Tarsal Coalition Treatment & Management

  • Author: Louis P Vu, MD; Chief Editor: Jason H Calhoun, MD, FACS   more...
 
Updated: Feb 9, 2010
 

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 apPlain 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.[31] See the image below of calcaneonavicular coalition.

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

The procedure as described by Badgley[7] 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.[32, 33] 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.[34] 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.[35]

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.[36] 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.[37] 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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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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Follow-up

For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center. Also, see eMedicine's patient education articles Ankle Sprain and Sprains and Strains.

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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.

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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, 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, Pediatric Orthopaedic Society of North America, and Scoliosis Research Society

Disclosure: Nothing to disclose.

Specialty Editor Board

James K DeOrio, MD  Director of Foot and Ankle Fellowship Program, Assistant Professor of Orthopedic Surgery, Orthopedic Surgery, St Lukes Hospital, Jacksonville, Florida

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

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Shepard R Hurwitz, MD  Executive Director, American Board of Orthopaedic Surgery

Shepard R Hurwitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for the Advancement of Science, American College of Rheumatology, American College of Sports Medicine, American College of Surgeons, American Diabetes Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Association for the Advancement of Automotive Medicine, Eastern Orthopaedic Association, Orthopaedic Research Society, Orthopaedic Trauma Association, and Southern Orthopaedic Association

Disclosure: Nothing to disclose.

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Jason H Calhoun, MD, FACS  Frank J Kloenne Chair in Orthopedic Surgery, Professor and Chair, Department of Orthopedics, The Ohio State University Medical Center

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, Missouri State Medical Association, Musculoskeletal Infection Society, Southern Medical Association, Southern Orthopaedic Association, Texas Medical Association, and Texas Orthopaedic Association

Disclosure: Nothing to disclose.

References

  1. Lemley F, Berlet G, Hill K, Philbin T, Isaac B, Lee T. Current concepts review: Tarsal coalition. Foot Ankle Int. Dec 2006;27(12):1163-9. [Medline].

  2. Petrover D, Schweitzer ME, Laredo JD. Anterior process calcaneal fractures: a systematic evaluation of associated conditions. Skeletal Radiol. Jul 2007;36(7):627-32. [Medline].

  3. 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. Oct 2009;75(5):654-60. [Medline].

  4. Upasani VV, Chambers RC, Mubarak SJ. Analysis of calcaneonavicular coalitions using multi-planar three-dimensional computed tomography. J Child Orthop. Aug 2008;2(4):301-7. [Medline]. [Full Text].

  5. Heiple KG, Lovejoy CO. The antiquity of tarsal coalition. Bilateral deformity in a Pre- Columbian Indian skeleton. J Bone Joint Surg Am. Jul 1969;51(5):979-83. [Medline].

  6. Cruveilhier J. Anatomie Pathologique du Corps Humain, tome 1, Paris, J.B. Balliere. 1829.

  7. Badgley CE. Coalition of the calcaneus and the navicular. Arch Surg. 1927;15:75-88.

  8. Harris RI, Beath T. Etiology of peroneal spastic flatfoot. J Bone Joint Surg Br. 1948;30:624-34.

  9. 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.

  10. Conway JJ, Cowell HR. Tarsal coalition: clinical significance and roentgenographic demonstration. Radiology. Mar 1969;92(4):799-811. [Medline].

  11. Deutsch AL, Resnick D, Campbell G. Computed tomography and bone scintigraphy in the evaluation of tarsal coalition. Radiology. Jul 1982;144(1):137-40. [Medline].

  12. Herzenberg JE, Goldner JL, Martinez S, Silverman PM. Computerized tomography of talocalcaneal tarsal coalition: a clinical and anatomic study. Foot Ankle. Jun 1986;6(6):273-88. [Medline].

  13. Wechsler RJ, Schweitzer ME, Deely DM, et al. Tarsal coalition: depiction and characterization with CT and MR imaging. Radiology. Nov 1994;193(2):447-52. [Medline].

  14. Rankin EA, Baker GI. Rigid flatfoot in the young adult. Clin Orthop. Oct 1974;0(104):244-8. [Medline].

  15. Vaughan WH, Segal G. Tarsal coalitions, special reference to roentogenographic interpretation. Radiology. 1953;60:855-63.

  16. Shands AR, Wentz IJ. Congenital anomalies, accessory bones, and osteochondritis in the feet of 850 children. Surg Clin North Am. 1953;33:1643-66.

  17. Leonard MA. The inheritance of tarsal coalition and its relationship to spastic flat foot. J Bone Joint Surg Br. Aug 1974;56B(3):520-6. [Medline].

  18. Snyder RB, Lipscomb AB, Johnston RK. The relationship of tarsal coalitions to ankle sprains in athletes. Am J Sports Med. Sep-Oct 1981;9(5):313-7. [Medline].

  19. Cooperman DR, Janke BE, Gilmore A, et al. A three-dimensional study of calcaneonavicular tarsal coalitions. J Pediatr Orthop. Sep-Oct 2001;21(5):648-51. [Medline].

  20. Stormont DM, Peterson HA. The relative incidence of tarsal coalition. Clin Orthop. Dec 1983;(181):28-36. [Medline].

  21. Jack EA. Bone anomalies of the tarsus in relation to "peroneal spastic flatfoot". J Bone Joint Surg Br. 1954;36:530-42.

  22. Bettin D, Karbowski A, Schwering L. Congenital ball-and-socket anomaly of the ankle. J Pediatr Orthop. Jul-Aug 1996;16(4):492-6. [Medline].

  23. Pistoia F, Ozonoff MB, Wintz P. Ball-and-socket ankle joint. Skeletal Radiol. 1987;16(6):447-51. [Medline].

  24. Takakura Y, Tamai S, Masuhara K. Genesis of the ball-and-socket ankle. J Bone Joint Surg Br. Nov 1986;68(5):834-7. [Medline].

  25. Lateur LM, Van Hoe LR, Van Ghillewe KV, et al. Subtalar coalition: diagnosis with the C sign on lateral radiographs of the ankle. Radiology. Dec 1994;193(3):847-51. [Medline].

  26. 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. May 2000;82(4):574-8. [Medline].

  27. Brown RR, Rosenberg ZS, Thornhill BA. The C sign: more specific for flatfoot deformity than subtalar coalition. Skeletal Radiol. Feb 2001;30(2):84-7. [Medline].

  28. 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. Nov-Dec 1987;7(6):709-11. [Medline].

  29. Cowell HR. Tarsal coalition--review and update. Instr Course Lect. 1982;31:264-71. [Medline].

  30. Nalaboff KM, Schweitzer ME. MRI of tarsal coalition: frequency, distribution, and innovative signs. Bull NYU Hosp Jt Dis. 2008;66(1):14-21. [Medline].

  31. Mubarak SJ, Patel PN, Upasani VV, Moor MA, Wenger DR. Calcaneonavicular coalition: treatment by excision and fat graft. J Pediatr Orthop. Jul-Aug 2009;29(5):418-26. [Medline].

  32. Philbin TM, Homan B, Hill K, Berlet G. Results of resection for middle facet tarsal coalitions in adults. Foot Ankle Spec. Dec 2008;1(6):344-9. [Medline].

  33. Migues A, Slullitel GA, Suárez E, Galán HL. Case reports: symptomatic bilateral talonavicular coalition. Clin Orthop Relat Res. Jan 2009;467(1):288-92. [Medline]. [Full Text].

  34. Comfort TK, Johnson LO. Resection for symptomatic talocalcaneal coalition. J Pediatr Orthop. May-Jun 1998;18(3):283-8. [Medline].

  35. Wilde PH, Torode IP, Dickens DR, Cole WG. Resection for symptomatic talocalcaneal coalition. J Bone Joint Surg Br. Sep 1994;76(5):797-801. [Medline].

  36. Luhmann SJ, Schoenecker PL. Symptomatic talocalcaneal coalition resection: indications and results. J Pediatr Orthop. Nov-Dec 1998;18(6):748-54. [Medline].

  37. Mann RA, Baumgarten M. Subtalar fusion for isolated subtalar disorders. Preliminary report. Clin Orthop. Jan 1988;(226):260-5. [Medline].

  38. Asher MA, Mosher K. Coalition of the talocalcaneal middle facet: treatment by surgical excision and fat graft interposition. Orthop Trans. 1983;7:149-150.

  39. Berman AT, Finn CA, Van Horne J, Fye MA. Answer please. Tarsal coalition. Orthopedics. Aug 1990;13(8):910-1, 915-7. [Medline].

  40. Cowell HR. Diagnosis and management of peroneal spastic flatfoot. Instr Course Lect. 1975;24:94-103.

  41. Cowell HR. Talocalcaneal coalition and new causes of peroneal spastic flatfoot. Clin Orthop. 1972;85:16-22. [Medline].

  42. Cowell HR, Elener V. Rigid painful flatfoot secondary to tarsal coalition. Clin Orthop. Jul-Aug 1983;(177):54-60. [Medline].

  43. Crim JR, Cracchiolo A, Bassett LW, et al. Magnetic resonance imaging of the hindfoot. Foot Ankle. Aug 1989;10(1):1-7. [Medline].

  44. Danielsson LG. Talo-calcaneal coalition treated with resection. J Pediatr Orthop. Sep-Oct 1987;7(5):513-7. [Medline].

  45. Elkus RA. Tarsal coalition in the young athlete. Am J Sports Med. Nov-Dec 1986;14(6):477-80. [Medline].

  46. Emery KH, Bisset GS 3rd, Johnson ND, Nunan PJ. Tarsal coalition: a blinded comparison of MRI and CT. Pediatr Radiol. Aug 1998;28(8):612-6. [Medline].

  47. Gonzalez P, Kumar SJ. Calcaneonavicular coalition treated by resection and interposition of the extensor digitorum brevis muscle. J Bone Joint Surg Am. Jan 1990;72(1):71-7. [Medline].

  48. 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. May 26 1998;77(4):322-9. [Medline].

  49. Hark FW. Congenital anomalies of the tarsal bones. Clin Orthop. 1960;16:21-5.

  50. Haygood TM. Magnetic resonance imaging of the musculoskeletal system: part 7. The ankle. Clin Orthop. Mar 1997;(336):318-36. [Medline].

  51. Jacobs AM, Sollecito V, Oloff L, Klein N. Tarsal coalitions: an instructional review. J Foot Surg. Winter 1981;20(4):214-21. [Medline].

  52. Jayakumar S, Cowell HR. Rigid flatfoot. Clin Orthop. Jan-Feb 1977;(122):77-84. [Medline].

  53. Kitaoka HB, Wikenheiser MA, Shaughnessy WJ, An KN. Gait abnormalities following resection of talocalcaneal coalition. J Bone Joint Surg Am. Mar 1997;79(3):369-74. [Medline].

  54. Kulik SA Jr, Clanton TO. Tarsal coalition. Foot Ankle Int. May 1996;17(5):286-96. [Medline].

  55. Kumai T, Takakura Y, Akiyama K, et al. Histopathological study of nonosseous tarsal coalition. Foot Ankle Int. Aug 1998;19(8):525-31. [Medline].

  56. 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. Apr 1992;74(4):529-35. [Medline].

  57. McCormack TJ, Olney B, Asher M. Talocalcaneal coalition resection: a 10-year follow-up. J Pediatr Orthop. Jan-Feb 1997;17(1):13-5. [Medline].

  58. Morgan RC Jr, Crawford AH. Surgical management of tarsal coalition in adolescent athletes. Foot Ankle. Dec 1986;7(3):183-93. [Medline].

  59. Mosier KM, Asher M. Tarsal coalitions and peroneal spastic flat foot. A review. J Bone Joint Surg Am. Sep 1984;66(7):976-84. [Medline].

  60. Newman JS, Newberg AH. Congenital tarsal coalition: multimodality evaluation with emphasis on CT and MR imaging. Radiographics. Mar-Apr 2000;20(2):321-32; quiz 526-7, 532. [Medline].

  61. Pachuda NM, Lasday SD, Jay RM. Tarsal coalition: etiology, diagnosis, and treatment. J Foot Surg. Sep-Oct 1990;29(5):474-88. [Medline].

  62. Percy EC, Mann DL. Tarsal coalition: a review of the literature and presentation of 13 cases. Foot Ankle. Aug 1988;9(1):40-4. [Medline].

  63. Pineda C, Resnick D, Greenway G. Diagnosis of tarsal coalition with computed tomography. Clin Orthop. Jul 1986;(208):282-8. [Medline].

  64. Plotkin S. Case presentation of calcaneonavicular coalition in monozygotic twins. J Am Podiatr Med Assoc. Sep 1996;86(9):433-8. [Medline].

  65. Resnik CS, Aiken MW, Kenzora JE. Case report 780. Fracture of talar beaks in tarsal coalition. Skeletal Radiol. 1993;22(3):214-7. [Medline].

  66. Sakellariou A, Claridge RJ. Tarsal coalition. Orthopedics. Nov 1999;22(11):1066-73; discussion 1073-4; quiz 10. [Medline].

  67. Smith RW, Staple TW. Computerized tomography (CT) scanning technique for the hindfoot. Clin Orthop. Jul-Aug 1983;(177):34-8. [Medline].

  68. Spero CR, Simon GS, Tornetta P 3rd. Clubfeet and tarsal coalition. J Pediatr Orthop. May-Jun 1994;14(3):372-6. [Medline].

  69. Stoskopf CA, Hernandez RJ, Kelikian A, et al. Evaluation of tarsal coalition by computed tomography. J Pediatr Orthop. May 1984;4(3):365-9. [Medline].

  70. Stuecker RD, Bennett JT. Tarsal coalition presenting as a pes cavo-varus deformity: report of three cases and review of the literature. Foot Ankle. Nov-Dec 1993;14(9):540-4. [Medline].

  71. Sullivan JA. Pediatric flatfoot: evaluation and management. J Am Acad Orthop Surg. Jan 1999;7(1):44-53. [Medline].

  72. 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. Nov 1999;81(6):1001-4. [Medline].

  73. Tanaka Y, Takakura Y, Sugimoto K, Kumai T. Non-osseous coalition of the medial cuneiform-first metatarsal joint: a case report. Foot Ankle Int. Dec 2000;21(12):1043-6. [Medline].

  74. Thometz J. Tarsal coalition. Foot Ankle Clin. Mar 2000;5(1):103-18, vi. [Medline].

  75. Varner KE, Michelson JD. Tarsal coalition in adults. Foot Ankle Int. Aug 2000;21(8):669-72. [Medline].

  76. Vincent KA. Tarsal coalition and painful flatfoot. J Am Acad Orthop Surg. Sep-Oct 1998;6(5):274-81. [Medline].

  77. Warren MJ, Jeffree MA, Wilson DJ, MacLarnon JC. Computed tomography in suspected tarsal coalition. Examination of 26 cases. Acta Orthop Scand. Dec 1990;61(6):554-7. [Medline].

  78. Wheeler R, Guevera A, Bleck EE. Tarsal coalitions: review of the literature and case report of bilateral dual calcaneonavicular and talocalcaneal coalitions. Clin Orthop. May 1981;(156):175-7. [Medline].

  79. 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.

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