® anchors (Arthrex, Naples, FL). At 14 months postoperatively, the patient was free of pain with unrestricted movement, although the follow-up imaging studies showed complete bony fusion on the medial aspect of the coalition between the talus and calcaneus. Approximately 1.5 years after surgery, our female patient at 12.5 years old complained of the same problems on her right foot, definitely occurring only around the fibula. The same procedure was performed as she had undergone on the left foot. At the last follow-up examination, she was asymptomatic 2.5 years after the initial surgery of the left foot and 11 months after surgery on the right. Talocalcaneal coalition can cause moderate to severe hindfoot deformity, leading to fibulocalcaneal impingement. Hence, treatment should be determined accordingly.

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.

The "Double Medial Malleolus": A New Physical Finding in Talocalcaneal Coalition

PURPOSE

It has been the observation of the senior author that there is a bony fullness or "double medial malleolus" over the middle facet as a consistent finding with most talocalcaneal coalitions (TCC). To document this observation, we reviewed records and radiographs in 3 patient groups.

METHODS

Part 1: retrospective chart review was completed for 111 feet to determine the clinical presence of a palpable "double medial malleolus." Part 2: computed tomography (CT) scans for evaluation of tarsal coalition or symptomatic flatfoot between January 2006 and December 2014 were retrospectively reviewed for the same cohort. Soft tissue thickness was measured as the shortest distance between bone and skin surface at both the medial malleolus and the middle facet/coalition. The volume of the middle facet or coalition was measured at their midpoint. These findings were compared among feet with TCC (n=53), calcaneonavicular coalition (CNC) (n=20), and flatfoot (n=38).

RESULTS

Part 1-clinical: from medical records, 38 feet (34%) had documented record of a palpable medial prominence. Of the feet reviewed with a "double medial malleolus," all had TCC (no false positives or false negatives). Clinical and CT prominence demonstrated significant correlation (rs=0.519, P=0.001). Part 2-radiographic: CT observation of "double medial malleolus" is significantly associated with TCC (P<0.001). CT observation of double medial malleolus is 81% sensitive and 79% specific as a predictive test for TCC. The middle facet-to-skin distance was significantly closer in those with TCC versus controls (P<0.001). The ratio was larger in patients with TCC versus CNC (P=0.006) or flatfeet (P<0.001). Volume was nearly twice the size in patients with TCC versus the controls (P<0.001).

CONCLUSIONS

TCCs have a bony prominence below the medial malleolus on clinical exam and CT scan not present in flatfeet or CNCs. This abnormal middle facet is almost twice the size of the normal middle facet. Obesity or severe valgus may mask this finding. If a palpable bony prominence is noted just below the medial malleolus during examination of a painful foot with a decrease in subtalar motion, the likely diagnosis is TCC. With this added clinical finding, appropriate images can be ordered to confirm the diagnosis of the latter. We advise CT scans with 3D images for surgical planning. The primary finding for tarsal coalitions in textbooks is decreased subtalar motion. This new finding of a palpable enlarged medial prominence just below the medial malleolus is highly associated with TCCs.

LEVEL OF EVIDENCE

Level III.

Pediatric Flatfoot: Pearls and Pitfalls

Pediatric flatfeet are common, are usually asymptomatic, and typically improve over time as young children age. It is critical to differentiate flexible from rigid flatfeet and to assess for associated Achilles contracture with a careful history, physical examination, and initial radiographs. Although there are limited data, nonsurgical management of symptomatic flatfeet, both flexible and rigid, should be exhausted before considering surgical intervention. If patients fail conservative treatment, surgical management with joint-preserving, deformity-corrective techniques is typically used for pediatric flexible flatfeet in conjunction with deformity-specific soft tissue procedures.

Subtalar Coalitions: Does the Morphology of the Subtalar Joint Involvement Influence Outcomes After Coalition Excision?

Posteromedial subtalar (PMST) coalitions are a recently described anatomic subtype of tarsal coalitions. We compared with clinical patient-based outcomes of patients with PMST and standard middle facet (MF) coalitions who had undergone surgical excision of their coalition. The included patients had undergone surgical excision of a subtalar tarsal coalition, preoperative computed tomography (CT), and patient-based outcomes measures after surgery (including the American Orthopaedic Foot and Ankle Society [AOFAS] scale and University of California, Los Angeles [UCLA], activity score). Blinded analysis of the preoperative CT scan findings determined the presence of a standard MF versus a PMST coalition. The perioperative factors and postoperative outcomes between the MF and PMST coalitions were compared. A total of 51 feet (36 patients) were included. The mean follow-up duration was 2.6 years after surgery. Of the 51 feet, 15 (29.4%) had a PMST coalition and 36 (70.6%) had an MF coalition. No difference was found in the UCLA activity score; however, the mean AOFAS scale score was higher for patients with PMST (95.7) than for those with MF (86.5; p = .018). Of the patients with a PMST, none had foot pain limiting their activities at the final clinical follow-up visit. However, in the group with an MF subtalar coalition, 10 (27.8%) had ongoing foot pain limiting activity at the final follow-up visit (p = .024). Compared with MF subtalar tarsal coalitions, patients with PMST coalitions showed significantly improved clinical outcomes after excision. Preoperative identification of the facet morphology can improve patient counseling and expectations after surgery.

Surgical Reconstruction for Talocalcaneal Coalitions With Severe Hindfoot Valgus Deformity

INTRODUCTION

Coalition resection can restore motion, and improve pain in patients with talocalcaneal coalitions (TCCs) and an aligned foot. However, there is some debate regarding appropriate treatment of patients with associated valgus deformity. The purpose of this study was to present the outcomes and complications following surgical reconstruction, with or without coalition resection, in a series of patients with TCC and severe hindfoot valgus.

METHODS

Thirteen consecutive patients (14 feet) were evaluated. Eleven patients were male. Mean age was 14 years. Mean follow-up was 43.8 months. Seven patients (8 feet) underwent simultaneous resection of the coalition and reconstruction, and 6 patients (6 feet) isolated reconstruction. The talar-first metatarsal angle, the talar-horizontal angle, and calcaneal pitch were measured preoperatively and postoperatively. Clinical evaluation was made according to the American Orthopaedic Foot and Ankle Society ankle-hindfoot score.

RESULTS

All radiographic values improved significantly and were within the normal ranges postoperatively. The average American Orthopaedic Foot and Ankle Society ankle-hindfoot score had improved from 45 to 98 points (P<0.001) in the group of simultaneous resection and reconstruction, and from 60 to 92.3 points (P=0.002) in the group of isolated reconstruction. All patients were asymptomatic at the last follow-up and were satisfied with the procedure.

DISCUSSION

Surgical reconstruction with or without coalition resection can achieve significant functional and radiographic improvements, and symptoms relief in selected patients with TCCs and severe valgus deformity.

LEVEL OF EVIDENCE

Level IV-therapeutic study.

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

[Surgical treatment of talocalcaneal coalition : Experience with 80 cases of pediatric or adolescent patients]

INTRODUCTION

There is still a controversial discussion on the treatment of talocalcaneal coalition with and without planovalgus deformity. From 2002-2014 80 cases of talocalcaneal coalition in children and adolescents under 18 years of age were surgically treated by J. Hamel. The objective of this study is a retrospective analysis, especially of unfavourable results.

METHODS

Patients with minimum follow up of 12 months were included (35.7 months on average). In 31 cases treatment consisted of resection and fat-grafting (group 1), in 26 additional cases tarsal osteotomy was added because of planovalgus-deformity (group 2), and in 23 cases primary fusion of the talocalcaneal joint was performed (group 3).

RESULTS

In group 1 one patient was lost to follow-up early with a severe peroneal spasticity and unknown further course. Two further patients still had remarkable pain after 15 months, and another patient had to undergo secondary fusion because of persistent pain. In group 2 secondary fusion was undertaken in two cases and offered in four other cases. In group 3 two patients still suffered from moderate tarsal pain, although complete fusion occurred; one of these patients underwent bilateral treatment. All other patients were pain free or nearly pain free on the last follow-up visit, with marked improvement in comparison to the preoperative situation.

DISCUSSION

Surgical treatment of talocalcaneal coalition is successful in most cases in the short to medium follow-up, but unfavourable results are not uncommon and may require secondary fusion. Differential indication between resection, additional deformity correction, or primary fusion seems to be most important.

Arthroscopic Talocalcaneal Coalition Resection in Children

PURPOSE

To present the technique and outcomes of arthroscopic talocalcaneal coalition (TCC) resection in pediatric patients.

METHODS

We performed a prospective study of 16 consecutive feet with persistent symptomatic TCCs in 15 children. The mean age was 11.8 years (range, 8 to 15 years), and the mean follow-up period was 28 months (range, 12 to 44 months). A posterior arthroscopic TCC resection was performed. The plantar footprint, subtalar motion, pain, and the American Orthopaedic Foot & Ankle Society Ankle-Hindfoot scale score were evaluated preoperatively and postoperatively. Preoperative computed tomography (CT) scans were used to classify the coalition according to the Rozansky classification, to measure the percentage of involvement of the surface area, and to determine the degree of hindfoot valgus. Postoperative CT scans at 1 year (n = 15) and 3 years (n = 5) were used to assess recurrences. Patient satisfaction was also evaluated.

RESULTS

The TCC distribution according to the Rozansky classification was type I in 7 cases, type II in 3, type III in 3, and type IV in 3. In all cases the arthroscopic approach enabled complete coalition resection. All patients increased by at least 1 stage in the footprint classification and showed clinical subtalar mobility after surgery. All patients showed a statistically significant improvement in pain after surgery except for 1 patient in whom complex regional pain syndrome developed (P < .001). The mean American Orthopaedic Foot & Ankle Society score was 56.8 (range, 45 to 62) preoperatively versus 90.9 (range, 36 to 100) postoperatively, showing a statistically significant increase (P < .001). Preoperative CT scans showed that all TCCs involved the medial subtalar joint facet, with mean involvement of 40.8% of the articular surface. All postoperative CT scans showed complete synostosis resections with no recurrences at final follow-up. At final follow-up, all patients were either satisfied (n = 4 [27%]) or extremely satisfied (n = 10 [67%]) with the outcome, except the 1 patient (7%) in whom complex regional pain syndrome developed.

CONCLUSIONS

Arthroscopic TCC resection provides good outcomes (symptom relief and restoration of subtalar motion), with no recurrence of the coalition.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Talocalcaneal Coalitions

Talocalcaneal coalitions present with complaints of flatfeet, foot or ankle pain after minor injury, or recurrent ankle sprains. Physical examination findings include limited subtalar motion and prominence inferior to the medial malleolus. Use of computed topography (CT) scan is recommended for preoperative planning. Confirmation of resection with intraoperative CT. Resection of talocalcaneal coalitions with fat-graft interposition has superior results to primary arthrodesis. Improved outcomes have been reported after resection, with foot scores averaging 90/100 (AOFAS).

Sacroiliac Coalition: First Description and Report of a Successful Resection

Study Design Case report. Objective This report describes the first case of a sacroiliac coalition, its clinical features, the diagnostic difficulties, and the surgical treatment chosen in this case. Methods A 33-year-old man presented to our outpatient clinics complaining of severe left-sided low back pain with an intermitted nondermatomal radiation into the left thigh. The only abnormality on a pelvic radiograph was a coin-size, faint hyperdensity, which was almost overlooked. Subsequent computed tomography (CT) and magnetic resonance imaging (MRI) confirmed two bridging bone spurs on the anterior surface of the left joint with a fibrous interruption at the apex. After the conservative treatment failed, a surgical treatment was offered to the patient. The coalition was resected via an anterior retroperitoneal approach and through the tissue plane between the psoas and the iliacus muscles. A histopathologic examination was performed and confirmed the diagnosis of a coalition. Results The patient's pain resolved immediately after surgery. After 8 months, a follow-up CT scan showed complete removal of the coalition without any signs of recurrence, and at 12 months' follow-up, the patient remained pain-free. Conclusions This is the first published case of a sacroiliac coalition. The only sign of this rare condition on the plain radiographs was very easy to miss. As has been discussed in the literature, CT and MRI are important in the differential diagnostics of such lesions. The histopathologic findings included that of a fibrous bar, confirming the diagnosis, which is further corroborated by the complete resolution of the symptoms.

Patient-reported Outcomes of Tarsal Coalitions Treated With Surgical Excision

PURPOSE

There are little patient-reported data on functional outcomes of tarsal coalition resection in children and adolescents. The purpose of this study is to evaluate the medium-term (>2 y) outcomes in patients who have had surgical excision of their symptomatic tarsal coalition and to compare patient-based outcomes in patients who have calcaneonavicular (CN) coalitions to those with talocalcaneal (TC) coalitions.

METHODS

A billing query was conducted to identify patients who had surgical excision of their tarsal coalition between 2003 and 2008. Eligible patients were mailed questionnaires consisting of a modified American Orthopaedic Foot and Ankle Society (AOFAS) score and the University of California at Los Angeles (UCLA) activity scale. Patients were also specifically asked if their activity level was limited by their foot pain. Only patients who returned questionnaires were included. Demographics and diagnostic images were reviewed. A nonresponder analysis was completed. Complications such as infection and reoperation were reported.

RESULTS

Sixty-three patients (22 females, 41 males) who returned questionnaires were included in the analysis. Twenty-four patients had bilateral surgery. TC coalitions were present in 20 patients (32%); CN coalitions were present in 43 patients (68%).Overall, mean modified AOFAS score was 88.3 and mean UCLA activity score was 8.33 at an average of 4.62 years after surgery. Patients who had TC coalitions had similar modified AOFAS scores (88.4) and UCLA activity scores (8.4) when compared with those with CN coalitions (88.0 and 8.3, both not significant).Of the 73% (46/63) patients who reported that their activity levels were not limited by their foot pain, the mean AOFAS score was 93.9 and the mean UCLA activity score was 8.9; 32 of these were CN and 14 were TC coalitions. Of the 27% (17/63) patients who reported that their activity levels were limited by their foot pain, the mean AOFAS score was 72.9 and the mean UCLA activity score was 6.9; 11 of these were CN and 6 were TC coalitions. There was a statistically significant difference in these groups both in modified AOFAS score (P<0.0001) and UCLA activity score (P=0.006). There was no difference in outcomes between those who were treated for a TC and CN coalition.

CONCLUSIONS

Patient-reported outcomes after surgical excision of tarsal coalition reveal that >70% of patients' activities are not limited by pain and their functional outcome is terrific. A few patients continue to have problems with ongoing foot pain and activity limitations. The type of coalition does not seem to be an indicative factor in determining outcome.

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.

Tarsal Coalitions: Preliminary Results After Operative Excision and Silicone Sheet Interposition in Children

Symptomatic tarsal coalitions that begin in early adolescence are usually treated by resection and interposition (fat, muscle, or bone wax) to prevent recurrence. The purpose of the present retrospective study was to describe our operative technique and report our clinical and radiologic outcomes with sterile silicone sheet interposition after resection of painful tarsal coalitions in 4 children (4 feet). The present series included 1 case of talocalcaneal synchondrosis and 3 of synostosis (2 talocalcaneal and 1 cuboid-navicular). Two validated functional scales were used to assess the patients' overall outcome and satisfaction with the procedure: the American Orthopaedic Foot and Ankle Society ankle-hindfoot score and the Foot Function Index. Conventional radiography, computed tomography with 3-dimensional reconstruction, and magnetic resonance imaging were performed at the final follow-up visit. The mean follow-up period was 40 (range 12 to 80) months. The mean age at surgery was 10.5 (range 8 to 13) years. All patients had achieved their desired activity level at 6 months postoperatively. The mean American Orthopaedic Foot and Ankle Society ankle-hindfoot score was 93.5 (range 74 to 100), and the mean Foot Function Index was 3.25% (range 0% to 13%). No recurrence of the coalition on imaging at the final follow-up visit was observed in this patient series. Sterile silicone sheet interposition can be used to prevent recurrence of tarsal coalition in symptomatic tarsal coalitions after failure of conservative management.

The use of a portable CT scanner for the intraoperative assessment of talocalcaneal coalition resections

BACKGROUND

Intraoperative assessment of talocalcaneal (TC) coalition resection can be challenging, with no reliable plain radiographic view available for evaluation. Therefore, in March of 2011, we began using a CereTom portable CT scanner to assess TC coalition resections intraoperatively. This study evaluates the use of intraoperative CT during surgical resection of TC coalitions.

METHODS

Patients who received CT scans before and after TC coalition resection, by a single surgeon, were included. Those treated without (control group, n=12 feet) and with (intraoperative CT group, n=14 feet) intraoperative CT scan were retrospectively compared. Two blinded pediatric orthopaedic surgeons assessed the quality of resection using a side-by-side comparison of preoperative and postoperative CT scans. Each resection was rated as "excellent," "fair," or "poor," and medical records were reviewed to evaluate clinical outcome.

RESULTS

Substantial agreement was found between blinded reviewers (κ=0.71, 81% absolute agreement). Quality of resection was improved in the intraoperative CT group, with 57% of patients receiving an excellent rating compared with 25% in the control group. Patients in the intraoperative CT group were 4.0 times more likely to have a complete resection as compared with patients in the control group; however, this was not statistically significant (odds ratio, P>0.05; 95% confidence interval, 0.74-21.5). Intraoperative CT altered surgical decision making in 3 feet (21%) in the intraoperative CT group, leading to further resection and a subsequent excellent postoperative rating in 2 of these patients. There was 1 reoperation in the control group for continued pain and residual coalition identified on postoperative CT scan. In the intraoperative CT group there have been no reoperations for recurrent or residual qcoalition.

CONCLUSIONS

This study illustrates that intraoperative CT can alter surgical decision making and may improve the ability to obtain a complete resection in TC coalition surgery. In these technically challenging cases, intraoperative scans give immediate imaging feedback to surgeons, allowing intervention if residual resection is identified. If intraoperative CT scan is available, it should be considered for surgical treatment of TC coalition resections.

LEVEL OF EVIDENCE

Level III retrospective case-control study.

Flatfoot deformity in children and adolescents: surgical indications and management

Most children with flatfeet are asymptomatic and will never require treatment. In general, flatfoot deformity is flexible and will not cause pain or disability; it is a normal variant of foot shape. Thus, it is essential to reassure and educate patients and parents. A flatfoot with a contracture of the Achilles tendon may be painful. In these cases, a stretching program may help relieve pain. Scant convincing evidence exists to support the use of inserts or shoe modifications for effective relief of symptoms, and there is no evidence that those devices change the shape of the foot. The surgeon must be vigilant to identify the rare rigid flatfoot. Indications for flatfoot surgery are strict: failure of prolonged nonsurgical attempts to relieve pain that interferes with normal activities and occurs under the medial midfoot and/or in the sinus tarsi. In nearly all cases, an associated contracture of the heel cord is present. Osteotomies with supplemental soft-tissue procedures are the best proven approach for management of [corrected] flatfoot.

[Diagnosis and treatment of tarsal coalitions and synostoses in children and adolescents]

The majority of tarsal coalitions are located in the calcaneonavicular and talocalcaneal regions and other locations are rare. Complete early ossified synostoses are found not only in major limb deficiencies but also in otherwise normal feet. Magnetic resonance imaging (MRI) and computed tomography (CT) scans are the most important imaging techniques especially for preoperative planning. Early resection is advisable in calcaneonavicular coalitions as soon as it is detected in childhood and adolescence. Indications for or against resection or limited tarsal fusion are much more difficult in talocalcaneal coalition. The patient's complaints, extension and location of the coalition, additional malalignment and especially patient age are some of the factors that should be considered carefully. Results of surgical resection are not always satisfactory with a long-lasting rehabilitation especially in older children or adolescents and the necessity for secondary procedures can never be ruled out. In cases of malalignment corrective tarsal osteotomy can be considered as a simultaneous or staged procedure. An overview with special emphasis on surgical options is presented with typical examples as well as rare conditions and a review of important literature from recent years is included.