Stress fracture of the talus following resection of a talocalcaneal coalition: a case report

We report the case of a 15-year-old male with bilateral talocalcaneal coalition. Following resection of the symptomatic coalition, the patient developed a painful ankle. MR imaging revealed a stress fracture of the talar body. In this report we discuss presentation and treatment of a symptomatic talocalcaneal coalition complicated by a later stress fracture as well as a review of the literature.     

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.     

疼痛性跟距联合的治疗

目的 :探讨疼痛性跟距联合手术治疗适应证及术式。方法 :根据术前跟距轴位CT扫描所测量的跟距联合与跟距后关节二者横向切面之比率及跟骨外翻角度来决定采取跟距骨桥局部切除或三关节融合术。共治疗 12例 16足 ,其中男 8例 ,女 4例。平均随访时间 18个月。结果 :术后根据患者症状消失程度分为优良、可、差。单纯行跟距联合切除者 9例 12足 ,其中优 6例 ,可 3例 ;三关节融合者 3例 4足 ,均为优良。结论 :经保守治疗无效者可行手术治疗 ,跟距联合与跟距后关节二者横向切面之比率 <5 0 % ,跟骨外翻角 <2 1°时可行跟距骨桥局部切除术 ,反之则应行三关节融合术。     

Subtalar fusion for isolated subtalar disorders. Preliminary report

Retrospective observations on subtalar fusions performed for isolated subtalar disorders in 11 feet were performed to determine whether a satisfactory result could be obtained without significant changes to the talonavicular and calcaneocuboid joints. Preoperative diagnoses included five feet with degenerative arthritis secondary to a calcaneal fracture, four feet with a talocalcaneal bar, one foot with a degenerative subtalar arthropathy of unknown cause, and one foot with an unstable subtalar joint secondary to a peroneal tendon rupture. The average follow-up period was 41.5 months (range, 23-103 months). The hindfoot was fused in a average of 6 degrees of valgus. The feet maintained approximately 50% of their transverse tarsal motion, compared with the contralateral side. No foot developed hypermobility of any tarsal joint. Three feet fused for degenerative joint disease developed very mild talar beaking, and two feet fused for a tarsal coalition developed a mild progression or increase in talar beaking. Three feet demonstrated very minimal osteophyte formation at the calcaneocuboid joint. Functional and pain ratings for patients who had fusions for talocalcaneal bars or degenerative joint disease were good to excellent. Minimal radiographic changes at the talonavicular and calcaneocuboid joints secondary to increased stress brought about by the fusion did not seem to be clinically significant. Isolated subtalar fusion for lesions limited to the subtalar joint, which includes talocalcaneal bars, is a satisfactory method of treatment.     

手术治疗跟距骨桥疗效观察

目的探讨跟距骨桥的手术治疗方法及疗效。方法 2008年7月-2010年10月,手术治疗跟距骨桥患者10例。男4例,女6例;年龄16～70岁,平均53.5岁。先天性骨桥2例,继发性骨桥8例。跟距中间关节面骨桥3例,后关节面骨桥7例。术前患者疼痛视觉模拟评分(VAS)为(9.0±0.4)分;根据美国矫形足踝协会(AOFAS)后足评分标准为(42.4±1.4)分。合并距下关节退变2例。8例单纯跟距骨桥患者行骨桥切除并脂肪组织植入,2例合并距下关节退变患者行骨桥切除联合距下关节融合术。结果术后切口均Ⅰ期愈合。8例获随访,随访时间12～36个月,平均18个月。末次随访时VAS评分为(2.0±0.7)分,与术前比较差异有统计学意义(t=6.425,P=0.000)。AOFAS后足评分为(86.9±2.3)分,与术前比较差异有统计学意义(t=7.634,P=0.000)。单纯骨桥切除者末次随访时X线片检查示无骨桥复发及关节退变发生,关节融合者X线片示达骨性融合。结论跟距骨桥根据不同发生部位和合并症,分别采用单纯骨桥切除或联合距下关节融合术可取得较好疗效。     

The relative incidence of tarsal coalition

The overall incidence of tarsal coalition in the general population is unknown, but it is far less than 1%. Calcaneonavicular coalition was found to be the most common type (53%), followed by talocalcaneal coalition (37%). The other types appear infrequently. Most calcaneonavicular and talocalcaneal coalitions present as a painful foot of some type. Peroneal spastic flatfoot is a rare finding and occurred in only two of 22 talocalcaneal coalitions in the present study. Talonavicular coalitions were always associated with other congenital foot anomalies and were typically asymptomatic. Age at presentation, sex, and time to diagnosis were not statistically different among patients with coalitions at different locations. It is thought that clinical presentation corresponds to ossification of the coalition, which occurs an average of three to four years later.     

Treatment of symptomatic talocalcaneal coalition

The cases of fourteen patients who had twenty-three symptomatic talocalcaneal coalitions were reviewed at a mean of 3.9 years (range, 2.2 to 9.5 years) after treatment. Five feet in three patients became completely asymptomatic after immobilization in a cast, and four feet underwent triple arthrodesis. Fourteen feet had resection of the coalition when the symptoms were not relieved by immobilization in a cast. The indications for resection of a talocalcaneal coalition include failure of non-operative treatment, a coalition that is less than one-half of the surface area of the talocalcaneal joint, and the absence of degenerative arthritic changes in the talonavicular joint. Good results were noted in thirteen feet and satisfactory results, in ten, for all forms of treatment.     

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.     

Massive Osteochondral Lesion of the Talus in a Skeletally Immature Patient Associated With a Tarsal Coalition and Valgus Hindfoot

Rarely, osteochondral lesions of the talus occur without a history of trauma. Accurate interpretation of the mechanical load distributions onto the ankle leading to potential atraumatic cartilage damage must always be studied. The published data on the optimal treatment of talar osteochondral lesions in skeletally immature patients are scarce, especially when the lesions are associated with hindfoot malalignment. We describe the case of a pediatric female with an atraumatic osteochondral lesion of the talus associated with a talocalcaneal coalition and a valgus hindfoot, which we consider the first case to be reported. She presented with prolonged bilateral ankle pain and catching during gait of approximately 2 years’ duration with a restricted range of motion, with the pain more excruciating in the right ankle. Radiographs revealed a large osteochondral lesion located at the lateral talar dome. The patient underwent partial osteochondral allograft transplantation, together with hindfoot realignment and coalition resection with a fat graft interposition. At the 2-year follow-up examination, the patient was free of pain in her right foot and ankle, with no signs of radiologic failure.     

Significance of talar distortion for ankle mobility in idiopathic clubfoot

The abnormal bony feature found most consistently in clubfeet is talar distortion. The significance of the talar distortion for mobility of the tibiotalar joint was investigated. Twenty-seven congenital clubfeet in 19 patients were examined at a minimal followup of 20 years. In all patients Turco's posteromedial release was done because of idiopathic clubfoot. Radiographic assessment of the feet included measurement of the talocalcaneal angle and index, and the tibiocalcaneal angle. The degree of talar flattening was estimated by the ratio of the curvature of the talar dome to the length of the talar bone (radius to length ratio). Three-dimensional gait analysis was done to assess the dynamic range of ankle motion. The static range of motion was measured with a goniometer. The degree of talar flattening correlated significantly with the dynamic range of ankle motion but not with the static mobility. For assessment of idiopathic clubfoot, evaluation of talar flattening should be done because of its significance for dynamic ankle mobility.     

Dorsomediale talokalkaneare Koalition

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.     

成人跟距联合术后功能的影响因素分析

背景：成人跟距联合手术治疗方案临床报道较少,术后的功能评估尚不明确。目的：探讨影响成人跟距联合术后功能的相关因素,从而决定更好的手术方案。方法：回顾性研究2011年1月至2013年7月我院收治且获得完整随访资料的24例行跟距联合术的患者资料,男13例,女11例;年龄19~53岁,平均31.5岁。根据术前症状及影像学检查决定手术方案。记录患者年龄、跟距联合分型、跗骨联合的大小、有无距下骨关节炎、后足的外翻角度。应用美国足踝医师协会踝-后足评分表（AOFAS-AH）和踝关节Karlsson-Peterson评分对患者术后的踝关节功能进行评估,并对上述因素进行相关性分析。结果：24例患者获得平均19.5个月的随访（4~33个月）。单纯联合切除术19例,其中4例进行三角韧带修补,1例行外侧韧带重建,1例行跟骨截骨内移术。距下关节融合术5例,其中3例患者仍有疼痛症状。术后的AOFAS评分和Karlsson-Peterson评分均明显改善。经Logistic回归分析,距下关节骨关节炎是术后踝关节功能的影响因素,而跟距联合分型、跗骨联合的大小和后足的外翻角度无明显相关性。结论：距下关节骨关节炎影响跟距联合患者术后的踝关节功能评分,即使行距下关节融合术,在一定程度上也影响患者术后踝关节功能。     

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。     

In situ arthrodesis with lateral-wall ostectomy for the sequelae of fracture of the os calcis

Distraction bone-block arthrodesis has been advocated for the treatment of the late sequelae of fracture of the os calcis. Between 1997 and 2003 we studied a consecutive series of 17 patients who had in situ arthrodesis for subtalar arthritis after fracture of the os calcis with marked loss of talocalcaneal height. None had undergone any previous attempts at reconstruction. We assessed the range of dorsiflexion and plantar flexion and measured the talocalcaneal height, talocalcaneal angle and talar declination angle on standing lateral radiographs, comparing them with the normal foot. The mean follow-up was for 78.7 months (48 to 94). The mean American Orthopaedic Foot and Ankle Society hindfoot score improved from 29.8 (13 to 48) to 77.8 (48 to 94) (Student's t-test, p < 0.001). The mean loss of talocalcaneal height was 10.3 mm (2 to 17) and the mean talar declination angle was 6.7 degrees (0 degrees to 16 degrees) which was 36% of the normal side. One patient suffered anterior ankle pain but none had anterior impingement. Two patients complained of difficulty in ascending slopes and stairs and four in descending. The mean ankle dorsiflexion on the arthrodesed side was 11.6 degrees (0 degrees to 24 degrees) compared with 14.7 degrees (0 degrees to 24 degrees) on the normal side, representing a reduction of 21.1%. The mean plantar flexion on the arthrodesed side was 35.5 degrees (24 degrees to 60 degrees) compared with 44.6 degrees (30 degrees to 60 degrees ) on the normal side, a reduction of 20.4%. These results suggest that anterior impingement need not to be a significant problem after subtalar arthrodesis for fracture of the os calcis, even when the loss of talocalcaneal height is marked. We recommend in situ arthrodesis combined with lateral-wall ostectomy for all cases of subtalar arthritis following a fracture of the os calcis, without marked coronal deformity, regardless of the degree of talocalcaneal height loss.     

Talonavicular synostosis with lateral ankle instability—A case report and review of the literature

Talonavicular coalition is a rare autosomal recessive congenital anomaly that is usually asymptomatic and detected incidentally on radiographs. It is associated with symphalangism, clinodactyly, a great toe that is shorter than the second toe, clubfoot, calcaneonavicular coalition, talocalcaneal coalition and a ball-and-socket ankle joint.The authors present a review of the literature and case report of a patient with complete osseous talonavicular coalition, talocalcaneal coalition and lateral ankle instability which was successfully treated with subtalar fusion and lateral ligament reconstruction.     

Acquired talo-calcaneal coalition due to injury to the os trigonum

The os trigonum has been associated with a variety of conditions, most of which result in painful syndromes at the posterior aspect of the ankle joint. An uncommon complication is formation of a talocalcaneal coalition. We present a previously undescribed case of posterior talocalcaneal coalition that resulted after a plantarflexion injury of the os trigonum.     

手术治疗跟距骨桥临床疗效观察

目的探讨单纯性骨桥切除术治疗跟距骨桥的临床疗效。方法回顾性分析2008年7月~2013年8月我院收治的15例跟距骨桥患者的临床资料,均行单纯性骨桥切除术。手术前后分别采用视觉模拟评分法(VAS)进行疼痛评分,美国矫形足踝协会(AOFAS)后足评分标准评价踝关节功能。结果本组15例患者均获得随访,平均时间12.3(4~24)个月。术后所有患者切口均Ⅰ期愈合,无伤口或关节感染、血管神经损伤、跟距坏死等早期并发症发生。末次随访时VAS评分平均(1.7±1.2)分,明显低于术前的(8.7±0.3)分(P0.01);末次随访AOFAS后足评分平均(90.1±4.3)分,显著高于术前的(40.2±2.1)分(P0.001)。末次随访时X线检查示无骨桥复发及关节退变发生,未见关节间隙狭窄,患者进行负重行走时无明显不适。末次随访时对患者进行满意度调查:非常满意8例,满意5例,一般2例,满意率为86.7%。结论单纯性骨桥切除术是一种治疗跟距骨桥的有效方法。     

Role of talocalcaneal osteotomy in clubfoot surgery: results in 31 surgically treated feet

The most important deformities in clubfeet can be demonstrated by simultaneous arthrography of the talonavicular and talocrural joints. In patients with a severe talar deformity, wedge osteotomy through the talar neck and calcaneus has been performed as a prerequisite for correction. Our series consisted of 20 patients with 31 idiopathic clubfeet with pronounced talar deformity. The mean observation time after osteotomy was 11 years 3 months. The principles and aims are described, as are the indications for talocalcaneal osteotomy. Results were good in 19 feet (60%), fair in six (20%), and poor in six (20%).     

Symptomatic talocalcaneal coalition. Its clinical significance and treatment

The clinical significance of symptomatic talocalcaneal coalition was described subjectively, objectively, and identified roentgenographically after examining 67 feet of 42 patients between 1977 and 1987. Computed tomographic examinations, conducted on 29 of 42 patients, were useful in recognizing the extent of coalition, the condition of union, and the postoperative results. Tarsal tunnel syndrome was present in 23 feet with the coalition. Thirty-one feet (24 patients) were treated conservatively and 36 feet (29 patients) surgically. Of the surgically treated feet, the coalition was excised in 33 and talocalcaneal fusion was performed in three. Follow-up examinations were performed at an average of 5.3 years (range, 2.25-11.2 years). In the excision group, the results were excellent in 24 feet, good in seven, and fair in two. The results were good in three feet treated by arthrodesis.