0198-0211/92/1305-0251 $03.00/0 FOOT
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ANKLE
Copyright © 1992 by the American Orthopaedic Foot Society, Inc.
Talocalcaneal Coalition: Diagnosis and Surgical Management Osny setomao, M.D.: Manlio Mario Marco Napoli, M.D.,t Antonio Egydio de Carvalho, Jr., M.D.,f Tulia Diniz Fernandes, MD.,f Julio Marques, M.D..+ and Arnalda Jose Hernandez, M.D.f Sao Paulo, Brazil
ABSTRACT The authors studied 22 patients who had 32 feet with symptomatic talocalcaneal coalition. All feet were treated with excision of the bar and interposition of an autogenous free fat graft. These cases were assessed clinically and radiographically before and after the operation. They conclude that this technique is a good surgery with gratifying results. In the final outcome, 78.1% of feet became completely painless and 21.8% achieved relief of pain. There was improvement of the deformity in 68.7% and of range of motion in 75%.
was more affected than the right side in unilateral cases (9:3) (Table 1). All patients had disabling, painful, rigid flat feet diagnosed clinically and radiographically. In the first six patients, plaster cast immobilization was done initially without good results. Since then, we have been doing surgical treatment for these cases as the first procedure. This study includes patients treated surgically by resection of the coalition with interposition of a free fat graft. The follow-up ranged from 12 months to 66 months, with an average follow-up of 25 months (Table 2). All feet had pre- and postoperative clinical, radiographic, and CT scan assessment. Twenty patients (30 feet) had valgus deformity of the hindfoot and all patients had stiffness of the subtalar joint. The valgus position of the heel was maintained when patients stood on tip toe (Figs. 1 and 2). Usually on plantarflexion of the foot, the heel should go into varus position, mainly because of the pull action of the Achilles tendon." All patients complained of pain on walking. Six patients reported a history of one episode of ankle sprain as their first symptom. The roentgenographic evaluation included anteroposterior and lateral views on weightbearing to measure the talocalcaneal angle and to identify associated abnormalities, such as dorsal beak of the talus, narrowing of the subtalar joint (closure of sinus tarsi), and enlargement of the lateral process of the talus 1-3,7,10,20 (Figs. 3 and 4). An oblique view was taken to identify a calcaneonavicular coalition, which can be present in addition to a talocalcaneal coalition (Fig. 5). A routine axial view (Harris and Beath) was done. In the normal foot, the middle and posterior facets are parallel. When a coalition of the midsubtalar joint is present, the middle facet is seen in the oblique position in relation to the posterior facet (Fig. 6). This obliquity of the middle facet is the most important indirect radiographic sign of a midfacet coalition. When this obliquity reaches 20° or more,1-3,6,11 there is a great possibility of talocalcaneal coalition (Fig. 7).
Tarsal coalition was probably first described in 1769 by Buffon. The earliest anatomical description of talocalcaneal coalition was made by Zuckerkandl in 1877. Harris and Beath (1948) popularized the relationship between tarsal coalition and painful peroneal spastic flatfoot. 6,11,12.16 Tarsal coalition is present in 1% of the general population, with slightly more common incidence at the talocalcaneal region. B.1 0.12,16,23 Talocalcaneal coalition is usually unilateral, but bilateral cases had been described to be as high as 50% in some series by several authors.B,10.24 We propose to review our experience with surgical excision of the symptomatic talocalcaneal coalitions treated between May 1984 and August 1990. MATERIALS AND METHODS
Our series consisted of 35 feet in 24 patients. Two patients were lost to follow-up, so we studied 32 feet in 22 patients, 10 bilateral and 12 unilateral. The mean age was 14 years and ranged from 10 to 23 years. In 22 patients, 16 were female and six male. The left side * Associate Professor, School of Medicine, University of Sao Paulo, Sao Paulo, Brazil. To whom requests for reprints should be addressed at Av. Santo Amaro, 5350, CEP: 04702, Sao Paulo, Brasil. t Chief, Department of Orthopaedics and Traumatology, School of Medicine, University of Sao Paulo, Sao Paulo, Brazil. From the Department of Orthopaedics and Traumatology, School of Medicine, University of Sao Paulo, Sao Paulo, Brazil.
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TABLE 1 Surgical Management of Talocalcaneal Coalition: Preoperative" Physical findings
Side inAge (yr) Sex volved Pain Subtalar Heel AP motion valgus (0)
01 14 F 02 11 M 03 04 05 06
13 19 14 13
F M M
F
07 13 F 08 13 F 09 12 F 10 15 F 11 16 F 12 17 M 13 23 F 14 15 M 15 14 F 16 17 18 19 20 21
14 11 15 10 13 15
F F F F F M
22 13 F
L R
L L R R R L R L L R L R L L R L R L L R L L L L R L R L R L
+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
Average
+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
Radiological findings
LT A Indirect (0) signs
38 30 21 11 30 30 28 30 38 25 32 27 35 27 40 25 32 35 30 32 35 30 35 25 30 20 36 30 28 20 28 30 33 30 34 30 44 35 40 42 35 22 40 30 38 30 35 30 40 30 35 28 30 35 35 30 42 35 42 30 34 25 35 30 34.6 29.1
• +, Present; -, Absent;
+ + + + + + + + + + + + + + + + + + + + + + + + + + + +
+
+ + + + + + + + + + + + + + + + + + + + + + + + + + +
+ +
+
R, right; L, left; AP, anteroposterior view; LT, lateral view; A, axial view (Harris and Beath).
Fig. 1.
Valgus deformity of the right hindfoot.
Fig. 2. Absence of variation of the right hindfoot during plantarflexion (see variation of the left hindfoot).
Fig. 3.
Anteroposterior x-ray view showing the talocalcaneal angle.
Fig. 4. Lateral view showing the same angle and the indirect signs of coalition (dorsal spur of the talus and narrowing of the subtalar joint).
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TALOCALCANEAL COALITION DIAGNOSIS
Fig. 5. Obliqueincidenceshowing a calcaneonavicular coalition.
Fig. 8. CT scan. Normal A, posterior and B, middle facets are at left. C, Middle talocalcaneal coalition is at right.
TABLE 2 Surgical Management of Talocalcaneal Coalition: Results'
Pain
Fig. 6. Harrisand Beathincidenceshowing an obliquityof the middle facet A, in relation to the posterior facet and B, in the right foot. Normalaspect in the left foot.
01 02
Subtalar Heel motion valgus
Improved
+ + + +
03 04 05 06
+ +
07
+
+ + 08 09
+ + + +
Improved 10 11
Improved
12 13
+ Improved Improved
21 22 Average Fig. 7. Obliquity of the middle facet.
+ +
+
14 15 16 17 18 19 20
+ + + + + +
+ + + + + + + +
+
+
Radiological findings AP
LT
(0)
(0)
30 20 30 25 30 28 32 35 26 30 34 29 30 35 25 28 28 32 35 30 25 30 35 35 32 30 25 35 40 35 30 34 30.56
20 20 30 28 25 30 26 25 33 32 30 23 20 25 20 25 30 20 36 38 28 24 25 30 25 28 24 30 35 27 25 28 27.34
Length of follow-up (mo) 20
18
12 15 14 17
12 24
13 39 34 14 38 66 58
15 35
12 16 24 25 30
• +, Present; -, absent; AP, anteroposteriorview; LT, lateral view.
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Fig. 9. Medial curvilinear incision showing the osseus bar between the talus and the calcaneus.
Fig. 12. Interposition of fat graft in the subtalar joint.
tween 20° and 42°, with an average of 29.1°. Indirect signs were also observed. One foot had an association with calcaneonavicular bar clearly visible in the oblique view. SURGICAL TECHNIQUE
Fig. 10. After resection of some layers of bone, the subtalar joint is visible.
Fig. 11. Subtalar joint completely free of the osseus bar.
In addition to conventional x-rays, computerized axial tomographic images were made in the coronal plane (Fig. 8); with this examination, measurement of the width of the coalition through the computer is possible.9 .14 ,26 The coalition width measured 9 mm to 16.4 mm, with an average of 13 mm. The talocalcaneal angle in the anteroposterior view ranged between 21 and 44°, with an average of 34.6°. In the lateral view, the talocalcaneal angle ranged be-
In a series of 32 feet, the coalition was completely resected, with interposition of an autogenous free fat graft obtained through the same surgical incision. The bar was approached by a medial incision, about 6 em long. It was made behind the medial malleolus parallel to the posterior tibial neurovascular bundle, which was identified and retracted. The middle facet was located above the sustentaculum tali between flexor digitorum longus and flexor hallucis longus tendons. The periosteum over the bar was incised and reflected. The subtalar joint is identified anterior and posterior to the bar (Fig. 9). The bar was sliced off in "onion skin" layers until the subtalar joint was visible (Fig. 10); we put a flat instrument into the joint in order to mobilize it. Then, capsulotomy around the subtalar joint was done and the interosseus ligament was divided. Through the medial incision, it was possible to reach the lateral aspect of the subtalar joint in order to do the lateral capsulotomy. The desired movement should be gained at the time of the surgery (Fig. 11). The rough, bony surface was cauterized with an electric cauter and bony wax was used to prevent bleeding. Then, a free fat graft was taken off the subcutaneous and placed between the talus and calcaneus space (Fig. 12). The wound was closed and a compressive dressing was applied; no immobilization was used at all. The physiotherapy was begun the following day. It consisted of active and passive exercises; weightbearing was allowed 3 weeks after surgery (Fig. 13, A and B).
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Fig. 13 A, Pre· and B, postoperative bilateral CT scan.
DISCUSSION
In our study, we found that the mean age of 14 years was comparable to that reported in the uterature." Calcaneonavicular coalition usually becomes symptomatic at an earlier age. The onset of symptoms in talocalcaneal coalition occurs in older children more than calcaneonavicular coalition because ossification of this bar occurs later on." Some authors think that . at any age.24 symptoms may beqm The three most important signals or symptoms are pain, valgus deformity of the hindfoot, and stiffness of the subtalar joint. All of our patients complained of these symptoms. Some authors have reported varus deformity of the hindfoot 4 ,6 ; our experience was not similar. We found the valgus deformity to be a characteristic position of the hindfoot. 6 - 8 ,17,18 The absence of heel varus when on tip toe has not been mentioned or stressed in the literature. In our experience, we found this sign to be one of the most helpful. In those patients with rigid subtalar joint, the heel remains in the valgus position. This sign is the most reliable and was present in all cases. Diagnosis with routine x-rays is difficult because, anatomically, the subtalar facets are not in the same plane. The advent of the CT scan has facilitated the diagnosis and location of talocalcaneal coalition. 4,9,13, 14, 19,22 In all feet, indirect signs were seen in talonavicular, calcaneocuboid, and subtalar joints. Talonavicular beaking, calcaneocuboid arthrosis, and closure of the sinus tarsi should raise a high degree of suspicion, although routine radiographs did not show the bar.2 ,7 ,8,1o,2o In one case, we found an additional calcaneonavicular coalition. Two coalitions have been reported by others.":" ,27 The Harris and Beath axial view of the hindfoot has been shown to be one of the most reliable radiographic aids to diagnosis. The CT scan showed the talocalcaneal coalition in all feet, even when the routine x-rays were normal or inconclusive. Computed tomography is the most relia-
ble method of diagnosis. 4 ,9 ,13,14,19 ,25 This examination localizes the bar and, in addition, provides information regarding the size and width of the bar. The principal indication to surgical treatment is the disabling pain that interferes with everyday activities and norrnal lifestyle.V Prior to 1984, we used to perform triple arthrodesis for this deformity. In our opinion, the presence of mild degenerative changes is not a contraindication for resection of the bar, as reported by others.":" ,15,27 Postoperatively, 25 feet (78.1%) had no pain and seven feet (21.8%) remained paintul, but the pain was less intensive than before. There was partial correction of the deformity in 22 feet (68.7%). In 10 feet, there was no correction, considering x-ray measurements and clinical evaluation. The mobility of the subtalar increased in 24 feet (75%). Subtalar mobility was assessed by varus angulation of the heel on the tip toe test plus clinical examination of subtalar motion. The measurement of the talocalcaneal angle in anteroposterior and lateral radiographs was used to assess the surgical correction, not as a diagnostic aid. Postoperative decreases of the talocalcaneal angle were correlated with correction of the valgus deformity of the hindfoot. There were no significant surgical complications, including infected wounds or neurovascular problems. This study corroborated the opinions of the other authors who noted that resection of talocalcaneal coalition is a worthwhile procedure. There is a difference of opinion regarding the merits of bar excision. Some believe that triple arthrodesis at skeletal maturity is the treatment of chotce.?" CONCLUSIONS
Based on our study, we drew the following conclusions: (1) suspect tarsal coalition in children with painful, rigid flat feet; (2) the tip toe test is a reliable method of clinical evaluation; (3) suspect tarsal coalition when routine x-rays show talonavicular beaking, calcaneocuboid spurs, and closed sinus tarsi; (4) a CT scan is
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routine x-rays show talonavicular beaking, calcaneocuboid spurs, and closed sinus tarsi; (4) a CT scan is the most useful and reliable tool in diagnosing talocalcaneal coalition; and (5) surgical resection of the bar with fat graft interposition produces gratifying results. REFERENCES 1. Conway, J.J., and Cowell, H.R.: Tarsal coalition: clinical significance and roentgenographic demonstration. Radiology, 92:799811,1969. 2. Cowell, H.R.: Talocalcanealcoalition and new cases of peroneal spastic flatfoot. Clin. Orthop., 85:16-22,1972. 3. Cowell, H.R., and Elener, V.: Rigid painful flatfoot secondary to tarsal coalition. Clin. Orthop., 177:54-60, 1983. 4. Deutsch, A.L., Resnick, D., and Campbell, G.: Computed tomography and bone scintilography in the evaluation of tarsal coalition. Radiology, 144:137-140, 1982. 5. Elkus, R. R.: Tarsal coalition in the young athlete. Am. J. Sports Med., 14:477-480,1986. 6. Harris, R.I., and Beath, T.: Etiology of peroneal spastic flatfoot. J. Bone Joint Surg., 30A:624-634, 1948. 7. Harris, R.I.: Rigid valgus foot due to calcaneal bridge. J. Bone Joint Surg., 37A:169-183, 1955. 8. Harris, R.I.: Follow-up notes on articles previously published in the journal: retrospect-peroneal spastic flatfoot (rigid valgus foot). J. Bone Joint Surg., 47A:1657-1667, 1965. 9. Herzemberg, J.E., Goldner, J.L., Martinez, S., and Silverman, P.M.: Computerized tomography of talocalcanealtarsal coalition. A clinical and anatomy study. Foot Ankle, 6:273-288,1986. 10. Jack, E.A.: Bone anomalies of the tarsus in relation to "peroneal spastic flatfoot." J. Bone Joint Surg., 36B:530-542, 1954. 11. Jayakumar, S., and Cowell, H.R.: Rigid flatfoot. Clin. Orthop., 122:77-84,1977. 12. Leonard, M.R.: The inheritance of tarsal coalition relationship to spastic flatfoot. J. Bone Joint Surg., 56B:520-526, 1974. 13. Marchisello, P.J.: The use of computerized axial tomography for the evaluation of talocalcaneal coalition. J. Bone Joint Surg., 69A:609-611 , 1987.
14. Martinez, S., Herzemberg, J.E., and Apple, J.S.: Computed tomography of the hindfoot. Orthop. Clin. North Am., 16:481496,1985. 15. Morgan, R.C., and Crawford, A.H.: Surgical management of tarsal coalition in adolescent athletes. Foot Ankle, 7:183-193, 1986. 16. Mosier, K.M., and Asher, M.: Tarsal coalitions and peroneal spastic flatfoot. J. Bone Joint Surg., 66A:976-983, 1984. 17. Olney, B.W., and Asher, M.: Excision of symptomatic coalition of the middle facet of the talocalcaneal joint. J. Bone Joint Surg., 69A:539-544,1987. 18. Percy, E.C., and Mann, D.L.: Tarsal coalition: a review of the literature and presentation of 13 cases. Foot Ankle, 9:40-44, 1988. 19. Pineda, C., Resnick, D.L., and Greenway, G.: Diagnosis of tarsal coalition with computed tomography. Clin Orthop.,
208:282-288, 1986. 20. Sartoris, D.J., and Resnick, D.L.: Tarsal coalition. Arthritis Rheum., 28:331-338,1985. 21. Saunders, J.B.C.M., Inman, V.T., and Eberhart, H.D.:The major determinants in normal and pathological gait. J. Bone Joint Surg., 35A:543-558, 1953. 22. Scranton, P.E.: Treatment of symptomatic talocalcaneal coalition. J. Bone Joint Surg., 69B:533-538, 1987. 23. Snyder, R.B., Lipscomb, A.B., and Johnston, R.K.: The relationship of tarsal coalition to ankle sprains in athletes. Am. J. Sports Med., 9:313-317,1981. 24. Stormont, D.M., and Peterson, H.A.: The relative incidence of tarsal coalition. Clin. Orthop., 181:28-36, 1983. 25. Stoskopt, C.A., Hernandez, R.J., Kelikian, A., and Dias, L.S.: Evaluation of tarsal coalition by computed tomography. J. Pediatr. Orthop., 4:365-369, 1984. 26. Swiontkowski, M.F., Seraton, P.E., and Hansen, S.: Tarsal coalition: long-term results of surgical treatment. J. Pediatr. Orthop., 3:287-292,1983. 27. Weeler, R., Guevera, A., and Bleck, E.E.: Tarsal coalition: review of the literature and case report of bilateraldual calcaneonavicular and talocalcaneal coalitions. Clin. Orthop., 156:175177,1981.
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ANKLE
Copyright © 1992 by the American Orthopaedic Foot Society, Inc.
Talocalcaneal Coalition: Diagnosis and Surgical Management Osny setomao, M.D.: Manlio Mario Marco Napoli, M.D.,t Antonio Egydio de Carvalho, Jr., M.D.,f Tulia Diniz Fernandes, MD.,f Julio Marques, M.D..+ and Arnalda Jose Hernandez, M.D.f Sao Paulo, Brazil
ABSTRACT The authors studied 22 patients who had 32 feet with symptomatic talocalcaneal coalition. All feet were treated with excision of the bar and interposition of an autogenous free fat graft. These cases were assessed clinically and radiographically before and after the operation. They conclude that this technique is a good surgery with gratifying results. In the final outcome, 78.1% of feet became completely painless and 21.8% achieved relief of pain. There was improvement of the deformity in 68.7% and of range of motion in 75%.
was more affected than the right side in unilateral cases (9:3) (Table 1). All patients had disabling, painful, rigid flat feet diagnosed clinically and radiographically. In the first six patients, plaster cast immobilization was done initially without good results. Since then, we have been doing surgical treatment for these cases as the first procedure. This study includes patients treated surgically by resection of the coalition with interposition of a free fat graft. The follow-up ranged from 12 months to 66 months, with an average follow-up of 25 months (Table 2). All feet had pre- and postoperative clinical, radiographic, and CT scan assessment. Twenty patients (30 feet) had valgus deformity of the hindfoot and all patients had stiffness of the subtalar joint. The valgus position of the heel was maintained when patients stood on tip toe (Figs. 1 and 2). Usually on plantarflexion of the foot, the heel should go into varus position, mainly because of the pull action of the Achilles tendon." All patients complained of pain on walking. Six patients reported a history of one episode of ankle sprain as their first symptom. The roentgenographic evaluation included anteroposterior and lateral views on weightbearing to measure the talocalcaneal angle and to identify associated abnormalities, such as dorsal beak of the talus, narrowing of the subtalar joint (closure of sinus tarsi), and enlargement of the lateral process of the talus 1-3,7,10,20 (Figs. 3 and 4). An oblique view was taken to identify a calcaneonavicular coalition, which can be present in addition to a talocalcaneal coalition (Fig. 5). A routine axial view (Harris and Beath) was done. In the normal foot, the middle and posterior facets are parallel. When a coalition of the midsubtalar joint is present, the middle facet is seen in the oblique position in relation to the posterior facet (Fig. 6). This obliquity of the middle facet is the most important indirect radiographic sign of a midfacet coalition. When this obliquity reaches 20° or more,1-3,6,11 there is a great possibility of talocalcaneal coalition (Fig. 7).
Tarsal coalition was probably first described in 1769 by Buffon. The earliest anatomical description of talocalcaneal coalition was made by Zuckerkandl in 1877. Harris and Beath (1948) popularized the relationship between tarsal coalition and painful peroneal spastic flatfoot. 6,11,12.16 Tarsal coalition is present in 1% of the general population, with slightly more common incidence at the talocalcaneal region. B.1 0.12,16,23 Talocalcaneal coalition is usually unilateral, but bilateral cases had been described to be as high as 50% in some series by several authors.B,10.24 We propose to review our experience with surgical excision of the symptomatic talocalcaneal coalitions treated between May 1984 and August 1990. MATERIALS AND METHODS
Our series consisted of 35 feet in 24 patients. Two patients were lost to follow-up, so we studied 32 feet in 22 patients, 10 bilateral and 12 unilateral. The mean age was 14 years and ranged from 10 to 23 years. In 22 patients, 16 were female and six male. The left side * Associate Professor, School of Medicine, University of Sao Paulo, Sao Paulo, Brazil. To whom requests for reprints should be addressed at Av. Santo Amaro, 5350, CEP: 04702, Sao Paulo, Brasil. t Chief, Department of Orthopaedics and Traumatology, School of Medicine, University of Sao Paulo, Sao Paulo, Brazil. From the Department of Orthopaedics and Traumatology, School of Medicine, University of Sao Paulo, Sao Paulo, Brazil.
+
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TABLE 1 Surgical Management of Talocalcaneal Coalition: Preoperative" Physical findings
Side inAge (yr) Sex volved Pain Subtalar Heel AP motion valgus (0)
01 14 F 02 11 M 03 04 05 06
13 19 14 13
F M M
F
07 13 F 08 13 F 09 12 F 10 15 F 11 16 F 12 17 M 13 23 F 14 15 M 15 14 F 16 17 18 19 20 21
14 11 15 10 13 15
F F F F F M
22 13 F
L R
L L R R R L R L L R L R L L R L R L L R L L L L R L R L R L
+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
Average
+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
Radiological findings
LT A Indirect (0) signs
38 30 21 11 30 30 28 30 38 25 32 27 35 27 40 25 32 35 30 32 35 30 35 25 30 20 36 30 28 20 28 30 33 30 34 30 44 35 40 42 35 22 40 30 38 30 35 30 40 30 35 28 30 35 35 30 42 35 42 30 34 25 35 30 34.6 29.1
• +, Present; -, Absent;
+ + + + + + + + + + + + + + + + + + + + + + + + + + + +
+
+ + + + + + + + + + + + + + + + + + + + + + + + + + +
+ +
+
R, right; L, left; AP, anteroposterior view; LT, lateral view; A, axial view (Harris and Beath).
Fig. 1.
Valgus deformity of the right hindfoot.
Fig. 2. Absence of variation of the right hindfoot during plantarflexion (see variation of the left hindfoot).
Fig. 3.
Anteroposterior x-ray view showing the talocalcaneal angle.
Fig. 4. Lateral view showing the same angle and the indirect signs of coalition (dorsal spur of the talus and narrowing of the subtalar joint).
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TALOCALCANEAL COALITION DIAGNOSIS
Fig. 5. Obliqueincidenceshowing a calcaneonavicular coalition.
Fig. 8. CT scan. Normal A, posterior and B, middle facets are at left. C, Middle talocalcaneal coalition is at right.
TABLE 2 Surgical Management of Talocalcaneal Coalition: Results'
Pain
Fig. 6. Harrisand Beathincidenceshowing an obliquityof the middle facet A, in relation to the posterior facet and B, in the right foot. Normalaspect in the left foot.
01 02
Subtalar Heel motion valgus
Improved
+ + + +
03 04 05 06
+ +
07
+
+ + 08 09
+ + + +
Improved 10 11
Improved
12 13
+ Improved Improved
21 22 Average Fig. 7. Obliquity of the middle facet.
+ +
+
14 15 16 17 18 19 20
+ + + + + +
+ + + + + + + +
+
+
Radiological findings AP
LT
(0)
(0)
30 20 30 25 30 28 32 35 26 30 34 29 30 35 25 28 28 32 35 30 25 30 35 35 32 30 25 35 40 35 30 34 30.56
20 20 30 28 25 30 26 25 33 32 30 23 20 25 20 25 30 20 36 38 28 24 25 30 25 28 24 30 35 27 25 28 27.34
Length of follow-up (mo) 20
18
12 15 14 17
12 24
13 39 34 14 38 66 58
15 35
12 16 24 25 30
• +, Present; -, absent; AP, anteroposteriorview; LT, lateral view.
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Fig. 9. Medial curvilinear incision showing the osseus bar between the talus and the calcaneus.
Fig. 12. Interposition of fat graft in the subtalar joint.
tween 20° and 42°, with an average of 29.1°. Indirect signs were also observed. One foot had an association with calcaneonavicular bar clearly visible in the oblique view. SURGICAL TECHNIQUE
Fig. 10. After resection of some layers of bone, the subtalar joint is visible.
Fig. 11. Subtalar joint completely free of the osseus bar.
In addition to conventional x-rays, computerized axial tomographic images were made in the coronal plane (Fig. 8); with this examination, measurement of the width of the coalition through the computer is possible.9 .14 ,26 The coalition width measured 9 mm to 16.4 mm, with an average of 13 mm. The talocalcaneal angle in the anteroposterior view ranged between 21 and 44°, with an average of 34.6°. In the lateral view, the talocalcaneal angle ranged be-
In a series of 32 feet, the coalition was completely resected, with interposition of an autogenous free fat graft obtained through the same surgical incision. The bar was approached by a medial incision, about 6 em long. It was made behind the medial malleolus parallel to the posterior tibial neurovascular bundle, which was identified and retracted. The middle facet was located above the sustentaculum tali between flexor digitorum longus and flexor hallucis longus tendons. The periosteum over the bar was incised and reflected. The subtalar joint is identified anterior and posterior to the bar (Fig. 9). The bar was sliced off in "onion skin" layers until the subtalar joint was visible (Fig. 10); we put a flat instrument into the joint in order to mobilize it. Then, capsulotomy around the subtalar joint was done and the interosseus ligament was divided. Through the medial incision, it was possible to reach the lateral aspect of the subtalar joint in order to do the lateral capsulotomy. The desired movement should be gained at the time of the surgery (Fig. 11). The rough, bony surface was cauterized with an electric cauter and bony wax was used to prevent bleeding. Then, a free fat graft was taken off the subcutaneous and placed between the talus and calcaneus space (Fig. 12). The wound was closed and a compressive dressing was applied; no immobilization was used at all. The physiotherapy was begun the following day. It consisted of active and passive exercises; weightbearing was allowed 3 weeks after surgery (Fig. 13, A and B).
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255
Fig. 13 A, Pre· and B, postoperative bilateral CT scan.
DISCUSSION
In our study, we found that the mean age of 14 years was comparable to that reported in the uterature." Calcaneonavicular coalition usually becomes symptomatic at an earlier age. The onset of symptoms in talocalcaneal coalition occurs in older children more than calcaneonavicular coalition because ossification of this bar occurs later on." Some authors think that . at any age.24 symptoms may beqm The three most important signals or symptoms are pain, valgus deformity of the hindfoot, and stiffness of the subtalar joint. All of our patients complained of these symptoms. Some authors have reported varus deformity of the hindfoot 4 ,6 ; our experience was not similar. We found the valgus deformity to be a characteristic position of the hindfoot. 6 - 8 ,17,18 The absence of heel varus when on tip toe has not been mentioned or stressed in the literature. In our experience, we found this sign to be one of the most helpful. In those patients with rigid subtalar joint, the heel remains in the valgus position. This sign is the most reliable and was present in all cases. Diagnosis with routine x-rays is difficult because, anatomically, the subtalar facets are not in the same plane. The advent of the CT scan has facilitated the diagnosis and location of talocalcaneal coalition. 4,9,13, 14, 19,22 In all feet, indirect signs were seen in talonavicular, calcaneocuboid, and subtalar joints. Talonavicular beaking, calcaneocuboid arthrosis, and closure of the sinus tarsi should raise a high degree of suspicion, although routine radiographs did not show the bar.2 ,7 ,8,1o,2o In one case, we found an additional calcaneonavicular coalition. Two coalitions have been reported by others.":" ,27 The Harris and Beath axial view of the hindfoot has been shown to be one of the most reliable radiographic aids to diagnosis. The CT scan showed the talocalcaneal coalition in all feet, even when the routine x-rays were normal or inconclusive. Computed tomography is the most relia-
ble method of diagnosis. 4 ,9 ,13,14,19 ,25 This examination localizes the bar and, in addition, provides information regarding the size and width of the bar. The principal indication to surgical treatment is the disabling pain that interferes with everyday activities and norrnal lifestyle.V Prior to 1984, we used to perform triple arthrodesis for this deformity. In our opinion, the presence of mild degenerative changes is not a contraindication for resection of the bar, as reported by others.":" ,15,27 Postoperatively, 25 feet (78.1%) had no pain and seven feet (21.8%) remained paintul, but the pain was less intensive than before. There was partial correction of the deformity in 22 feet (68.7%). In 10 feet, there was no correction, considering x-ray measurements and clinical evaluation. The mobility of the subtalar increased in 24 feet (75%). Subtalar mobility was assessed by varus angulation of the heel on the tip toe test plus clinical examination of subtalar motion. The measurement of the talocalcaneal angle in anteroposterior and lateral radiographs was used to assess the surgical correction, not as a diagnostic aid. Postoperative decreases of the talocalcaneal angle were correlated with correction of the valgus deformity of the hindfoot. There were no significant surgical complications, including infected wounds or neurovascular problems. This study corroborated the opinions of the other authors who noted that resection of talocalcaneal coalition is a worthwhile procedure. There is a difference of opinion regarding the merits of bar excision. Some believe that triple arthrodesis at skeletal maturity is the treatment of chotce.?" CONCLUSIONS
Based on our study, we drew the following conclusions: (1) suspect tarsal coalition in children with painful, rigid flat feet; (2) the tip toe test is a reliable method of clinical evaluation; (3) suspect tarsal coalition when routine x-rays show talonavicular beaking, calcaneocuboid spurs, and closed sinus tarsi; (4) a CT scan is
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routine x-rays show talonavicular beaking, calcaneocuboid spurs, and closed sinus tarsi; (4) a CT scan is the most useful and reliable tool in diagnosing talocalcaneal coalition; and (5) surgical resection of the bar with fat graft interposition produces gratifying results. REFERENCES 1. Conway, J.J., and Cowell, H.R.: Tarsal coalition: clinical significance and roentgenographic demonstration. Radiology, 92:799811,1969. 2. Cowell, H.R.: Talocalcanealcoalition and new cases of peroneal spastic flatfoot. Clin. Orthop., 85:16-22,1972. 3. Cowell, H.R., and Elener, V.: Rigid painful flatfoot secondary to tarsal coalition. Clin. Orthop., 177:54-60, 1983. 4. Deutsch, A.L., Resnick, D., and Campbell, G.: Computed tomography and bone scintilography in the evaluation of tarsal coalition. Radiology, 144:137-140, 1982. 5. Elkus, R. R.: Tarsal coalition in the young athlete. Am. J. Sports Med., 14:477-480,1986. 6. Harris, R.I., and Beath, T.: Etiology of peroneal spastic flatfoot. J. Bone Joint Surg., 30A:624-634, 1948. 7. Harris, R.I.: Rigid valgus foot due to calcaneal bridge. J. Bone Joint Surg., 37A:169-183, 1955. 8. Harris, R.I.: Follow-up notes on articles previously published in the journal: retrospect-peroneal spastic flatfoot (rigid valgus foot). J. Bone Joint Surg., 47A:1657-1667, 1965. 9. Herzemberg, J.E., Goldner, J.L., Martinez, S., and Silverman, P.M.: Computerized tomography of talocalcanealtarsal coalition. A clinical and anatomy study. Foot Ankle, 6:273-288,1986. 10. Jack, E.A.: Bone anomalies of the tarsus in relation to "peroneal spastic flatfoot." J. Bone Joint Surg., 36B:530-542, 1954. 11. Jayakumar, S., and Cowell, H.R.: Rigid flatfoot. Clin. Orthop., 122:77-84,1977. 12. Leonard, M.R.: The inheritance of tarsal coalition relationship to spastic flatfoot. J. Bone Joint Surg., 56B:520-526, 1974. 13. Marchisello, P.J.: The use of computerized axial tomography for the evaluation of talocalcaneal coalition. J. Bone Joint Surg., 69A:609-611 , 1987.
14. Martinez, S., Herzemberg, J.E., and Apple, J.S.: Computed tomography of the hindfoot. Orthop. Clin. North Am., 16:481496,1985. 15. Morgan, R.C., and Crawford, A.H.: Surgical management of tarsal coalition in adolescent athletes. Foot Ankle, 7:183-193, 1986. 16. Mosier, K.M., and Asher, M.: Tarsal coalitions and peroneal spastic flatfoot. J. Bone Joint Surg., 66A:976-983, 1984. 17. Olney, B.W., and Asher, M.: Excision of symptomatic coalition of the middle facet of the talocalcaneal joint. J. Bone Joint Surg., 69A:539-544,1987. 18. Percy, E.C., and Mann, D.L.: Tarsal coalition: a review of the literature and presentation of 13 cases. Foot Ankle, 9:40-44, 1988. 19. Pineda, C., Resnick, D.L., and Greenway, G.: Diagnosis of tarsal coalition with computed tomography. Clin Orthop.,
208:282-288, 1986. 20. Sartoris, D.J., and Resnick, D.L.: Tarsal coalition. Arthritis Rheum., 28:331-338,1985. 21. Saunders, J.B.C.M., Inman, V.T., and Eberhart, H.D.:The major determinants in normal and pathological gait. J. Bone Joint Surg., 35A:543-558, 1953. 22. Scranton, P.E.: Treatment of symptomatic talocalcaneal coalition. J. Bone Joint Surg., 69B:533-538, 1987. 23. Snyder, R.B., Lipscomb, A.B., and Johnston, R.K.: The relationship of tarsal coalition to ankle sprains in athletes. Am. J. Sports Med., 9:313-317,1981. 24. Stormont, D.M., and Peterson, H.A.: The relative incidence of tarsal coalition. Clin. Orthop., 181:28-36, 1983. 25. Stoskopt, C.A., Hernandez, R.J., Kelikian, A., and Dias, L.S.: Evaluation of tarsal coalition by computed tomography. J. Pediatr. Orthop., 4:365-369, 1984. 26. Swiontkowski, M.F., Seraton, P.E., and Hansen, S.: Tarsal coalition: long-term results of surgical treatment. J. Pediatr. Orthop., 3:287-292,1983. 27. Weeler, R., Guevera, A., and Bleck, E.E.: Tarsal coalition: review of the literature and case report of bilateraldual calcaneonavicular and talocalcaneal coalitions. Clin. Orthop., 156:175177,1981.
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