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Current Orthopaedics (1998) 12, 135-142

1998 Harcourt Brace & Co. Ltd


Foot and ankl e
Tarsal coalition: aetiology, diagnosis and treatment
A. Sakellariou, R. J. Claridge
INTRODUCTION AETIOLOGY
Tarsal coalition was probably first described by Buffon
in 1769. Subsequently, the discovery of a variety of
coalitions and their characterizations has been aided
by the evolution and refinement of plain radiology
and, more recently, by computerized tomography
(CT) and magnetic resonance imaging (MRI).
Tarsal coalition refers to a condition characterized
by a restriction or absence of hindfoot motion, sec-
ondary to an abnormal union between two or more
bones of the hindfoot or, less commonly, the midfoot.
Coalitions may be cartilaginous (synchondrosis),
fibrous (syndesmosis), or bony (synostosis) and the
condition may be congenital or acquired. Often
asymptomatic, the congenital form may go unrecog-
nized until such time as a minor sprain or hindfoot
trauma leads to its incidental diagnosis. Once symp-
tomatic, children and adolescents are those usually
affected, although presentation in young adults is
fairly common. Following presentation, however,
tarsal coalition may continue unrecognized as the
cause of chronic pain or discomfort in the hindfoot,
often leading to incorrect diagnosis and inappropriate
treatment.
The purpose of this article, therefore, after outlin-
ing the aetiology, is to focus on the accurate diagnosis
and management of tarsal coalition, and to discuss
aspects of its treatment that remain controversial.
Anthony Sakellariou BSc MB FRCS(Orth), Visiting Fellow;
Richard J. Claridge MD FRCS(C), Foot and Ankle Clinic,
Department of Orthopaedics, Mayo Clinic Scottsdale, 13400 East
Shea Boulevard, Scottsdale, Arizona 85259, USA.
Correspondence to: Mr Anthony Sakellariou, West Cottage,
Walton Manor, Walton-on-the-Hill, Surrey KT20 7SA, UK.
Heredity
Two theories have been proposed for the aetiology of
tarsal coalition. The first of these arose from the
observation that accessory ossicles are often noted at
the sites of some coalitions. This led to the suggestion
that these accessory bones gradually become ossified
into a bony union, resulting in coalition. The exis-
tence of the anomaly in fetuses, however, does not
support the theory of accessory ossification. The
theory currently most favoured is that the condition
represents a failure of segmentation of primitive mes-
enchyme. The observation of familial occurrence
suggests that this condition is inherited, and the
finding in some cases of involvement of subsequent
generations further suggests a dominant type of
inheritance. ~,2Further work in this field by Leonard in
19743 has now led to the general acceptance that
tarsal coalition is usually due to an inherited auto-
somal dominant disorder with variable penetrance.
The overall prevalence of tarsal coalition in the
general population is reported to be in the region of
1%. 2~ However, as many coalitions remain asymp-
tomatic in life, the actual figure may be higher. Race
does not appear to be significant and, of those
affected, between 50 and 60% have the condition
bilaterally? '3'5 The relative incidence of the two most
common types of coalition is almost equal (talocal-
caneal 48%, calcaneonavicular 44%), and together
they account for the great majority of coalitions? Of
the talocalcaneal coalitions, most involve the middle
facet; posterior and anterior facet subtalar coalitions
are much less commonJ ,7 Talonavicular coalitions
account for only 1% and calcaneocuboid about the
same. Other types of coalition make up the remain-
der, but individually are very rareY Some patients
135
136 Current Orthopaedics
may have more t han one coalition in the same foot
and a high percentage are bilateral.
Although failure of segmentation is the most com-
mon cause of tarsal coalition, acquired ' coalition' of
any of the tarsal bones may occur secondary to
t rauma (intra-articular fracture), inflammatory
arthropathy, neoplasm or even osteonecrosis, resulting
in a rigid painful flatfoot. 74
Pathomechanics
The subtalar joint complex consists of the subtalar
joint itself and the transverse tarsal joint, consisting
of the talonavicular and calcaneocuboid joints. This
complex functions as a torque converter of the forces
transmitted to the foot, from the tibia. The position of
the subtalar joint is critical in determining the degree
of mobility at the transverse tarsal joint in that, when
the hindfoot is everted into a valgus position, the
transverse tarsal joint is unlocked and the forefoot is
flexible. Conversely, when the hindfoot is in varus, the
transverse tarsal joint is rigid. 9 Restriction of motion
in any one of these joints, therefore, by a coalition,
limits motion of the others and subjects them to
higher stresses. These abnormal stresses, plus a
reduced adaptive ability, together result in a predispo-
sition to ankle instability as well as pain and inflam-
mation, which eventually lead to joint degeneration.
However, since patients do not in general become
symptomatic before early adolescence, it is thought
that the mild restriction of mot i on caused by a carti-
lagenous coalition is not enough to produce symp-
toms. With increasing age, though, as the
cartilagenous coalition ossifies, significant restriction
in hindfoot movement occurs, leading to the appear-
ance of symptoms. Should total ossification occur,
subtalar motion becomes markedly restricted. As
mentioned, many adults with this condition remain
asymptomatic. These individuals are generally
t hought to have enough compensatory motion in
adjacent joints to have protected them from develop-
ing symptoms.
DIAGNOSIS
Clinical presentation
Patients become symptomatic as they lose mot i on in
the foot due to ossification of the coalition, and due
also to the usual increase in activity typical of child-
hood and early adolescence. Talonavicular coalitions
ossify in patients from 3 to 5 years of age, calcaneon-
avicular coalitions between the ages of 8 and 12 years,
and talocalcaneal coalitions between the ages of 12
and 16 years. 7 Althot~gh these figures represent the
typical age of presentation of the different coalitions,
this is certainly not always the case and presentation
later in the second and third decade of life is not
uncommon, especially with talocalcaneal coalition.
A history of intermittent, vague, aching, hindfoot
pain over several months, which is usually not very
well localized, and often aggravated by activity or pro-
longed standing, is the usual presenting symptom.
Although the onset is often insidious, some patients
may have been symptom-free until a relatively trivial
' ankle sprain' or sudden increase in activity renders
them symptomatic. ~ Many patients give a history of
recurrent sprains and of a sensation of instability on
uneven ground which can lead to misdiagnosis.
A large proportion of patients with tarsal coalition
are asymptomatic 3,7 and the diagnosis is made inciden-
tally on routine clinical examination of the foot.
Many will remain asymptomatic.
Physical examination
This should be conducted with the patient both stand-
ing, and seated with the legs and feet dependent.
Patients can present with a painful flatfoot (planoval-
gus) deformity which is to be distinguished from the
painless flexible flatfoot commonly found in both chil-
dren and adults. The hindfoot is often held in valgus
resulting in an increased tibiocalcaneal angle. Accom-
panying forefoot abduction can give rise to the ' too
many toes' sign more typical of posterior tibial ten-
don pathology (Fig. 1). Nevertheless, it is important
to note that the foot can appear entirely normal
despite limited subtalar mot i on or, rarely, coalition
can present with a cavovarus deformity. Typically,
however, they do not display normal hindfoot inver-
sion on single stance heel rise and have absent or
markedly reduced subtalar motion when tested with
the foot plantigrade. Because it is difficult to demon-
strate subtalar mot i on accurately, the 'heel-tip' test
has been used to evaluate restricted tarsal motion. H
The patient stands while the examiner supinates the
foot by raising the medial border of the forefoot. The
lateral border of the foot and heel remain flat on the
floor. Since supination of the foot causes external
rotation of the tibia, this will be visible by external
rotation of the patella. Al t hough bot h talocalcaneal
and calcaneonavicular coalitions can eliminate sub-
talar motion and produce valgus malalignment of the
Fig. 1 Valgus hindfoot on the right as demonstrated by an
increased tibiocalcaneal angle. Note also the presence of the 'too
many toes sign'.
Tarsal coalition 137
hindfoot, the former is more likely to do so.
Symptomatic tarsal coalition with painful limitation
of inversion is also invariably accompanied by point
tenderness laterally, deep in the sinus tarsi, or occa-
sionally over the site of the coalition. The latter sign is
more common in coalitions that are incomplete or
cartilaginous.
Very occasionally, a patient may present with the
classic ' peroneal spastic flatfoot' in which the hindfoot
is held in rigid valgus and the forefoot is abducted due
to peroneal muscle spasm. Despite the term ' peroneal
spastic flatfoot' , patients do not have spasticity;
rather, as a result of limited subtalar motion and pro-
gressive hindfoot valgus, the peroneal muscle-tendon
unit shortens adaptively. When inversion is attempted,
the shortened peroneal muscles contract to protect the
painful subtalar joint, resulting in the clinical finding
of protective peroneal spasm, not spasticity.
Peroneal spasm with a flatfoot deformity can also
arise as a result of degenerative or inflammatory pro-
cesses within the midfoot or hindfoot. Thus, although
this is the most impressive presentation of tarsal coali-
tion, not only is it rare, but it is also not pathog-
nomonic. Use of the term ' peroneal spastic flatfoot'
synonymously with tarsal coalition is, therefore, inap-
propriate. The term 'rigid flatfoot' describes the condi-
tion more accurately.
Finally, careful examination should help exclude
other conditions that can also give rise to a painful
rigid flatfoot. Deformity and previous skin t rauma
should raise the suspicion of previous injury to the
talus and/or calcaneus, and erythema with effusion
and diffuse synovial swelling, especially if involving
other joints too, may suggest an inflammatory
arthropathy such as rheumatoid arthritis or Reiter's
syndrome.
Imaging
Plain radiographs
Routine radiographs consisting of weight-bearing AP
and lateral views, as well as a 45 oblique view, are
used to screen for tarsal coalition. Although coali-
tions are often not identified on these views, they
remain essential as they can provide numerous clues
as to their presence. They are also useful in delineating
possible coexistent pathology or joint degeneration as
well as identification of some of the rarer types of
coalition.
The AP view of the foot can demonstrate the rare
talonavicular and calcaneocuboid coalitions, and an
AP projection of the ankle can demonstrate the pres-
ence of a ' ball-and-socket' articulation, which is an
uncommon secondary change associated with any
tarsal coalition.
The standing lateral projection is the most useful in
that both primary and secondary signs of coalition
may be evident on this view. Narrowing of the pos-
terior subtalar joint space, failure to visualize the
middle subtalar joint and the more recently described
'C-sign', which is a C-shaped line formed by the
medial outline of the talar dome and the inferior out-
line of the sustentaculum tali, ~2are considered pri-
mary signs. Of the secondary signs ' talar beaking' is
the most significant (Fig. 2). This periosteal traction
spur of the superoanterior surface of the talar head at
the talonavicular joint is secondary to abnormal
motion of the tarsal complex and is not regarded as a
sign of degenerative change. 5,6,1,~3,14Other secondary
signs of tarsal coalition on the lateral radiograph
include blunting of the lateral process of the talus and
concave undersurface of the talar neck. Not all of
these signs are necessarily present at one time and
none is pathognomonic. However, they should alert
the examiner to the possibility of tarsal coalition. The
uncommon posterior facet coalition may also be visu-
alized on the lateral radiograph. This is demonstrated
by a bony mass in the area of the os trigonum, accom-
panied by talar beaking. A fairly consistent sign of
calcaneonavicular coalition on the lateral radiograph
is the presence of a long thin extension of the anterior
process of the calcaneus toward the navicular, known
as the ' anteater nose' sign ~5(Fig. 3).
The 45 oblique view best demonstrates a calca-
neonavicular coalition (Fig. 4). Bony coalitions are
Fig. 2 Weight-bearing lateral projection of a talocalcaneal coalition (medial subtalar), showing several radiological signs of tarsal
coalition. A large talar beak is apparent on the dorsum of the talar head (white arrow). The posterior facet is narrowed (three small black
arrows) and there is blunting of the lateral process of the talus (curved black arrow). Also note the C-sign (outlined by white arrowheads),
typical of a subtalar coaIition.
138 Current Orthopaedics
Fig. 3 Weight-bearing lateral radiograph of a calcaneonavicular
coalition demonstrating elongation of the anterior process of the
calcaneus (arrow) - the 'anteater nose sign'. A talar beak is also
present.
easily noted. Secondary signs on this view suggestive
of fibrous or cartilaginous calcaneonavicular coali-
tion include proximity of the calcaneus to the navicu-
lar, irregularity of the cortical surface of the navicular
at the site of coalition, and flattening of the calcaneus
as it approaches the navicular.
If a coalition is suspected clinically and not
demonstrated on the initial radiographs, the axial
(' ski-jump' ) view of the hindfoot, first described by
Korvin z6 and later popularized by Harris and Beath ~
can be obtained. This is taken with the patient stand-
ing on the cassette, bending forward at the ankle
about 10 . The X-ray beam is then directed from
behind downward and forward t hrough the heel and
subtalar j oi nt at 45 to the vertical. In the normal
foot, this view will show bot h the middle and poste-
rior talocalcaneal facets. These are oriented in a paral-
lel fashion, the medial facet being located above that
of the posterior (Fig. 5). As middle facet coalitions
are the most common site of talocalcaneal coalition,
abnormalities are usually seen on the medial side. If a
bony coalition is present, the j oi nt line is obliterated.
If the coalition is cartilaginous or fibrous, it may be
difficult to appreciate. However, irregular and/ or
sclerotic facet surfaces, and loss of the parallel orien-
tation of the two facets are strong evidence of coali-
tion, even if the facet appears open ~,68,1~ (Fig. 5).
Ant eri or facet coalitions are quite rare and much
more difficult to visualize with plain radiography.
Tomographic examination of the suspect region, as
described by Conway and CowelP has, until relatively
recently, been used to detect anterior talocalcaneal
coalition. CT however, has superseded t omography as
Fig. 4 (A) Pre-operative 45 oblique radiograph of a fibrous
calcaneonavicular coalition; (B) 45 oblique view of same patient,
three months following calcaneonavicular bar resection.
an imaging option and, in most cases, the Harris axial
view. CT should now be considered part of the routine
radiological work-up of suspected tarsal coalition
together with the standard 3-view foot series.
Computerized tomography
CT is now regarded as the gold standard for imaging
of talocalcaneal coalitions? 7-2 It is also a useful tool
for surgical planning because of its ability to demon-
strate bot h the nature and cross-sectional area of the
coalition (Fig. 6), as well as the presence and extent of
any degenerative arthritis present in the joints. For the
coronal views, the patient lies supine with the hips and
knees flexed and feet plantarflexed 20 at the ankles.
The transverse plane views are said to be appropriate
for the rare talonavicular and calcaneocuboid coali-
tions. CT can be used for calcaneonavicular coali-
tions, but is not as helpful as for talocalcaneal
coalitions and the plain 45 oblique radiograph
remains the best met hod of detecting this type. 17,18
Bone isotope scanning
Radionucleotide scanning, using technetium-99, has
been used to aid the diagnosis of symptomatic tarsal
coalition. 21 It could potentially provide i mport ant
Tarsal coalition 139
Fig. 5 Harris-Beath axial projection of the calcaneus showing a
fibrous right middle facet subtalar coalition. Note the obliquity of
the middle facet on the right, compared to its opposite on the left,
which is horizontal and parallel to the posterior facet lying below it.
Fig. 7 A Tl-weighted, gradient echo sequence MR image of a
fibrous medial subtalar coalition.
Fig. 8 Use of ankle braces such as this, which can be worn over a
sock and inside any lace-up shoe or trainer can, in patients with
symptomatic coalition, provide relief of symptoms by reducing
subtalar motion.
Fig. 6 Coronal section CT scan of a unilateral osseous medial
subtalar (talocalcaneal) coalition.
localizing information in difficult cases where it may
be used as a screening procedure. ~9Howevel; because
of its lack of specificity and detail, its place in the
investigation of tarsal coalition should be considered
as limited.
Magnetic resonance imaging
The Tl-weighted sequence of the MRI (Fig. 7) has
been reported to be more sensitive than CT in the
identification of fibrous or cartilaginous coalitions? ,=
This would be advantageous in the investigation of
the non-ossified coalitions of children and adoles-
cents potentially missed by CT. Should MRI become
as easily available as CT is now, then this may become
the investigation of choice.
TREATMENT
For asymptomatic tarsal coalitions, where the diag-
nosis is incidental, especially with children, simple
observation is a reasonable course of action. Many
will remain asymptomatic into adulthood. Such
patients do not require treatment.
Nonoperative treatment
Symptomatic coalitions deserve conservative manage-
ment initially, irrespective of the type of coalition,
although talocalcaneal coalitions are much more
likely to respond than calcaneonavicular bars, or the
rarer talonavicular coalitions. Treatment should
include activity modification, anti-inflammatory med-
ication and shoe modifications and/or orthoses 5,9
aimed at reducing stress across the subtalar joint and
supporting the foot. A medial heel wedge, Thomas
heel, or medial arch support designed to help decrease
subtalar mot i on can be helpful. The authors also pre-
scribe a proprietary ' airsplint' ankle brace, which may
also provide some increased subtalar stability, bot h
mechanically and through increased proprioceptive
feedback (Fig. 8). Boots or ' high-top' shoes are an
alternative where the symptoms are mild and compli-
ance likely to be suboptimal, as in the adolescent or
young adult. For more severe pain, stiffness, and
deformity, or failure to respond to the more conserva-
tive treatment options, immobilization in a short leg
walking cast in neutral for 6 weeks often results in
resolution of symptoms. On removal of the cast, an
orthotic shoe insert or ankle brace should be pre-
scribed. A second period of casting may be necessary
if symptoms are not completely resolved after the first
6 weeks, or recur shortly after. Should symptoms be
relieved in the cast but recur on removal, then a rigid
140 Current Orthopaedics
custom-made ankle-foot orthosis (AFO) may be con-
sidered, depending on the likely compliance and
expectations of the patient. If two periods of casting
fail to achieve resolution of symptoms, however, then
surgery should be considered.
Operative treatment
Should a patient fail a trial of nonoperative treat-
ment, the operative choice is essentially one between
resection of the coalition or arthrodesis (although cal-
caneal osteotomy has been reported), 23and is deter-
mined by factors such as the age of the patient, type
and extent of coalition, and the presence or absence of
degenerative changes in the affected and/or adjacent
tarsal joints. Should an arthrodesis be deemed neces-
sary, the choice should be between an isolated sub-
talar or triple arthrodesis depending on the extent of
degenerative joint disease (DJD) present in the tarsus.
Despite the fact that plain radiographs and CT
help determine both the presence and extent of DJD
in the tarsal joints, radiographic signs do not always
correlate with clinical findings. The authors believe,
therefore, that a diagnostic local anaesthetic block
performed by a skilled radiologist using contrast fluo-
roscopy provides important localizing information
(Fig. 9). This relatively straightforward investigation
not only helps to decide whether arthrodesis is likely
to abolish symptoms but also, by selective infiltration
of the suspect joints, in deciding which joints need to
be fused.
Calcaneonavicular coalition
As calcaneonavicular bars tend in general to present
at an earlier age than talocalcaneal coalitions, they are
less likely to have developed associated degenerative
changes. Simple resection of the coalition, therefore,
is likely to be successful 7'2~27 provided there is no radi-
ological evidence of DJD in the tarsus. Long-term
follow-up data reveal 69-77% good-to-excellent
results. 2~,28,2~A talar beak, which represents increased
stress across the talonavicular joint rather than degen-
erative change, should not be regarded as a con-
traindication. 9 Excision of the coalition can be
performed in older patients, but the risk of undetected
degenerative change exists and persistent pain may
require a subsequent triple arthrodesis. 25'29
The technique of calcaneonavicular bar excision
consists of a standard lateral approach to the sinus
tarsi, followed by a generous resection of the coalition
(Fig. 4b). It should be noted that there is a tendency to
resect an inadequate amount of bone, especially from
the navicular. It is important that the shape of the
excised piece should be trapezoidal and that the proxi-
mal and distal cut surfaces are parallel and not conver-
gent. One must also avoid breaching the capsule of the
talonavicular joint, as this may allow subluxation of
the navicular on the talus? 4 Next, extensor digitorum
Fig. 9 Fluoroscopically guided diagnostic local anaesthetic block
of the subtalar joint.
brevis (EDB) 1,9,25or autogenous adipose tissue 5,24is
interposed between the resected ends of the calcaneus
and navicular in an attempt to limit haematoma for-
mation and bony regrowth. Bone wax applied to the
resected surfaces is also often used as a supplement to
the interpositional material. 9'24 Mitchell and Gibson 29
using no interpositional material, reported a signifi-
cant recurrence of coalitions. However, some authors
report reasonable results with resection of a larger
rectangle of bone and not placing EDB into the
defect. 2 Postoperatively, splint immobilization is
used for 7 1 0 days, within which early active motion
is started. Increased range of active motion is
encouraged following removal of the splint. Gradual
weight-bearing is allowed as pain decreases and range
of motion increases.
Although limited hindfoot motion is often not
greatly improved by the procedure, especially in
adults, most patients obtain good pain relief. In those
that don't, we believe the source of persisting pain to
be a degenerate subtalar joint. In such a case, we
would perform a local anaesthetic diagnostic block
under fluoroscopy to confirm that this is the source of
pain and, if satisfactory relief is obtained, would pro-
ceed with an isolated subtalar fusion (Fig. 10). If pain
relief is incomplete following the block, or there is sig-
nificant DJD in the midtarsal joints, triple arthrodesis
is indicated.
Talocalcaneal coalition
Traditionally, triple arthrodesis has been recom-
mended as the procedure required if conservative
treatment has failed. ~,5,7,14Many authors, however, have
reported good results following resection of the coali-
tion, 1,24,3-34although with rates of success ranging
from 50% 30to 94%, 32the results of simple resection do
not appear as predictable as for calcaneonavicular
coalition. It has been argued that resection seldom
produces satisfactory results because secondary
changes will have already developed in the subtalar
joint by the time of presentation. 8 This is probably due
to the fact that talocalcaneal coalitions present later
than calcaneonavicular ones and, in general, restrict
Tarsal coalition 141
Fig. 10 Isolated subtalar fusion.
subtalar mot i on to a greater degree2 Both are factors
that increase the likelihood of secondary DJD pres-
ence, ~ thus militating against successful simple exci-
sion. Cowell has also report ed that resection of the
coalition at the middle facet disturbs hindfoot
mechanics and places undue stress on the remainder
of the subtalar joint. 7 Nevertheless, proponent s of
excision cite their results and also, that with the
advent of CT, it is now possible to assess accurately
the presence of secondary DJD, which would pre-
clude resection as an option. Some believe that the
extent of coalition is also i mport ant and that success-
ful resection depends on 50% or less of the area of the
j oi nt being involved? '3 Most reports of successful
resection of talocalcaneal coalition though, have
follow-up of less t han five years, ~'24,31'33'~4and have
involved mostly young patients with a mean age of
less t han 16. 24,3-33 Results of a recent report, however,
involving a slightly older average age group of
patients, with longer follow-up and a more critical
met hod of grading, were less favourable. Al t hough
most of their patients had some improvement, few
were completely asymptomatic and the results were
worse for patients followed for five or more years25
Interestingly, they also showed continuing difficulties
with function of the hindfoot and ankle after resec-
tion, which is in contrast to several previous reports
citing improved function as one of the reasons to
perform r e s e c t i on. 1,24,31.33,34 Therefore, the efficacy of
resection of a talocalcaneal coalition remains
controversial.
The technique of resection of a medial subtalar
facet coalition has been well described. 2,9,1,33 For poste-
rior facet coalition resection, Scranton * has described
a lateral approach, either anterior or posterior to the
fibula so as to avoid disturbance of the fibular collat-
eral ligaments. As with calcaneonavicular resection,
authors vary as to whether or not to use interposi-
tional material. Of those who do, most use bone wax
and an autogenous fat gr af t ; 9'~'31'33 others have used
slips of flexor hallucis longus. 34,35 Postoperatively, the
patient is started on a rehabilitation regimen similar
to that for calcaneonavicular bar resection, consisting
of protected early active movement with no weight-
bearing. Gradual weight-bearing is introduced when
there is no pain on movement of the subtalar joint,
and range of mot i on is similar to that obtained at the
time of surgery.
The authors are of the opinion that, by the time
most talocalcaneal coalitions present, secondary
changes already exist, which are generally confined to
the subtalar j oi nt and that, although the subtalar j oi nt
has little or no clinical motion, there is enough micro-
mot i on to cause pain. If, as Ki t aoka et a135 have
shown, resection does not result in improved function
of the hindfoot, then the principal aim of operative
intervention remains the abolition of pain. It is our
belief that a pri mary subtalar fusion achieves this
more reliably than resection in the case of talocal-
caneal coalition and is therefore, certainly in the older
patient, our preference provided there is no evidence
of DJD in the midtarsaljoints. If there is any doubt as
to the source of pain, we would perform a diagnostic
local anaesthetic block as outlined previously.
We also agree with Mann et al ~3that an isolated
subtalar fusion with the heel in an appropriate degree
of valgus, is preferable to a triple arthrodesis if the
problem is isolated to the subtalar joint because it
results in a more mobile forefoot. Fusion of only the
subtalar j oi nt results in more residual midtarsal j oi nt
mobility t han either double or triple arthrodesis 36 and
the foot is thus able to dissipate more energy. Other
authors also recommend a subtalar arthrodesis in
preference to a triple, but as a salvage procedure for a
failed resection with little or no degenerative change
present, rather t han as a pri mary procedure?
For those patients primarily presenting with degen-
erative changes and pain in bot h hindfoot and mid-
foot or, if clinically significant changes occur
subsequent to a subtalar arthrodesis, then triple
arthrodesis is indicated.
SUMMARY
Tarsal coalition is an uncommon, autosomal domi-
nant hereditary disorder of the hindfoot that pri-
marily affects adolescents but often presents in adults.
Calcaneonavicular and talocalcaneal coalitions are
the commonest types. Ma W coalitions are asymp-
tomatic but commonl y present with a rigid, painful
flatfoot. Peroneal spastic flatfoot is the least common
but most impressive presentation. A history of
repeated ankle sprains is not unusual and misdiag-
nosis not uncommon. Despite advances in diagnostic
imaging, a t horough history and physical examination
remain the keys to its diagnosis. Al t hough plain radio-
graphs remain important, bot h CT and MRI have
proved to be the most sensitive investigations.
Nonoperative treatment should be tried initially in all
patients. The indication for surgery is failed nonoper-
ative treatment of a symptomatic coalition. The oper-
ative choice is dependent on various factors, but is
essentially one between resection of coalition and
142 Current Orthopaedics
arthrodesis. Resection appears best for calcaneonavic-
ular coalitions. Results are less predictable for talocal-
caneal coalitions, especially in adults, for which the
authors advocate isolated subtalar arthrodesis. Triple
arthrodesis should be reserved for those with signifi-
cant degenerative changes in other joints too.
ACKNOWLEDGEMENT
The authors would like to thank Ian J. Alexander MD FRCS(C)
for permission to use Figure 5.
REFERENCES
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2. Ehrlich MG, Elmer EB. Tarsal Coalition. In: Jahss MH, ed.
Disorders of the Foot and Ankle. Philadelphia: WB Saunders,
1991; 921-938.
3. Leonard MA. The inheritance of tarsal coalition and its
relationship to spastic flat foot. J Bone Joint Surg 1974; 56B:
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