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.     

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.     

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.     

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.     

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.     

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。     

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 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.     

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.     

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.     

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.     

The rigid flatfoot. Tarsal coalitions

Tarsal coalitions are the major cause of painful rigid flatfoot deformity in children and adolescents. Talocalcaneal and calcaneonavicular coalitions are the most common sites. They are often bilateral and may be asymptomatic. They represent a failure of fetal mesenchymal differentiation, and onset of symptoms in children often corresponds to the time of ossification of the fibrous or cartilaginous coalition. The most common presenting symptom is pain, and diagnosis is aided by plain radiographs and computerized tomography. Some patients respond to conservative measures, but surgical treatment is often required. Resection and interposition of fat or tendon (talocalcaneal) or muscle (calcaneonavicular) are the most common operative treatments, with arthrodesis reserved for symptomatic recurrences, patients with degenerative changes, and those with multiple coalitions.     

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.     

Characteristics and reoperation rates of paediatric tarsal coalitions: a population-based study

PurposeTarsal coalitions are congenital fusions of two or more tarsal bones and can lead to foot pain and stiffness. Few studies examine the long-term reoperation rates following paediatric tarsal coalition surgery.MethodsA population-based database, linking medical records at all medical centres to capture the entire medical history of the full population of a Midwest county, was used to identify tarsal coalitions in children between 1966 and 2018. Records were reviewed for clinical data, surgical records and followed up to identify any subsequent surgical interventions.ResultsA total of 58 patients (85 coalitions) were identified; 46 calcaneonavicular (CN) coalitions, 30 talocalcaneal (TC) coalitions and nine other coalitions (seven talonavicular, one naviculocuboid, one naviculocuneiform). In all, 46 coalitions were treated surgically (43 coalition resections, three arthrodeses) and 39 were treated nonoperatively. Patients treated surgically were less likely to report ongoing symptoms at final follow-up compared with patients managed nonoperatively (33% versus 67%; p = 0.0017). With a median 14.4 years (interquartile range 9.3 to 19.7) follow-up, there was an overall re-operation rate of 8.7% (4/46). Differences in reoperation rates by initial surgery (resection versus arthrodesis; p = 0.2936), coalition type (CN versus TC versus Other; p = 0.6487) or composition (osseous versus fibrocartilaginous; p = 0.29) did not reach statistical significance.ConclusionThis is the first population-based study demonstrating the durability of surgical management of tarsal coalitions in a paediatric population. At final follow-up, patients treated surgically are less likely to report persistent symptoms compared with patients managed nonoperatively. Long-term reoperation rates appear to be low (8.7%).Level of evidence:III     

Diagnostik und Therapie der Koalitionen und Synostosen bei Kindern und Jugendlichen

The majority of tarsal coalitions are located in the calcaneonavicular and talocalcaneal regions and other locations are rare. Complete early ossified synostoses are found not only in major limb deficiencies but also in otherwise normal feet. Magnetic resonance imaging (MRI) and computed tomography (CT) scans are the most important imaging techniques especially for preoperative planning. Early resection is advisable in calcaneonavicular coalitions as soon as it is detected in childhood and adolescence. Indications for or against resection or limited tarsal fusion are much more difficult in talocalcaneal coalition. The patient’s complaints, extension and location of the coalition, additional malalignment and especially patient age are some of the factors that should be considered carefully. Results of surgical resection are not always satisfactory with a long-lasting rehabilitation especially in older children or adolescents and the necessity for secondary procedures can never be ruled out. In cases of malalignment corrective tarsal osteotomy can be considered as a simultaneous or staged procedure. An overview with special emphasis on surgical options is presented with typical examples as well as rare conditions and a review of important literature from recent years is included.     

An Incidental Finding of a Talonavicular and Talocalcaneal Joint Coalition After a Tibial Pilon Fracture: A Case Report

It has been proposed that patients with talocalcaneal and talonavicular coalitions have decreased ankle joint range of motion. It has also been reported that rotational forces regularly absorbed by the talocalcaneal joint are transferred to the ankle joint in patients with coalitions, increasing the stress on the ankle joint after trauma. To the best of our knowledge, only 1 reported study has detailed the increased stress placed on the ankle joint secondary to a coalition. We present a case study of a 53-year-old female who experienced a traumatic fall and subsequent right ankle fracture. Advanced imaging studies revealed a comminuted tibial pilon fracture and talocalcaneal and talonavicular joint coalitions. She underwent open reduction and internal fixation for treatment of the fracture, and the coalitions were not treated because they were asymptomatic. She was kept non-weightbearing for 6 weeks postoperatively and was returned to a regular sneaker at 10 weeks postoperatively. The postoperative films revealed stable intact fixation and pain-free gait with no increased restriction in her ankle joint range of motion. The hardware was removed at 13 months postoperatively. She had not experienced increased pain or arthritic changes at 15 months postoperatively.     

Calcaneonavicular coalition treated by resection and interposition of the extensor digitorum brevis muscle

Seventy-five feet in forty-eight patients that had calcaneonavicular coalition were evaluated at two to twenty-three years after resection of the coalition and interposition of the extensor digitorum brevis muscle. The result was excellent or good in fifty-eight feet (77 per cent). Three feet that were rated initially as having a fair result improved over time, and at the last follow-up the result in those feet was rated as good. Only five feet (7 per cent) had a poor result. The best results were in patients who had a cartilaginous coalition and who were less than sixteen years old at the time of operation.     

Osseous and non-osseous coalition of the middle facet of the talocalcaneal joint.

Sixteen patients (eighteen feet) who had a coalition of the middle facet of the talocalcaneal joint had operative resection of the coalition because nonoperative treatment, such as casts, failed to relieve the symptoms. The patients were symptomatic for an average of one and a half years (range, four months to two years) before they were seen by us. The average age at the time of the operation was fourteen years (range, seven to nineteen years). Three feet had resection with no material interposed, six had resection with interposition of fat, and nine had resection with interposition of half of the tendon of the flexor hallucis longus muscle. The average length of follow-up was four years (range, two to eight years). The result was excellent for eight feet, good for eight feet, and fair for one foot; for one foot, the result was poor because the coalition recurred. Three types of coalition were identified on preoperative computed-tomography scans that correlated with the operative findings. Type I was an osseous bridging of the middle facet joint (five feet). Type II (cartilaginous coalition) was marked narrowing of the middle facet joint with cortical irregularity (three feet). In Type III (fibrous coalition), there was only slight narrowing of the middle facet joint (ten feet). The type of coalition did not influence the result. Fibrous coalitions were the most difficult to detect; bone scintigraphy was used to confirm the diagnosis when other tests were equivocal. We believe that symptomatic coalition of the middle facet of the talocalcaneal joint should be treated with resection when non-operative methods fail to relieve symptoms.     

Functional and Radiological Outcomes After Tarsal Coalition Resections: A Minimum 5-Year Follow-Up

Few studies have evaluated the long-term functional and radiological outcomes of tarsal coalition resections. This study aimed to report and compare the functional and radiological outcomes after talocalcaneal (TC) and calcaneonavicular (CN) coalition resections. Thirty-three patients between 12 and 35 years old with symptomatic tarsal coalitions participated, each undergoing tarsal coalition resections (24 TC and 9 CN). The range of motion, visual analog scale score, American Orthopedic Foot and Ankle Society hindfoot scale, Maryland foot score, tripod index, and modified Kellgren-Lawrence scale for subtalar osteoarthritis were used to evaluate the functional and radiological outcomes. The mean age at the time of surgery and mean follow-up in the TC group were 17.8 ± 5.6 years (range 13 to 35) and 6.2 ± 1.7 years (range 5 to 12), respectively, and 16.0 ± 4.4 years (range 12 to 23) and 7.7 ± 3.0 years (range, 5 to 12) in the CN group. There was no difference in the range of motion, outcome scores, tripod index score, and modified Kellgren-Lawrence scale score between patients in the 2 groups. A positive correlation was noted between the size of the TC coalition, coalition/joint surface ratio, and hindfoot valgus angle regarding outcome scores. However, there was no association between the modified Kellgren-Lawrence scale score and outcome scores. At the minimum 5-year follow-up, the functional and radiological outcomes were similar between TC and CN resections. Subtalar joint osteoarthritis developed in all patients with TC resections and most patients with CN resections, but patients did not have functional impairment.