summary Tarsal Coalition is a common congenital condition caused by failure of embryonic segmentation leading to abnormal coalition 2 or more of the tarsal bones. The condition is usually asymptomatic, but may present with a flatfoot deformity or recurrent ankle sprains. Diagnosis is made with plain radiographs of the foot and ankle showing a coalition, most commonly a calcaneonavicular or talocalcaneous coalition. Treatment is usually a course of casting and NSAIDs for symptomatic patients. Surgical coalition resection or joint arthrodesis is indicated for patients with persistent symptoms who fail conservative management. Epidemiology Prevalence varies from 1%-2% Demographics age of onset calcaneonavicular usually 8-12 years old talocalcaneal usually 12-15 years old Anatomic location calcaneonavicular (most common) talocalcaneus Etiology Two types congenital most common acquired less common and caused by trauma degenerative infections Pathophysiology embryology failure of mesenchymal segmentation leading to coalition between two or three tarsal bones develops into a fibrous coalition, or undergoes metaplasia to cartilage +/- bone pathoanatomy gait mechanics subtalar joint will normally rotate 10 degrees internally during stance phase in presence of coalition, internal rotation does not occur deformity flattening of longitudinal arch abduction of forefoot valgus hindfoot peroneal spasticity (also known as peroneal spastic flatfoot) pain generator theories ossification of previously fibrous or cartilaginous coalition microfracture at coalition bone interface secondary chondral damage or degenerative changes increased stress on other hindfoot joints Associated conditions nonsyndromic autosomal dominant syndromic fibular hemimelia carpal coalition FGFR-associated craniosynostosis (FGFR-1, FGFR-2, FGFR-3) Apert syndrome, Pfeiffer, Crouzon, Jackson-Weiss and Muenke Classification Anatomic classification calcaneonavicular between calcaneus and navicular bones (most common) talocalcaneal middle facet of talocalcaneal joint Pathoanatomic classification 3 types fibrous coalition (syndesmosis) cartilagenous coalition (synchondrosis) osseous coalition (synostosis) Presentation History history of prior recurrent ankle sprains Symptoms asymptomatic most coalitions are found incidentally 75% of people are asymptomatic pain location of pain sinus tarsi and inferior fibula suggests calcaneonavicular distal to medial malleolus or medial foot suggests talocalcaneal pain worsened by activity onset of symptoms correlates with age of ossification of coalition calf pain secondary to peroneal spasticity Physical exam inspection hindfoot valgus forefoot abduction pes planus range of motion limited subtalar motion heel cord contractures arch of foot does not reconstitute upon toe-standing hindfoot remains in valgus (does not swing into varus) upon toe-standing special tests reverse Coleman block test evaluate for subtalar rigidity Imaging Radiographs recommended views required anteroposterior view standing lateral foot view 45-degree internal oblique view most useful for calcaneonavicular coalition Harris view of heel findings calcaneonavicular coalition "anteater" sign elongated anterior process of calcaneus talocalcaneal coalition talar beaking on lateral radiograph occurs as a result of limited motion of the subtalar joint irregular middle facet joint on Harris axial view c-sign c-shaped arc formed by the medial outline of the talar dome and posteroinferior aspect of the sustentaculum tali dysmorphic sustentaculum appears enlarged and rounded CT scan Has been suggested as part of the preoperative workup to rule-out additional coalitions incidence approx. 5% determine size, location and extent of coalition size of talocalcaneal coalition based on size of posterior facet using coronal slices MRI may be helpful to visualize a fibrous or cartilaginous coalition STIR sequences help to differentiate inflammatory changes (e.g. tendinitis) in local structures Treatment Nonoperative observation, shoe inserts indications unclear. techniques medial arch support and preserved hindfoot alignment outcomes In rigid flat feet shoe inserts may be the cause of discomfort. immobilization with casting, analgesics indications initial treatment for symptomatic cases techniques below-knee walking cast for six-weeks outcomes up to 30% of symptomatic patients will become pain-free with a short period of immobilization Operative coalition resection with interposition graft, +/- correction of associated foot deformity indications persistent symptoms despite nonoperative management coalition involves <50% of joint surface area techniques open vs arthroscopic coalition resection interposition material extensor digitorum brevis (calcaneonavicular coalition) split flexor hallucis longus tendon (talocalcaneal coalition) interposed fat graft bone wax correction of associated hindfoot, midfoot or forefoot deformities calcaneal osteotomy for hindfoot valgus calcaneal lengthening to create arch after resection heel cord lengthening if intraoperative ankle dorsiflexion is not past neutral outcomes 80-85% will experience pain relief poor outcomes coalition resection >50% size of joint surface area uncorrected hindfoot valgus associated degenerative changes subtalar arthrodesis indications role has not been well established consider if coalition involves >50 % of the joint surface of a talocalcaneal coalition technique open vs. arthroscopic consider an associated calcaneal osteotomy with severe hindfoot malalignment triple arthrodesis (subtalar, calcaneocuboid, and talonavicular) indications advanced coalitions that fail resection diffuse associated degenerative changes affecting calcaneocuboid and talonavicular joints technique open vs. arthroscopic Techniques Calcaneonavicular coalition resection approach lateral or sloppy lateral position 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 Talocalcaneal coalition resection approach positioned supine 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 weeks Complications 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
Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Calcaneonavicular Coalition Excision Deirdre Ryan Robert M. Kay Pediatrics - Tarsal Coalition Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Talocalcaneal Coalition Resection Orthobullets Team Robert M. Kay Deirdre Ryan Pediatrics - Tarsal Coalition
QUESTIONS 1 of 27 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Previous Next (SBQ20FA.24) A 14-year-old male presents to the office with several weeks of ankle pain localized just distal to the medial malleolus. He also reports numerous ankle sprains since learning to play basketball over the last several months. Representative radiographs are shown in Figure A and B. Which of the following is the most likely cause of his pain? QID: 215837 FIGURES: A B Type & Select Correct Answer 1 Abnormal collagen cross linking via a glycine substitution 4% (46/1125) 2 Mutation of the fibrillin-1 gene 5% (59/1125) 3 Failure of mesenchymal segmentation 65% (736/1125) 4 Fracture through the hypertrophic zone of the physis 19% (213/1125) 5 Fracture through the proliferative zone of the physis 6% (63/1125) L 3 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ18FA.85) Figure A is the radiograph of a 14-year-old male who presents to the clinic with recurrent of recurrent ankle sprains despite nonoperative treatment. What is the appropriate interval for surgical resection for this patient? QID: 212034 FIGURES: A Type & Select Correct Answer 1 Between the extensor and peroneal tendons 72% (902/1257) 2 Posterior between the Achilles and peroneal tendons 5% (63/1257) 3 Posterior between the Achilles and flexor hallucis longus (FHL) 3% (39/1257) 4 Medial between posterior tibial tendon and flexor digitorum longus (FDL) 14% (178/1257) 5 Medial between FHL and FDL 5% (66/1257) L 2 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (OBQ18.79) A 12-year-old boy presents with atraumatic right foot pain. Physical examination is remarkable for pes planus and tenderness at the sinus tarsi. He has no other musculoskeletal or developmental abnormalities, but reports that his older brother had a "foot problem" when he was around the patient's age. His radiographs are shown in Figures A and B. Which of the following is the most likely diagnosis and pattern of inheritance of the patient's condition? QID: 212975 FIGURES: A B Type & Select Correct Answer 1 Accessory navicular; autosomal dominant 2% (47/2049) 2 Calcaneonavicular tarsal coalition; autosomal dominant 65% (1329/2049) 3 Talonavicular tarsal coalition; autosomal dominant 9% (181/2049) 4 Calcaneonavicular tarsal coalition; X-linked recessive 21% (430/2049) 5 Accessory navicular; X-linked recessive 2% (47/2049) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ17.186) A 16-year-old presents with lateral based ankle pain of the sinus tarsi. Examination reveals a rigid flatfoot with diminished subtalar motion. The ankle is stable to anterior drawer testing. The patient states that he has had recurrent ankle sprains while playing sports. A lateral radiograph of the foot is shown in Figure A. This reveals an abnormal connection between which two bones, and what is the next step in treatment? QID: 210273 FIGURES: A Type & Select Correct Answer 1 Calcaneus and talus; short period of immobilization 5% (93/2050) 2 Navicular and calcaneus; coalition resection 34% (706/2050) 3 Cuboid and navicular; coalition resection 3% (70/2050) 4 Calcaneus and navicular; short period of immobilization 55% (1127/2050) 5 Calcaneus and talus; shoe-wear modification 2% (34/2050) L 4 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ10.22) A 13-year-old female complains of a year long history of anterior and lateral foot and ankle pain. Physical exam demonstrates limited subtalar motion compared to her contralateral foot. A lateral radiograph is shown in Figure A. A selected CT image of the hindfoot is shown in Figure B. What foot deformity is commonly associated with this condition? QID: 3110 FIGURES: A B Type & Select Correct Answer 1 Hindfoot varus 13% (522/4008) 2 Rigid pes planus 77% (3101/4008) 3 Pes Cavus 4% (158/4008) 4 Equino-cavovarus 3% (139/4008) 5 Rocker bottom foot 2% (65/4008) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ09.203) A 13-year-old girl presents to the office for the first time with a history of occasional ankle sprains while playing soccer. A history reveals activity-related pain localized to the sinus tarsi. Clinical exam demonstrates pes planus without instability. A radiograph is shown in figure A. What is the most appropriate next step in treatment? QID: 3016 FIGURES: A Type & Select Correct Answer 1 Triple arthrodesis 0% (10/2345) 2 Coalition excision 41% (973/2345) 3 Subtalar arthrodesis 1% (32/2345) 4 Plantar fascia repair 0% (10/2345) 5 Cast immobilization 56% (1314/2345) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK This is an AAOS Self Assessment Exam (SAE) question. Orthobullets was not involved in the editorial process and does not have the ability to alter the question. If you prefer to hide SAE questions, simply turn them off in your Learning Goals. (SAE07PE.76) Figure 33 shows the oblique radiograph of an 11-year-old boy who has a mild left flatfoot deformity. Examination reveals that subtalar motion is limited and painful. Despite casting for 6 weeks, the patient reports foot pain that limits participation in sport activities. A CT scan shows no subtalar joint abnormalities. Management should now include QID: 6136 FIGURES: A Type & Select Correct Answer 1 manipulation of the foot under general anesthesia. 1% (8/563) 2 peroneal lengthening. 4% (20/563) 3 coalition resection with interposition of fat or muscle. 89% (503/563) 4 distal calcaneal lengthening osteotomy. 4% (24/563) 5 triple arthrodesis. 1% (7/563) L 1 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (OBQ07.124) A 10-year-old girl complains of foot pain for the past 4 weeks while playing basketball for her school team. A radiograph is shown in Figure A. What is the most appropriate treatment? QID: 785 FIGURES: A Type & Select Correct Answer 1 coalition excision with fat interposition 16% (559/3591) 2 coalition excision with extensor digitorum brevis interposition 8% (270/3591) 3 subtalar arthrodesis 1% (20/3591) 4 4 weeks of immobilization in a short leg cast 74% (2658/3591) 5 excision of accessory navicular 2% (61/3591) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ06.148) A 14-year-old girl complains of left midfoot pain with activity. She has recently sustained multiple inversion sprains of this ankle. Radiographs of the left foot are shown in figures A and B. Shoe modification and bracing and therapy have failed to provide relief. Surgical management should consist of: QID: 334 FIGURES: A B Type & Select Correct Answer 1 Resection of periarticular osteophytes at the talonavicular joint 4% (92/2379) 2 Excision of the os trigonum 1% (33/2379) 3 Mobilization of the flexor hallucis longus and excision of Steida's tubercle 2% (45/2379) 4 Resection of the calcaneonavicular coalition and interposition of the extensor digitorum brevis 82% (1962/2379) 5 Resection of the talonavicular coalition and interposition of the flexor hallucis longus 10% (239/2379) L 1 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ05.156) A 10-year-old girl has had recurrent left ankle sprains for the past 9-months. She has tried immobilization in a cast for 5-weeks which has failed to provide relief. She is tender to palpation at the tarsal sinus. Radiographs and CT scan of the left foot show an isolated calcaneonavicular coalition and physical exam revealed a neutral hind foot. What is the next best step in management? QID: 1042 Type & Select Correct Answer 1 Resection of coalition at the middle facet if <20° hindfoot valgus is present 9% (90/1033) 2 Coalition resection and interposition of extensor digitorum brevis 81% (838/1033) 3 Complete excision of sustentaculum tali 1% (15/1033) 4 Resection of coalition with concomitant calcaneal neck lengthening or medial slide 7% (76/1033) 5 Triple arthrodesis 1% (8/1033) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (OBQ05.140) A 14 year-old girl has chronic foot pain which has failed to respond to previous surgical coalition resection and soft tissue interposition. A radiograph of her foot is shown in Figure A. A CT scan demonstrates a talocalcaneal coalition with almost complete involvement of the subtalar joint. What is the treatment of choice? QID: 1026 FIGURES: A Type & Select Correct Answer 1 revision coalition resection and extensor digitorum brevis interposition 19% (293/1506) 2 revision coalition resection and fat interposition 12% (176/1506) 3 tibiotalocalcaneal arthrodesis 7% (103/1506) 4 talonavicular arthrodesis 5% (68/1506) 5 triple arthrodesis 57% (860/1506) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ04.81) A 14-year-old female presents with 6 months of bilateral foot pain at the tarsal sinus. Clinical images of standing examination and heel rise are shown in Figures A and B, respectively. Radiographs of the left foot are shown in Figure C and D. Which of the following findings most likely is associated with this patient's condition? QID: 1186 FIGURES: A B C D Type & Select Correct Answer 1 Dynamic supination during swing phase of gait 1% (24/1901) 2 Limited push-off power, limited forefoot contact, and excessive heel contact during stance phase of gait 14% (271/1901) 3 Recurrent ankle sprains 54% (1035/1901) 4 Posterior tibial tendon insufficiency 27% (506/1901) 5 Weak tibialis anterior relative to the peroneus longus resulting in first ray plantar flexion 2% (45/1901) L 3 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic
All Videos (3) Podcasts (2) Login to View Community Videos Login to View Community Videos Resection of Talocalcaneal Tarsal Coalition and Fat Autograft Interposition Kemal Gokkus Pediatrics - Tarsal Coalition C 6/17/2021 170 views 5.0 (1) Login to View Community Videos Login to View Community Videos Managing the Challenging Tarsal Coalition - Dr. Mark Myerson Pediatrics - Tarsal Coalition A 11/12/2016 730 views 5.0 (2) Login to View Community Videos Login to View Community Videos Tarsal Coalitions: Cradle to the Grave - University of Washington Department of Orthopaedic & Sports Medicine Grand Rounds Team Orthobullets (J) Pediatrics - Tarsal Coalition A 11/12/2016 644 views 5.0 (3) Pediatrics | Tarsal Coalition Pediatrics - Tarsal Coalition Listen Now 18:20 min 10/16/2019 922 plays 5.0 (4) Question Session⎪ Tarsal Coalition, Calcaneus Fractures & Posterior Tibial Tendon Insufficiency Orthobullets Team Pediatrics - Tarsal Coalition Listen Now 47:19 min 11/11/2019 119 plays 5.0 (1)