Talocalcaneal tarsal coalitions and the calcaneal lengthening osteotomy: the role of deformity correction

Comparative analysis of clinical outcomes of talocalcaneal coalition resection: subtalar joint middle and posterior facet involvement versus isolated posterior facet involvement - a retrospective cohort study

BACKGROUND

Despite coalition resection being the preferred treatment for talocalcaneal coalition (TCC), postoperative complications, suboptimal functional recovery, and recurrence risks remain challenges. Although current TCC classification systems guide personalized surgical plans, the impact of middle and posterior facet coalitions on TCC resection surgery's effectiveness is still poorly understood. Therefore, this study aims to compare the clinical outcomes of TCC patients with and without involvement of the subtalar joint's (STJ) middle and posterior facets undergoing coalition resection to explore the potential impact of these coalitions on surgical outcomes.

METHODS

We conducted a retrospective study on 115 patients who underwent coalition resection surgery due to symptomatic TCC between November 2009 and February 2023. According to preoperative CT scan results, patients were divided into an isolated posterior facet coalition (P-type) group and a middle-posterior facet coalition (MP-type) group. Demographic characteristics (including age, sex, body mass index (BMI), follow-up time, and medical history duration), pre-and postoperative assessments (including Visual Analog Scale (VAS), American Orthopaedic Foot & Ankle Society (AOFAS) score, Pain Interference (PI) and Physical Function (PF) scores from the Patient-Reported Outcomes Measurement Information System (PROMIS)), as well as postoperative self-assessment of efficacy (excellent, good, fair, poor) and hindfoot stiffness, were compared between the two groups. Postoperatively, TCC recurrence was evaluated through imaging follow-up examinations.

RESULTS

69 patients meeting the inclusion criteria were included, with 30 patients in the P-type group and 39 in the MP-type group. There were no statistically significant differences between the two groups in demographic characteristics (P<0.05). There were also no statistically significant differences between the two groups in preoperative VAS score, AOFAS score, PI score, and PF score. However, postoperatively, there were statistically significant differences between the two groups in VAS score (1(1,1.5) vs. 2(1,2), P<0.01), AOFAS score (92.5(87,96.5) vs. 82(69.5,87), P<0.01), PI score (39(39,43) vs. 39(39,51), P = 0.014), PF score (73(61,73) vs. 55(51,73), P = 0.001), fair or poor outcome (4(13%) vs. 14(35.9%), P = 0.034), and hindfoot stiffness (3(10.3%) vs. 16(37.2%), P = 0.011). There was no statistically significant differences in the recurrence rate between the two groups postoperatively (0(0%) vs. 3(7.69%), P = 0.252).

CONCLUSION

Even with complete coalition resection during surgery and rehabilitation following standardized protocols, the surgical outcomes in MP-type TCC patients are still inferior to those in P-type patients.

Clinical characterization of patients with tarsal coalitions. 12 years of experience in a high complexity hospital

BACKGROUND

Tarsal coalitions are aberrant unions of two or more tarsal bones which may condition variable foot and ankle conditions. Their incidence is also variable but most frequently diagnosed coalitions are talocalcaneal and calcaneonavicular. This article aims to evaluate clinical and epidemiological characteristics of patients diagnosed with tarsal coalitions.

MATERIALS AND METHODS

Cross-sectional descriptive study of patients with tarsal coalitions from August 2007 to January 2020 in a private University Hospital in Madrid, Spain. Data on age, sex, type of coalition according to anatomical location and tissue type, laterality and hindfoot condition and symptoms were obtained and analyzed.

RESULTS

Of the 57 patients identified (80 feet), there were 31 males (54.4%) and 26 females (45.6%). Average age was 36.9 years. The total number of coalitions was 85. There were 48 bilateral coalitions (56,5%). Fifty-two talocalcaneal coalitions (TCC) (61.2%), 32 calcaneonavicular coalitions (CNC) (37.6%) and 1 calcaneocuboid coalition (1.2%) were registered. Our series showed 36 osseous coalitions (42.4%) and 49 fibrocartilaginous coalitions (57.6%). When evaluated separately, 35 of the TCC were osseous (67.3%) and 17 were fibrocartilaginous (32.7%); 1 of the CNC was osseous (3.1%) and 31 were fibrocartilaginous (96.9%).

DISCUSSION

In our review, TCC was the most frequent subtype, with the majority being the bony in nature. In the distribution according to sex, a higher incidence of males is found within the CCN group (Fisher's Exact test, P=.032). Some of the results obtained are different from what was previously reported in the literature, which gives rise to new studies that explain this difference in our population.

Talocalcaneal coalition classifications: A critical analysis review and suggested new classification system with implications for treatment

Talocalcaneal coalitions (TCC) is the second most frequent tarsal coalition reported. Our aim was to review talocalcaneal coalition classifications and to propose a new classification emphasizing a therapeutic approach. None of the classifications described for TCC mention the presence of flatfoot or valgus hindfoot, which are the key elements when defining the optimal treatment of this disease. We defined five clinical and radiological factors that would guide the choice of surgical treatment and based on these, we proposed a new classification system.

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.

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.

Coalition excision and corrective osteotomies versus coalition excision and arthroereisis in management of pes planovalgus with talo-calcaneal coalition in adolescents: A randomized controlled trial

BACKGROUND

Talocalcaneal coalition is the most common cause of rigid flat foot in adolescents. It presents with recurrent ankle sprains, foot and ankle pain, and foot deformity. Management is still controversial. Multiple options were utilized during the last 40 years, including coalition excision only or coalition excision with hind foot arthrodesis or corrective osteotomies. However, the effect of arthroereisis after coalition excision is still questionable.

PATIENTS AND METHODS

Thirty feet in 28 patients with rigid flat foot due to talocalcaneal coalition, who presented to our institution between September 2018 and April 2020, were prospectively analyzed. Randomization was performed by random allocation using a computer-based system into two groups: group A for coalition excision and arthroereisis, group B for coalition excision and osteotomies. Functional and radiological outcomes and complications were recorded and analyzed using Statistical Package for the Social Sciences software.

RESULTS

Thirty feet in 28 patients were included in the final analysis (15 feet in each group). One patient in each group had bilateral affection. The mean age was 14.5 years, and the mean follow-up duration was 24 months. At final follow-up, the mean AOFAS was 78.8 ± 4.04 in group A and 76.73 ± 4.66 in group B, while the FAAM scores were 80 ± 5 and 79 ± 3 in groups A and B, respectively. The complication rate was higher in group A, however with no statistical significance.

CONCLUSION

The combination of talocalcaneal coalition resection with either corrective osteotomies or arthroereisis had a significant improvement of functional and radiological outcomes in the management of rigid pes planovalgus.

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.

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.

Medial talar resection: how much remains stable?

Purpose

Pathologies of the medial talus (e.g., fractures, tarsal coalitions) can lead to symptomatic problems such as pain and nonunion. Bony resection may be a good solution for both. It is unclear how much of the medial talus can be taken before the subtalar joint becomes unstable. The aim of this study was to evaluate the effect a limited resection of the medial talar facet and the anteromedial portion of the posterior talar facet has on subtalar stability.

Methods

Eight fresh-frozen human cadaveric lower limbs were mounted in a frame for simulated weight-bearing. Computed tomography scans were obtained under 700 N single-legged stance loading, with the foot in neutral, 15° inversion, and 15° eversion positions. A sequential resection of 10, 20, and 30% of the medial facet and the anteromedial portion of the posterior talar facet to the calcaneus, based on the intact talus width, was performed. Measurements of subtalar vertical angulation, talar subluxation, coronal posterior facet angle and talocalcaneal (Kite) angle in the anteroposterior and lateral view were performed.

Results

Gross clinical instability was not observed in any of the specimens. No significant differences were detected in the measurements between the resected and intact states (P ≥ 0.10) as well as among the resected states (P ≥ 0.11).

Conclusion

In a biomechanical setting, resecting up to 30% of the medial facet and anteromedial portion of the posterior facet based on the intact talus width—does not result in any measurable instability of the subtalar joint in presence of intact ligamentous structures.

Level of evidence

V.

Outcomes of Posterior Arthroscopic Subtalar Arthrodesis for Medial Facet Talocalcaneal Coalition

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level IV, case series.

Bony Procedures for Correction of the Flexible Pediatric Flatfoot Deformity

The pediatric flexible flatfoot is a common foot shape that is most often asymptomatic and may be a physiologic variant of normal. Surgery is only indicated when nonoperative interventions have failed to resolve symptoms. The goal of surgery is to alleviate symptoms by improving hindfoot alignment and restoring the medial arch while preserving joint mobility. This article focuses on the common bony techniques for surgical correction of the pediatric flexible flatfoot that has failed nonoperative management, including calcaneal, midfoot, and supramalleolar osteotomies and distal tibial hemiepiphyseodesis.

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.

Tarsal coalitions as a cause of pain in the foot of children: Therapeutic options

BACKGROUND AND OBJECTIVE

The tarsal coalition can be a cause of mid-hindfoot pain in older children. The objective is to analyze the types of coalition treated in our hospital from 2010 to 2019 as well as the treatment carried out.

MATERIAL AND METHOD

Observational, descriptive and retrospective study of 18 patients with tarsal coalition, 8 women and 10 men, aged 11.9±2.6 years. Epidemiological data, clinical findings and imaging tests, and treatment performed were collected.

RESULTS

Twenty-five feet (38.8% bilateral) were reviewed. The main symptom was pain. Sixty-four percent were associated with flat-valgus foot. Fifty-two percent were located in the calcaneal-scaphoid joint, and 40% in the calcaneal-talar joint. Treatment was conservative in 44.4% of cases and surgical in 56% (coalition resection). There was only one case of recurrence. The results were mostly excellent or good (88%) after a mean follow-up period of 4 years.

CONCLUSIONS

The most frequently diagnosed type of tarsal coalition was that located in the calcaneal-scaphoid joint followed by the calcaneal-talar joint, but they can appear in any joint of the foot. Almost half responded well to conservative treatment with mostly good results, but the rest required surgical treatment due to persistence of the symptoms, the results of which were excellent in all cases except one who suffered a recurrence. In cases of calcaneal-talar coalitions associated with severe hindfoot valgus, correction of this deformity, associated or not with resection of the coalition, is recommended.

Surgical Treatment of Severe Idiopathic Flexible Flatfoot by Evans-Mosca Technique in Adolescent Patients: A Long-Term Follow-Up Study

Flexible idiopathic flatfoot is very common in growing age and rarely causes pain or disability. Surgery is indicated only in severe symptomatic cases that are resistant to conservative treatment, and numerous surgical procedures have been proposed. Lateral column calcaneal lengthening as described by Evans and modified by Mosca is a widely used surgical technique for the correction of severe symptomatic flexible flatfoot. In the present study, we report the long-term clinical and radiographic results in 14 adolescent patients (mean age: 12.8 years) affected by severe symptomatic flexible flatfoot, surgically treated by Evans–Mosca procedure, for a total of 26 treated feet (12 cases bilateral and 2 unilateral). In all cases, surgery was indicated for the presence of significant symptoms resistant to nonsurgical management. Clinical evaluation was made according to the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale, the Foot and Ankle Disability Index (FADI) Score, and Yoo et al.'s criteria. Radiographic evaluation was made using anteroposterior and lateral weight-bearing radiographs of the feet to evaluate Meary's angle and Costa–Bertani's angle and to evaluate possible osteoarthritic changes in the midtarsal joints. At follow-up (mean: 7 years and 7 months), we observed a satisfactory result in all patients. The mean average score of the AOFAS Ankle-Hindfoot Scale improved from 60.03 points to 95.26; the mean FADI score improved from 71.41 to 97.44; and according to Yoo et al.'s criteria, the average clinical outcome score was 10.96. At radiographic examination, nonunion of the calcaneal osteotomy was never observed. Meary's angle improved from an average preoperative value of 25° to 1.38° at follow-up; Costa–Bertani's angle improved from an average preoperative value of 154.2° to 130.9° at follow-up. In no case, significant radiographic signs of midtarsal joint arthritis were observed. According to our results, we believe that Evans–Mosca technique is a valid option of surgical treatment for severe idiopathic flexible flatfoot and allows a satisfactory correction of the deformity with a low rate of complications.

Incidence of Symptomatic Pediatric Tarsal Coalition in Olmsted County: A Population-Based Study

BACKGROUND

Tarsal coalitions are an important reason for foot pain in children. Early estimates placed the prevalence at up to 2%, while more recent data suggest that it is as high as 11% to 13%. To our knowledge, there have been no population-based studies to determine the true incidence of symptomatic tarsal coalitions in a pediatric population.

METHODS

A population-based database was used to identify all new diagnoses of symptomatic tarsal coalitions in children 18 years old or younger between 1966 and 2018. Patient records were reviewed for clinical data, and comparisons were made between the types and characteristics of the coalitions identified to determine differences in the affected populations. The annual age-specific, sex-specific, and type-specific incidence rates were estimated.

RESULTS

During the study period, 58 patients with a total of 79 symptomatic tarsal coalitions were identified (annual incidence = 3.5 per 100,000 children). There were 43 calcaneonavicular (CN) coalitions (annual incidence = 1.9 per 100,000 children), 27 talocalcaneal (TC) coalitions (annual incidence = 1.2 per 100,000 children), as well as 9 other coalitions (7 talonavicular, 1 naviculocuboid, and 1 naviculocuneiform) (annual incidence = 0.4 per 100,000 children). The overall incidence peaked between the ages of 10 and 14 years for both boys and girls (8.1 per 100,000 and 7.4 per 100,000 children, respectively). Statistical differences were identified between the types of tarsal coalitions. TC coalitions present at an older age relative to CN and other coalitions (mean,13.9, 12.7, and 11.4 years, respectively; p = 0.02). While CN and TC coalitions were similar in composition (23% and 30%, respectively, were osseous as opposed to fibrocartilaginous), other coalitions were more likely to be osseous (78%) (p = 0.0035). Other coalitions were also less likely to require surgery than CN and TC coalitions (11%, 74%, and 56%, respectively; p = 0.0015).

CONCLUSIONS

This population-based study demonstrates differences in the clinical presentation of tarsal coalitions and provides an estimate of the true incidence of symptomatic tarsal coalitions in a pediatric population.

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

Background

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

Methods

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

Results

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

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

Conclusion

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

Surgical treatment of tarsal coalitions in children and adolescents

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

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

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

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

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

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Tarsal coalition

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Functional and Radiological Outcomes After Tarsal Coalition Resections: A Minimum 5-Year Follow-Up

Few studies have evaluated the long-term functional and radiological outcomes of tarsal coalition resections. This study aimed to report and compare the functional and radiological outcomes after talocalcaneal (TC) and calcaneonavicular (CN) coalition resections. Thirty-three patients between 12 and 35 years old with symptomatic tarsal coalitions participated, each undergoing tarsal coalition resections (24 TC and 9 CN). The range of motion, visual analog scale score, American Orthopedic Foot and Ankle Society hindfoot scale, Maryland foot score, tripod index, and modified Kellgren-Lawrence scale for subtalar osteoarthritis were used to evaluate the functional and radiological outcomes. The mean age at the time of surgery and mean follow-up in the TC group were 17.8 ± 5.6 years (range 13 to 35) and 6.2 ± 1.7 years (range 5 to 12), respectively, and 16.0 ± 4.4 years (range 12 to 23) and 7.7 ± 3.0 years (range, 5 to 12) in the CN group. There was no difference in the range of motion, outcome scores, tripod index score, and modified Kellgren-Lawrence scale score between patients in the 2 groups. A positive correlation was noted between the size of the TC coalition, coalition/joint surface ratio, and hindfoot valgus angle regarding outcome scores. However, there was no association between the modified Kellgren-Lawrence scale score and outcome scores. At the minimum 5-year follow-up, the functional and radiological outcomes were similar between TC and CN resections. Subtalar joint osteoarthritis developed in all patients with TC resections and most patients with CN resections, but patients did not have functional impairment.

Realignment Calcaneal Osteotomy for Bilateral Complete Talocalcaneal Synostosis: A Case Report

Talocalcaneal synostosis is a congenital failure of the segmentation between tarsal bones. It may be very difficult to differentiate from talocalcaneal coalition, known as the most common tarsal coalition, especially in cases with a large bone bridge. Complete talocalcaneal synostosis is very rare, and there are few references in the literature about the clinical outcomes and operative methods for symptomatic synostosis. We report a case of a 15-year-old female with bilateral complete talocalcaneal synostosis and heel varus deformity who has experienced good clinical results after lateral sliding calcaneal osteotomy for hindfoot realignment.

Management of foot and ankle injuries in pediatric and adolescent athletes: a narrative review

In this review, we focus on the treatment of injuries to the foot and ankle in the adolescent athlete. While many injuries in the adolescent foot and ankle are similar to or overlap with their counterparts in the adult population, the anatomy of the adolescent ankle, especially the presence of growth plates, results in different injury patterns in many cases and calls for specific management approaches. We discuss the unique anatomy of the pediatric patient as well as the diagnostic evaluation and treatment of common injuries in the young athlete.

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.

Reliability of the talocalcaneal angle for the evaluation of hindfoot alignment

INTRODUCTION

Recent studies suggest that hindfoot deformity should be considered in the surgical treatment of tarsal coalitions. Many authors have used the angle between the talus and the calcaneus (TCA) for decision-making. However, its reliability has not been demonstrated and the measurement technique has not been standardized. The objective of this study was to standardize the TCA measurement technique, and to evaluate the inter and intra-observer reproducibility of the proposed technique.

METHODS

The foot CT scans of a group of 30 patients between 10 and 17 years of age were analysed. Ten patients had talocalcaneal coalitions, ten calcaneonavicular coalitions and ten had no coalitions. The inter and intra-observer reproducibility of the TCA was evaluated by the intraclass correlation coefficient (ICCs). A mixed-effects ANOVA model was used to calculate the ICCs for ICC2 agreement (A, 1). This procedure was applied to the three observers (inter-observer variability), and to the test-retest of observer 1 (intra-observer variability). A two-tailed p value of ≤.05 was considered significant.

RESULTS

The inter-observer and intra-observer agreements were excellent for the TCA. Inter-observer agreement: ICC2 (A, 1)=.95 (p<.001, CI 95%: .77-.93). Intra-observer agreement: ICC2 (A, 1)=.99 (p<.001, CI 95%: .97-.99).

CONCLUSION

The TCA is a reliable way to evaluate hindfoot alignment. This method of measurement, as described in this study, can be safely used for surgical planning in patients with tarsal coalitions.

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.

Does arthroscopic resection of a too-long anterior process improve static disorders of the foot in children and adolescents?

PURPOSE

A too-long anterior process of the calcaneus is a common cause of pain and hind-foot instability. Our goal was to evaluate the early results of arthroscopic resection in terms of static foot disorders in children and adolescents.

METHODS

We retrospectively studied 11 ft (10 patients). The inclusion criteria were treatment of TLAP by arthroscopic resection and a minimum follow-up period of six months. Surgery was indicated in cases with persistent symptomatic TLAP resistant to orthopaedic treatment.

RESULTS

The mean age at surgery was 11 (range, 7-15) years. The mean follow-up duration was 15 (range, 8-28) months. Pre-operatively, we diagnosed four flat feet, two cavus feet and five feet with normal footprints, but loss of physiological hind-foot valgus. All patients presented with subtalar joint stiffness. At the last follow-up, four feet with no hind-foot valgus were normal, two were unchanged and the other feet had improved. The mean AOFAS increased from 61.9 (range, 47-73) to 89.1 (range, 71-97; P = 0.009). The mean radiological angles were near normal, exhibiting significant improvements in the lateral talo-metatarsal and Djian-Annonier angles.

CONCLUSIONS

Arthroscopic resection of a TLAP is safe. In the short term, the restoration of subtalar mobility reduces pain, and improves instability and static disorders. Longer follow-up of a larger patient series is required.

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.

Evans Osteotomy Complications

In 1975, Evans published an article describing the surgical management of the "calcaneo-valgus deformity," pointing out that the deformity was due to relative shortening of the lateral column of the foot. Correction involved "equalizing" both columns by performing an osteotomy in the neck of the calcaneus 1.5 cm from the calcaneocuboid joint, where a trapezoidal wedge of tricortical bone was placed. Although it was considered a success, there were complications, including sural nerve injury, surgical wound dehiscence, undercorrection, and graft subsidence. The osteotomy grew in popularity. Indications extended to other forms of flatfoot with a low incidence of complications.

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.

What's New in Pediatric Flatfoot?

BACKGROUND

Children with flatfeet are frequently referred to pediatric orthopaedic clinics. Most of these patients are asymptomatic and require no treatment. Care must be taken to differentiate patients with flexible flatfeet from those with rigid deformity that may have underlying pathology and have need of treatment. Rigid flatfeet in infants may be attributable to a congenital vertical talus (CVT); whereas those in older children and adolescents may be due to an underlying tarsal coalition. We performed a review of the recent literature regarding evaluation and management of pediatric flatfeet to discuss new findings and suggest areas where further research is needed.

METHODS

We searched the PubMed database for all papers related to the treatment of pediatric flatfoot, tarsal coalition, and CVT published from January 1, 2011 to December 31, 2014, yielding 85 English language papers.

RESULTS

A total of 18 papers contributed new or interesting findings.

CONCLUSIONS

The pediatric flexible flatfoot (FFF) remains poorly defined, making the understanding, study, and treatment of the condition extremely difficult.Pediatric FFF is often unnecessarily treated. There is very little evidence for the efficacy of nonsurgical intervention to affect the shape of the foot or to influence potential long-term disability for children with FFF. The treatment of tarsal coalition remains challenging, but short-term and intermediate-term outcome studies are satisfactory, whereas long-term outcome studies are lacking. Management of the associated flatfoot deformity may be as important as management of the coalition itself. The management of CVT is still evolving; however, early results of less invasive treatment methods seem promising.

LEVEL OF EVIDENCE

Level 4-literature review.

[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.

Talocalcaneal coalition: A focus on radiographic findings and sites of bridging

BACKGROUND

Verifying the exact location of talocalcaneal (TC) coalition is important for surgery, but the complicated anatomy of the subtalar joint makes it difficult to visualize on radiographs. No study has used computed tomography (CT) or magnetic resonance imaging (MRI) to verify the radiological characteristics of TC coalition or those of different facet coalitions. Therefore, this study verified the radiological findings used to identify TC coalitions and those of different facet coalitions using CT and MRI.

MATERIALS AND METHODS

Plain with/without weight bearing anteroposterior and lateral radiographs, CT, and MRI of 43 feet in 39 patients with TC coalitions were reviewed retrospectively. CT or MRI was used to verify the location of the TC coalition. Secondary signs for the presence of a coalition in the anteroposterior and lateral plain radiographs, including talar beak, humpback sign, duck-face sign, and typical or deformed C-sign, were evaluated. Three independent observers evaluated the radiographs twice at 6-week intervals to determine intraobserver reliability. They examined the radiographs for the secondary signs, listed above, and coalition involved facets.

RESULTS

The average rates from both assessments were as follows: Middle facet 5%, middle and posterior facets 27%, and posterior facet 68%. The deformed C-sign is more prevalent in posterior facet coalitions. The posterior facet has the highest prevalence of involvement in TC coalitions, and the deformed C-sign and duck-face sign have high correlations with TC coalitions in the posterior subtalar facet.

CONCLUSION

A posterior facet is the most prevalent for TC coalition, and the C-sign is useful for determining all types of TC coalition.

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).

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.

Subtalar coalition in pediatrics

Subtalar tarsal coalition is an autosomal dominant developmental maldeformation that affects between 2% and 13% of the population. The most common locations are between the calcaneus and navicular and between the talus and calcaneus. If prolonged attempts at nonoperative management do not relieve the pain, surgery is indicated. The exact surgical technique(s) should be based on the location of the pain, the size and histology of the coalition, the health of the other joints and facets, the degree of foot deformity, and the excursion of the heel cord.

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.

Adult flatfoot

Adult flatfoot is defined as a flattening of the medial arch of the foot in weight-bearing and lack of a propulsive gait. The 3 lesion levels are the talonavicular, tibiotarsal and midfoot joints. The subtalar joint is damaged by the consequent rotational defects. Clinical examination determines deformity and reducibility, and assesses any posterior tibialis muscle deficit, the posterior tibialis tendon and spring ligament being frequently subject to degenerative lesions. Radiographic examination in 3 incidences in weight-bearing is essential, to determine the principal level of deformity. Tendon (posterior tibialis tendon) and ligamentous lesions (spring ligament and interosseous ligament) are analyzed on MRI or ultrasound. In fixed deformities, CT explores for arthritic evolution or specific etiologies. 3D CT reconstruction can analyze bone and joint morphology and contribute to the planning of any osteotomy. Medical management associates insoles and physiotherapy. Acute painful flatfoot requires strict cast immobilization. Surgical treatment associates numerous combinations of procedures, currently under assessment for supple flatfoot: for the hindfoot: medial slide calcaneal osteotomy, calcaneal lengthening osteotomy, or arthroereisis; for the midfoot: arthrodesis on one or several rays, or first cuneiform or first metatarsal osteotomy; for the ankle: medial collateral ligament repair with tendon transfer. Fixed deformities require arthrodesis of one or several joint-lines in the hindfoot; for the ankle, total replacement after realignment of the foot, or tibiotalocalcaneal fusion or ankle and hindfoot fusion; and, for the midfoot, cuneonavicular or cuneometatarsal fusion. Tendinous procedures are often associated. Specific etiologies may need individualized procedures. In conclusion, adult flatfoot tends to be diagnosed and managed too late, with consequent impact on the ankle, the management of which is complex and poorly codified.

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.

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.