Introduction: Congenital tarsal coalition is one of the most prevalent (1–6%) anomalies of the hindfoot and midfoot. Its etiology is unknown. By definition there are boney, cartilaginous or fibrous brigdes between 2 bones of the hindfoot and midfoot, which are classified by their localization; the most common coalitions are calcaneonavicular (53%) and talocalcaneal (37%). Patients and Methods: From 2001 to 2007 28 patients with 37 coalitions had surgery at the Orthopedic Hospital Vienna-Speising. 32 calcaneonavicular coalitions were surgically excised and an autogenous free fat graft was interponed to prevent a relapse. 1 calcaneonavicluar coalition also had an interposition of the extensor digitorum brevis after resection, while 1 calcaneonavicular coalition had lengthening of the short peroneal tendon in addition to excision and autogenous free fat graft. 1 calcaneonavicular coalition had to have an arthrodesis of the talocalcaneal joint. From 2 talocalcaneal coalitions 1 had excision the other 1 talocalcaneal arthrodesis. Both of the coalitions that had arthrodesis had short-leg plastercasts for 12 to 13 weeks. For patients with bilateral coalition pedobarography was performed and the foot that had been treated compared to the untreated contralateral side. For these patients the AOFAS ankle and hind foot score and pain according to the VAS were evaluated. Results: 22 coalitions that had had surgery were uncomplaining after intervention, including 1 patient who had had arthrodesis. 3 calcaneonavicular coalitions that had had excision and autogenous free fat graft had a relapse within 2 to 3 years. 2 of them had a revision and second-look excision of the bridge. 1 patient showed a suspicious relapse in MRI after excision of a calcaneonavicular coalition. 1 talocalcaneal coaltion that had had excision continued to have pain after surgery. Both patients did not want a revision. 1 patient who was treated by an arthrodesis of the subtalar joint had a fracture of the tibial head, where autogenous bone graft had been taken. Osteosynthesis of the tibia was performed. 4 patients had pain after excision of a calcaneonavicular coalition but could be relieved by conservative treatment. For 5 patients adequate follow up is still pending due to short interval to surgery. Pedobarography showed tendecies of improved pressure distribution of the treated feet that were not significant. Conclusion: Excision and autogenous free fat graft should be first approach to surgery of symptomatical congenital tarsal coalitions for whom conservative treatment was not satisfying. When resected sufficiently the rate of relapse of the boney, cartilaginous or fibrous bridge is 7%. Depending on the patients age, the size of the affected area of the joint (50%) and secondary arthrotic changes of the joint an arthrodesis of the talo-calcaneal joint should be performed

Between 1978 and 1999, surgical treatment for talocalcaneal coalitions which failed to respond to any conservative treatment was performed. Materials consisted of 46 patients (50 feet), including 26 males (29 feet) and 20 females (21 feet). The patients’ age at the time of operation ranged from 8 to 66 years (average, 22.5 years). Major symptoms included local pain (43 feet), tumor (19 feet), numbness of the plantar side (17 feet), peroneal muscle spasm (13 feet), and varus instability of the ankle (3 feet). Major signs included limited motion of the subtalar joint (50 feet), palpation of tumor (34 feet), sensory disturbance of the plantar side (14 feet), peroneal spastic flat foot (3 feet), and limited dorsiflexion of the ankle due to contracture of the gastrocnemius muscle (2 feet). The regions of the coalitions included middle type (36 feet), posterior type (9 feet), and diffuse type (3 feet). The coalitions were all incomplete unions, that is to say fibrous or cartilaginous unions. Surgical treatments were as follows: coalitions were excised and subtalar joints were mobilized in 31, resections alone were carried out on 16, and 3 feet underwent arthrodesis of the subtalar joint. Results of surgical treatments were evaluated using our own clinical scoring system. 28 feet were excellent, 13 were good, 8 were fair, and one foot was poor. In principle, the purpose of surgical treatment of these coalitions involved excising the tumor to release the plantar nerve from compression and resection the coalition to gain physiological subtalar motion. However, patients experiencing osteoarthrotic changes and whose coalitions occupy most of the subtalar joint should undergo an arthrodesis of the subtalar joint

Surgical resection of the persistently painful talocalcaneal tarsal coalition has not been shown to reliably relieve symptoms in patients with coalitions that are large and have associated hindfoot valgus and subtalar arthrosis. It has been recommended that these patients undergo triple arthrodesis, a procedure that is known to lead to premature arthrosis of the ankle joint. To avoid additional stress on this important joint, treatment of this patient group using calcaneal lengthening osteotomy (CLO), with or without resection of the coalition, has been performed at our institution for the last 15 years. A retrospective review of all patients with talocalcaneal coalitions who had undergone CLO was performed. Clinical and radiographic records were reviewed. Demographic data, and pre- and post-operative pain and function were recorded. Pre- and post-operative radiographs and computed tomography (CT) scans were reviewed and measurements recorded. CT scans were used to calculate the degree of hindfoot valgus and the size of the coalition. Patients were invited to return for clinical examination and follow-up x-rays if two years had passed since their operation. They completed American foot and ankle hindfoot scores, VAS pain scores and were asked satisfaction questionnaires. Radiographic measurements were performed. There were 13 patients who underwent 19 CLOs. Of these 13 patients, eight patients with 13 CLO’s returned for clinical examination and radiographs. Five patients had nine CLO’s to correct deformity without resection of a large middle facet talocalcaneal coalition with severe hindfoot deformity. All patients had restoration of normal foot shape with improvement in comfort and function. One patient had improvement in comfort and function following bilateral simultaneous coalition resection of cartilaginous coalition and CLO to correct significant hindfoot deformity. Two patients had improvement in pain and function in a foot that had residual pain and deformity following prior talocalcaneal coalition resection. CLO, usually accompanied by a heel cord lengthening, is a useful operation both in the failed middle facet resection where there is persistent pain and deformity, and also in the very large coalition with associated deformity and/or arthrosis that is not appropriate for resection. It corrects the foot deformity, improves comfort and function, maintains motion in Chopart’s joints and therefore, unlike triple arthrodesis, avoids additional stresses in the ankle joint

A retrospective review of records, radiographs, Computerized Tomography (CT) scans, and Magnetic Resonance Imaging (MRI) scans was done from January 1994 to January 2002. Of the 35 patients in this study, 15 were females and 20 males. The mean age of the patients was 12.8 years (range, 9 to 19 years). There were 14 feet with bilateral coalition, 8 were right and 13 were left. There were 28 talo-calcaneal (all middle facets) coalitions of which 9 were bilateral. There were 20 calcaneo-navicular coalitions of which 5 were bilateral. One patient had a naviculo-cuboid coalition. The mean followup was 6.4 months (range, 1.2 to 36 months). Twenty six patients were treated conservatively with satisfactory outcome. Of the 23 patients operated 16 patients had good outcome, 5 had fair outcome, and 2 had poor outcome. Totally there were 10 out of 329 patients that had multiple tarsal coalition when we reviewed our cases and the literature. This gave an incidence of 3 percent of all the symptomatic tarsal coalition i.e. in other words the true incidence of multiple coalition is around 0.03%. This is the only study that establishes the incidence of multiple coalition

Purpose: The current study assessed the post-operative long-term outcome of up to 9 years follow-up of tarsal coalition treated with resection, utilizing the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score. To the best of our knowledge this is the first study utilizing that score in regard to Tarsal coalition resection as a sole treatment. Materials and Methods: Between 1988 and 1999, 36 patients (36 feet) with painful flatfoot and restricted range of motion attributable to talocalcaneal and calcaneonavicular coalition were treated with resection of the coalition in multiple medical centers in Israel. Thirty-one patients were male and five female. Twentyfive patients had unilateral coalition and eleven patients had bilateral coalition. Coalition types were talocalcaneal(29) and calcaneonavicular(7). The patients were interviewed and examined during a follow-up period of 12 to 108 months, with an average of 51.6 months. Results: Outcome was based on the ankle hindfoot clinical rating system of the American Orthopaedic Foot and Ankle Society. The clinical results were also evaluated statistically. Favorable outcome was evident in only 50% of cases. Average score was 79.2 in talocalcaneal coalition patients and 85.4 in calcaneonavicular coalition patients (not statistically significant). A multivariate statistical analysis was done and an equation was found, which elucidates the connection between age, gender and diagnosis, and AOFAS score. Conclusions: On the basis of these results, three parameters were found to affect the operative outcome: age, type of coalition and gender. Age itself stands alone as a predictive tool to the postoperative outcome. The equation that was found to correlate age, type of coalition and gender with the score can act as a predictive tool of the outcome and aid in preoperative patient selection for tarsal coalition resection

We examined seven patients with tarsal tunnel syndrome in one foot caused by talocalcaneal coalition and a ganglion. We excised the coalition and the ganglion in six of them. All the patients had pain, sensory disturbance in the sole, and a positive Tinel’s sign. Older patients with a long history showed atrophy and weakness of the plantar muscles. Talocalcaneal coalition can be diagnosed on a plain lateral radiograph and an anteroposterior radiograph externally rotated 20°, and confirmed by CT. MRI is also useful for diagnosis. The coalitions were medial, and the ganglion had developed from the incomplete part of the coalition; it was multilocular in some patients. After resection, there was early pain relief but sensory disturbances and Tinel’s sign persisted. The postoperative results were excellent in one patient, good in four and fair in one

Over a nine-year period, 20 feet with persistently symptomatic talocalcaneal coalition were treated by resection of the bar. The 17 patients were all under 16 years of age. Excellent or good long-term results were achieved in the ten feet in which preoperative coronal CT had shown that the area of coalition measured 50% or less of the area of the posterior facet of the calcaneum. In these feet heel valgus was less than 16 degrees and there were no radiographic signs of arthritis of the posterior talocalcaneal joint. Talar beaking was present in 70% of these feet but it did not impair the clinical result. Fair or poor results were observed in the ten feet in which preoperative CT had shown the area of relative coalition to be greater than 50%. In these feet, heel valgus was greater than 16 degrees and most had narrowing of the posterior talocalcaneal joint and impingement of the lateral process of the talus on the calcaneum

Introduction: Many surgeons recommend surgical resection of symptomatic tarsal coalition. The success of this procedure in reducing symptoms has been well described in the literature, but long term results remain scarce. In 1967 Mitchell et al described a series of 41 resections of calcaneonavicular coalition with an average 6 year follow up. In 1990 Gonzalez et al described two groups who underwent a total of 75 resections of calcaneonavicular coalition by multiple surgeons. We describe the largest combined series of calcaneonavicular and talocalcaneal coalition resection with a minimum follow up of 3 years and a maximum of 12 years (average 9.5 years). Methods: We retrospectively studied the clinical results of a consecutive series of 79 primary resections for tarsal coalition in 63 patients carried out by the senior author over a 12 year period. A standard resection procedure was performed in each case. Duration of symptoms, side of maximal symptoms, activity level, family history, peroneal spasm, and patient weight preoperatively was recorded retrospectively using medical records. Visual analogue pain scores, analgesia requirement, activity level, time to return to maximum activity, occupation, patient and parent satisfaction level, peroneal spasm, range of motion, AOFAS ankle-hindfoot score, and patient body mass index was recorded at follow up. Results: At follow up the majority of patients had mild or no pain and did not require regular analgesia, had some limitation of recreational activities but not of daily activities, and had some stiffness. The majority of patients and parents were satisfied with the outcome. Discussion: Resection of tarsal coalition is recommended when symptomatic but also is recommended bilaterally when present regardless of symptomatology of the lesser affected foot

1. A clinical and radiological survey has been made of the families of thirty-one patients with peroneal spastic flat foot and tarsal coalition (twenty-seven calcaneo-navicular, four talo-calcaneal). 2. Thirty-nine per cent of ninety-eight first degree relatives were found to have some type of tarsal coalition. 3. A surprise finding was that not one of the first degree relatives had ever had symptoms referred to the tarsus. 4. No case of "ball and socket" ankle joint or of carpal coalition was found in this series

We analysed 42 weight-bearing lateral radiographs of the ankle, 20 of which were from patients with a clinical and plain radiological diagnosis of talocalcaneal coalition (TCC) who subsequently had CT. The remainder were from 22 healthy volunteers with no clinical findings suggestive of hindfoot pathology. Four observers, blinded to the CT findings, independently evaluated the radiographs on two separate occasions. With the 95% confidence interval and using the CT findings as the comparison we calculated the sensitivity, specificity, accuracy, and positive and negative predictive values for the C-sign, and for other signs known to be associated with TCC. Similarly, we also calculated the interobserver and intraobserver reliability for these signs using the kappa statistic. Our results suggest that the C-sign is highly sensitive and specific for TCC. It is an accurate indicator and significantly more reliable than other previously recognised radiological signs of TCC. Features of the C-sign, however, cannot be relied upon to indicate whether the TCC is fibrous or bony

1. Tarsal coalition often presents with the clinical picture of a peroneal spastic flat foot, but may present with a painful varus foot and spasm of the tibial muscles. 2. Three cases of tibialis spastic varus foot are described with a calcaneo-navicular bar as the associated anomaly. 3. Complete excision of the bar with interposition of the origin of the extensor digitorum brevis muscle appears to be a satisfactory method of treatment when carried out at a sufficiently early age

Peroneal spastic flatfeet without coalition or other known etiologies in adolescence remain a challenge to manage. We present eight such cases with radiological and surgical evidence of bony abnormalities in the subtalar region just anterior to the posterior facet. All patients had presented as tertiary referrals with recalcitrant pain and had undergone a trial of orthotics and physiotherapy. Diagnostic workup included a clinical and radiographic evaluation. Clinical examination consisted of gait examination, foot alignment, range of motion, torsional profile of the lower limbs and marking of symptomatic foci. All patients had standing weightbearing AP and lateral projections of the foot and ankle. CT and/or MRI scans of the foot were performed in axial coronal and saggital planes. Coalitions and other intraarticular known pathologies were ruled out. All patients had bilateral flatfeet but unilateral peroneal spasm. All patients had an accessory talar facet in front of the posterior subtalar facet. This caused lateral impingement between the facet and the calcaneum, confirmed by bone edema around the sinus tarsi. All patients had stiff subtalar joints with very limited movement under anaesthesia, indicating peroneal muscle contracture. Patients were treated with a combination of facet excision, peroneal lengthening and calcaneal lengthening to correct the flatfoot and prevent lateral impingement. We propose a mechanism of subtalar impingement between the anterior extra-articular part of the talar lateral process and the Gissane angle and believe that resection of the accessory facet without addressing the the primary driving force for impingement, which is the structural malalignment in flatfeet, would only give partial relief of symptoms. This impingement appears to occur with growth spurts in adolescents, in patients with known flatfeet

Painful peroneal spastic flatfeet without coalition or other known etiologies in adolescence, remains a difficult condition to treat. We present eight such cases with radiological and surgical evidence of bony abnormalities in the lateral subtalar region just anterior to the posterior facet. All patients had presented as tertiary referrals with recalcitrant pain and had undergone a trial of orthotics and physiotherapy. Diagnostic workup included a clinical and radiographic evaluation. Clinical examination consisted of gait examination, foot alignment, range of motion, torsional profile of the lower limbs and marking of symptomatic foci. All patients had standing weightbearing anteroposterior and lateral projections of the foot and ankle, CT and/or MRI scans of the foot. Coalitions and other known intra-articular pathologies like subtalar arthritis were ruled out. All patients had bilateral flatfeet but unilateral peroneal spasm. All patients had an accessory anterolateral talar facet (ATF) which was arising as an anterior and distal extension of the lateral process of the talus. This caused lateral impingement between the facet and the calcaneum, confirmed by bone edema around the sinus tarsi and marked at the apex of the angle of Gissane on MRI scans. All patients had stiff subtalar joints with very limited movement under anaesthesia, indicating peroneal muscle contracture. Patients were treated with a combination of facet excision, fractional peroneal and gastrosoleus lengthening and calcaneal lengthening to correct the flatfoot and prevent lateral impingement

Aim. Historically, surgeons have focused on isolated simple coalition resection in symptomatic tarsal coalition with concomitant rigid flat foot. However, recent evidence suggests that coalitions with severe preoperative planovalgus malposition treated with resection alone are associated with continued disability and deformity. We believe that concomitant severe flatfoot should be considered as much as a pathological component and pain generator as the coalition itself. Our primary hypothesis is that simple resection of middle facet tarsal coalitions and simultaneous flat foot reconstruction can improve clinical outcomes. Method. We identified eleven children (13 feet) who had resections of middle facet tarsal coalitions with or without complex foot reconstruction (calcaneal lengthening, medial cuneiform osteotomy) for concurrent severe planovalgus between 2003 and 2011. Clinical examination, American Orthopaedic Foot and Ankle Society (AOFAS) hind-foot scores, and radiographic assessments were evaluated after resection of middle facet tarsal coalitions with simultaneous flat foot reconstruction. Results. Isolated coalition resection provided short to intermediate term pain relief for three children that had this as a solitary procedure. Calcaneal lengthening osteotomy performed as an additional procedure in patients with very severe and stiff planovalgus provided excellent correction and symptomatic pain relief in all six patients (Mean AOFAS: 91). Two patients had insertion of sinus tarsi implants in addition to resection also had satisfactory hind foot function (Mean AOFAS: 87.3) post operatively. Conclusion. This study shows that calcaneal lengthening osteotomy in addition to coalition resection in patients with severe rigid flat feet provides excellent pain relief and function. Rigid flat feet should be considered as a significant contributor to the pain complex in this cohort of patients

Introduction. Historically, surgeons have focused on isolated simple coalition resection in symptomatic tarsal coalition with concomitant rigid flat foot. However, a review of literature suggests that coalitions with severe preoperative planovalgus malposition treated with resection alone are associated with continued disability and deformity. We believe that concomittant severe flatfoot should be considered as much as a pathological component and pain generator as the coalition itself. Our primary hypothesis is that simple resection of middle facet tarsal coalitions and simultaneous flat foot reconstruction can improve clinical outcomes. Methods. Thirteen consecutively treated patients (eighteen feet) were retrospectively reviewed from the senior author's practice. Clinical examination, American Orthopaedic foot and Ankle Society (AOFAS) hindfoot scores, and radiographic assessments were evaluated after resection of middle facet tarsal coalitions with simultaneous flat foot reconstruction. Results. All patients with resection and simultaneous flat foot reconstruction (calcaneal lengthening, medial cuneiform osteotomy) were satisfied and would have the same procedure again. Most patients were able to return to a higher level of sporting activity compared with preoperative ability. None of the patients had a fair or poor outcome as adjudged by their AOFAS scores. Conclusion. Our study shows that concomittant flatfoot reconstruction in patients with symptomatic middle facet tarsal coalition increased hindfoot motion, corrected malalignment and significantly improved pain. We believe that coalition resection and concomitant flatfoot reconstruction is better option than surgical resection alone or hindfoot fusion in this cohort of patients. Triple arthrodesis should be reserved as a salvage procedure

The incidence of tarsal coalitions (TC) is not known. Most of the clinical studies report it as less then 1% but they disregard the asymptomatic coalitions. Two main theories have been elaborated regarding their etiology: 1) they result by incorporation of accessory bones into the nearby tarsals; 2) they occur as a result of the failure of differentiation and segmentation of the foetalmes-enchyme. Tarsal coalitions have been associated with degenerative arthritic changes. Computer tomography 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. For this purpose we have undertaken coronal and sagittal CTs of 114 cadaveric feet which were subsequently dissected. The dissections identified 10 non-osseous tarsal coalitions, two talocalcaneal and eight calcaneonavicular. In nine cases we identified a synovial joint between the calcaneus and the navicular. We identified eight os trigonum, one accessory lateral malleolus bone, 38 sesamoid bones in the tendon of tibialis posterior and 19 sesamoid bones in the tendon of fibularis longus. Tarsal arthritis was identified in 37 cases. Both talocalcaneal coalitions were associated with talocal-caneal arthritis while none of the calcaneonavicular coalitions were associated with tarsal arthritis. The CT examination of five of the cases of calcaneonavicular coalitions showed one coalition and was suspicious of a coalition in another two instances. In conclusion our study demonstrated that the incidence of tarsal coalition is higher than previously thought (8.8%). The calcaneonavicular coalitions are more common (7%) but they do not seem to be associated with arthritic changes in the tarsal bones. The 7.9% of the calcaneonavicular synovial joint demonstrate that the “abnormality” of the calcaneonavicular space can take any form. Our preliminary CT results demonstrate a low sensitivity in the detection of nonosseous coalitions