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.

Bone stress injuries in the presence of tarsal coalition as a cause of hindfoot pain in adolescents: case series of 6 patients with literature review.

OBJECTIVE: To highlight causal relationship between stress fracture in the presence of tarsal coalition and hindfoot pain in adolescents on magnetic resonance imaging (MRI). MATERIAL AND METHODS: A retrospective review was performed of the clinical and MRI imaging findings of 6 adolescents referred for MRI to evaluate symptoms of hindfoot pain with possible tarsal coalition. MRI studies were systematically assessed for cause of hindfoot pain, types of tarsal coalition, patterns of stress fractures, bone marrow oedema and any other associated features. RESULTS: All the 6 patients (4 male: 2 female) aged between 12 and 19 years developed insidious onset of hindfoot or midfoot pain over a period of weeks to months. On MRI, all 6 cases had features of fibrous tarsal coalition predominantly in the calcaneonavicular articulation (5 out of 6 patients). Associated stress fractures/response were in the posterior facet/body of the calcaneus (3), talar head (2), cuboid (1) and third metatarsal bone in one patient. CONCLUSION: Stress fractures/response adjacent to tarsal coalition could be because of altered biomechanics and can be an unusual cause of hindfoot pain in adolescents. A high index of suspicion and complementary MRI findings is crucial to interpret this condition to direct appropriate patient management.

Accessory anterolateral talar facet associated with tarsal coalition: prevalence and cross-sectional characterization.

OBJECTIVE: The accessory anterolateral talar facet (AALTF) is a developmental entity described as a potential cause for rigid, painful flat foot. This study evaluates the possible association between the AALTF and other flat foot etiologies, specifically different types of tarsal coalitions. MATERIALS AND METHODS: We evaluated patients with tarsal coalition or sinus tarsi syndrome for an AALTF on CT and MRI. Exclusion criteria included acute ankle trauma, recent surgery, motion or metal artifacts. We evaluated the AALTF length and height, and the lateral talocalcaneal structures for associated findings. The presence of calcaneonavicular (CNC), intra-articular middle facet talocalcaneal (MFTCC), posterior facet talocalcaneal (PFTCC), extra-articular posteromedial talocalcaneal (EATCC) and other rare coalitions were also evaluated. RESULTS: One hundred eighty-seven patients were included (age range 14-91 years; mean ± SD; 50 ± 17 years). The AALTF prevalence in the study population was 31.55% (59/187), 40.91% in men, and 23.23% in women. The AALTF average length was 4.5 ± 1.1 mm, and average height was 8.9 ± 3.4 mm. The AALTF was found to be significantly associated with lateral talocalcaneal osseous changes such as cortical thickening and cystic changes (34/59 and 24/59 respectively, P < 0.01). The AALTF was also found to be significantly associated with sinus tarsi edema on MRI (45/52, P < 0.05). The AALTF was also significantly associated with EATCC (19/59, P < 0.01) and MFTCC (7/59, P < 0.05). No significant association was found with CNC, PFTCC or other rare coalitions. CONCLUSION: The AALTF is common and significantly associated with some tarsal coalitions, specifically EATCC and MFTCC. When an AALTF or coalition is identified, special attention should be made to evaluate for other associated pathologies, as this could potentially affect management.

Correlation between the accessory anterolateral talar facet, bone marrow edema, and tarsal coalitions.

OBJECTIVE: The purposes of this study was to determine the prevalence of the accessory anterolateral talar facet (AALTF); to evaluate the relationship between AALTF, focal abutting bone marrow edema (FABME), and sinus tarsi edema; and to study the prevalence of tarsal coalitions in patients with the AALTF utilizing ankle MR images. MATERIALS AND METHODS: 5-T ankle MR images were reviewed for the presence of AALTF, FABME, sinus tarsi edema, tarsal coalition, and location and type of coalition (cartilaginous, fibrous, and osseous). Multivariate analysis was performed to examine the correlation between AALTF and the other variables. RESULTS: Three hundred ninety-one consecutive patients were included (age range 5-86 years; mean age 45 years). An AALTF was present in 3.6% (14/391) of patients. The AALTF prevalence was 2% in women and 6.6% in men. There was a significantly association between AALTF and FABME (9/14, p < 0.05), sinus tarsi edema (13/14, p < 0.05), and tarsal coalition (4/14, p < 0.05). CONCLUSION: AALTF is relatively often detected on MRI of the ankle and significantly associated with BME, sinus tarsi edema, and subtalar coalition. Patients with a tarsal coalition should be evaluated for the concurrent presence of an AALTF.

The natural course of pain in patients with symptomatic tarsal coalitions: A retrospective clinical study.

BACKGROUND: This study aims to examine changes in pain intensity in the long course of symptomatic tarsal coalition. METHODS: Thirty consecutive patients who were treated for symptomatic tarsal coalition was retrospectively reviewed. The patients were divided into two groups: the nonsurgical group (14 patients) and the surgical group (16 patients). To assess pain intensity, the visual analogous scale (VAS) was utilized. RESULTS: On admission, the mean VAS was 4,9 ± 1,9 in the nonsurgical group and 7,7 ± 1,3 in the surgical group (p < 0,05). After 6 months of nonoperative treatment, the mean VAS was decreased from 4,9 ± 1,9 to 2,8 ± 1,0 in the nonsurgical group (p < 0,05) and from 7,7 ± 1,3 to 7,1 ± 0,8 in the surgical group (p > 0,05). At the final follow-up, the mean VAS was 2,3 ± 2,4 in the nonsurgical group and 3,1 ± 2,7 in the surgical group (p > 0,05). The decrease in the VAS after surgery was significant in the surgical group (p < 0,01). CONCLUSION: For patients with symptomatic tarsal coalitions who present with an initial VAS score of 6 and above, early surgery may be more effective than nonoperative treatment in relieving pain intensity.

Posteromedial Ankle Impingement Caused by Hypertrophy of Talocalcaneal Coalition: A Report of Five Cases and Introduction of a Novel Index System.

Ankle impingement syndromes are common disorders that can be attributed to many factors. To the best of our knowledge, posteromedial ankle impingement syndromes caused by talocalcaneal coalition have never been previously reported. The present report describes 5 patients with posteromedial ankle pain and inversion limitation. The physical examination, radiographic, and magnetic resonance imaging findings suggested posteromedial ankle impingement syndrome and talocalcaneal coalition. The 5 patients underwent surgery after conservative treatment had failed. A novel index system, namely the angle and thickness of the medial talocalcaneal facet, was introduced. The talocalcaneal coalitions protruded medially and impinged on the malleolus medialis. The medial facet of the talus and calcaneum had a wider angle and thickness than normal. Pain relief was noted, and good long-term outcomes were achieved after resection of the medial prominence and coalition in all 5 patients. Talocalcaneal coalition can cause posteromedial ankle impingement syndrome when the coalition is hypertrophic. The angle and thickness of the medial talus facet could be a simple index to diagnose this disorder.

Tibialis spastic varus foot without tarsal coalition: a case report.

Tibialis spastic varus foot (TSVF) is an uncommon clinical entity primarily associated with tarsal coalition. This case report presents a rare instance of TSVF without tarsal coalition in an 8­year-old male patient. Successful treatment was achieved through a conservative approach involving botulinum toxin injections and a plaster cast, highlighting the potential of nonsurgical interventions for this rare condition.

Cuboid-navicular coalition in a female junior athlete.

Tarsal coalition is an uncommon cause of insidious-onset foot pain typically affecting adolescents. Cuboid-navicular coalitions are among the rarest variety, comprising less than 1% of all tarsal coalitions. This case report describes a female competitive gymnast in middle childhood with a 6-month history of worsening insidious onset right foot pain that forced withdrawal from all sporting activities. The patient reported a background of intermittent foot pain and bilateral ankle instability over the past 2 years. A comprehensive history and physical examination, alongside MRI, enabled the diagnosis of a fibro-osseous cuboid-navicular coalition. Through early diagnosis, a targeted and prompt trial of non-operative management was implemented, consisting of physiotherapy, a deloading protocol, orthotics and analgesia. At 6-month follow-up, this led to improvements in pain symptoms and functional outcomes as well as a return to competitive sport. Early recognition of cuboid-navicular coalition is essential to prevent early degenerative joint disease.

Tarsal Coalition of the Cuneiforms in a Young Athlete: A Case Report.

CASE: Tarsal coalitions are relatively common, but there are no reports of cuneiform-to cuneiform coalition in the English language literature. The authors present a case of medial-to-intermediate cuneiform coalition in a young female track athlete. Previous nonoperative treatments had been unsuccessful. Coalition release and medial-intermediate cuneiform arthrodesis enabled her to return initially to full athletic participation without pain, but she had return of pain that persists despite removal of hardware. CONCLUSION: Medial-intermediate cuneiform coalition is rare. Surgery in this patient provided a short period of pain-free athletic participation, but long-term outcomes are not proven, and further research is needed.

Sustentaculum Tali Fracture Adjacent to Talocalcaneal Tarsal Coalitions: A Report of 2 Cases.

CASE: An 11-year-old boy demonstrated chronic medial hindfoot pain. A 12-year-old boy experienced acute pain and swelling in his right medial ankle and hindfoot after a fall. This is the first report of sustentaculum tali fractures adjacent to a talocalcaneal tarsal coalition, likely resulting from a stress riser created by a rigid subtalar joint. CONCLUSION: These 2 cases represent unique causes of foot pain in the setting of tarsal coalitions, never before described. Patient-reported outcome measures demonstrated expected improved outcomes after excision of tarsal coalition. Awareness to this possibility will help clinicians treating foot and ankle conditions in children optimize their care.

Ankle Ganglion Associated with Tarsal Coalition: A Case Report with a 5-Year Follow-up.

CASE: Talocalcaneal coalition (TCC) is a common type of coalition, often neglected. This case is of a 10-year-old girl with a painful ankle mass, diagnosed with TCC and a ganglion cyst. Examination revealed stiff subtalar motion, a submalleolar prominence, and well-circumscribed, tender mass at the posteromedial ankle. Treatment options include short period of casting/observation, excision vs. aspiration of the cyst, resection of the TC coalition, or a combination of the above. She underwent TCC resection with cyst aspiration. CONCLUSION: At the 5-year follow-up, the patient's examination and imaging revealed normal motion without cyst recurrence, indicating resolution of the cyst with coalition resection.

Unsuspected tarsal coalitions in equinus and varus foot deformities.

Tarsal coalitions have been reported in the setting of equinovarus foot deformities, but only as rare isolated findings. Failure to recognize this diagnosis may inhibit successful equinovarus correction. Here, we review a series of tarsal coalitions seen in congenital and neuropathic equinovarus deformity at two institutions, to report the breakdown of types of coalitions encountered, and to suggest methodology to facilitate earlier diagnosis. The records of all patients treated by two of the authors for bilateral equinovarus deformities and found to have either a unilateral or bilateral tarsal coalition between 2006 and 2016 were reviewed. Nine feet with tarsal coalition (calcaneonavicular n = 7 and talocalcaneal n = 2) were reviewed. Five of these cases occurred in patients with idiopathic equinovarus and four cases in patients with equinovarus related to a neurologic disease. All patients were definitively diagnosed by computed tomography scans with 3D reconstruction. In 56% of cases, the patient had previously undergone at least one open procedure before the coalition was recognized. The mean age at diagnosis of the coalition was 11.4 years. Our experience suggests that tarsal coalitions, particularly calcaneonavicular coalitions, may occur more frequently in equinovarus deformities than previously reported. Upon recognition and removal of these coalitions, we were able to achieve improved correction of the equinovarus deformities and improved range of motion. We recommend that surgeons maintain an awareness of this potential concomitant problem in all equinovarus foot deformities and consider advanced imaging in cases which fail to respond to traditional treatment.

Reliability of the talocalcaneal angle for the evaluation of hindfoot alignment. / Fiabilidad del ángulo astrágalo-calcáneo para la evaluación de la alineación del retropié.

INTRODUCTION: Recent studies suggest that hindfoot deformity should be considered in the surgical treatment of tarsal coalitions. Many authors have used the angle between the talus and the calcaneus (TCA) for decision-making. However, its reliability has not been demonstrated and the measurement technique has not been standardized. The objective of this study was to standardize the TCA measurement technique, and to evaluate the inter and intra-observer reproducibility of the proposed technique. METHODS: The foot CT scans of a group of 30 patients between 10 and 17 years of age were analysed. Ten patients had talocalcaneal coalitions, ten calcaneonavicular coalitions and ten had no coalitions. The inter and intra-observer reproducibility of the TCA was evaluated by the intraclass correlation coefficient (ICCs). A mixed-effects ANOVA model was used to calculate the ICCs for ICC2 agreement (A, 1). This procedure was applied to the three observers (inter-observer variability), and to the test-retest of observer 1 (intra-observer variability). A two-tailed p value of ≤.05 was considered significant. RESULTS: The inter-observer and intra-observer agreements were excellent for the TCA. Inter-observer agreement: ICC2 (A, 1)=.95 (p<.001, CI 95%: .77-.93). Intra-observer agreement: ICC2 (A, 1)=.99 (p<.001, CI 95%: .97-.99). CONCLUSION: The TCA is a reliable way to evaluate hindfoot alignment. This method of measurement, as described in this study, can be safely used for surgical planning in patients with tarsal coalitions.

Bilateral tarsal tunnel syndrome attributed to bilateral fibrous tarsal coalition and symmetrical hypertrophy of the sustentaculum tali.

Tarsal tunnel syndrome (TTS) is one of the frequently encountered entrapment neuropathies of the lower limb. Most often the aetiology is considered to be idiopathic. However, it has to be thoroughly investigated to rule out diverse extrinsic and intrinsic causes. The sustentaculum tali (ST) forms the superior part of the distal tarsal tunnel, and any increase in its size may result in irritation of the tibial nerve or its branches, the medial and lateral plantar nerves or decrease the overall volume of the tarsal tunnel culminating to clinical features of TTS. A hypertrophied ST is an extremely rare cause for TTS, and we report perhaps a first case of bilateral TTS in a young adult due to bilateral symmetrical hypertrophied ST which in turn was a result of bilateral fibrous tarsal coalition. Staged bilateral surgical excision of the hypertrophied part of ST and the underlying fibrous tarsal coalition ensured prompt symptomatic relief.

Tarsal Coalition in Children.

Tarsal coalition (a congenital fibrous, cartilaginous, or bony connection between two bones) classically presents with recurrent ankle sprains or with insidious onset of a painful, stiff flatfoot. Flatfoot is a benign finding most of the time, but it is important to distinguish the rigid flatfoot from the flexible flatfoot. A patient with recurrent sprains of the ankle or a stiff flatfoot should be evaluated for a tarsal coalition. The key to making the diagnosis is careful examination for stiffness in the subtalar joint and appropriate imaging studies. Both nonoperative and operative measures can be used to treat this condition.

A rare presentation of foot pain: bilateral navicular-medial cuneiform coalition.

In this case report, we discuss a rare tarsal coalition occurring bilaterally between the navicular and the medial cuneiform in a 15-year-old girl and highlight the management of such cases.

Coalición calcáneo-navicular asociada a pie plano rígido infantil. A propósito de un caso / Calcaneus-navicular coalition associated to flatfoot in a child. A case report

Las coaliciones tarsales (unión fibrosa, cartilaginosa u ósea congénita entre dos huesos) a menudo son asociadas a una deformidad de pie plano en niños. Normalmente se presenta con esguinces de tobillo recurrentes o con inicio insidioso de un pie plano rígido doloroso y con limitación al movimiento de las articulaciones mediotarsianas y subastragalina. El diagnóstico clínico se confirma con radiografía, tomografía axial computerizada (TAC) y resonancia magnética nuclear (RMN). El signo de la nariz del oso hormiguero es causado por un alargamiento tubular del proceso anterior del calcáneo que se acerca o se superpone con el escafoides tarsiano y se asemeja a la nariz de un oso hormiguero en una radiografía lateral del pie o tobillo. El tratamiento de esta unión es primeramente sintomático, pero si el dolor persiste debe ser quirúrgico. Se presenta el caso de un niño de 10 años con coalición calcáneo-navicular bilateral asociada a pie plano valgo rígido (AU)

Tarsal coalition (a congenital fibrous, cartilaginous or bony connection between two bones) often leads to a flatfoot deformity in children. Usually it presents with recurrent ankle sprains or insidious onset of a painful rigid flatfoot and movement limitation of midtarsal and subtalar joints. Clinical diagnosis is confirmed by X-rays, computed axial tomography and nuclear magnetic resonance. The anteater nose sign is caused by a tubular elongation of the anterior process of the calcaneus that approaches or overlaps the tarsal scaphoid (navicular) and resembles the nose of an anteater on a lateral foot or ankle radiograph. The treatment of this union is primarily symptomatic but if the pain persists must be surgical. For a child of 10 years with bilateral calcaneus - navicular coalition associated with valgus rigid flatfoot arises (AU)