Tarsal Coalition

PROF. DR. MOHAMMED HEGAZY. MD,

DEFINITION

▶ Tarsal coalition is a congenital bridging of two or more tarsal bones

of the foot.
▶ Calcaneus is held in eversion cause of peroneal spastic flatfoot,
which is a complex of pain, rigid valgus deformity of the hind foot
and forefoot, and peroneal muscle spasm.
▶ Rigid flat foot in children is most often due to tarsal coalition.
ETIOLOGY AND HEREDITY

▶ autosomal dominant inheritance

▶ failure of embryonic segmentation of primitive mesenchyme.
▶ Incomplete division leads to tarsal coalition
▶ The condition is known to run in families
▶ 50% bilateral
▶ Incidence - 0.4-6%
 ANATOMY

The talocalcaneal joint is

composed of the posterior,
middle, and anterior articular facets
The middle and anterior facets may
be separate, partially
fused, or completely fused

The anterior process of the calcaneus

is aligned obliquely with the navicular.
Classification

Etiological
1. Acquired
▶ Arthritis
▶ Infection
▶ Neoplasia
▶ Trauma

2. Congenital
Classification
Tissue type
▶ Bone -- synostosis
▶ Cartilage -- synchondrosis
▶ Fibrous tissue-- syndesmosis
Classification
Anatomical
▶ Talo-calcaneal
▶ Calcaneo-navicular
▶ Post talo-calcaneal
▶ Cubo-navicular
▶ Talo-navicular
▶ Calcaneo-cuboid
PATHOMECHANICS
▶ normal external rotation of the calcaneus through the subtalar joint
is blocked (inversion).
▶ Compensatory motion must occur in the ankle joint or distal to the
subtalar joint, causing progressive laxity. The calcaneus is forced into
valgus. The forefoot is abducted, the arch flattens,
▶ the navicular overrides the talus to cause talar beaking.
▶ Because the subtalar joint cannot invert, peroneal tendon excursion
is limited, and eventually the tendon is shortened. If an attempt is
made to invert the foot, the peroneal muscles contract, resulting in
peroneal spasm.
Associated conditions

▶ Talipes cavo varus

▶ Talipes equino varus
▶ Fibular hemimelia
▶ PFFD
▶ Neivergelt-pearlman syndrome- massive tarsal and carpalcoalitions
▶ Apert’s syndrome-synostosis of tarsal bones
Clincal presentation

▶ history of prior recurrent ankle sprains

▶ Asymptomatic :most coalitions are found incidentally
▶ 75% of people are asymptomatic
▶ Symptoms : do not develop until ossification of the fibrosyndesmosis
or the cartilagious synchondrosis
▶ Syndesmosis and synchondrosis are usually more troublesome than
synostosis
▶ Symptoms – vague foot pain, difficulty in walking on uneven
surfaces, foot fatigue, painful limp
▶ Tenderness is present along the bar
▶ Incidence - 0.4-6%
DIAGNOSTIC EVALUATIONS
special tests: reverse Coleman block test
evaluate for subtalar rigidity
Plain Radiographs
▶ AP view is the least useful, but may demonstratea talonavicular
coalition.
▶ lateral is a useful view
▶ oblique views of varying angles may be needed, starting with 45°.
▶ Harris view : ankle slightly dorsiflexed at 10°, the beam is directed
through the hindfoot at a 45° angle
Computerized Tomography determine size, location and extent of
coalition
Magnetic Resonance Imaging visualize a fibrous or cartilaginous
coalition
 Laterai radiograph of a normal hind foot

false coalition from overlapping structures

"tarsal pseudocoalition"
lateral radiograph shows the posterior articular
facet joint {arrows} and the middle articular Laterai radiograph of a
facet joint (arrowheads),which are usually normal hindfoot with slight
parallel! and angled 45° to the long axis of the abduction
calcaneus.
Talocalcaneal Coalition
Lateral Radiograph

Lateral radiograph shows secondary signs of a

patient with talocalcaneal coalition. A talar beak is
apparent on the dorsum of
the talus (white arrow).
The lateral process of the talus is broad and rounded
(black arrow).
The posterior facet articular joint is narrowed (black
arrowheads), as is the middle facet articular joint
(white arrowheads)
Lateral radiograph of the foot reveals a classic C sign
(arrows), which is a C-shaped line formed by the
medial outline of the talar dome and the inferior
outline of the sustentaculum tali. The C sign is a
reliable indicator of subtalar coalition on lateral
radiographs.
Anteater Nose
Lateral Radiograph
Calcaneonavicular Coalition
Lateral radiograph demonstrates an elongation of the
anterior process of the calcaneus, or "anteater nose,"
which is a consistent sign of calcaneonavicular coalition.
 Downey Articular classification
system
▶ Juvenile (Osseous Immaturity)
Type I - Extra- articular coalition
A - No secondary arthritis B - Secondary arthritis
Type II - Intra- articular coalition
A - No secondary arthritis B - Secondary arthritis
▶ Adult (Osseous Maturity)
Type I - Extra- articular coalition
A - No secondary arthritis B - Secondary arthritis
Type II - Intra- articular coalition
A - No secondary arthritis B - Secondary arthritis
Talo-calcaneal coalition

Ossify between 12-16 yrs

Foot fatigue
Hind foot pain
Loss of longitudinal arch
Peroneal spasm
Subtalar motion – reduced or absent
Sinus tarsi tenderness
Tenderness over talo-navicular joint
Heel valgus
 Calcaneo-navicular coalition
Clinical features

Ossifies at 8-12 yrs

Incomplete coalitions – more symptomatic
Vague dorsolateral foot pain
Difficulty to walk on uneven surfaces
Foot fatigue Painful limp
Subtalar motion – reduced
Longitudinal arch flattening
Hindfoot valgus
Peroneal spasm
Fracture of the bar or sprain of the fibrous bar produces severe
pain and peroneal spasm
Management

Surgical options
▶ Resection of bar
▶ Subtalar arthrodesis
▶ Calcaneal osteotomy
▶ Triple arthrodesis
Indication of Triple arthrodesis

▶ Extensive talocalcaneal coalition

▶ Multiple coalition
▶ Development of sec. degenerative arthritis
▶ Ball and socket ankle joint
▶ When the coalition involves more than 50% articular surfaceof
talocalcaneal joint or more than 50% of the posterior facet
Juvenile - IA
▶ Resection with interposition of EDB muscle
▶ Resection with interposition of adipose tissue
▶ Resection with varus-producing calcaneal osteotomy
▶ Resection with insertion of implant
▶ Varus-producing osteotomy alone
Juvenile - IB
▶ Resection with interposition of EDB muscle
▶ Resection with interposition of adipose tissue
▶ Resection with varus-producing calcaneal osteotomy
▶ Resection with insertion of implant
▶ Varus-producing osteotomy alone
▶ Triple arthrodesis
Juvenile - IIA
▶ Resection alone
▶ Resection with interposition of adipose tissue
▶ Resection with interposition of arthroereisis
▶ Resection with varus-producing calcaneal osteotomy
▶ Varus-producing calcaneal osteotomy alone
▶ Isolated/single arthrodesis
▶ Triple arthrodesis
Juvenile - IIB
▶ Triple arthrodesis
▶ Adult - IA
Resection with interposition of EDB muscle
Resection with interposition of adipose tissue
Resection with varus-producing calcaneal osteotomy Resection with
insertion of implant
Varus-producing osteotomy alone
Triple arthrodesis
▶ Adult - IB
 Resection with isolated/single arthrodesis
 Triple arthrodesis
▶ Adult - IIA
 Isolated/single arthrodesis
 Triple arthrodesis
▶ Adult - IIB
 Triple arthrodesis
Talocalcaneal coalition resection
▶ approach
medial approach to hindfoot
▶ incision
horizontal or curved incision centered over sustentaculum tali
between flexor digitorum longus and neurovascular bundle
▶ technique
sustentaculum tali usually just plantar to the talocalcaneal coalition
identify normal subtalar joint cartilage by dissecting out the anterior and posterior
facets
this will help determine location and size of coalition resection
confirm with two needles immediately anterior and posterior to coalition clinically
and confirm with fluorscopy
resect coalition with high speed-burr, ronguers and curettes
invert and evert subtalar joint to demonstrate improvement in subtalar motion
interpose fat, bone wax or portion of flexor hallucis longus tendon into defect
▶ post-operative
short-leg non-weight bearing cast for three we
Calcaneonavicular coalition resection
▶ approach
▶ anterolateral approach over coalition
▶ incision
▶ oblique incision just distal to subtalar joint
▶ between extensor tendons and peroneal tendons
▶ technique
▶ protect branches of superficial peroneal and sural nerves
▶ reflect fibrofatty tissues in sinus tarsi anterior and extensor digitorum brevis distally
▶ identify coalition between anterior process of calcaneus and navicular bones
and confirm with fluorscopy
▶ excise bar with saw or osteotomes, which leaves defect ~1cm in size
▶ interpose fat, bone wax or portion of extensor digitorum brevis muscle into
defect
▶ post-operative
▶ short-leg, non-weight bearing cast for 3-4 weeks
Complication

▶ incomplete resection
▶ Recurrence of the coalition
▶ Residual pain or stiffness
due to malalignment or associated arthritis
due to unrecognized 2nd coalition - this should be identified by a
preoperative CT scan
Take home message

▶ Tarsal coalition is a congenital bridging of two or more tarsal bones

of the foot.
▶ Rigid flat foot in children is most often due to tarsal coalition
▶ autosomal dominant inheritance runs in families
▶ most coalitions are found incidentally
▶ CT scan suggested as part of the preoperative workup
▶ shoe inserts and conservative treatment cause of discomfort with
unclear indication
▶ Triple arthrodesis is indicated in severe cases with multiple coalitions