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Tarsal Coalition

From WikiSM

Other Names

  • Talocalcaneal coalition
  • Calcaneonavicular coalition
  • Peroneal spastic flatfoot

Background

  • This page refers to abnormal connections of the tarsal bones, commonly referred to as 'tarsal coalition'

History

  • First described by Buffon in 1750 or 1769 (need citation)
  • In 1948, Harris and Beath were the first to identify tarsal coalition as a cause of painful and rigid pes planovalgus[1]

Epidemiology

  • Prevalence
    • Estimated to be between 1% and 13% of the population[2]
    • Likely under-reported due to vast majority being asymptomatic
    • Appear bilaterally in 50% - 68% of all cases, 20% have multiple coalitions[3]
    • Solomon found a prevalence of non-osseous coalition to be 12.75 in a cadaveric study[4]

Introduction

Illustration of calcaneonavicular coalition[5]
Illustration of talocalcaneal coalition[6]
Illustration of calcaneonavicular coalition[7]

osseous cubonavicular coalition (arrowheads) with an absence of joint space.[8]]]

General

  • Definition: abnormal osseous, cartilaginous or fibrous connection between two or more tarsal bones
  • Due to a failure of differentiation and segmentation of primitive mesenchyme into the distinct tarsal bones
  • The coalition can be bony (synostosis), cartilaginous (synchondrosis), or fibrous (syndesmosis)
  • May involve fusion of the accessory ossicles[9]
  • It is an often unrecognized cause of foot and ankle pain

Natural History

  • Majority are cartilaginous at birth and are therefore asymptomatic
  • Evidence suggests coalitions remain asymptomatic into adulthood[10]
  • When symptoms arise, thought to be a result of microfractures of the coalition and inflammation of the surrounding soft tissue from repetitive overload[11]
  • Age of presentation varies, depending on which bones are involved
  • Appears to be approximately 3--4 years after ossification of the coalition

Location

  • General
    • Talocalcaneal and calcaneonavicular coalitions are its most common subtypes, represent about 90% of junctions[3]
  • Talocancaneal
    • Most common, affecting 48% of the patients[3]
    • Commonly concerns the middle subtalar facet[12]
    • Rarely involves he anterior and posterior facets
  • Calcaneonavicular
    • Other investigators have reported a nearly equal prevalence of talocalcaneal and calcaneonavicular coalitions[13]
    • More readily diagnosed with conventional radiography, which may contribute to their reported higher prevalence
  • Talonavicular
  • Calcaneocuboid
  • Naviculocuneiform
  • Cubonavicular

Etiology

  • Thought to be due to a failure of segmentation of primitive mesenchyme during development[14]
  • Genetics
    • There may be an autosomal dominant pattern of inheritance of a coalition[15]
    • Pro250Arg mutation in the fibroblast growth factor receptor 3 (FGFR3) gene has been associated[16]
  • Acquired
    • May occur due to may occur because of degenerative joint diseases
    • Examples: inflammatory arthritis, fibular hemimelia, congenital talipes equinovarus, Apert syndrome, arthrogryposis, and Nievergelt--Pearlman syndrome

Associated Conditions

  • Pes Planus
  • Other congenital malformations
    • Including carpal fusions, carpal synostosis with radial head subluxation, symphalangism, and partial adactyly
  • Ankle Sprain

Pathoanatomy

Risk Factors

  • Slight male predominance[17]
  • Race

Differential Diagnosis

Differential Diagnosis Foot Pain

Clinical Features

Pictures demonstrate left hindfoot valgus that does correct into varus with double stance tiptoeing. This implies restricted movement of the subtalar joint complex.[19]

History

  • Symptoms initiate with the onset of ossification, calcaneonavicular (8-12 years), talocalcaneal (8-12 years), talonavicular (3-5 years)[20]
  • Mid-, hindfoot or tarsal pain, sometimes diffuse
  • Trouble walking on uneven surfaces
  • If there is a precipitating event, trauma, weight gain, or an increase in athletic activity
  • Pain is diffuse, exacerbates during physical activity, and may be triggered by minimal trauma[21]
  • Progressing to decreased range of motion, especially inversion/eversion of the subtalar joint
  • Rigid deformity is usually the end point

Physical Exam: Physical Exam Foot

    • Rigid pes planus, hindfoot valgus
    • Inability to roll onto lateral side of foot (secondary to rigid pes planus)
    • Tightness of peroneal muscles, long extensors which may be obvious dorsally
    • "Double medial malleolus" with talocalcaneal coalition[22]
    • Ankle range of motion is normal while subtalar range of motion is restricted

Special Tests

Evaluation

Lateral radiograph showing the C-sign, a primary sign for TCC (white arrows). This image also shows blunting of the lateral talar process (blue arrow).[19]
Coronal CT scan reconstruction of a fibrous middle facet TCC.[19]
coronal fat suppressed PD-weighted image demonstrates a narrowed joint with subchondral bony irregularity (arrow), subcortical marrow edema (asterisks),and bony hypertrophy (arrowheads) at the far medial aspect of the posterior facet of the subtalar joint.[23]

Radiographs

  • Standard Radiographs Foot, Standard Radiographs Ankle
    • Initial imaging modality of choice
    • Views should include anteroposterior, lateral, oblique, and axial weight-bearing
  • Harris axial view (Harris-Beath)
    • Sometimes termed Harris projection or penetrated axial projection
    • Special radiographic view that is used for assessment of talocalcaneal coalition
    • X-ray beam is angled between 35 and 45 degrees
  • Calcaneonavicular coalitions
    • Best visualized on internal oblique 45° view
    • Coalition is seen in 90% of cases[24]
    • 'Anteater nose' sign is a characteristic finding
      • Initially described in the oblique view, better visualized on lateral view
      • Sensitivity 18-50%, specificity 100%[25][26]
  • Talocalcaneal coalitions
    • 'C' sign
      • C-shaped line composed of the medial dome of the talus and posteroinferior outline of the sustentaculum tali
      • Seen in lateral views, specific but not sensitive[27][28]
    • Absent middle facet may be a more accurate radiographic finding[29]
    • Dorsolateral talar beak
      • Thought to occur due to impaired subtalar joint motion, subsequently the navicular overrides the talus.
      • Periosteal elevation occurs at the insertion of the talonavicular ligament, a cycle of osseous leads to formation[30]
      • Alternatively, may occur due to peroneal spasm with repetitive dorsolateral overload, compression of the talar head
      • Note: may occur absent a tarsal coalition

MRI

  • More sensitive, more specific than xray
  • Also assesses for soft tissue injuries, bone edema

CT

  • Similar utility for osseous connections, but less for fibrous
  • offers a more precise evaluation of the site and size of coalition
  • Help determine determine surgical approach, i.e. resection, arthrodesis
  • Can exclude multiple coalitions and readily depicts associated degenerative changes[31]

Classification

Classification of talocalcaneal coalitions based on 3D reconstruction of computer tomography by Rozansky et al[32]

Downey Classification

  • Considers joint involvement, arthrosis extension to help in recommending surgical therapy[33]
    • Type IA: extra-articular coalition without secondary arthritis
    • Type IB: intra-articular coalition with secondary arthritis
    • Type IIA: extra-articular coalition without secondary arthritis
    • Type IIB: intra-articular coalition with secondary arthritis

Rozansky Classification

  • Based on three-dimensional reconstructed computed tomography images[34]
    • Type I: linear coalitions (41%)
    • Type II: linear coalitions with posterior hook (17%)
    • Type III: shingled coalitions (15%)
    • Type IV: complete osseous coalitions (11%)
    • Type V: posterior coalitions (17%)

Short Walking Boot

Management

Nonoperative

  • Indications
    • Asymptomatic or incidentally discovered lesions
    • Most symptomatic lesions upon initial presentation
  • Initial therapy
    • NSAIDS
    • Shoe inserts
    • Activity modification
  • If symptoms persist, consider
    • Custom orthotics
    • Cast immobilization

Operative

  • Indications
    • Failure of conservative management
  • Objective
    • Achieve painless functional hindfoot movement without deformity
  • Technique
    • Subtalar or triple arthrodesis
    • Excision of coalition with or without interposition of fat or tendon

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play/ Work

  • Needs to be updated

Complications and Prognosis

Prognosis

  • Incidental or asymptomatic lesions
    • No evidence suggesting that asymptomatic coalition may lead to future problems[27]
  • Conservative vs surgical management
    • Calcaneonavicular coalitions respond less to conservative treatment than talocalcaneal coalitions[35]
  • Surgical outcomes
    • Mahan et al observed 73% of patients achieved good results, regardless of the type of coalition[36]
    • Khoshbin et al reevaluated patients after resection of calcaneonavicular and talocalcaneal coalitions, found that 85% of the patients did not require additional procedures[37]
    • Mosca showed 87% of patients achieved good results after talocalcaneal coalition resection[38]
  • Predictors of good outcome with conservative management (need citation)
    • Skeletal immaturity at presentation
    • Nonathletic patient
    • Ankylosed subtalar joint in neutral

Complications

See Also

Internal

External

References

  1. ↑ Harris RI, Beath T. Etiology of peroneal spastic flat foot. J Bone Joint Surg Br 1948; 30B:624–634.
  2. ↑ Bohne WH. Tarsal coalition. Curr Opin Pediatr 2001; 13:29–35.
  3. ↑ 3.0 3.1 3.2 Stormont DM, Peterson HA. The relative incidence of tarsal coalition. Clin Orthop 1983; (181):28–36.
  4. ↑ Solomon LB, Rühli FJ, Taylor J, et al. A dissection and computer tomograph study of tarsal coalitions in 100 cadaver feet. J Orthop Res. 2003;21:352–358
  5. ↑ Image courtesy of concordortho.com
  6. ↑ Image courtesy of concordortho.com
  7. ↑ Image courtesy of musculoskeletalkey.com
  8. ↑ Kummer, Anne, Eric Dugert, and Mouas Jammal. "Complete cubonavicular coalition associated with midfoot osteoarthritis." Case Reports in Orthopedics 2020.1 (2020): 8850768.
  9. ↑ Mosier KM, Asher M. Tarsal coalitions and peroneal spastic flat foot: a review. J Bone Joint Surg. 1984;66-A:976–984
  10. ↑ Conway JJ, Cowell HR. Tarsal coalition: clinical significance and roentgenographic demonstration. Radiology. 1969; 92:799--811.
  11. ↑ Kumai T, Takakura Y, Akiyama K, et al. Histopathological study of nonosseous tarsal coalition. Foot Ankle Int. 1998; 19:525--531.
  12. ↑ Moe DC, Choi JJ, Davis KW. Posterior subtalar facet coalition with calcaneal stress fracture. AJR Am J Roentgenol. 2006;186(1):259–64.
  13. ↑ Kulik SA, Clanton TO. Tarsal coalition. Foot Ankle Int. 1996;17:286–296
  14. ↑ Vincent KA. Tarsal coalition and painful flatfoot. J Am Acad Orthop Surg. 1998;6:274–281
  15. ↑ Leonard MA. The inheritance of tarsal coalition and its relationship to spastic flat foot. J Bone Joint Surg Br 1974; 56B:520–526.
  16. ↑ Graham JM, Braddock SR, Mortier GR, et al. Syndrome of coronal craniosynostosis with brachydactyly and carpal/tarsal coalition due to Pro250Arg mutation in FGFR3 gene. Am J Med Genet 1998; 77:322–329.
  17. ↑ Swensen SJ, Otsuka NY. Tarsal coalitions–calcaneonavicular coalitions. Foot Ankle Clin 2015; 20:669–679.
  18. ↑ Burnett SE, Wilczak CA. Tarsal and tarsometatarsal coalitions from Mound C (Ocmulgee Macon Plateau site, Georgia): implications for understanding the patterns, origins, and antiquity of pedal coalitions in Native American populations. Homo Int Z Vgl Forsch Am Menschen 2012; 63:167–181.
  19. ↑ 19.0 19.1 19.2 Afolayan, John O., Alexander Dinneen, and Anthony Sakellariou. "Tarsal coalitions–what you need to know." Orthopaedics and trauma 30.1 (2016): 30-40.
  20. ↑ Cowell HR. Tarsal coalition–review and update. Instr Course Lect 1982; 31:264–271.
  21. ↑ Fuson S, Barrett M. Resectional arthroplasty: treatment for calcaneonavicular coalition. J Foot Ankle Surg 1998; 37:11–15.
  22. ↑ Rocchi V, Huang M-T, Bomar JD, Mubarak S. The ‘double medial malleolus’: a new physical finding in talocalcaneal coalition. J Pediatr Orthop 2018; 38:239–243.
  23. ↑ Image courtesy of radsource.us, "tarsal coalition"
  24. ↑ Newman JS, Newberg AH. Congenital tarsal coalition: multimodality evaluation with emphasis on CT and MR imaging. Radiographics 2000; 20:321–332.
  25. ↑ Kernbach KJ. Tarsal coalitions: etiology, diagnosis, imaging, and stigmata. Clin Podiatr Med Surg 2010; 27:105–117.
  26. ↑ Crim JR, Kjeldsberg KM. Radiographic diagnosis of tarsal coalition. AJR Am J Roentgenol 2004; 182:323–328.
  27. ↑ 27.0 27.1 Taniguchi A, Tanaka Y, Kadono K, et al. C sign for diagnosis of talocalcaneal coalition. Radiology 2003; 228:501–505.
  28. ↑ Brown RR, Rosenberg ZS, Thornhill BA. The C sign: more specific for flatfoot deformity than subtalar coalition. Skeletal Radiol. 2001; 30:84--87.
  29. ↑ Liu PT, Roberts CC, Chivers FS, et al. ‘Absent middle facet’: a sign on unenhanced radiography of subtalar joint coalition. AJR Am J Roentgenol 2003; 181:1565–1572.
  30. ↑ Resnick D. Talar ridges, osteophytes, and beaks: a radiologic commentary. Radiology. 1984; 151:329--332.
  31. ↑ Wechsler RJ, Schweitzer ME, Deely DM, et al. Tarsal coalition: depiction and characterization with CT and MR imaging. Radiology. 1994; 193:447--452.
  32. ↑ Wähnert, Dirk, et al. "An unusual cause of ankle pain: fracture of a talocalcaneal coalition as a differential diagnosis in an acute ankle sprain: a case report and literature review." BMC Musculoskeletal Disorders 14 (2013): 1-9.
  33. ↑ Downey MS. Tarsal coalitions. A surgical classification. J Am Podiatr Med Assoc 1991; 81:187–197.
  34. ↑ Rozansky A, Varley E, Moor M, et al. A radiologic classification of talocalcaneal coalitions based on 3D reconstruction. J Child Orthop 2010; 4:129–135.
  35. ↑ Klammer G, Espinosa N, Iselin LD. Coalitions of the tarsal bones. Foot Ankle Clin 2018; 23:435–449.
  36. ↑ Mahan ST, Spencer SA, Vezeridis PS, Kasser JR. Patient-reported outcomes of tarsal coalitions treated with surgical excision. J Pediatr Orthop 2015; 35:583–588.
  37. ↑ Khoshbin A, Bouchard M, Wasserstein D, et al. Reoperations after tarsal coalition resection: a population-based study. J Foot Ankle Surg 2015; 54:306–310.
  38. ↑ Mosca VS. Subtalar coalition in pediatrics. Foot Ankle Clin 2015; 20:265–281.
Created by:
John Kiel on 15 November 2021 19:14:44
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21 February 2026 13:04:01
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