Tarsal coalition in adults.

Adult tarsal coalition consists in abnormal union of two or more tarsal bones. Reported incidence ranges between 1 and 13%. It is generally a congenital condition, due to dominant autosomal chromosome disorder, but with some acquired forms following trauma or inflammatory pathology. Poorly specific clinical signs and the difficulty of screening on conventional X-ray may lead to diagnostic failure. The present review of tarsal coalition addresses the following questions: how to define tarsal coalition? How to diagnose it? How to treat it? And what results can be expected? There are 3 types of tarsal coalition, according to the type of tissue between the united bones: bony in pure synostosis, cartilaginous in synchondrosis, and fibrous in syndesmosis. Location varies; the most frequent forms are talocalcaneal (TC) and calcaneonavicular (CN), accounting for more than 90% of cases. Cuneonavicular, intercuneal and cuboideonavicular locations are much rarer, at less than 10%. Tarsal coalition is classically painful, often with valgus spastic flatfoot in young adults. The pain is caused by the biomechanical disturbance induced by the bone, cartilage or fibrous bridges which partially or completely hinder hindfoot and/or midfoot motion. Conventional imaging, with weight-bearing X-ray and CT, is standard practice. Weight-bearing CT is increasingly the gold standard, displaying abnormalities in 3 dimensions. Functional imaging on MRI and tomoscintigraphy assess direct and indirect joint impact at the affected and neighboring joint lines. Non-operative treatment can be proposed, with orthoses, rehabilitation and/or injections. But surgery is the most frequent option: either resection of the bony, cartilaginous or fibrous constructs to restore optimally normal anatomy, or arthrodesis in the affected joint line or the entire joint. Surgery can be open, arthroscopic or percutaneous, depending on the severity of the biomechanical impact on the affected and neighboring joints. Resecting the abnormality is the standard practice in all locations if it affects less than 50% of the talocalcaneal joint line and there is no osteoarthritis to impair the functional outcome. Otherwise, fusion is required. Level of evidence: V; expert opinion.

Outcomes of surgical management for tarsal coalitions: a systematic review.

PURPOSE: To analyze the outcome of surgical treatment of tarsal coalition, assess the role of the surgical technique, as well as of coalition size and type on outcomes. METHODS: The search followed the Preferred Reporting Items of Systematic Review and Meta-Analysis and was performed in four databases: MEDLINE, Central, Scopus and Web of Science. The protocol has been registered in the international prospective register of systematic reviews. Patient-reported outcomes (PROMs), complications, revisions and radiographic recurrence were collected. Risk of bias was assessed using MINORS criteria. A random-effects model for meta-analysis was applied for analysis of data heterogeneity. RESULTS: Twenty-five studies including 760 tarsal coalitions were included and had a weighted average follow-up of 44 months. Studies scored fair to poor on the risk of bias assessment with a mean MINORS score of 67% (44-81%). In 77.8% (37.5-100%) of surgically treated tarsal coalitions, good/excellent/non-limiting or improved PROMs were reported. Calculated data heterogeneity was moderate (I2 = 57%). Open bar resection with material interposition had a clinical success rate of 78.8% (50-100%). Complications occurred in 4.96% of cases. Coalition size did not prove to be a determining factor in postoperative outcome. The influence of the coalition type was not investigated by any of the studies. CONCLUSION: Data on outcomes of surgical management for tarsal coalitions is limited to retrospective case series with high risk of bias and moderate data heterogeneity. In about ¾ of cases, open resection and interposition of material results in improved PROMs. The arbitrary margin of ≥ 50% of TC coalition size in relation to the posterior facet has little importance in surgical decision-making. None of the studies reported on the influence of the coalition type on postoperative clinical success.

Decision-Making and Management of Tarsal Coalition in the Young Adult Patient: A Critical Analysis Review.

¼ Tarsal coalitions most commonly affect the calcaneonavicular and talocalcaneal joints in up to 13% of the general population. They alter the mechanics of the subtalar joint, limiting inversion and eversion, and place excessive stress on neighboring joints causing pain, recurrent ankle sprains, and/or progressive pes planus during the adolescent growth spurt.¼ While many coalitions are identified on radiographs, advanced imaging with computed tomography or magnetic resonance imaging is sometimes required. These advanced imaging modalities also serve an essential role for surgical planning to quantify coalition involvement, identify fibrous or cartilaginous coalitions, and aid in determining the degree of deformity within the foot.¼ Surgical treatment is reserved for feet with persistent activity-related pain not relieved by prolonged attempts at nonoperative management, which include nonsteroidal anti-inflammatory drugs, shoe orthotics, and periods of non-weight-bearing in a cast. These conservative modalities may be successful in up to 85% of cases.¼ For adolescent patients, recent surgical options attempt to avoid arthrodesis and focus on coalition resection and interposition grafting with or without deformity correction. The ultimate decision is based on the location of the pain, the size and histology of the coalition, the health of the posterior subtalar facet, the degree of flatfoot deformity, and the presence of degenerative changes in the subtalar and/or adjacent joints.¼ While many studies focus on subtalar motion and gait kinematics, the critical outcomes remain pain relief and future need for arthrodesis, which may be related not only to resection of the coalition but assessment of deformity, including after the resection has been performed.

Surgical Management and Outcomes of Patients with Idiopathic Peroneal Spastic Flatfoot: A Retrospective Case Series.

BACKGROUND: Although tarsal coalition represents the most common cause of peroneal spastic flatfoot, its existence cannot be verified in several cases. In some patients with rigid flatfoot, no cause can be detected after clinical, laboratory, and radiologic examination, and the condition is called idiopathic peroneal spastic flatfoot (IPSF). This study aimed to present our experience with surgical management and outcomes in patients with IPSF. METHODS: Seven patients with IPSF, who were operated on between 2016 and 2019, and followed for at least 12 months were included, whereas those with known causes, such as tarsal coalition or other causes (eg, traumatic) were excluded. All patients were followed up for 3 months with botulinum toxin injection and cast immobilization as a routine protocol, and clinical improvement was not achieved. The Evans procedure and grafting with tricortical iliac crest bone graft in five patients and subtalar arthrodesis in two patients were performed. The American Orthopaedic Foot and Ankle Society ankle-hindfoot scale scores and Foot and Ankle Disability Index scores were obtained preoperatively and postoperatively from all patients. RESULTS: On physical examination, all feet manifested rigid pes planus with varying degrees of hindfoot valgus and limited subtalar motion. Overall, the mean American Orthopaedic Foot and Ankle Society and Foot and Ankle Disability Index scores significantly increased from 42 (range, 20-76) and 45 (range, 19-68) preoperatively (P = .018) to 85 (range, 67-97) and 84 (range, 67-99) (P = .043) at the final follow-up, respectively. No major intraoperative or postoperative complications were observed in any of the patients. All computed tomographic and magnetic resonance imaging scans revealed no evidence of tarsal coalitions in any of the feet. All radiologic workups failed to demonstrate secondary signs of fibrous or cartilaginous coalitions. CONCLUSIONS: Operative treatment seems to be a good option in the treatment of patients with IPSF who do not benefit from conservative treatment. In the future, it is recommended to investigate the ideal treatment options for this group of patients.

Fibrin Glue is a Viable Alternative to Fat Graft for Interposition After Tarsal Coalition Resection.

BACKGROUND: Tarsal coalition is one of the most common foot and ankle pathologies in children, yet there is no consensus regarding what to interpose after resection. Fibrin glue could be considered, but the literature comparing fibrin glue to other interposition types is sparse. The purpose of this study was to evaluate the effectiveness of fibrin glue for interposition compared with fat graft by analyzing the rate of coalition recurrence and wound complications. We hypothesized that fibrin glue would have similar rates of coalition recurrence and fewer wound complications compared with fat graft interposition. METHODS: A retrospective cohort study was performed examining all patients who underwent a tarsal coalition resection at a free-standing children's hospital in the United States from 2000 to 2021. Only patients undergoing isolated primary tarsal coalition resection with interposition of fibrin glue or fat graft were included. Wound complications were defined as any concern for an incision site that prompted the use of antibiotics. Comparative analyses were conducted using χ 2 and Fisher exact test to examine relationships among interposition type, coalition recurrence, and wound complications. RESULTS: One hundred twenty-two tarsal coalition resections met our inclusion criteria. Fibrin glue was used for interposition in 29 cases and fat graft was used in 93 cases. The difference in the coalition recurrence rate between fibrin glue and fat graft interposition was not statistically significant (6.9% vs. 4.3%, P =0.627). The difference in wound complication rate between fibrin glue and fat graft interposition was not statistically significant (3.4% vs 7.5%, P = 0.679). CONCLUSION: Fibrin glue interposition after tarsal coalition resection is a viable alternative to fat graft interposition. Fibrin glue has similar rates of coalition recurrence and wound complications when compared with fat grafts. Given our results and the lack of tissue harvesting required with fibrin glue, fibrin glue may be superior to fat grafts for interposition after tarsal coalition resection. LEVEL OF EVIDENCE: Level III, a retrospective comparative study between treatment groups.

Review of the role of bone-SPECT/CT in tarsal coalitions.

Tarsal coalition (TC) is a congenital abnormal connection (fibrous, cartilaginous, or osseous) between two or more bones in the hind and midfoot, mostly consisting of calcaneonavicular or talocalcaneal coalition, and is often asymptomatic. However, TCs may result in foot motion limitation and pain with or without flatfoot (pes planus), arising in adolescents and young adults. Appropriate imaging is needed to pinpoint foot pain in the (suspected) TC, starting with plain radiographs. Still, normal radiographs do not exclude TCs. Computed tomography (CT) and MRI are frequently used advanced imaging techniques. CT alone has known limited sensitivity in cartilaginous and fibrous TCs and correlation between CT abnormalities and pain may be challenging, as solely anatomical changes in TCs are often asymptomatic. MRI can depict soft tissue abnormalities in TC with high accuracy. Nonetheless, after the implantation of metallic osteosynthesis material, MRI is often limited due to image distortion, signal loss, and misregistration. Bone scintigraphy with [99mTc]Tc-diphosphonate single photon emission computed tomography/CT (bone-SPECT/CT) is a known sensitive tool to detect osteoblastic bone pathology. However, the literature concerning bone-SPECT/CT in TC patients is limited. This article reviews bone-SPECT/CT patterns in TCs, how it complements other imaging techniques and their relation to clinical complaints. Bone-SPECT/CT excels in accurate bone pathology characterization in TC, confidently excluding synchronous lesions elsewhere, and offering optimal insight into osseous structures and 3D-localization of bone metabolism for surgery planning. Furthermore, even with implanted osteosynthesis material, bone-SPECT/CT can pinpoint the culprit pain generator, where MRI is either contra-indicated or considerably hampered.

A retrospective magnetic resonance imaging analysis of bone and soft tissue changes associated with the spectrum of tarsal coalitions.

We aimed to investigate the bone and soft tissue changes accompanying tarsal coalition (TC) and aimed to evaluate their association with the location and type of coalition. Ankle magnetic resonance imagings of 65 patients with TC were included. The relationship between the location and type of coalition and bone marrow edema, subchondral cysts, sinus tarsi syndrome, tarsal tunnel syndrome, posterior impingement syndrome, accessory bone, tibiotalar effusion, talar osteochondritis dissecans, ganglion cysts, and calcaneal spur were evaluated. Twenty-nine patients without coalition were selected as the control group, and the distribution of these variables between the two groups was analyzed. There were 33 females and 32 males in the coalition group (mean age: 42.0 ± 15.63 years), and 22 females and seven males in the control group (mean age: 44.79 ± 12.33 years). Coalition was most common in the talocalcaneal joint (n = 33, 50.8%), and the most common coalition type was non-osseous (n = 57, 87.6%). We find no significant difference between the pathologies defined in terms of coalition location and type. Sinus tarsi syndrome, tarsal tunnel syndrome, subchondral cysts, and tibiotalar effusion were found to be more common in the coalition group (p = 0.028, p = 0.010, p = 0.023, and p = 0.006, respectively). The presence of coalition increased the probability of developing tarsal tunnel syndrome 9.91 times (95% CI: [1.25-78.59]; p = 0.029), and sinus tarsi syndrome 3.66 times (95% CI: [1.14-11.78]; p = 0.029). Tarsal coalition may predispose bone and soft tissue changes. In this study, sinus tarsi syndrome, tarsal tunnel syndrome, subchondral cysts and tibiotalar effusion were found to be more common in the coalition group.

The Rare Presence of an Asymptomatic Os Sustentaculum in a Young Athlete.

The presence of an os sustentaculum bone is extremely rare. Given the scarcity of clinical literature reporting such a finding, the condition may be misdiagnosed as a fracture of the sustentaculum tali. We describe such an incident in a 16-year-old male athlete presenting for a recent ankle sprain with no other history of trauma or pain on the medial aspect of the ankle. The original computed tomographic scan reported a possible nonunion of a sustentaculum fracture, or peripherally corticated ossification in association with a possible talocalcaneal fibrocartilaginous coalition. Given no history of high-level trauma to the area, the clinical presentation, and the radiographic findings, the more likely diagnosis was confirmed to be an os sustentaculum. The goal of the authors of this article is to report such findings to raise awareness of a rare clinical presentation to avoid misdiagnosis.

Cubonavicular Coalition in a Middle-Aged Woman: A Case Report.

Cubonavicular coalition is a rare type of tarsal coalition that can be described as osseous or nonosseous (fibrous, cartilaginous, or fibrocartilaginous). Typically, it manifests symptoms during adolescence, as it presents with pain at the Mid-hindfoot and with decreased range of motion at the midtarsal joints, hindfoot valgus deformity, or peroneal spasm. Here, we present a rare case of cubonavicular coalition in a middle-aged woman with atypical presentation and a review of the literature. We conclude that this abnormality should be taken into account in the differential diagnosis of mid-hindfoot pain, even in middle-aged adults.

Racial differences in prevalence and anatomical distribution of tarsal coalition.

Previous studies have reported a prevalence of tarsal coalition of 0.03-13%. Calcaneonavicular coalition is known as main anatomical type, and the bilateral occurrence of tarsal coalition is known to be 50% or more. These are the results of studies on Caucasians, there have been few studies targeting large number of East Asians so far. We hypothesized that the prevalence and characteristics of tarsal coalition in East Asians might differ from those in Caucasians. The medical records of 839 patients who underwent bilateral computed tomography on foot and ankle in our hospital from January 2012 to April 2021 were retrospectively reviewed. The overall prevalence was 6.0%, talocalcaneal coalition was the most common anatomical type. The overall bilateral occurrence was 56.5%, talocalcaneal coalition had the highest bilateral occurrence (76.0%) among anatomical types. Isolated union of the posterior facet was the most common subtype of talocalcaneal coalition (43.2%). Talocalcaneal coalition had a significantly higher proportion of coalition-related symptomatic patients than calcaneonavicular coalition (p = 0.019). Our study showed a similar trend to other East Asian studies, confirming the existence of racial differences. The possibility of tarsal coalition in foot and ankle patients in East Asians should always be considered, and bilateral examination is essential for diagnosis.

Double and Triple Tarsal Fusions in the Complex Cavovarus Foot.

The cavovarus (cavus) foot is one of the most perplexing and challenging of all foot deformities and may prove to be one of the most difficult conditions to treat. This deformity is characterized by increased plantar flexion of the forefoot and midfoot in relation to the hindfoot resulting in high foot arch. Because cavus foot rarely occurs in an isolated form, the term "cavus foot" rather describes a part of a complex multiplanar foot deformity. Because the underlying disease is mostly neurogenic characterized by muscle imbalance in almost every case a combined bony and soft tissue surgery is inevitable.

Double and Triple Tarsal Fusions in the Severe Rigid Flatfoot Deformity.

A flatfoot deformity is a multiplanar foot deformity characterized by forefoot abduction and supination and hindfoot valgus. With progressive pathology, a rigid deformity may develop. In the setting of a rigid deformity, the appropriate procedure to use is not without controversy. The extent of joints to involve in the arthrodesis depends on the ability to obtain a plantigrade foot. Both double and triple arthrodesis have been suggested. Care must be taken to avoid lateral column shortening and loss of foot reduction when fusing the CC joint. The concerns about lateral skin breakdown led some surgeons to describe a single medial incision for a triple or modified double arthrodesis. The necessity of bone grafting has been controversial. Implant selection is essential to achieve solid stabilization of the arthrodesis sites. To decrease the risk of overcorrection and malunion, the surgeon should be familiar with the hindfoot biomechanics and generate, based on the clinical examination and imaging, a meticulous preoperative plan to address and balance both the soft tissue and bony deformity.

Tarsal coalition resections: a long-term retrospective analysis of 97 resections in 78 patients.

BACKGROUND: Resection of tarsal coalitions provides good patient satisfaction scores, reduced pain, and improved long-term function in both athletic and non-athletic populations. This study aimed to determine when athletic patients undergoing resection of a tarsal coalition were able to return to their desired activity, and whether they experienced a decreased desired activity level (DDA). METHODS: Data on a total of 78 patients who underwent 97 tarsal coalition resections (49 talocalcaneal coalitions, 47 calcaneo-navicular, 14 cuboid-navicular, and three cuneo-navicular; some patients had more than one coalition) operated between January 2001 and June 2020 were prospectively collected. To subjectively assess outcomes, the Roles and Maudsley score (RM) was utilized. RESULTS: At an average follow-up from the index procedure of 33.6 ± 41.5 months, return to activity for the entire cohort was 18.3 ± 9.6 weeks. Post-RM was 1.3 ± 0.6. CONCLUSION: Surgical excision of tarsal coalitions produced favorable results, with most patients able to return to their desired activity level. LEVEL OF EVIDENCE: IV.

Talocalcaneal Tarsal Coalition Size: Evaluation and Reproducibility of MRI Measurements.

BACKGROUND: The size of talocalcaneal tarsal coalitions (TCCs) is one of the main factors that is thought to influence patient outcomes after resection. Magnetic resonance imaging (MRI) is increasingly being used to diagnose and characterize TCCs. However, there is no reproducible MRI-based measurement of TCC size reported in the literature. The purpose of this study was to create a method to reproducibly measure TCC size using MRI. METHODS: Twenty-seven patients with TCCs diagnosed by a hindfoot coronal proton density (PD) MRI between 2017 and 2020 were included. Five independent raters measured coalition width, healthy posterior facet width, and healthy middle facet width on individual slices of coronal PD hindfoot MRIs using discrete MRI measurement guidelines. Individual slice measurements were summed to determine total size of the coalition and the remaining healthy cartilage of the posterior and middle facets. Inter-rater reliability of MRI measurements between the 5 independent examiners was evaluated using intraclass correlation coefficient (ICC). ICC was calculated for total coalition width, total healthy posterior facet width, total coalition width/total healthy posterior facet width, total coalition width/total healthy middle facet width, total coalition width/total healthy subtalar facet width (posterior facet+middle facet), and total coalition width/total subtalar facet width (coalition+posterior facet+middle facet). RESULTS: The ICC scores for all but one of the MRI measurements indicated good to excellent inter-rater reliability among the 5 examiners. The ICC was 0.932 (95% confidence interval: 0.881-0.966) for measurement of total coalition width/total healthy posterior facet width and 0.948 (95% confidence interval: 0.908-0.973) for measurement of total coalition width/total subtalar facet width (middle+posterior+coalition). CONCLUSIONS: Measurements of coalition size using novel MRI guidelines were reproducible with good to excellent inter-rater reliability. These guidelines allow for determination of TCC size using coronal PD MRI. LEVEL OF EVIDENCE: Level II-diagnostic reproducibility study.

Midterm Outcomes of Talocalcaneal Coalition Arthroscopic Resection in Adults.

BACKGROUND: Arthroscopic resection of the talocalcaneal coalition (TCC) has been reported to be associated with good short-term outcomes. However, the midterm outcomes of this approach remain uncertain. METHODS: We performed a retrospective study of patients who underwent arthroscopic resection for symptomatic TCC. The patients were divided into 2 groups (group P, patients with isolated posterior facet coalition; and group MP, patients with both middle and posterior facet coalition). The preoperative and postoperative visual analog scale (VAS) scores for pain and American Orthopaedic Foot & Ankle Society (AOFAS) scale scores were calculated. The postoperative AOFAS and VAS scores between the 2 groups were analyzed. Patient satisfaction was also assessed. RESULTS: Thirty-two patients were included in this study. The mean age at the time of surgery was 26.0±8.5 years, and the mean follow-up period was 56.9±18.0 months. Thirteen (41%) patients were in group P, whereas 19 (59%) patients were in group MP. Postoperative VAS and AOFAS scores improved more significantly than preoperative scores. At the final follow-up, excellent and good subjective outcomes were attained in 26 patients (81%), fair and poor outcomes in 6 patients (19%). There were no statistical differences in the postoperative AOFAS (91.0±7.0 vs 85.8±10.8, P = .532) and VAS score (2.1±1.7 vs 4.0±2.6, P = .537) between patients with the ratio of coalition/posterior facet more than or less than 50%. There were no statistical differences in postoperative VAS score (1.8±1.3 vs 2.6±2.2, P = .236) and AOFAS score (92.5±5.6 vs 89.2±8.7, P = .297) between group P (n=13) and group MP (n=19), either. Three patients (9.4%) had complications, including these notable findings: 1 patient complained of restricted dorsal flexion, 1 with computed tomography-proven coalition recurrence, and 1 with partial tibial nerve injury. CONCLUSION: We found that TCC arthroscopic resection was generally associated with reasonable outcomes at midterm follow-up. LEVEL OF EVIDENCE: Level IV, case series.

What is New in Pediatric Orthopaedic Foot and Ankle.

BACKGROUND: This paper aims to report on the last 5 years of relevant research on pediatric foot and ankle pathology with specific focus on clubfoot, congenital vertical talus, toe walking, tarsal coalitions, pes planovalgus with or without accessory navicular, foot and ankle trauma, and talar dome osteochondritis dessicans. METHODS: The Browzine platform was used to review the table of contents for all papers published in the following target journals related to the treatment of pediatric foot and ankle conditions. Search results were further refined to include clinical trials and randomized controlled trials published from March 1, 2015 to November 15, 2021. RESULTS: A total of 73 papers were selected for review based on new findings and significant contributions in treatment of clubfoot, congenital vertical talus, toe walking, tarsal coalitions, pes planovalgus with or without accessory navicular, foot and ankle trauma, and talar dome osteochondritis dessicans. Also included were several papers that did not fit into any of these categories but provided new insight into specific foot and ankle pathologies. CONCLUSIONS: Treatment strategies for children with foot and ankle pathology are continually evolving. We review many of the most recent publications with the goal of improving understanding of these pathologies and highlighting current best practices. LEVEL OF EVIDENCE: Level III.

8 out of 10 patients do well after surgery for tarsal coalitions: A systematic review on 1284 coalitions.

BACKGROUND: The primary aim was to determine the clinical success rate after treatment for talocalcaneal (TCC) and calcaneonavicular coalitions (CNC). The secondary aim was to evaluate the complication, recurrence and revision rate. METHODS: A search was carried out in MEDLINE, EMBASE and Cochrane Library. Methodological quality was assessed using the Methodological Index for Non-Randomised Studies (MINORS) criteria. The primary outcome was the clinical success rate and was pooled per type of coalition and treatment modality. 95% Confidence Intervals (CI) of the success rates were calculated. Secondary outcomes included complication rates, coalition recurrence rates, revision rates and pain improvement using the Visual Analogue Scale (VAS). A sub-analysis on interposition material was performed. RESULTS: 43 articles comprising of 1284 coalitions were included, with a pooled mean follow-up of 51 months. Methodological quality was fair. The overall pooled success rate for TCCs was 79% (95% CI, 75%-83%). Conservative treatment, open resection and arthroscopic resection of TCCs resulted in success rates of 58% (95% CI, 42%-73%), 80% (95% CI, 76%-84%) and 86% (95% CI, 71%-94%), respectively. CNCs have an overall success rate of 81% (95% CI, 75%-85%), with 100% (95% CI, 34%-100%), 80% (95% CI, 74%-85%) and 100% (95% CI, 65%-100%) for conservative treatment, open resection and arthroscopic resection, respectively. Pooled complication rates of 4% (95% CI, 3%-7%) for TCCs and 6% (95% CI, 4%-11%) for CNCs were found. The success rates of resection with and without interposition material for TCCs were 83% (95% CI, 78%-87%) and 79% (95% CI, 65%-88%), and for CNCs 81% (95% CI, 76%-86%) and 69% (95% CI, 44%-85%), respectively. CONCLUSION: Treatment of tarsal coalitions can be considered good to excellent as well as safe, with an overall clinical success rate of 79% for TCCs and 81% for CNCs. Arthroscopic resection of the coalition appears to be non-inferior to open resection of TCCs and CNCs. LEVEL OF EVIDENCE: Level IV, Systematic Review.

The Efficacy of Intra-articular Subtalar Steroid Injection for Symptomatic Talocalcaneal Coalitions: A 30-Year Single Institution Experience.

PURPOSE: While intra-articular steroid injection has been used anecdotally in patients with symptomatic talocalcaneal coalitions recalcitrant to traditional conservative modalities, the ability of this treatment to provide symptomatic relief and obviate or delay surgical intervention remains unknown. The purpose of this study is, therefore, to assess the treatment efficacy of intra-articular subtalar steroid injection in children with symptomatic talocalcaneal coalitions. METHODS: A retrospective study of all patients with isolated subtalar coalitions was performed at a single pediatric orthopaedic institution over a 30-year period. Radiographs were analyzed to identify the type of coalition (osseous or nonosseous), presence of any posterior facet involvement, and presence of a planovalgus foot deformity. Patients who underwent a subtalar joint steroid injection after failing other conservative treatments were identified and compared with those who did not receive an injection as part of their nonoperative management with regard to the need for ultimate surgical intervention and the time from presentation to surgery when applicable. RESULTS: A total of 83 patients (125 feet) met inclusion criteria, of whom 25 patients (34 feet) received a subtalar steroid injection. When compared with the 58 patients (91 feet) treated with standard nonoperative modalities, there were no differences with regard to sex, age at presentation (12.4 and 12.3 y, respectively), facet involvement, type of coalition, or the presence of a planovalgus deformity. In all, 12/34 (35%) feet in the injection group eventually elected surgical intervention compared with 36/91 (39%) feet that did not receive an injection (P=0.72). For those patients ultimately selecting surgical intervention, the average time from initial presentation to surgery was 878 days in the injection group versus 211 days in the noninjection group (P<0.001). CONCLUSIONS: While subtalar steroid injection can alleviate symptoms in some patients with a talocalcaneal coalition, this intervention does not appear to decrease the need for surgery when compared with traditional nonoperative therapies. In patients failing other forms of conservative treatment, subtalar steroid injections can delay surgical intervention by an average of nearly 2 years. LEVEL OF EVIDENCE: Level-III-therapeutic study.

Tarsal Coalitions.

Tarsal coalitions are recognized as a congenital anomaly whereby the two or more bones of the hindfoot and midfoot are fused resulting in limitation of foot motion and pain. Tarsal coalitions were found to be the cause of painful flatfeet in adolescents and young adults. Developing a clinical understanding of tarsal coalitions as well as developing a step-wise conservative and surgical approach for their treatment can alleviate patient symptomatology and provide excellent long-term benefits. Conservative treatment consists of immobilization, NSAIDs, and casting for symptomatic patients, and surgical treatment for symptomatic tarsal coalition consists of resection and/or arthrodesis.

The painful lateral column of the foot: from back to front.

The purpose of this article is to focus attention on the abnormalities which the radiologist may encounter in patients presenting with lateral ankle or foot pain outside of the context of acute trauma. These include anterolateral impingement, subfibular impingement, subtalar instability and tarsal sinus syndrome, tarsal coalition, sural neuromas, peroneal tendon abnormalities, calcaneocuboid instability and occult cuboid fractures, and painful accessory ossicles. The expected and unexpected findings on radiographs, CT, US, and MRI are discussed.