Tarsal Coalition Treatment & Management
- Author: Louis P Vu, MD; Chief Editor: Jason H Calhoun, MD, FACS more...
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.
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.
Given the ease and relatively good results of surgical treatment, coalition resection prior to onset of arthritic changes has become more commonly indicated. See the image below of calcaneonavicular coalition.
The procedure as described by Badgley and Cowell 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.
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. 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.
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. 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. 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.
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. 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.
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.
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.
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.
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. 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. 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.
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.
Lemley F, Berlet G, Hill K, Philbin T, Isaac B, Lee T. Current concepts review: Tarsal coalition. Foot Ankle Int. 2006 Dec. 27(12):1163-9. [Medline].
Petrover D, Schweitzer ME, Laredo JD. Anterior process calcaneal fractures: a systematic evaluation of associated conditions. Skeletal Radiol. 2007 Jul. 36(7):627-32. [Medline].
Heiple KG, Lovejoy CO. The antiquity of tarsal coalition. Bilateral deformity in a Pre- Columbian Indian skeleton. J Bone Joint Surg Am. 1969 Jul. 51(5):979-83. [Medline].
Cruveilhier J. Anatomie Pathologique du Corps Humain, tome 1, Paris, J.B. Balliere. 1829.
Badgley CE. Coalition of the calcaneus and the navicular. Arch Surg. 1927. 15:75-88.
Harris RI, Beath T. Etiology of peroneal spastic flatfoot. J Bone Joint Surg Br. 1948. 30:624-34.
Kirmission E. Double pied bot varus par malformation osseuse primitive associe a des ankyloses congenitales des doigts et des arteils chez quatre membres di' une meme Famille. Rev Orthop. 1998. 9:392-8.
Conway JJ, Cowell HR. Tarsal coalition: clinical significance and roentgenographic demonstration. Radiology. 1969 Mar. 92(4):799-811. [Medline].
Deutsch AL, Resnick D, Campbell G. Computed tomography and bone scintigraphy in the evaluation of tarsal coalition. Radiology. 1982 Jul. 144(1):137-40. [Medline].
Herzenberg JE, Goldner JL, Martinez S, Silverman PM. Computerized tomography of talocalcaneal tarsal coalition: a clinical and anatomic study. Foot Ankle. 1986 Jun. 6(6):273-88. [Medline].
Wechsler RJ, Schweitzer ME, Deely DM, et al. Tarsal coalition: depiction and characterization with CT and MR imaging. Radiology. 1994 Nov. 193(2):447-52. [Medline].
Rankin EA, Baker GI. Rigid flatfoot in the young adult. Clin Orthop. 1974 Oct. 0(104):244-8. [Medline].
Vaughan WH, Segal G. Tarsal coalitions, special reference to roentogenographic interpretation. Radiology. 1953. 60:855-63.
Shands AR, Wentz IJ. Congenital anomalies, accessory bones, and osteochondritis in the feet of 850 children. Surg Clin North Am. 1953. 33:1643-66.
Leonard MA. The inheritance of tarsal coalition and its relationship to spastic flat foot. J Bone Joint Surg Br. 1974 Aug. 56B(3):520-6. [Medline].
Snyder RB, Lipscomb AB, Johnston RK. The relationship of tarsal coalitions to ankle sprains in athletes. Am J Sports Med. 1981 Sep-Oct. 9(5):313-7. [Medline].
Cooperman DR, Janke BE, Gilmore A, et al. A three-dimensional study of calcaneonavicular tarsal coalitions. J Pediatr Orthop. 2001 Sep-Oct. 21(5):648-51. [Medline].
Stormont DM, Peterson HA. The relative incidence of tarsal coalition. Clin Orthop. 1983 Dec. (181):28-36. [Medline].
Jack EA. Bone anomalies of the tarsus in relation to "peroneal spastic flatfoot". J Bone Joint Surg Br. 1954. 36:530-42.
Thorpe SW, Wukich DK. Tarsal coalitions in the adult population: does treatment differ from the adolescent?. Foot Ankle Clin. 2012 Jun. 17(2):195-204. [Medline].
Lisella JM, Bellapianta JM, Manoli A 2nd. Tarsal coalition resection with pes planovalgus hindfoot reconstruction. J Surg Orthop Adv. 2011 Summer. 20(2):102-5. [Medline].
Bettin D, Karbowski A, Schwering L. Congenital ball-and-socket anomaly of the ankle. J Pediatr Orthop. 1996 Jul-Aug. 16(4):492-6. [Medline].
Pistoia F, Ozonoff MB, Wintz P. Ball-and-socket ankle joint. Skeletal Radiol. 1987. 16(6):447-51. [Medline].
Takakura Y, Tamai S, Masuhara K. Genesis of the ball-and-socket ankle. J Bone Joint Surg Br. 1986 Nov. 68(5):834-7. [Medline].
Lateur LM, Van Hoe LR, Van Ghillewe KV, et al. Subtalar coalition: diagnosis with the C sign on lateral radiographs of the ankle. Radiology. 1994 Dec. 193(3):847-51. [Medline].
Sakellariou A, Sallomi D, Janzen DL, et al. Talocalcaneal coalition. Diagnosis with the C-sign on lateral radiographs of the ankle. J Bone Joint Surg Br. 2000 May. 82(4):574-8. [Medline].
Brown RR, Rosenberg ZS, Thornhill BA. The C sign: more specific for flatfoot deformity than subtalar coalition. Skeletal Radiol. 2001 Feb. 30(2):84-7. [Medline].
Oestreich AE, Mize WA, Crawford AH, Morgan RC Jr. The "anteater nose": a direct sign of calcaneonavicular coalition on the lateral radiograph. J Pediatr Orthop. 1987 Nov-Dec. 7(6):709-11. [Medline].
Cowell HR. Tarsal coalition--review and update. Instr Course Lect. 1982. 31:264-71. [Medline].
Nalaboff KM, Schweitzer ME. MRI of tarsal coalition: frequency, distribution, and innovative signs. Bull NYU Hosp Jt Dis. 2008. 66(1):14-21. [Medline].
Mubarak SJ, Patel PN, Upasani VV, Moor MA, Wenger DR. Calcaneonavicular coalition: treatment by excision and fat graft. J Pediatr Orthop. 2009 Jul-Aug. 29(5):418-26. [Medline].
Philbin TM, Homan B, Hill K, Berlet G. Results of resection for middle facet tarsal coalitions in adults. Foot Ankle Spec. 2008 Dec. 1(6):344-9. [Medline].
Comfort TK, Johnson LO. Resection for symptomatic talocalcaneal coalition. J Pediatr Orthop. 1998 May-Jun. 18(3):283-8. [Medline].
Wilde PH, Torode IP, Dickens DR, Cole WG. Resection for symptomatic talocalcaneal coalition. J Bone Joint Surg Br. 1994 Sep. 76(5):797-801. [Medline].
Luhmann SJ, Schoenecker PL. Symptomatic talocalcaneal coalition resection: indications and results. J Pediatr Orthop. 1998 Nov-Dec. 18(6):748-54. [Medline].
Mann RA, Baumgarten M. Subtalar fusion for isolated subtalar disorders. Preliminary report. Clin Orthop. 1988 Jan. (226):260-5. [Medline].
de Wouters S, Tran Duy K, Docquier PL. Patient-specific instruments for surgical resection of painful tarsal coalition in adolescents. Orthop Traumatol Surg Res. 2014 Jun. 100(4):423-7. [Medline].
Skwara A, Zounta V, Tibesku CO, Fuchs-Winkelmann S, Rosenbaum D. Plantar contact stress and gait analysis after resection of tarsal coalition. Acta Orthop Belg. 2009 Oct. 75(5):654-60. [Medline].
Khoshbin A, Bouchard M, Wasserstein D, Leroux T, Law PW, Kreder HJ, et al. Reoperations after Tarsal Coalition Resection: A Population-based Study. J Foot Ankle Surg. 2014 Jul 5. [Medline].
Asher MA, Mosher K. Coalition of the talocalcaneal middle facet: treatment by surgical excision and fat graft interposition. Orthop Trans. 1983. 7:149-150.
Berman AT, Finn CA, Van Horne J, Fye MA. Answer please. Tarsal coalition. Orthopedics. 1990 Aug. 13(8):910-1, 915-7. [Medline].
Cowell HR. Diagnosis and management of peroneal spastic flatfoot. Instr Course Lect. 1975. 24:94-103.
Cowell HR. Talocalcaneal coalition and new causes of peroneal spastic flatfoot. Clin Orthop. 1972. 85:16-22. [Medline].
Cowell HR, Elener V. Rigid painful flatfoot secondary to tarsal coalition. Clin Orthop. 1983 Jul-Aug. (177):54-60. [Medline].
Crim JR, Cracchiolo A, Bassett LW, et al. Magnetic resonance imaging of the hindfoot. Foot Ankle. 1989 Aug. 10(1):1-7. [Medline].
Danielsson LG. Talo-calcaneal coalition treated with resection. J Pediatr Orthop. 1987 Sep-Oct. 7(5):513-7. [Medline].
Elkus RA. Tarsal coalition in the young athlete. Am J Sports Med. 1986 Nov-Dec. 14(6):477-80. [Medline].
Emery KH, Bisset GS 3rd, Johnson ND, Nunan PJ. Tarsal coalition: a blinded comparison of MRI and CT. Pediatr Radiol. 1998 Aug. 28(8):612-6. [Medline].
Gonzalez P, Kumar SJ. Calcaneonavicular coalition treated by resection and interposition of the extensor digitorum brevis muscle. J Bone Joint Surg Am. 1990 Jan. 72(1):71-7. [Medline].
Graham JM Jr, Braddock SR, Mortier GR, et al. Syndrome of coronal craniosynostosis with brachydactyly and carpal/tarsal coalition due to Pro250Arg mutation in FGFR3 gene. Am J Med Genet. 1998 May 26. 77(4):322-9. [Medline].
Hark FW. Congenital anomalies of the tarsal bones. Clin Orthop. 1960. 16:21-5.
Haygood TM. Magnetic resonance imaging of the musculoskeletal system: part 7. The ankle. Clin Orthop. 1997 Mar. (336):318-36. [Medline].
Jacobs AM, Sollecito V, Oloff L, Klein N. Tarsal coalitions: an instructional review. J Foot Surg. 1981 Winter. 20(4):214-21. [Medline].
Jayakumar S, Cowell HR. Rigid flatfoot. Clin Orthop. 1977 Jan-Feb. (122):77-84. [Medline].
Kitaoka HB, Wikenheiser MA, Shaughnessy WJ, An KN. Gait abnormalities following resection of talocalcaneal coalition. J Bone Joint Surg Am. 1997 Mar. 79(3):369-74. [Medline].
Kulik SA Jr, Clanton TO. Tarsal coalition. Foot Ankle Int. 1996 May. 17(5):286-96. [Medline].
Kumai T, Takakura Y, Akiyama K, et al. Histopathological study of nonosseous tarsal coalition. Foot Ankle Int. 1998 Aug. 19(8):525-31. [Medline].
Kumar SJ, Guille JT, Lee MS, Couto JC. Osseous and non-osseous coalition of the middle facet of the talocalcaneal joint. J Bone Joint Surg Am. 1992 Apr. 74(4):529-35. [Medline].
McCormack TJ, Olney B, Asher M. Talocalcaneal coalition resection: a 10-year follow-up. J Pediatr Orthop. 1997 Jan-Feb. 17(1):13-5. [Medline].
Morgan RC Jr, Crawford AH. Surgical management of tarsal coalition in adolescent athletes. Foot Ankle. 1986 Dec. 7(3):183-93. [Medline].
Mosier KM, Asher M. Tarsal coalitions and peroneal spastic flat foot. A review. J Bone Joint Surg Am. 1984 Sep. 66(7):976-84. [Medline].
Newman JS, Newberg AH. Congenital tarsal coalition: multimodality evaluation with emphasis on CT and MR imaging. Radiographics. 2000 Mar-Apr. 20(2):321-32; quiz 526-7, 532. [Medline].
Pachuda NM, Lasday SD, Jay RM. Tarsal coalition: etiology, diagnosis, and treatment. J Foot Surg. 1990 Sep-Oct. 29(5):474-88. [Medline].
Percy EC, Mann DL. Tarsal coalition: a review of the literature and presentation of 13 cases. Foot Ankle. 1988 Aug. 9(1):40-4. [Medline].
Pineda C, Resnick D, Greenway G. Diagnosis of tarsal coalition with computed tomography. Clin Orthop. 1986 Jul. (208):282-8. [Medline].
Plotkin S. Case presentation of calcaneonavicular coalition in monozygotic twins. J Am Podiatr Med Assoc. 1996 Sep. 86(9):433-8. [Medline].
Resnik CS, Aiken MW, Kenzora JE. Case report 780. Fracture of talar beaks in tarsal coalition. Skeletal Radiol. 1993. 22(3):214-7. [Medline].
Sakellariou A, Claridge RJ. Tarsal coalition. Orthopedics. 1999 Nov. 22(11):1066-73; discussion 1073-4; quiz 10. [Medline].
Smith RW, Staple TW. Computerized tomography (CT) scanning technique for the hindfoot. Clin Orthop. 1983 Jul-Aug. (177):34-8. [Medline].
Spero CR, Simon GS, Tornetta P 3rd. Clubfeet and tarsal coalition. J Pediatr Orthop. 1994 May-Jun. 14(3):372-6. [Medline].
Stoskopf CA, Hernandez RJ, Kelikian A, et al. Evaluation of tarsal coalition by computed tomography. J Pediatr Orthop. 1984 May. 4(3):365-9. [Medline].
Stuecker RD, Bennett JT. Tarsal coalition presenting as a pes cavo-varus deformity: report of three cases and review of the literature. Foot Ankle. 1993 Nov-Dec. 14(9):540-4. [Medline].
Sullivan JA. Pediatric flatfoot: evaluation and management. J Am Acad Orthop Surg. 1999 Jan. 7(1):44-53. [Medline].
Takakura Y, Tanaka Y, Kumai T, Sugimoto K. Development of the ball-and-socket ankle as assessed by radiography and arthrography. A long-term follow-up report. J Bone Joint Surg Br. 1999 Nov. 81(6):1001-4. [Medline].
Tanaka Y, Takakura Y, Sugimoto K, Kumai T. Non-osseous coalition of the medial cuneiform-first metatarsal joint: a case report. Foot Ankle Int. 2000 Dec. 21(12):1043-6. [Medline].
Thometz J. Tarsal coalition. Foot Ankle Clin. 2000 Mar. 5(1):103-18, vi. [Medline].
Varner KE, Michelson JD. Tarsal coalition in adults. Foot Ankle Int. 2000 Aug. 21(8):669-72. [Medline].
Vincent KA. Tarsal coalition and painful flatfoot. J Am Acad Orthop Surg. 1998 Sep-Oct. 6(5):274-81. [Medline].
Warren MJ, Jeffree MA, Wilson DJ, MacLarnon JC. Computed tomography in suspected tarsal coalition. Examination of 26 cases. Acta Orthop Scand. 1990 Dec. 61(6):554-7. [Medline].
Wheeler R, Guevera A, Bleck EE. Tarsal coalitions: review of the literature and case report of bilateral dual calcaneonavicular and talocalcaneal coalitions. Clin Orthop. 1981 May. (156):175-7. [Medline].
Wright DG, Desai SM, Henderson WH. Action of the subtalar and ankle-joint complex during the stance phase of walking. J Bone Joint Surg Am. 1964. 46:361-82.