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Tarsal Coaliltion

- See:
        - Talocalcaneal Coalition
        - Calcaneonavicular Coalition

- Discussion:
    - coalition between tarsal bones is frequent cause of painful flatfoot (pes planus) in the older child or adolescent;
          - tarsal coalition may be osseous, cartilaginous, or fibrous.
    - calcaneonavicular coalition bar is most common, followed by middle facet of talocalcaneal coalition joint;
          - single coalition is most common, > one are occassionally found
    - there is a tendency to progressive ossification of bar w/ increasing age, and this often corresponds with the onset of symptoms;
          - ossification occurs at 8 - 12 yrs for calcaneonavicular bars and between 12 - 15 years for talocalcaneal coalitions.
    - ankle sprain are common;
    - autosomal dominance w/ variable penetrance is mechanism of inheritance;
    - majority of tarsal coalitions are asymptomatic, & evidence indicates that they remain so in adulthood;
    - symptomatic lesions often are treated initially by immobilization for three to six weeks, followed by an orthosis;

- Exam:
    - painful flat foot, limitied subtalar movement, and tenderness in subtalar area;
    - valgus heel and everted forefoot w/ limited sub talar motion
    - w/ progressive restriction of motion in the sub-talar joint, compensatory movement occurs at ankle, leading to ligamentous laxity;
    - subtalar motion is decr, esp for talocalcaneal bar, & rigid flatfoot w/ contracture of peroneal tendons (peroneal spastic flatfoot) exists;
    - pain in subtalar or midtarsal area often develops in early adolescence & is typically relieved by rest;
         - restricted subtalar motion leads to spasm of peroneal muscles, hence the term "peroneal spastic flatfoot."
    - patients are often unable to stand on lateral aspect of foot;

- Radiographic Studies:
    - radiographic features of talocalcaneal coalition;
    - radiographic features of calcaneonavicular coalition:
         - lateral view:
                  - often has signs suggestive of coalition:
                  - blunting of subtalar process, elongation of anteior calcaneal process, narrowing of posterior subtalar joint, & talar beaking;

- Non Operative Treatment:
    - asymptomatic coalition does not require surgical treatment;
    - orthotic objectives:
    - reduce subtalar motion or stresses;
    - reduce medial-lateral hindfoot forces;
    - UCBL
    - total contact orthosis supporting subtalar joint;
    - high top for medial lateral stability;

- Indications for Surgery:
    - talocalcaneal coalition
    - calcaneonavicular coalition
    - for symptomatic coalition before degenerative changes have occured usually in pts under age of 14 years), resection is
            usual treatment;
    - this procedure is not appropriate if cartilagenous bar is completely ossified and degenerative changes have occurred or if coalition
            between the talus and calcaneus is also present;
    - in pts over age of 14, who have degenerative changes, a below knee, wt bearing cast, a plastizoate insert for the shoe, or an AFO
            may relieve the pain;
            - failure to respond to these conservative measures & presence of degenerative changes indicate the need for triple arthrodesis

Subtalar fusion for isolated subtalar disorders. Preliminary report.

Resection as a method of treatment of tarsal coalitions

The inheritance of tarsal coalition and its relationship to spastic flat foot.

Tarsal coalitions: long-term results of surgical treatment.

Surgical management of tarsal coalition in adolescent athletes.