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Tarsal Coalition Treatment & Management

  • Author: Louis P Vu, MD; Chief Editor: Jason H Calhoun, MD, FACS  more...
 
Updated: Dec 16, 2014
 

Medical Therapy

Calcaneonavicular coalitions

Initial conservative treatment may include soft shoe inserts or a trial of walking cast immobilization. These treatments have been described in the literature to extend from 3-6 weeks each. Cast immobilization trials have been repeated once prior to surgery if the first attempt did not relieve symptoms. Immobilization must be with the hind foot in neutral and away from valgus.

In most symptomatic calcaneonavicular coalitions, conservative treatment yielded poor results. See the image below of calcaneonavicular coalition.

Plain radiograph (Slomann view) showing typical ap Plain radiograph (Slomann view) showing typical appearance of calcaneonavicular coalition.

Talocalcaneal coalition

In contrast to calcaneonavicular coalitions, conservative treatment decreasing subtalar motion or stress has been found to have good results in cases of first presentation with no evidence of arthritic changes. See the image below of talocalcaneal coalition.

CT scan appearance of talocalcaneal coalition. CT scan appearance of talocalcaneal coalition.
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Surgical Therapy

Calcaneonavicular coalitions

Given the ease and relatively good results of surgical treatment, coalition resection prior to onset of arthritic changes has become more commonly indicated.[32] See the image below of calcaneonavicular coalition.

Plain radiograph (Slomann view) showing typical ap Plain radiograph (Slomann view) showing typical appearance of calcaneonavicular coalition.

The procedure as described by Badgley[5] and Cowell[29] and others includes an anterolateral approach over the coalition, resection of at least 1 cm of the coalition, resection of a block rather than wedge section, interposition of the head of the extensor digitorum brevis muscle, and avoidance of the talonavicular joint to prevent theoretical subluxation of the navicular over the talar head. Some modifications of the original technique include use of bone wax or electrocautery to treat the remaining surfaces after bar resection and tying the interposition sutures over the plantar fascia and under the skin rather than securing them with a button over the skin. Various long-term studies of this technique have shown excellent or good results in 77-100% of patients.

Talonavicular coalition

Surgical treatment for symptomatic talonavicular coalition traditionally has been triple arthrodesis. Resection of the middle-facet coalition was not very successful prior to the advent of CT secondary to poor visualization of the coalition. Such resections have become more popular and are indicated in cases in which conservative treatment has failed, visualization of the middle-facet coalition is good, and no evidence of arthritic changes is present.[33, 34] Talar beaking is no longer considered by many to be evidence of degenerative change.

Comfort and Johnson found that there was an 80% success rate when the coalition involved one third or less of the total surface area of the subtalar joint on CT.[35] Wilde et al found that a valgus greater than 16º and a coalition surface area greater than 50% of the posterior facet on CT were predictors of poor results after resection.[36]

Luhmann and Shoenecker found that although an association existed between poor results and a heel valgus of 21º or a coalition greater than 50% of the posterior facet, some patients still had good postoperative results.[37] They therefore recommended that resection be tried as a first procedure and that patients be informed that they could still have a good result in cases in which the poor predictive factors are present. Various long-term studies have shown excellent, good, or improved rates of 80-100%.

The resection is approached medially, distal to the medial malleolus. The middle facet is exposed by retraction of the flexor hallucis longus tendon. The prominent joint is resected with a rongeur, and fat is interposed.

In cases in which a resection is not possible or desired, Mann and Baumgarten have proposed fusion of the subtalar joint only, instead of the traditional triple arthrodesis, reasoning that any motion saved in the midtarsal joints would maintain force transfer during motion, decreasing or slowing degenerative changes in adjacent joints.[38] However, in cases in which degenerative changes are apparent, triple arthrodesis is indicated, as isolated subtalar fusion would only accelerate the changes in the midtarsal joints. In cases in which skeletal immaturity is present, a Grice-Green extra-articular arthrodesis may be indicated as an intermediate procedure.

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Intraoperative Details

de Wouters et al reported on the use of a patient-specific, made-to-measure surgical guide for tarsal coalition resections in nine consecutive patients.[39] The guide was created by 3D modeling from a CT scan of the foot. After being placed on the bone surface, the guide was used to orient the saw blade to resect the bone bridge at the appropriate depth. A fascia lata allograft was interposed. Complete resection and absence of recurrence were checked on postoperative CT for patients with talocalcaneal coalitions and on radiography for those with calcaneonavicular coalitions. In all cases, resection was complete, and there were no recurrences at the final follow-up. The results suggested that use of such a guide can make tarsal coalition resection easier and more reliable and improve precision.

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Postoperative Details

Postoperative treatment includes immobilization for 3 weeks in a non – weight-bearing cast followed by 3 weeks of partial immobilization with nonweightbearing ankle cast and range-of-motion exercises out of the cast. This is then followed by gradual advance to full weight bearing and range-of-motion exercises with physiotherapy. Bilateral procedures are staged to allow full recovery of the first foot prior to surgery of the second foot.

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Complications

Infections and wound complications are possible with surgical resection. As previously stated, in the event of a failure to resolve symptoms in cases treated with resection of the coalition, various arthrodeses are appropriate as salvage or next-step treatment.

In the case of calcaneal navicular bar resection, violation of the talonavicular capsule may result in subluxation of the navicular on the talus, which may lead to abnormal motion of the midfoot and risk of pain and degenerative changes.

In the case of talocalcaneal coalition resections, it was found that coalitions 50% or greater in surface area than the posterior facet had a tendency to yield a poor result. This would imply that accidental resection of the middle facet 50% or greater than the posterior facet may yield a poor result.

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Outcome and Prognosis

Nonoperative treatment of patients with symptomatic tarsal coalitions has not been uniformly successful. As such, most long-term studies have focused on outcomes following surgical treatment. Proper patient selection is a prerequisite for optimal results.

Patients with extensive or multiple coalitions typically undergo fusion procedures, and those with less extensive or isolated coalitions undergo resection and soft-tissue interposition of their coalitions. Talar beaking must be critically evaluated but is not necessarily a contraindication to tarsal coalition resection. The vast majority of calcaneonavicular coalitions can be resected with the expectation of successful long-term results. Resection of symptomatic talocalcaneal coalitions yields optimal results when the coalition involves approximately one third or less of the total joint surface.

Skwara et al assessed the foot loading characteristics and foot function in 10 patients (15 feet) who underwent surgical correction for tarsal coalition. In 12 feet, calcaneonavicular coalition was present; in 3, talocalcaneal. Overall, the clinical results were fair regarding improvement of pain, range of motion, and walking distance. The American Orthopaedic Foot and Ankle Society scores were fair, as well (mean, 78.1) at follow-up. Gait analysis revealed alterations in kinematic and kinetic parameters for the operated foot, and pedobarographic analysis showed altered loadings for heel and forefoot.[40]

Khoshbin et al used an administrative database to follow up a cohort of patients who had undergone surgical resection of tarsal coalition with the aim of determining the rates and risk factors for subsequent resection or arthrodesis.[41] Their study cohort consisted of 304 patients (aged ≥ 8 years; average, 24.2 years) treated between July 1994 and August 2009. Patients with nonidiopathic coalitions were excluded. Of the 304 patients, 26 (8.6%) underwent subsequent resection, and 16 (5.3%) experienced mid- or hindfoot arthrodesis.

According to this study, the need for future fusion was more likely only if the primary resection had been performed at an academic hospital or if the patient had undergone concomitant arthrodesis at primary resection of the coalition.[41] The incidence of reoperation after primary tarsal coalition resection was low. More than 85% of the patients had not required an additional operative intervention an average of 9 years after the initial resection. The investigators suggested that primary treatment of tarsal coalition with resection and concomitant arthrodesis increases the risk of requiring a second fusion in the future.

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Future and Controversies

Tarsal coalitions are relatively rare congenital abnormalities of the foot in which 2 or more of the tarsal bones are joined by bone, cartilage, or fibrous tissue. The true incidence is unknown, as most are asymptomatic. The most common are calcaneonavicular and talocalcaneal coalitions. More than half are bilateral. Clinically, patients present with a history of chronic pain with activity or stress after a traumatic injury or repetitive sprains.

The condition is poorly visualized with the standard AP and lateral radiographs, but secondary signs such as the talar beak or the anteater-nose sign may suggest it. Axial and lateral views may offer better visualization. CT with coronal cuts is the criterion standard, particularly in evaluating talocalcaneal coalitions.

Conservative treatment includes soft shoe inserts and walking-cast immobilization. Surgical treatment includes resection of the coalition before onset of degenerative changes and subtalar fusion in the case of talocalcaneal coalitions.

Currently, it is not clear what should control the use of talocalcaneal coalition resection; the limiting factors of heel position and percentage of involvement do not consistently segregate good and bad outcomes. However, once global degenerative changes have begun, triple arthrodesis almost always is indicated.

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Contributor Information and Disclosures
Author

Louis P Vu, MD Orthopedic Surgeon, Private Practice

Louis P Vu, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Charles T Mehlman, DO, MPH Professor of Pediatrics and Pediatric Orthopedic Surgery, Division of Pediatric Orthopedic Surgery, Director, Musculoskeletal Outcomes Research, Cincinnati Children's Hospital Medical Center

Charles T Mehlman, DO, MPH is a member of the following medical societies: American Academy of Pediatrics, American Fracture Association, Scoliosis Research Society, Pediatric Orthopaedic Society of North America, American Medical Association, American Orthopaedic Foot and Ankle Society, American Osteopathic Association, Arthroscopy Association of North America, North American Spine Society, Ohio State Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Jason H Calhoun, MD, FACS Department Chief, Musculoskeletal Sciences, Spectrum Health Medical Group

Jason H Calhoun, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Diabetes Association, American Medical Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Michigan State Medical Society, Missouri State Medical Association, Southern Medical Association, Southern Orthopaedic Association, Texas Medical Association, Texas Orthopaedic Association, Musculoskeletal Infection Society

Disclosure: Nothing to disclose.

Additional Contributors

James K DeOrio, MD Associate Professor of Orthopedic Surgery, Duke University School of Medicine

James K DeOrio, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society

Disclosure: Received royalty from Merete for other; Received royalty from SBi for other; Received royalty from BioPro for other; Received honoraria from Acumed, LLC for speaking and teaching; Received honoraria from Wright Medical Technology, Inc for speaking and teaching; Received honoraria from SBI for speaking and teaching; Received honoraria from Integra for speaking and teaching; Received honoraria from Datatrace Publishing for speaking and teaching; Received honoraria from Exactech, Inc for speaking a.

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Plain radiograph (Slomann view) showing typical appearance of calcaneonavicular coalition.
CT scan appearance of talocalcaneal coalition.
 
 
 
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