Ronald L Soave, DPM reviews the etiology, epidemiology, clinical findings, imaging and treatment in patients with tarsal coalitions. Dr Soave includes in his discussion case examples showing intra-operative findings as well as provides tips on decreasing recurrence when addressing tarsal coalitions.
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Ronald Soave, DPM
Chief of Podiatry & Program Director
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Male Speaker: Okay. Today, I'm going to also finish up with tarsal coalition. Again, for time, we’re just going to keep it to the basics on this. What’s the definition of a coalition? It’s a union between two or more tarsal bones, can be partial or complete. If it’s bony, it’s synostosis. If it’s cartilage, it’s synchondrosis. If it’s fibrous, it’s syndesmosis and results in a limitation or absence of range of motion of the surrounding joints left longstanding could also lead to arthritis. Mike Downey also talked about whether they were intraarticular or extraarticular. Basically, intraarticular, the common one would be a talocalcaneal type of union versus an extraarticular would be considered like a CN coalition where it was not considered a joint. The coalitions are documented in less than 1% of the population. But a lot of these are asymptomatic so the true incidence is higher. A lot of people don’t even realize they have coalition. Or sometimes, later in life, it may come in to you, you may see it on an x-ray for some other reasons that they come in. Majority involve the TC joint, also the calcaneonavicular joint followed by the TN coalitions. Fifty percent could be bilateral, slight male predominance. Usually, a clinical finding is a peroneal spastic flatfoot. Congenital is more common than the acquired type. It’s usually seen in the adolescents. The acquired is usually caused by some sort of arthritis, infection, trauma, neoplasm which is a secondary coalition that’s going on. The acquired is less common than the congenital. What are the clinical presentations? The symptoms usually present during the second decade of life. It usually happens as the coalition starts to ossify. The TN coalition starts to ossify in three to five years, the CN coalition in eight to 12 years and the TC coalition, 12 to 15 years old. The most common symptom is deep aching pain in the area of the coalition. Secondary findings again could be a peroneal spastic flatfoot which is a secondary finding due to guarding. The pain is usually insidious. After you see they're playing sports or minor trauma aggravated by activity, relieved by rest. Sometimes they just come in for another reason. They think they just have an ankle sprain and so forth and then they come in and then you take an x-ray and you find this coalition. There’s usually limitation of motion of the subtalar joint. They could be in an everted attitude secondary to the peroneal spasm. How you identify this to see if it is more of a rigid type of deformity from the spasm is you could do the Hubscher maneuver or the toe raise test. Again, the Hubscher maneuver is just singly when you should if you raise your toe, you dorsiflex the toe, the arch should increase. The toe raise test, you should see that the foot inverts as they stand on their toes from a resting position. If you did not see the arch increase in either of these maneuvers, it’s indicative that you have more of a rigid-type deformity which could include a coalition and you have to rule that out. Diagnosis is by proper history. Evaluate for the range of motion. Evaluate them in the stance phase. Both I would evaluate nonweightbearing and weightbearing. If they’re into spasm, you want to see if once you relieve the spasm, will the range of motion return? You can perform a peroneal nerve block or in the case of a TC coalition, maybe you do the sinus tarsi injection. Basically, the peroneal nerve block, given at the neck of the fibula as the common peroneal nerve transverse is around to here. The purpose is, is that once you receive anesthesia in this area, the spasm should release and then the motion should increase in the foot. You could also give a local sinus tarsi injection. That would be for relief of pain as a diagnostic tool to see if the guarding also decreases. Remember, the guarding is secondary to the pain factor. Diagnosis, the TP view is best for the TN coalition. You can see there. There’s the talonavicular coalition.
The medial oblique view is best to identify a calcaneonavicular coalition. Other sign is the halo sign. You see that halo sign there which is really a circular density. It’s usually at the sustentaculum tali. It’s an increased density that you see there. It’s mostly seen with the TC coalition. You also see evidence of talar beaking. You see these both in the TC coalitions. It can happen in the CN coalition. These are indicative though, you have to look more advanced. You might be sought to get arthritic changes from this limitation of motion. Remember, when you have a coalition, you have limitation of motion at one joint, thereby causing a sense of stress on surrounding joints which then can lead to arthritis. The anteater sign, usually seen with CN coalition, as you see there. It’s the anterior process of the calcaneus. Then the TC coalition of the radiographic view, if you look on your left, you’ll see that they should be parallel. Your medial and posterior facet should be parallel in a Harris-Beath view. In a TC coalition, you’ll see obliquity of the medial facet on the calcaneus, indicative that there’s a TC coalition. Now, what do you do further once you see this? If you can, you get a CT scan. It’s the standard. You usually see well with an osseous-type coalition. But some of these, if you have a fibrous, it may not pick up as well. You’ll get indications that there are coalition. But an MRI would be better for a non-osseus coalition. As you can see there, you’ll get better for fibrous coalition. What do you with these? As far as first, you should try. Especially in a trial, I always try conservative management first. I don’t always find that it works all that well. But I’ll try nonweightbearing in a B-K cast. Usually, when I’ll do this, I’ve done this, I’ll give them a block to try to relieve the spasm. I try not to cast them in a position that they’re already in. I’ll try to give them a block, put the foot more of a neutral position and then cast them. This way as the stretch is there and I try to let them relieve. Give them, if you want, nonsteroidals after the casting, physical therapy, shoe modifications, orthotic therapy, more to keep it in the neutral position. Try to keep the foot. The goal of this will be relief of pain. You’re not going to correct the coalition. You have to let the parents know, if it’s a child, that there’s a high incidence that the pain may return and that the surgery will be required in the future. We deal with surgical management, the CN coalition. The classic is the Badgley procedure. We do anterolateral approach distal to the tip of the fibula obliquely to the base of their neck and resect the coalition, interpose the EDB muscle. Some people will use bone wax. With these coalitions, any type of surgery that you’re going to do, the key is to resect enough with the coalition. You want at least a 1 centimeter gap. Early on in my career, I was tentative, probably and didn’t resect enough and then sure enough, the pain would return. Now, more aggressive, you have to take out a good piece of the coalition and then interpose whatever you want. Usually, the CN coalition, the EDB muscle belly is very good. You could just use a suture with a buttonhole on the bottom if you like. Button on the bottom temporarily hold it that way. The CN coalition has a much higher success rate than a resection for a TC coalition. Again, here’s the Badgley type procedure. There is your incision. You’re taking out a good piece of the bone to resect it and there should be muscle belly and you interpose it right in between. What about TC coalition? Well, when do you do? You try to resect it or do you fuse it. Generally, you try always conservative therapy first. Then, if it’s a child, my feeling is try a resection with the understanding and the family understanding that you may need a fusion later on. I don’t like to try to fuse a joint in a child that’s still growing while the growth plates are still open. If it’s a child, I would resect it and then if you can, interpose. I will show you. But the key is removal enough of the coalition.
When you’re doing the surgery to resect it, you use fluoroscopy. You may want to use pins to go across to isolate it and then resect the coalition and then interpose it. If you want, you could put fat. I’ve tried fat and it just keeps the move. It just doesn’t seem well. One time, I used silicon, didn’t work. Also, you could use the flexor hallucis longus splitting it and putting it in between. Some people advocate, if you have a very high instance of a hindfoot valgus that you may want to correct the hindfoot valgus deformity along with the coalition resection at the same time. You could do a medial calcaneal slide osteotomy and lateral column lengthening or an adjunct medial column osteotomy. Some people also put in an MBA implant into the area of the subtalar joint after the resection. The purpose of that is just to keep the borders to keep it in a more of supinated position to keep that where you resected that coalition open. Again, that’s just the picture of your going in. You’re making your incision over the medial side of the calcaneus, over the sustentaculum tali area. Then what you’re going to do is you’re going to reflect your tibialis posterior up. Then down below, you’ll be able to see your flexor hallucis longus. Then what you're going to do is just to interpose, you split it. You try to interpose that between where you resect the coalition. Then after resection, you want to really immobilize them. I’ll tend to cast them for about three weeks just to keep any tissue in there for moving up. But some people do it a lot early because the key is really for resection’s early mobilization. You can put them in a CAM walker early just to keep the foot in a rectus position, but have them start some non-weightbearing range of motion. For the fusion, you do an isolate fusion for the CC joint unless you had severe arthritic changes in the midtarsal joint. If you start to see severe changes that ended up in the talonavicular joint, evidence of calcaneocuboid joint, then it would be necessary to do a full triple. Otherwise, an isolated subtalar joint fusion would suffice. Again, these are reserved for only arthritic changes that have developed secondary to the coalition. Here’s my references. Generally, just to discuss this. Also, discussed in the literature is also the size of the coalitions, especially the TC coalition. The greater the size of the coalition, the less chances of success. If you saw it’s involving more posteriorly, your resection of the subtalar calcaneal fusion success rate decreases. But again, generally, what I will do is in the children, I’ll try always resection before fusion. For adults, with this evidence of any arthritic changes developing, I’ll go to the fusion first. Thank you.