跗骨间骨桥临床诊断与治疗研究进展

目的总结跗骨间骨桥临床诊断与治疗研究进展。方法查阅近年关于跗骨间骨桥的诊断及治疗相关文献,进行综述分析。结果跗骨间骨桥是足部跗骨间桥接组织,常见类型为跟距骨桥和跟舟骨桥。跟舟骨桥在后足斜位X线片即可确诊,多数跟距骨桥需CT扫描确诊,MRI可用于软骨性和纤维组织性骨桥的诊断。石膏固定对于有症状患者是首选治疗方法;对于治疗失败未发生退行性变患者,切除骨桥可取得良好治疗效果。单纯距下关节融合可用于治疗跟距骨桥切除失败的患者,对于距下关节融合失败和跟舟骨桥切除失败的患者可行三关节融合术。微创治疗应严格掌控手术适应证。结论跗骨间骨桥诊断方法较为明确,应将临床表现和影像学检查结合以提高诊出率。手术治疗指征尚存在争议,仍需基于随机对照试验的长期随访报道。     

A comparative study of the clinical presentation of tarsal coalitions

Twenty patients have received the radiographic diagnosis of tarsal coalition. Seven were talocalcaneal (35 per cent), seven were calcaneonavicular (35 per cent), and six were talonavicular (30 per cent). The average age at time of diagnosis was 19.3 years for talocalcaneal coalition, 14.7 years for calcaneonavicular coalition, and 15.2 years for talonavicular coalition. Bilateral involvement was seen in more than half of the talocalcaneal and talonavicular coalitions. Symptoms were more severe in talocalcaneal and calcaneonavicular coalitions. All patients in these two groups had pain. Talonavicular coalitions either were asymptomatic (picked up on radiographs taken for other complaints) or were associated with painful medial navicular masses. In our study, five of the six patients (81 per cent) had this mass. We report a surprisingly high number of talonavicular coalitions for such a small group. In studies based on the investigation of peroneal spastic flatfoot, this form of coalition is not as frequently encountered. This suggests that talonavicular coalitions may be much more common than the literature to date has suggested.     

Calcaneus Secundarius Presenting as Calcaneonavicular Coalition: A Case Report

Calcaneus secundarius is an accessory ossicle of the anterior calcaneal facet identified in up to 5% of the population. Calcaneus secundarius rarely leads to symptoms, but its presence may generate pain around the ankle. The purpose of this case report is to describe this atypical accessory ossicle, which can mimic a calcaneonavicular coalition, and to explain the clinical approach to reach a diagnosis and determine treatment. The authors report the case of a 13-year-old girl who sustained several lateral sprains of the right ankle and had local chronic pain. Clinical findings were consistent with calcaneonavicular coalition but radiographic examinations revealed a calcaneus secundarius. The location of this ossicle may limit the range of motion of the subtalar joint, mimicking a calcaneonavicular coalition. Surgical excision of this bulky accessory ossicle was performed, and this treatment fully resolved the pain and improved subtalar motion.     

Tarsal coalition in adults

32 feet in 27 adults, seen at The Johns Hopkins Hospital Foot and Ankle Clinic from 1993-1998, with the diagnosis of tarsal coalition were retrospectively reviewed. There were 18 subtalar coalitions, 14 calcaneonavicular coalitions and 1 naviculocuneiform coalition. The average age was 40 years. Clinically, 22 feet had a neutral heel, 7 had a valgus heel with flattening of the longitudinal arch, 1 had a varus heel and 2 heels had an unknown position. Subtalar motion was decreased in 23 feet. Peroneal spasm was only seen in 2 patients. 11 feet were asymptomatic. Nonoperative treatment consisting of activity modification, nonsteroidal anti-inflammatory medications and casting was successful in the majority of patients. Subtalar fusion was performed in 4 feet and coalition resection in 1. The treatment of a symptomatic tarsal coalition in the adult is as in children but the clinical presentation may differ.     

Isolated navicular-medial cuneiform tarsal coalition revisited: a case report

Tarsal coalitions between the navicular and the cuneiforms occur infrequently when compared with the more common talocalcaneal and calcaneonavicular coalitions. Isolated cases of navicular-medial cuneiform coalitions have only rarely been reported; however, the diagnosis is likely underrecognized. Conservative management should be pursued initially for symptomatic patients, followed by surgical options for unresponsive cases. The few reports available recommend treatment with navicular-medial cuneiform fusions, but long-term follow-up is not available to assess outcome and it remains unclear whether an isolated arthrodesis of the navicular-medial cuneiform joint will in turn lead to differing biomechanics of adjacent joints. We report a case of a patient with an isolated navicular-medial cuneiform coalition, treated with resection and free-fat interposition rather than arthrodesis. To our knowledge, this is the first case of a navicular-medial cuneiform coalition reported in a patient of North American ancestry. At 2 years postoperatively, she is pain-free with all activities and has full range of motion of her ankle and subtalar joints, and full mobility at the navicular-medial cuneiform joint. This unique method provided a successful solution to this difficult situation.     

Posterior talocalcaneal coalition

Tarsal coalition is a rare congenital deformity. The most common coalitions involve the calcaneonavicular joint and the medial facet of the talocalcaneal joint. The posterior facet is rarely involved. We report a case of a patient with a posterior talocalcaneal bar who presented with painful limitation of subtalar motion without the classical appearance of spastic flat foot. Resection of the bar with interposition of fat graft resulted in an almost full range of pain-free subtalar motion.     

Fraktur einer Coalitio calcaneonavicularis

The causes of chronic posttraumatic ankle pain are manifold, ranging from ligament and tendon injuries and fractures to joint degeneration. Calcaneonavicular coalition, a bridge between the calcaneus and navicular bones, is a rare disease with an incidence below 1%. The morphology of this coalition is variable. It can occur as either a fibrous, cartilaginous or bony union of the involved bones. Symptoms usually occur in adolescence with chronic pain around the ankle, mainly lateral and anterior, following distortion trauma. Patients often claim to have a lateral ankle sprain. We report 2 cases of a fracture of the calcaneonavicular coalition as the cause of chronic posttraumatic ankle pain and demonstrate the characteristics of tarsal coalitions with a review of the literature.     

Analysis of calcaneonavicular coalitions using multi-planar three-dimensional computed tomography

Purpose  Computed tomography (CT) is the current imaging standard for confirming the diagnosis of a calcaneonavicular coalition. The purpose of this study was to evaluate three-dimensional (3D) multi-planar CT images of calcaneonavicular coalitions and adjacent tarsal relationships, compared to controls, in order to obtain an understanding of the 3D anatomy for classification and as an aid to surgical resection. Methods  All patients who underwent CT of bilateral feet at our institution to evaluate a suspected calcaneonavicular coalition between 9/2005 and 3/2008 were retrospectively reviewed. Seventy-four feet (37 patients) were included in this analysis. In addition, 12 patients with a presumed normal calcaneonavicular relationship, who underwent CT of bilateral feet for various other diagnoses, were included as a control cohort. Seven measurements were performed on the 3D reconstructions to quantify the shape of the coalition (dorsal and plantar widths of the calcaneal and navicular contributions, coalition depth of the calcaneal and navicular contributions, and coalition length). The coalitions were classified into four types based on their appearance and their relationship to adjacent tarsal bones. Results  32/37 patients (86%) were noted to have bilateral involvement (69 coalitions). Coalitions were categorized into four types: Type I (forme fruste)—28%, Type II (fibrous)—23%, Type III (cartilaginous)—45% and Type IV (osseous)—4%. The average shape of the coalition was found to be a curved wedge, which was on average 16 mm wide dorsally, 7 mm wide on the plantar surface, 10 mm in length, and 25 mm in depth. Conclusions  3D CT reconstructions enabled the classification of the spectrum of calcaneonavicular coalitions. The shape of the cuboid was found to correlate with the extent of ossification. In Type I or II coalitions, the cuboid extended medially plantar to the fibrous connection. In more complete Type III or IV coalitions, the cuboid was “squared off” and remained lateral to the osseous bridge. An understanding of the 3D anatomy is important when diagnosing milder forms of coalitions, and during resection in order to avoid iatrogenic injury to the calcaneus, head of the talus, or cuboid.     

Bilateral coexistent calcaneonavicular and talocalcaneal tarsal coalition: a case report.

Tarsal coalition refers to a union of two or more tarsal bones. The union may be fibrous, cartilaginous, or bony. The most common sites of tarsal coalition reported in the literature are the calcaneonavicular, the talocalcaneal, and, less commonly, the talonavicular areas. Bilateral coexistent multiple tarsal coalitions are a rare occurrence. The authors present a case report of a 17-year-old boy with bilateral coexistent calcaneonavicular and talonavicular bars. The diagnosis was established by radiographs and CT scanning. The patient was treated conservatively with immobilization of the foot in a below-knee walking plaster cast followed by the use of an orthosis with a lateral iron and a medial T strap. The patient was pain-free at 2-year follow-up.     

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.     

Computed tomography in suspected tarsal coalition. Examination of 26 cases

Coronal plane computed tomography (CT) was performed in 26 consecutive patients with clinical suspicion of tarsal coalition. Twenty patients had plain CT and 6 had CT talocalcaneonavicular arthrography. Fifteen patients were found to have coalition. Of these 15 patients, 12 had talocalcaneal coalition (9 bilateral, 3 unilateral), 2 patients had combined talocalcaneal and calcaneonavicular coalitions, and the remaining patient had bilateral calcaneonavicular coalitions. Surgical findings corroborated the CT diagnosis in 9 patients with talocalcaneal coalition and in 2 patients with calcaneonavicular coalition. Ossified talocalcaneal coalitions were found in children aged 6 and 10 years, i.e., well below the conventionally stated age range of 12 to 16 years. CT is the investigation of choice in suspected tarsal coalition if plain radiography is not diagnostic. CT arthrography did not generally provide further information, but may be useful if plain CT is equivocal.     

Computed tomography in suspected tarsal coalition: Examination of 26 cases

Coronal plane computed tomography (CT) was performed in 26 consecutive patients with clinical suspicion of tarsal coalition. Twenty patients had plain CT and 6 had CT talocalcaneonavicular arthrography. Fifteen patients were found to have coalition. Of these 15 patients, 12 had talocalcaneal coalition (9 bilateral, 3 unilateral), 2 patients had combined talocalcaneal and calcaneonavicular coalitions, and the remaining patient had bilateral calcaneonavicular coalitions. Surgical findings corroborated the CT diagnosis in 9 patients with talocalcaneal coalition and in 2 patients with calcaneonavicular coalition.

Ossified talocalcaneal coalitions were found in children aged 6 and 10 years, i.e., well below the conventionally stated age range of 12 to 16 years.

CT is the investigation of choice in suspected tarsal coalition if plain radiography is not diagnostic. CT arthrography did not generally provide further information, but may be useful if plain CT is equivocal.     

A dissection and computer tomograph study of tarsal coalitions in 100 cadaver feet.

Most of the clinical studies report the incidence of tarsal coalitions (TC) as less than 1% but they disregard the asymptomatic coalitions. TC have been associated with degenerative arthritic changes. After X-rays, computer tomography (CT) is the most commonly used diagnostic test in the detection of TC.The aims of our study were to establish the incidence of TC; the association between TC and accessory tarsal bones and between TC and tarsal arthritis; and to assess the sensitivity of CT as a diagnostic tool in TC. We performed spiral CT scans of 100 cadaver feet (mean age at death 77.7+/-10.4), which were subsequently dissected. The dissections identified nine non-osseous TC: two talocalcaneal and seven calcaneonavicular. There was no osseous coalition. Tarsal arthritis was identified in 31 cases. Both talocalcaneal coalitions were associated with arthritis while none of the calcaneonavicular coalitions were associated with tarsal arthritis. The CT diagnosed an osseous talocalcaneal coalition and was suspicious of fibrocartilaginous coalitions in eight cases. There was correlation between dissection and CT in two talocalcaneal coalitions and three calcaneonavicular coalitions thus CT identifying 55.5% of the coalitions. CT did not diagnose four non-osseous coalitions and diagnosed errouresly four possible coalitions. In conclusion our study demonstrated that the incidence of non-osseous TC is higher than previously thought (12.72%). The calcaneonavicular coalitions are the most common single type (9.09%) and they do not seem to be associated with arthritic changes in the tarsal bones. Our CT results suggest that spiral CT has a low sensitivity in the detection of non-osseous coalitions and questions if multislice CT should be used routinely when TC are suspected.     

Calcaneonavicular coalition

Tarsal coalition is a congenital condition, involving abnormal fusion between tarsal bones, often resulting in decreased mobility, pain, and deformity leading to a rigid planovalgus foot . The most common sites of tarsal coalition reported in the literature are the calcaneonavicular and the talocalcaneal areas. Clinical examination and three radiographic views of the foot, anteroposterior, 45° internal oblique and lateral, are often sufficient for the diagnosis of most calcaneonavicular coalitions. Nevertheless, fibrous and many cases of cartilaginous coalitions cannot be identified with standard radiographic examination and further investigation with CT and MRI is needed. Conservative treatment is the initial choice. Unfortunately, calcaneonavicular coalitions usually respond poorly to conservative treatment. Surgery with excision of the bar that bridges the two bones gives good results in 70 to almost 80% of the patients. Very rarely calcaneonavicular coalition gives symptoms during the third/fourth decade of the life. In these cases it is possible that concomitant degenerative changes have been developed. Many authors believe that triple arthrodesis is the initial treatment of choice for these patients as in the case presented.     

Bilateral Triple Talocalcaneal,Calcaneonavicular, and Talonavicular Tarsal Coalition: A Case Report

We report a rare case of a female, aged 42 years, with symptomatic bilateral triple tarsal coalition, that is, talocalcaneal, calcaneonavicular, and talonavicular tarsal coalition. The patient was treated conservatively by adjusting her activities. At the 12-month follow-up, the patient was asymptomatic. Bilateral triple tarsal coalition is a rare disorder, especially in nonsyndromic patients. The purpose of this case report was to highlight this rare type of multiple bilateral tarsal coalitions and to discuss the relevant existing literature.     

Case Reports: Symptomatic Bilateral Talonavicular Coalition

Congenital talonavicular coalition is reported less frequently than talocalcaneal or calcaneonavicular coalition and represent approximately 1% of all tarsal coalitions. Although reportedly transmitted as an autosomal-dominant disorder, tarsal coalition may be inherited as an autosomal-recessive trait. It has been associated with various orthopaedic anomalies, including symphalangism, clinodactyly, a great toe shorter than the second toe, clubfoot, calcaneonavicular coalition, talocalcaneal coalition, and a ball-and-socket ankle. Patients with talonavicular coalitions are usually asymptomatic and rarely undergo surgical treatment. We report the case of a 24-year-old woman with symptomatic bilateral talonavicular coalitions and previously unreported associated anomalies (nail hypoplasia and metatarsus primus elevatus) and review the relevant literature. The patient underwent surgery (calcaneocuboid joint distraction arthrodesis and a proximal plantar flexion osteotomy with a dorsal open wedge of the first metatarsal). At 1-year followup, she was pain-free with better alignment of both feet and showed radiographic consolidation of the arthrodesis. Although this condition is less likely to be clinically important than other tarsal fusions, it sometimes can be painful enough for the patient to undergo surgery. Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. Each author certifies that his or her institution either has waived or does not require approval for the reporting of this case and that all investigations were conducted in conformity with ethical principles of research.     

A Review of Tarsal Coalition and Pes Planovalgus: Clinical Examination,Diagnostic Imaging,and Surgical Planning

Pediatric pes planovalgus deformity may be classified as flexible or rigid. The rigid pes planovalgus is often a result of a tarsal coalition, which is typically characterized as a painful unilateral or bilateral deformity, frequently associated with peroneal spasm. However, many tarsal coalitions are asymptomatic and demonstrate no peroneal spasm or pes planovalgus deformity. Likewise, the severe pes planovalgus foot type can demonstrate some of the same clinical and radiographic features of a tarsal coalition, especially in the obese adolescent patient. Also, peroneal spasm may occur in the noncoalesced foot, making diagnosis and etiology more difficult to elucidate. The authors believe that many patients with a pes planovalgus deformity lie in this “gray zone”: somewhere between the frank osseous coalition and the flexible pes planovalgus. The “step-forward Hubscher maneuver” is introduced as an effective means of evaluating the flexibility of a pes planovalgus foot by negating the effects of a gastrocnemius or gastrocnemius-soleus equinus. This article focuses on the clinical examination and findings of specific imaging studies to assist in an accurate diagnosis of these complicated patients. This will also help to reveal the various surgical options that are appropriate for the individual patient. Emphasis is placed on computerized tomography (CT) imaging and offers enhanced methods for ordering this test to specifically evaluate middle facet coalitions of the subtalar joint. The authors also introduce “lateral tarsal wedging,” an image finding associated with severe deformities, the implications of this finding, as well as its impact on surgical planning.     

Prediction of spatial orientation and morphology of calcaneonavicular coalitions

BACKGROUND: Calcaneonavicular coalitions (CNC) have been reported to be associated with anatomical aberrations of either the calcaneus and/or navicular bones. These morphological abnormalities may complicate accurate surgical resection. Three-dimensional analysis of spatial orientation and morphological characteristics may help in preoperative planning of resection. MATERIALS AND METHODS: Sixteen feet with a diagnosis of CNC were evaluated by means of 3-D CT modeling. Three angles were defined that were expressed in relation to one reproducible landmark (lateral border of the calcaneus): the dorsoplantar inclination, anteroposterior inclination, and socket angle. The depth and width of the coalitions were measured and calculated to obtain the estimated contact surface. Three-dimensional reconstructions of the calcanei served to evaluate the presence, distortion or absence of the anterior calcaneal facet and presence of a navicular beak. The interrater correlations were assessed in order to obtain values for the accuracy of the measurement methods. Sixteen normal feet were used as controls for comparison of the socket angle; anatomy of the anterior calcaneal facet and navicular beak as well. RESULTS: The dorsoplantar inclination angle averaged 50 degrees (+/-17), the anteroposterior inclination angle 64 degrees (+/-15), and the pathologic socket angle 98 degrees (+/-11). The average contact area was 156 mm(2). Ninety-four percent of all patients in the CNC group revealed a plantar navicular beak. In 50% of those patients the anterior calcaneal facet was replaced by the navicular portion and in 44% the facet was totally missing. In contrast, the socket angle in the control group averaged 77 degrees (+/-18), which was found to be statistically different than the CNC group (p = 0.0004). Only 25% of the patients in the control group had a plantar navicular beak. High, statistically significant interrater correlations were found for all measured angles. CONCLUSION: Computer-aided CT analysis and reconstructions help to determine the spatial orientations of CNC in space and provide useful information in order to anticipate morphological abnormalities of the calcaneus and navicular.     

Tarsal Coalitions in the Adult Population: Does Treatment Differ from the Adolescent?

There is a paucity of information on adult coalitions without large, well-designed outcome studies. Current recommendations are thus similar to those for adolescents. Based on the available literature, current recommendations include an initial trial of adequate nonoperative treatment in symptomatic coalitions. Unlike adolescent coalitions, nonoperative treatment may be even more effective in the adult patient as many are asymptomatic or discovered after injury. If nonoperative treatment fails, then surgical intervention is considered and tailored to the location of the coalition, existing advanced arthrosis, and any existing deformity. Similar to the adolescent, surgical treatment for adult calcaneonavicular coalitions typically involves an attempt at resection with some type of interposition. Resection can be attempted for talocalcaneal coalitions that do not present with advanced arthrosis or significant hindfoot malalignment. For those patients with advanced arthrosis, more than 50% involvement of the joint hindfoot malalignment, subtalar or triple arthrodesis is recommended. The decision between resection and arthrodesis is controversial in the adolescent population. With few outcome studies in adults, it is even more difficult to make definitive treatment recommendations; however, the indications for resection are likely even more limited. It is likely that the adult subtalar coalition that becomes symptomatic and fails nonoperative treatment will require arthrodesis for full pain relief and improvement in objective outcome measures, such as the AOFAS hindfoot score. Our treatment algorithm focuses first on a trial of nonoperative treatment of at least 3 months regardless of coalition location. After failed nonoperative treatment, calcaneonavicular coalitions are in most cases treated with excision and interpositional fat graft. For talocalcaneal coalitions, resection is offered to patients with neutral hindfoot alignment, some preservation of subtalar joint motion and no adjacent joint arthrosis. The patients are advised that the outcome after resection of talocalcaneal coalitions is less predictable than resection of calcaneonavicular coalitions. Those patients with absent subtalar motion and relatively normal hindfoot alignment are candidates for in situ fusion of the subtalar joint. For those patients with greater than 15° of valgus hindfoot malalignment on a weight-bearing hindfoot alignment view or adjacent joint arthrosis, a triple arthrodesis is recommended with or without medial displacement osteotomy of the calcaneus. Adjacent joint arthrosis may be determined by radiographs, CT scan, or preoperative MRI.     

Nonsyndromic Massive Tarsal and Tarsometatarsal Coalitions in a Young Female

Tarsal coalition is an abnormal connection between 2 or more tarsal bones, with the most common sites being between the talus and the calcaneus and between the navicular and the calcaneus. The occurrence of multiple and massive tarsal coalitions is rare. We describe a rare case of nonsyndromic bilateral tarsal coalition involving most of the tarsal bones and extending to the metatarsal bones in a 4-year-old female. The condition was not painful and did not affect her gait. The main concern was the abnormal shape of her feet. Tarsal coalition can occur as an isolated anomaly or in association with other congenital disorders, usually presenting around the age of 12 years. The coexistence of nonsyndromic bilateral multiple tarsal coalitions is seldom reported. Regardless of the presentation, treatment is not indicated in cases of asymptomatic tarsal coalition. Our patient had a unique presentation of tarsal coalition, involving both the tarsal and tarsometatarsal bones. To our knowledge, this is the first report of this type of presentation.