Talocalcaneal Coalition Resection Research Articles

Arthroscopic Talocalcaneal Coalition Resection in Children

To present the technique and outcomes of arthroscopic talocalcaneal coalition (TCC) resection in pediatric patients. We performed a prospective study of 16 consecutive feet with persistent symptomatic TCCs in 15 children. The mean age was 11.8 years (range, 8 to 15 years), and the mean follow-up period was 28 months (range, 12 to 44 months). A posterior arthroscopic TCC resection was performed. The plantar footprint, subtalar motion, pain, and the American Orthopaedic Foot & Ankle Society Ankle-Hindfoot scale score were evaluated preoperatively and postoperatively. Preoperative computed tomography (CT) scans were used to classify the coalition according to the Rozansky classification, to measure the percentage of involvement of the surface area, and to determine the degree of hindfoot valgus. Postoperative CT scans at 1 year (n= 15) and 3 years (n= 5) were used to assess recurrences. Patient satisfaction was also evaluated. The TCC distribution according to the Rozansky classification was type I in 7 cases, type II in 3, type III in 3, and type IV in 3. In all cases the arthroscopic approach enabled complete coalition resection. All patients increased by at least 1 stage in the footprint classification and showed clinical subtalar mobility after surgery. All patients showed a statistically significant improvement in pain after surgery except for 1 patient in whom complex regional pain syndrome developed (P < .001). The mean American Orthopaedic Foot & Ankle Society score was 56.8 (range, 45 to 62) preoperatively versus 90.9 (range, 36 to 100) postoperatively, showing a statistically significant increase (P < .001). Preoperative CT scans showed that all TCCs involved the medial subtalar joint facet, with mean involvement of 40.8% of the articular surface. All postoperative CT scans showed complete synostosis resections with no recurrences at final follow-up. At final follow-up, all patients were either satisfied (n= 4 [27%]) or extremely satisfied (n= 10 [67%]) with the outcome, except the 1 patient (7%) in whom complex regional pain syndrome developed. Arthroscopic TCC resection provides good outcomes (symptom relief and restoration of subtalar motion), with no recurrence of the coalition. Level IV, therapeutic case series.

Use of a cannulated guide in talocalcaneal coalition resection: technique tip.

Use of a cannulated guide in talocalcaneal coalition resection: technique tip.

The Use of a Portable CT Scanner for the Intraoperative Assessment of Talocalcaneal Coalition Resections

Intraoperative assessment of talocalcaneal (TC) coalition resection can be challenging, with no reliable plain radiographic view available for evaluation. Therefore, in March of 2011, we began using a CereTom portable CT scanner to assess TC coalition resections intraoperatively. This study evaluates the use of intraoperative CT during surgical resection of TC coalitions. Patients who received CT scans before and after TC coalition resection, by a single surgeon, were included. Those treated without (control group, n=12 feet) and with (intraoperative CT group, n=14 feet) intraoperative CT scan were retrospectively compared. Two blinded pediatric orthopaedic surgeons assessed the quality of resection using a side-by-side comparison of preoperative and postoperative CT scans. Each resection was rated as "excellent," "fair," or "poor," and medical records were reviewed to evaluate clinical outcome. Substantial agreement was found between blinded reviewers (κ=0.71, 81% absolute agreement). Quality of resection was improved in the intraoperative CT group, with 57% of patients receiving an excellent rating compared with 25% in the control group. Patients in the intraoperative CT group were 4.0 times more likely to have a complete resection as compared with patients in the control group; however, this was not statistically significant (odds ratio, P>0.05; 95% confidence interval, 0.74-21.5). Intraoperative CT altered surgical decision making in 3 feet (21%) in the intraoperative CT group, leading to further resection and a subsequent excellent postoperative rating in 2 of these patients. There was 1 reoperation in the control group for continued pain and residual coalition identified on postoperative CT scan. In the intraoperative CT group there have been no reoperations for recurrent or residual qcoalition. This study illustrates that intraoperative CT can alter surgical decision making and may improve the ability to obtain a complete resection in TC coalition surgery. In these technically challenging cases, intraoperative scans give immediate imaging feedback to surgeons, allowing intervention if residual resection is identified. If intraoperative CT scan is available, it should be considered for surgical treatment of TC coalition resections. Level III retrospective case-control study.

Endoscopic Resection of a Talocalcaneal Coalition Using a Posteromedial Approach

Resection is a standard surgical procedure for a talocalcaneal coalition (TCC). A posterior approach is the representative technique for hindfoot endoscopy, and there is only 1 report of endoscopic resection of TCC using this approach. Disadvantages of the posterior approach for TCC are as follows: (1) the indication is limited to posterior-facet coalition, (2) the flexor hallucis longus can be an obstacle in approaching the coalition, (3) the acute insertion angle between the endoscope and instrument reduces operability, and (4) a position change and additional skin incision are essential for conversion to an open procedure. In contrast, a posteromedial approach for TCC with established portals at the entrance and exit of the flexor retinaculum is a useful technique because (1) the indication is allow to middle- and posterior-facet coalitions, (2) increased perfusion pressure allows the creation of sufficient working space, (3) operating the instrument only at the coalition site decreases the risk of tendon injury and neurovascular damage, (4) the obtuse insertion angle between the endoscope and instrument improves operability, and (5) a position change and additional skin incision are unnecessary for conversion to an open procedure.

Arthroscopic resection of talocalcaneal coalitions—A bicentre case series of a new technique

Symptomatic tarsal coalitions failing conservative treatment are traditionally managed by open resection. We describe an arthroscopic technique for excising talocalcaneal coalitions and present a retrospective two-surgeon case series of the first eight patients (nine feet). Outcome measures include restoration of subtalar movements, return to work and sports, visual analogue pain scales and Sports Athlete Foot and Ankle Scores (SAFAS). Follow-up ranges from 1 to 5.5 years. Pain and SAFAS improved in 7 patients. Subtalar movements were improved in all feet. All patients achieved early good function but one relapsed requiring subsequent fusions. One posterior tibial nerve was damaged. Minimal destruction of bone and soft tissues allows early mobilization and minimizes pain. Patient selection and preoperative planning are crucial to avoid relapse and complication. This series from two independent surgeons supports the feasibility and effectiveness of this technique.

Arthroscopic Resection of Talocalcaneal Coalitions

Excision of symptomatic talocalcaneal coalitions, after failure of an adequate conservative treatment, is a widely accepted surgical treatment when less than 50% of the subtalar joint is involved and in the absence of degenerative changes to the subtalar or surrounding tarsal joints. Favorable results have been reported in 80% to 100% of patients with open resection. The traditional medial incision to the subtalar joint provides excellent exposure of the middle facet but inadequate visualization of the posterior facet. Other common disadvantages of the traditional open technique include (1) risk of incisional neuroma formation, (2) risk of superficial wound infection and delayed wound healing, and (3) prolonged hospitalization for wound management and pain control. Prone ankle/subtalar arthroscopy has been reported to yield excellent results in the treatment of numerous hindfoot pathologies, with the advantage of reducing postoperative pain, hospital stay, infection rates, wound complications, and recovery time. A posterior arthroscopic technique for posterior-facet talocalcaneal coalition excision has been developed in an attempt to reduce the complications of the traditional open resection. Possible disadvantages of the arthroscopic procedure may include (1) longer learning curve, (2) increased surgical time, (3) possible tibial neurovascular bundle damage, and (4) difficulties in using interposition material.

Bilateral Single-stage Middle Facet Talocalcaneal Coalition Resection Combined with Flatfoot Reconstruction: A Report of 3 Cases and Review of the Literature. Investigations Involving Middle Facet Coalitions—Part 1

Talocalcaneal middle facet coalitions are associated with rigid pes planovalgus that often requires surgical intervention. Simple resection of the coalition is preferred for symptomatic cases in the absence of rearfoot arthritis. While resection of the coalition will remove the osseous restriction of motion and may eliminate pain, the procedure does not specifically correct the concomitant pes planovalgus. In this report of 6 feet in 3 patients, we advocate combining resection of the coalition with concomitant flatfoot reconstruction in a single-stage operation. The patients in this series averaged 13.67 (range 12-17) years of age at the time of their foot surgeries, and their follow-up averaged 30 (range 16-54) months. All of the patients displayed bilateral middle facet talocalcaneal coalitions and underwent bilateral resection combined with flatfoot reconstruction. Each patient had 1 foot corrected followed by a period of at least 6 months before the contralateral foot was corrected. The mean postoperative American Orthopaedic Foot and Ankle Society ankle-hindfoot score was excellent (94.33+/-2.81 points) overall. The median radiographic values for calcaneal inclination, Meary's, and anteroposterior talar-first metatarsal angles demonstrated statistically significant improvements: 9 degrees (3 degrees, 13 degrees) (P= .0273), 4 degrees (2 degrees, 7 degrees) (P= .0269), and 6 degrees (3 degrees, 11 degrees ) (P= .0277), respectively, and all feet demonstrated improved subtalar joint motion without pain. Although long-term results remain to be determined in a larger cohort, it is hoped that this combined approach to talocalcaneal coalition will delay or obviate future rearfoot arthrosis and the need for arthrodesis. 4.

Resection of talocalcaneal coalition—the effect on subtalar joint movements

Surgical resection of symptomatic coalition between the talus and calcaneus is recommended by many surgeons. The success of this procedure in reducing symptoms has been well described in the literature, but the quantitative effect of resection surgery on hindfoot movements and biomechanics has not been documented. We prospectively studied the mechanical effect of resection of talocalcaneal coalitions in a population of 14 feet in 12 patients, over a 2-year period. The mean age of the patients was 13 years (range 12–14). Seven patients were male and five were female. A standard resection procedure was performed by the same surgeon in each case. Visual analogue pain scores and the range of hindfoot movement were recorded before and after surgery. The minimum follow-up period was 6 months (range 6–24). All patients reported an improvement in their visual analogue pain scores (median improvement 7 points; range 2–10). The resting valgus attitude of the calcaneus did not change significantly in any case. However, active and passive inversion at the hindfoot increased significantly ( P<0.002) in all patients. These improvements in biomechanical parameters following resection of talocalcaneal coalitions have not previously been reported.

Symptomatic Talocalcaneal Coalition Resection: Indications and Results

We report our results of talocalcaneal coalition (TCC) resection in 25 feet after failed nonoperative treatment. Preoperative computed tomography (CT) scans were used to quantify the amount of heel valgus and the size of the coalition relative to the posterior facet. The ratio of mean TCC cross-sectional area to the surface area of the posterior facet was 53.4%. Mean hindfoot valgus was 17.8 degrees. The mean AOFAS (American Orthopaedic Foot and Ankle Society) hindfoot score was 81.9, at an average of 2.5 years after surgery. Statistical analysis determined a significant association between TCC > 50% the size of the posterior facet and poor outcome (p = 0.014). Similarly, heel valgus > 21 degrees was associated with poor outcome (p = 0.014). However, there were good postoperative results in feet with heel valgus > 21 degrees and in those whose TCC was > 50% of the posterior facet. Therefore we advocate using these CT-scan criteria for preoperative discussions with patients and families and not for determination of the index operative procedure (resection vs. arthrodesis). Hindfoot arthrodesis should only be used as a salvage procedure. We recommend those feet with heel valgus > 21 degrees use an orthosis postoperatively to stabilize the hindfoot or a secondary calcaneal procedure should nonoperative management fail.

Gait abnormalities following resection of talocalcaneal coalition.

Eleven patients (fourteen feet) had resection of a coalition of the middle facet of the talocalcaneal joint because of symptoms that had been present for a mean of four years (range, 0.5 to nine years). The mean age at the time of the resection was seventeen years (range, thirteen to thirty-two years). Nine patients were male and two were female. Five feet had resection of the bone bridge with interposition of fat or tendon, and nine had resection without any interposed material. The mean duration of follow-up was six years (range, two to thirteen years). The clinical result was excellent for five feet, good for four, fair for three, and poor for two. Inversion was 8 +/- 4.5 degrees (mean and standard deviation) on the involved side and 17 +/- 6.2 degrees on the uninvolved side (p = 0.002). Three feet later had evidence of osteoarthrosis of the subtalar joint. Gait analysis demonstrated decreased motion of the hindfoot and the ankle, compared with that in normal subjects and with that in the contralateral (uninvolved) foot, in the sagittal and coronal planes during walking on a level surface. Motion was also reduced, particularly in the sagittal and coronal planes, during walking on a side slope. Ground-reaction forces (F8 and F9), temporal force factors (T2, T3, and T7), and the percentage of the gait cycle that consisted of the stance phase on the side-sloping walkway were different from those in normal subjects or in the uninvolved foot. These data indicate that, although most of our patients who had resection of a talocalcaneal coalition had a successful clinical result, most had a residual functional deficit.

Talocalcaneal Coalition Resection: A 10-Year Follow-up

Eight patients (nine feet) who underwent resection of persistently symptomatic talocalcaneal middle-facet coalitions were reevaluated > or = 10 years after surgery. Satisfactory results persisted in eight of nine cases with no deterioration of symptom relief. There was no loss of motion or development of degenerative joint changes. No patient required a secondary surgery. It appears that resection of symptomatic talocalcaneal coalition provides satisfactory results in the majority of patients, and its benefits are maintained 10 years after the procedure.

Tarsal Coalitions

We reviewed 40 patients who had undergone 57 operations for tarsal coalition between 1965 and 1980. Ten patients were treated for talocalcaneal coalitions. Four had successful resections and the remainder had successful single or combination arthrodesis. Thirty patients had 39 calcaneonavicular resections and five primary triple arthrodeses. In the entire series only two patients had a poor end result due to either technically poor surgery or failed calcaneonavicular resection because of advanced degeneration. Polytomography, computed tomography, or both were valuable in determining if talocalcaneal coalition resection was feasible. Care must be taken in evaluating the talonavicular joint for degenerative changes. The talar "beak" is not necessarily a degenerative spur, but rather a traction process occurring secondary to increased motion.