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The optimum surgical procedure for talocalcaneal coalitions has not been definitively determined. The authors performed this study to evaluate the results achieved with talocalcaneal tarsal coalition resection with regard to preoperative radiographic findings in relation to postoperative outcomes. They reviewed the medical records of 7 patients and conducted telephone interviews using a modified American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale. The average age at surgery was 31 years (range, 15-56 years), and the follow-up period averaged 17.4 months (range, 7-36 months). In 6 cases, the resection was successful, with the mean preoperative Ankle-Hindfoot score of 36.5 improving to 50.5 (P = .51). One patient failed the resection and underwent a subtalar arthrodesis 1 year after the resection procedure. Radiographic evaluation showed that higher cartilaginous content of the tarsal coalition was associated with a better outcome in Ankle-Hindfoot scores (r = .894, P = .016); the relationship of patient age and changes in scores was r = .692 but was not statistically significant because of small sample size. Resection of tarsal coalition led to higher Ankle-Hindfoot scores for 6 of 7 patients at least 1 year postoperatively, and that higher cartilagenous content of the coalition was statistically significantly correlated with better postoperative outcomes.
A Critical Evaluation of Subtalar Joint Arthrosis Associated with Middle Facet Talocalcaneal Coalition in 21 Surgically Managed Patients: A Retrospective Computed Tomography Review. Investigations Involving Middle Facet Coalitions-Part III.
Kernbach KJ, Barkan H, Blitz NM. Clin Podiatr Med Surg. 2010 Jan;27(1):135-43.
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Symptomatic middle facet talocalcaneal coalition is frequently associated with rearfoot arthrosis that is often managed surgically with rearfoot fusion. However, no objective method for classifying the extent of subtalar joint arthrosis exists. No study has clearly identified the extent of posterior facet arthrosis present in a large cohort treated surgically for talocalcaneal coalition through preoperative computerized axial tomography. The authors conducted a retrospective review of 21 patients (35 feet) with coalition who were surgically treated over a 12-year period for coalition on at least 1 foot. Using a predefined original staging system, the extent of the arthrosis was categorized into normal or mild (Stage I), moderate (Stage II), and severe (Stage III) arthrosis. The association of stage and age is statistically significant. All of the feet with Stage III arthrosis had fibrous coalitions. No foot with osseous coalition had Stage III arthrosis. The distribution of arthrosis staging differs between fibrous and osseous coalitions. Only fibrous coalitions had the most advanced arthrosis (Stage III), whereas osseous coalitions did not. This suggests that osseous coalitions may have a protective effect in the prevention of severe degeneration of the subtalar joint. Concomitant subtalar joint arthrosis severity progresses with age; surgeons may want to consider earlier surgical intervention to prevent arthrosis progression in patients with symptomatic middle facet talocalcaneal coalition.
Plantar contact stress and gait analysis after resection of tarsal coalition.
Skwara A, Zounta V, Tibesku CO, Fuchs-Winkelmann S, Rosenbaum D. Acta Orthop Belg. 2009 Oct;75(5):654-60.
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The purpose of this study was to assess the foot loading characteristics and foot function of patients after operative correction of a tarsal coalition. Ten patients who had undergone operative treatment of a tarsal coalition were included in this study. One foot was affected in five patients and both feet in the other five. A calcaneonavicular coalition was present in 12 feet and a talocalcaneal coalition in three feet. Mean follow-up was 11.3 years. Clinical evaluation was based on a standardized questionnaire, a visual analogue scale for pain (VAS), the American Orthopaedic Foot and Ankle Society (AOFAS) Score and radiographic evaluation of the last radiographs. An objective analysis of foot loading characteristics was carried out with instrumented gait analysis and pedobarography. The clinical results were overall fair for pain, range of motion and walking distance. The AOFAS also showed fair results (mean: 78.1) at follow-up. Gait analysis revealed alterations in kinematic and kinetic parameters for the operated foot. Pedobarographic analysis showed altered loadings for heel and forefoot. In this study, operative treatment of tarsal coalition achieved fair clinical and radiographic results and did not restore physiologic gait and foot loading.
Preliminary report: resection and interposition of a deepithelialized skin flap graft in tarsal coalition in children.
Sperl M, Saraph V, Zwick EB, Kraus T, Spendel S, Linhart WE. J Pediatr Orthop B. 2009 Dec 24
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Six tarsal coalitions in children were managed surgically using a deepithelialized skin flap for interposition after resection of the bony, fibrous or cartilaginous coalition. The advantage of this technique is that due to positioning the skin flap, joint motion can be preserved. The clinical results using the Ankle Hindfoot Scale of the American Orthopedic Foot and Ankle Society were excellent in two and good in four cases. The radiographs at follow-up showed no recurrences of the resected coalitions. This study shows that the use of deepithelialized skin flap interposition is effective in providing pain relief for the patients in symptomatic coalitions.
Arthroscopic resection of talocalcaneal coalitions.
Bonasia DE, Phisitkul P, Saltzman CL, Barg A, Amendola A. Arthroscopy. 2011 Mar;27(3):430-5.
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Excision of symptomatic talocalcaneal coalitions, after failure of an adequate conservative treatment, is a widely accepted surgical treatment when less than 50% of the subtalar joint is involved and in the absence of degenerative changes to the subtalar or surrounding tarsal joints. Favorable results have been reported in 80% to 100% of patients with open resection. The traditional medial incision to the subtalar joint provides excellent exposure of the middle facet but inadequate visualization of the posterior facet. Other common disadvantages of the traditional open technique include (1) risk of incisional neuroma formation, (2) risk of superficial wound infection and delayed wound healing, and (3) prolonged hospitalization for wound management and pain control. Prone ankle/subtalar arthroscopy has been reported to yield excellent results in the treatment of numerous hindfoot pathologies, with the advantage of reducing postoperative pain, hospital stay, infection rates, wound complications, and recovery time. A posterior arthroscopic technique for posterior-facet talocalcaneal coalition excision has been developed in an attempt to reduce the complications of the traditional open resection. Possible disadvantages of the arthroscopic procedure may include (1) longer learning curve, (2) increased surgical time, (3) possible tibial neurovascular bundle damage, and (4) difficulties in using interposition material.
Tarsal coalitions often present in young adults as a painful pes planovalgus hindfoot deformity. Resection of moderate and even large coalitions has become accepted as an alternative to arthrodesis. A review of the literature, however, suggests that coalitions with severe preoperative planovalgus malposition treated with resection are associated with continued disability and deformity. The authors believe that malposition contributes to persistent pain and disability after simple coalition resection. The hypothesis is that resection of the coalition with simultaneous hindfoot reconstruction can improve clinical and radiographic outcomes. Seven consecutively treated patients (eight feet) were retrospectively reviewed from the senior author's practice. Clinical exam, American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scores, and radiographic measurements were evaluated after talocalcaneal coalition resection with simultaneous hindfoot reconstruction. All patients were satisfied and would have the same procedure again. All patients were either active students or gainfully employed at last follow-up. Clinical and radiographic hindfoot alignment was corrected reliably. The average increase in medial longitudinal arch height was 8.7 mm. After 2 years the average AOFAS hindfoot score was 88. Most patients had only mildly progressive arthrosis. There were two postoperative complications that resolved (superficial wound breakdown and calf deep vein thrombosis). This hindfoot reconstruction with coalition resection increased motion, reliably corrected malalignment, and improved pain. The authors believe that coalition resection and concomitant hindfoot reconstruction is a better option than resection alone or hindfoot fusion in patients with talocalcaneal coalition and painful pes planovalgus hindfoot deformity. Triple arthrodesis should be reserved as a salvage procedure.
Talocalcaneal coalitions are rare but a posterior facet talocalcaneal coalition is even rarer. There are three different types: fibrous, cartilaginous and osseous coalitions. Besides conventional x-rays computed tomography is essential for assessment of the subtarsal joint. In the absence of concomitant coalitions and foot deformity resection of the coalition is advocated due to good clinical results when there is an adequate size of the talocalcaneal joint (>50%) and without osteoarthrosis. A case of a rare posterior facet talocalcaneal coalition is reported.
Talocalcaneal coalition is an abnormal bridge between talus and calcaneus, causing pain and restriction of subtalar movement; its incidence is less than 1 %. The signs and symptoms usually become manifest in the second decade of life with ossification of the lesion. They involve flat foot, peroneal muscle spasm, tarsal tunnel syndrome, or valgus tilt of the heel. The sings need not be noticeable and may appear only as tiredness and vague pain in the hind foot after exercise or an easily twisted ankle. The authors describe the case of talocalcaneal coalition in a 20-year-old man, incidentally diagnosed at ankle fracture. The presence of C-sign led to CT examination and the exact diagnosis. Radiological demonstration of this abnormality may be difficult because plain X-ray images in both projections may show normal findings. Literature data report, in addition to C-sign, further secondary signs of talocalcaneal coalition present on lateral radiographs of the ankle joint. Although these signs do not directly point to talocalcaneal coalition, they reveal abnormal anatomy or movement of the joint and may initiate more thorough examination by CT or MRI and the establishment of an exact diagnosis. Therefore, to know the secondary signs and pay attention to them is very useful. Key words: talocalcaneal coalition, tarsal, subtalar joint, radiography.
BACKGROUND:
The purpose of this study was to review outcomes of patients treated for symptomatic talocalcaneal coalition with resection and interposition of fat graft.
METHODS:
A retrospective review was performed on all patients who underwent surgical treatment for symptomatic talocalcaneal coalition over a 13-year period. Ninety-three feet were treated with excision and fat graft interposition by 6 surgeons. All patients underwent a chart review. Patient's outcome was assessed at the last follow-up using the American Orthopaedic Foot and Ankle Society Hindfoot scale. Postoperative computed tomography scans were available for 20 feet.
RESULTS:
Forty-nine feet had follow-up of at least 12 months and had a score obtained through the American Orthopaedic Foot and Ankle Society Hindfoot scale. At an average of 42.6 months of follow-up, the average score obtained was 90/100 (excellent). The postoperative computed tomography scans demonstrated 1 recurrence (3%), which was treated with repeat excision. An additional patient was reoperated for failure to excise the coalition completely. Eleven patients (34%) underwent a subsequent surgery to correct the alignment of the foot. To the best of our knowledge, none of the patients excluded because of short follow-up had repeat surgery or recurrence.
CONCLUSIONS:
A symptomatic talocalcaneal coalition can be treated with excision and fat graft interposition, and achieve good to excellent results in 85% of patients. Patients should be counseled that a subset may require further surgery to correct malalignment.
BACKGROUND:
The purpose of this study was to review outcomes of patients treated for symptomatic talocalcaneal coalition with resection and interposition of fat graft.
METHODS:
A retrospective review was performed on all patients who underwent surgical treatment for symptomatic talocalcaneal coalition over a 13-year period. Ninety-three feet were treated with excision and fat graft interposition by 6 surgeons. All patients underwent a chart review. Patient's outcome was assessed at the last follow-up using the American Orthopaedic Foot and Ankle Society Hindfoot scale. Postoperative computed tomography scans were available for 20 feet.
RESULTS:
Forty-nine feet had follow-up of at least 12 months and had a score obtained through the American Orthopaedic Foot and Ankle Society Hindfoot scale. At an average of 42.6 months of follow-up, the average score obtained was 90/100 (excellent). The postoperative computed tomography scans demonstrated 1 recurrence (3%), which was treated with repeat excision. An additional patient was reoperated for failure to excise the coalition completely. Eleven patients (34%) underwent a subsequent surgery to correct the alignment of the foot. To the best of our knowledge, none of the patients excluded because of short follow-up had repeat surgery or recurrence.
CONCLUSIONS:
A symptomatic talocalcaneal coalition can be treated with excision and fat graft interposition, and achieve good to excellent results in 85% of patients. Patients should be counseled that a subset may require further surgery to correct malalignment.
Mid-term outcome of talocalcaneal coalition treated with interposition of a pedicle fatty flap after resection.
Imajima Y, Takao M, Miyamoto W, Imade S, Nishi H, Uchio Y. Foot Ankle Int. 2012 Mar;33(3):226-30.
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BACKGROUND:
We have previously reported a new technique to treat symptomatic talocalcaneal coalition. The purpose of the present study was to evaluate the mid-term outcome of the interposition of a pedicle fatty flap after the resection of a talocalcaneal coalition.
METHODS:
Six feet of 5 patients with persistently symptomatic talocalcaneal coalition were treated with this method. We investigated the clinical outcome using the visual analog scale (VAS) for hindfoot pain including around coalition and the American Orthopaedic Foot and Ankle Society (AOFAS) score pre- and postoperatively, and investigated whether or not recurrence was present using computed tomography (CT) at the final followup.
RESULTS:
The VAS score was significantly improved from 5.5 +/- 1.0 (mean +/- SD) to 9.7 +/- 0.5 points (p = 0.0006). The AOFAS hindfoot score was also improved significantly (from 73.3 +/- 26.7 points to 96.7 +/- 7.1 points). No recurrence was detected by CT at the final followup.
CONCLUSION:
The interposition of a pedicle fatty flap after resection has been a durable procedure for treating a symptomatic talocalcaneal coalition.
Thank you NewsBot and Admin2 for these postings. I was wondering if I could get feedback from anyone who has had experience with paediatric coalition patients, post-op. I have a 12y/o female client with bilateral coalitions at the talus-calcaneus near the sustentaculum tali. There is synostosis with an incomplete fusion. She has been in considerable pain for at least 12 months and the pain is deteriorating to the point where walking for any more than 20 minutes results in considerable pain. Conservative management has been limited in its success. The young lady has seen an orthpod who told her that surgery had a 50% chance of success. As I have had limited experience with coalitions which require surgery, I was wondering what some of the complications may be. Needless to say, both the young lady and her parents are anxious about how to make the best decision. Thanking you all in advance.
Background:
Surgical resection of persistently painful talocalcaneal tarsal coalitions may not reliably relieve symptoms in patients with large coalitions associated with excessive hindfoot valgus deformity and subtalar posterior facet narrowing. Since 1991, calcaneal lengthening osteotomy, with or without coalition resection, has been used at our institution to relieve symptoms and to preserve motion at the talonavicular and calcaneocuboid joints.
Methods:
We retrospectively reviewed the records for eight patients with thirteen painful talocalcaneal tarsal coalitions who had undergone a calcaneal lengthening osteotomy for deformity correction with or without coalition resection between 1991 and 2005. Preoperative and postoperative clinical, radiographic, and computed tomographic records were reviewed. The duration of clinical follow-up ranged from two to fifteen years.
Results:
Calcaneal lengthening osteotomy fully corrected the valgus deformity and provided short-to-intermediate term pain relief for the five patients (nine feet) in whom the talocalcaneal tarsal coalition was unresectable. The patient with resectable coalitions but excessive valgus deformities underwent calcaneal lengthening osteotomies along with coalition resections and had excellent deformity correction and pain relief in both feet. One of the two patients who underwent calcaneal lengthening osteotomy years after coalition resection had excellent correction and pain relief. The other patient had a coincident calcaneonavicular coalition and severe degenerative arthritis in the talonavicular joint. He underwent concurrent arthrodesis of the talonavicular joint and, although he had excellent deformity correction, had persistent pain. All feet underwent concurrent gastrocnemius or Achilles tendon lengthening.
Conclusions:
It is generally accepted that resection is the treatment of choice for an intractably painful small talocalcaneal tarsal coalition that is associated with a wide, healthy posterior facet and minimal valgus deformity of the hindfoot. Although triple arthrodesis has been recommended for those who do not meet all three criteria, the present study suggests that an algorithmic treatment approach is justified. Treatment of the valgus deformity appears to be as important as that of the coalition. Calcaneal lengthening osteotomy with gastrocnemius or Achilles tendon lengthening is effective for correcting deformity and relieving pain in rigid flatfeet, just as it is in flexible flatfeet.
Diagnosis and treatment of tarsal coalitions and synostoses in children and adolescents.
Hamel J. Orthopade. 2013 Feb 8.
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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.
OBJECTIVE:
To explore the operative method and effectiveness of talocalcaneal coalition.
METHODS:
Between July 2008 and October 2010, 10 patients with talocalcaneal coalition were treated, including 2 cases of congenital talocalcaneal coalition and 8 cases of secondary talocalcaneal coalition. There were 4 males and 6 females, aged 53.5 years on average (range, 16-70 years). Three patients had middle-facet talocalcaneal coalition and 7 had posterior-facet talocalcaneal coalition. The preoperative visual analogue score (VAS) was 9.0 +/- 0.4. According to American Orthopedic Foot and Ankle Society (AOFAS) hindfoot scale, the score was 42.4 +/- 1.4. Two cases complicated by subtalar degeneration. Resection of the bone bar and fat packing were performed in 8 cases of simple talocalcaneal coalition, and resection and subtalar arthrodesis in 2 cases of talocalcaneal coalition combined with subtalar degeneration.
RESULTS:
Primary healing of incisions was obtained in all patients. Eight patients were followed up 18 months on average (range, 12-36 months). At last follow-up, VAS was 2.0 +/- 0.7, showing siginificant difference when compared with preoperative score (t = 6.425, P = 0.000). AOFAS score was 86.9 +/- 2.3, showing significant difference when compared with preoperative score (t = 7.634, P = 0.000). The X-ray films showed that no recurrence of talocalcaneal coalition was observed in patients underdoing simple removal of bone bar, and bone fusion was observed in patients undergoing arthrodesis.
CONCLUSION:
To achieve satisfactory outcomes for talocalcaneal coalition, a reasonable surgical procedure should be chosen according to the specific facet and complication.
We describe a surgical technique and report outcomes for fibrin glue interposition after resection of a tarsal condition. An institutional review board--approved retrospective review of all pediatric patients with a tarsal coalition managed with resection was conducted between January 2002 and July 2010 by a single surgeon. All coalitions were resected with interposition of fibrin glue. Patients were evaluated for postoperative complications, pain, weight-bearing status, return to sports, and ankle and subtalar range of motion. Six feet without a coalition were used as a control group. Nine patients (12 feet) were identified with mean follow-up of 2.1 years (range, 7-72 months). Pre-operative complaints were predominantly foot and ankle pain. Patients also reported flatfeet and recurrent ankle sprains. There were no reported postoperative complications. All 9 patients were weight-bearing as tolerated and returned to sports by 6 months. Fibrin glue is a safe and reliable alternative to tissue grafts for interposition after resection of a tarsal coalition.
Ultrasound of talocalcaneal coalition: retrospective study of 11 patients
Stefano Bianchi, Douglas Hoffman Skeletal Radiology; May 2013
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Objective
To present the ultrasound appearance of talocalcaneal coalitions (TCC).
Materials and methods
We present a retrospective review of 11 patients (8 women and 3 men, age range 17–58 years, mean age 35.3 years) in which ultrasound, the first imaging study carried out, detected a TCC that was not known or suspected clinically. Patients were subsequently examined by standard radiographs, computed tomography (CT) or magnetic resonance imaging (MRI).
Results
In 9 patients with fibrous coalition ultrasound showed a reduced joint space of the medial aspect of the anterior talocalcaneal joint associated with an irregular, pointed appearance of its outline. In 2 patients with osseous coalitions ultrasound revealed a smooth continuity of the hyperechoic bone surface between the medial talus and the substentaculum tali. The diagnosis was confirmed in 4 patients with CT and in 3 with MRI. In the remaining 4 patients standard radiographs were consistent with TCC.
Conclusion
Owing to its tomographic capabilities ultrasound can detect TCC. We suggest that study of the anterior subtalar joint should be a part of every ankle ultrasound examination as it can show a clinically unsuspected TCC. Confirmation of the coalition by CT or MRI is required in the preoperative assessment to better assess the type and extent of the congenital anomaly as well as the adjacent joints.
Long-Term Functional Outcomes of Resected Tarsal Coalitions.
Khoshbin A, Law PW, Caspi L, Wright JG. Foot Ankle Int. 2013 May 12.
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BACKGROUND:
There are few long-term studies evaluating tarsal coalition resections. The purpose of this study was to compare patient outcomes following resection of calcaneonavicular (CN) and talocalcaneal (TC) bars and to determine the relationship between the extent of a coalition and the outcome of resection.
METHODS:
Patients younger than 18 years receiving resection for symptomatic tarsal coalition (1991-2004 inclusive) were eligible to participate. Follow-up evaluation included clinical examination to assess range of motion and self-reported functional outcome questionnaires. Two validated functional scales were used: the American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle Module, and the Foot Function Index (FFI). Twenty-four patients with 32 tarsal coalition resections (19 CN and 13 TC feet) were included in this study. For CN and TC patients, the mean age at the time of surgery was 11.8 ± 1.1 and 11.9 ± 2.5 years, and the mean age at follow-up was 27.1 ± 1.1 and 25.0 ± 2.5 years, respectively.
RESULTS:
Inversion and eversion were significantly less for TC feet when compared with CN (P = .03 and P = .01, respectively). No difference was noted between the CN and TC groups with respect to outcome scores. Furthermore, no association was noted between the size of TC coalition or hindfoot valgus angle with respect to outcome scores.
CONCLUSION:
Resected CN and TC bars behaved similarly in the long term in terms of function and patient satisfaction. Favorable results were attained when resections were performed on TC coalitions that were greater than 50% of the posterior facet and hindfoot valgus angles greater than 16 degrees.
Talocalcaneal coalition
Linear Mode
