Please confirm topic selection

Are you sure you want to trigger topic in your Anconeus AI algorithm?

Updated: 6/3/2022

Tarsal Coalition

0%
Topic
Review Topic
0
0
0%
0%
Flashcards
9
N/A
N/A
Questions
27
0
0
0%
0%
Evidence
35
0
0
0%
0%
Videos / Pods
3
0%
Techniques
2
Topic
Images
https://upload.orthobullets.com/topic/4068/images/anteater.jpg
https://upload.orthobullets.com/topic/4068/images/key image.jpg
https://upload.orthobullets.com/topic/4068/images/flatfoot.jpg
https://upload.orthobullets.com/topic/4068/images/screen_shot_2014-05-25_at_10.11.02_pm.jpg
https://upload.orthobullets.com/topic/4068/images/45-degree oblique.jpg
https://upload.orthobullets.com/topic/4068/images/talar beaking.jpg
  • 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 Guides (2)
Flashcards (9)
Cards
1 of 9
Questions (27)

(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:

Abnormal collagen cross linking via a glycine substitution

4%

(46/1125)

Mutation of the fibrillin-1 gene

5%

(59/1125)

Failure of mesenchymal segmentation

65%

(736/1125)

Fracture through the hypertrophic zone of the physis

19%

(213/1125)

Fracture through the proliferative zone of the physis

6%

(63/1125)

L 3 E

Select Answer to see Preferred Response

Question locked
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:

Between the extensor and peroneal tendons

72%

(902/1257)

Posterior between the Achilles and peroneal tendons

5%

(63/1257)

Posterior between the Achilles and flexor hallucis longus (FHL)

3%

(39/1257)

Medial between posterior tibial tendon and flexor digitorum longus (FDL)

14%

(178/1257)

Medial between FHL and FDL

5%

(66/1257)

L 2 E

Select Answer to see Preferred Response

(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:

Accessory navicular; autosomal dominant

2%

(47/2049)

Calcaneonavicular tarsal coalition; autosomal dominant

65%

(1329/2049)

Talonavicular tarsal coalition; autosomal dominant

9%

(181/2049)

Calcaneonavicular tarsal coalition; X-linked recessive

21%

(430/2049)

Accessory navicular; X-linked recessive

2%

(47/2049)

L 2 A

Select Answer to see Preferred Response

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
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:

Calcaneus and talus; short period of immobilization

5%

(93/2050)

Navicular and calcaneus; coalition resection

34%

(706/2050)

Cuboid and navicular; coalition resection

3%

(70/2050)

Calcaneus and navicular; short period of immobilization

55%

(1127/2050)

Calcaneus and talus; shoe-wear modification

2%

(34/2050)

L 4 A

Select Answer to see Preferred Response

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
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:

Hindfoot varus

13%

(522/4008)

Rigid pes planus

77%

(3101/4008)

Pes Cavus

4%

(158/4008)

Equino-cavovarus

3%

(139/4008)

Rocker bottom foot

2%

(65/4008)

L 2 C

Select Answer to see Preferred Response

Question locked
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:

Triple arthrodesis

0%

(10/2345)

Coalition excision

41%

(973/2345)

Subtalar arthrodesis

1%

(32/2345)

Plantar fascia repair

0%

(10/2345)

Cast immobilization

56%

(1314/2345)

L 3 B

Select Answer to see Preferred Response

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(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:

manipulation of the foot under general anesthesia.

1%

(8/563)

peroneal lengthening.

4%

(20/563)

coalition resection with interposition of fat or muscle.

89%

(503/563)

distal calcaneal lengthening osteotomy.

4%

(24/563)

triple arthrodesis.

1%

(7/563)

L 1 E

Select Answer to see Preferred Response

(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:

coalition excision with fat interposition

16%

(559/3591)

coalition excision with extensor digitorum brevis interposition

8%

(270/3591)

subtalar arthrodesis

1%

(20/3591)

4 weeks of immobilization in a short leg cast

74%

(2658/3591)

excision of accessory navicular

2%

(61/3591)

L 2 B

Select Answer to see Preferred Response

(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:

Resection of periarticular osteophytes at the talonavicular joint

4%

(92/2379)

Excision of the os trigonum

1%

(33/2379)

Mobilization of the flexor hallucis longus and excision of Steida's tubercle

2%

(45/2379)

Resection of the calcaneonavicular coalition and interposition of the extensor digitorum brevis

82%

(1962/2379)

Resection of the talonavicular coalition and interposition of the flexor hallucis longus

10%

(239/2379)

L 1 D

Select Answer to see Preferred Response

(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

Resection of coalition at the middle facet if <20° hindfoot valgus is present

9%

(90/1033)

Coalition resection and interposition of extensor digitorum brevis

81%

(838/1033)

Complete excision of sustentaculum tali

1%

(15/1033)

Resection of coalition with concomitant calcaneal neck lengthening or medial slide

7%

(76/1033)

Triple arthrodesis

1%

(8/1033)

L 2 C

Select Answer to see Preferred Response

(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:

revision coalition resection and extensor digitorum brevis interposition

19%

(293/1506)

revision coalition resection and fat interposition

12%

(176/1506)

tibiotalocalcaneal arthrodesis

7%

(103/1506)

talonavicular arthrodesis

5%

(68/1506)

triple arthrodesis

57%

(860/1506)

L 2 D

Select Answer to see Preferred Response

(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:

Dynamic supination during swing phase of gait

1%

(24/1901)

Limited push-off power, limited forefoot contact, and excessive heel contact during stance phase of gait

14%

(271/1901)

Recurrent ankle sprains

54%

(1035/1901)

Posterior tibial tendon insufficiency

27%

(506/1901)

Weak tibialis anterior relative to the peroneus longus resulting in first ray plantar flexion

2%

(45/1901)

L 3 D

Select Answer to see Preferred Response

Evidence (35)
VIDEOS & PODCASTS (5)
EXPERT COMMENTS (32)
Private Note