Nyska Et Al. (1996) - Posterior Talocalcaneal Coalition

8/10/2019 Nyska Et Al. (1996) - Posterior Talocalcaneal Coalition

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The Foot (1996) 6, 178-180

9 1996 Pearson Professmnal Lrd

CASE REPORT

Posterior talocalcaneal coalition

M. Nyska*, C. B. Howard*, Y. Kollander+,A. Payser, S. Porat*

*Department of Orthopaedic Surgery, Hudassah Medical Centre, Hebrew University, Jerusalem and Department

of Orthopaedic Surgery, Soroka Medical Centre, Faculty of Health Sciences, Ben-Gurion University of the Negev,

Beer-Sheva, Israel

SUMMARY

Tarsal coalition is a rare congenital deformity. The most common coalitions involve the

calcaneonavicular joint and the medial facet of the talocalcaneal joint. The posterior facet is rarely involved. We

report a case of a patient with a posterior talocalcaneal bar who presented with painful limitation of subtalar

motion without the classical appearance of spastic flat foot. Resection of the bar with interposition of fat graft

resulted in an almost full range of pain-free subtalar motion.

INTRODUCTION

Tarsal coalition was described f irst by Buffon in 1750.

One of the earliest examples (c. 1769) is an original

specimen of John Hunters and resides in the

Hunterian Museum of the Royal College of Surgeons

in London. Talocalcaneal coalition was first reported

by Zuckerkandel in 1877 and Curvi lhier described the

calcaneonavicular bar in 1829.1 2.3 arris4 suggested

the linkage between spastic flat foot and tarsal coali-

tion. Moisher and Asherj revised the vast number of

reports on the clin ical appearance and incidence of

tarsal coalition. The most common coalitions involve

the calcaneonavicular joint and the medial facet of

the talocalcaneal joint. Salomao6 in a series of 32 feet

with medial facet talocalcaneal bar had satisfactory

results from surgical resection and free fat graft inter-

position. The posterior facet is rarely involved.

Harris7 in 1955 presented two such patients. In 1965

he reported a retrospective study of 102 cases of

tarsal coalition, of which only four had a posterior

talocalcaneal coalition.5 We have been able to find

only a further four cases in the literature that also

formed a part of a larger series.3A case with posterior

talocalcaneal coalition is reported.

CASE REPORT

A 16-year-old woman presented with a 2-year history

of effort-induced pain in her right foot. She was a

medium-distance runner. The pain was around the

sinus tarsi and gradually became severe enough to

Correspondence to M. Nyska, MD, Department of Orthopaedic

Surgery, Hadassah University Hospital, POB 12000. Ein-Kerem,

Jerusalem 9 1120, Israel.

prevent her from running. On examination the

appearance of the foot was normal and the ankle had

a full pain-free range of motion. There was severe

painful limitation in subtalar motion. No pain was

elicited in the toes during walking. Plain lateral radi-

ography demonstrated a bony mass protruding from

the posterior tuberosity of the calcaneum towards the

talus (Fig. 1). Coronal computerized tomography

(CT) demonstrated the area of fibrotic fusion to lie

on the posteromedial aspect of the talus (Fig. 2).

A gap between the bony mass and the talus was pre-

sent laterally. The bony mass was better visualized on

plain lateral radiographs than in the CT images.

There was increased uptake of Technetium 99m on

the posterior side of the ankle joint (Fig. 3).

The patient was treated conservatively with a

below-knee walking cast for two periods of 3 weeks

with only temporary relief of the pain and it was

therefore decided to resect the bony bridge. Through

Fig. 1-Plam lateral radiograph demonstrating the posterior bar.

178


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Posterior talocalcaneal coalition 179

Fig. Increased uptake of the posterior side of the ankle m

Technetium 99m bone scan.

Fig. 2-A coronal CT of the talus and calcaneum showing the

posterior bar and fibrotic union to the talus.

a lateral curved incision the upper surface of the cal-

caneum was exposed and the base of the bony bridge

was resected flush with the upper border of the calca-

neum. The dissection was continued anteriorly

towards the posteromedial side of the talus and com-

plete resection of the medial tubercle of the talus was

performed. Good subtalar motion was obtained only

after resection of the tubercle and exposure of the

subtalar joint posteriorly. A free fat graft was inserted

into the defect and the wound closed. The postopera-

tive treatment consisted of posterior slab for a week,

followed by physiotherapy and non-weight-bearing

for 6 weeks. At 3 months follow-up there was sti ll

limitation of subtalar motion with mild pain on walk-

ing. After one year there was no pain on running, but

she had not returned to competitive sport. On exami-

nation there was almost full range of motion of the

subtalar joint. Radiographs taken postoperatively

showed complete resection of the bar (Fig. 4).

DISCUSSION

The clin ical appearance of this case shares some

of the typical features of other tarsal coalitions.8

Fig. LPostoperatlve lateral radiograph demonstrating complete

resection of the posterior bar.

Children usually begin to complain from 12 to 15

years of age and pain i s exercise-related, vague and

diffuse. Our patient began to complain of pain after

long-distance running when she was 14 years old.

The exact cause of pain in tarsal coalition is

unknown but has been attributed to secondary strain

of the ankle ligaments, peroneal muscle spasm, sinus

tarsi irritation, subtalar joint irritation or degenera-

tive changes.5 Although our patient did not have the


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180 The Foot

typical peroneal spastic flat foot she did have pain in the

sinus tarsi and marked limitation in subtalar motion.

Plain lateral radiography clear ly demonstrated the

posterior bar. However, the standard images of CT

demonstrated the bar to lie more on the medial side of

the calcaneum. On the medial side the bony calcaneal

mass was intimately fused with the talus, making it

difficult to decide the exact plane of vertical resection

between these two bones. The CT showed that there

was a recess between the bony mass and the talus on

the lateral side. This was the deciding factor in choos-

ing the lateral approach. In the medial facet bar or the

calcaneonavicular bar there is a need for special radi-

ographic views - the Harris view and the lateral

oblique in 45 respectively. CT demonstrates these

bars better.4,9 However, in the present case a plain lat-

eral radiograph was sufficient to reveal the pathology.

The CT provided useful anatomical information that

aided the surgical approach.

In talocalcaneal bars the increased uptake in bone

scan is usually located in the talonavicular joint or the

posterior facet. This may be due to local inflamma-

tory reaction eventually leading to arthritic changes.

In our patient there were no arthrit ic changes (she

was only 16 years old at operation) and the increased

uptake may indicate a stress concentration area or

local synovitis.

Immobilization in a plaster cast gave only tempo-

rary relief and therefore an operative approach was

indicated. The operative alternatives for treatment are

either triple arthrodesis or resection of the bar. In cases

where there are no arthritic changes the preferred

method is resection of the bar. The space may be filled

with silicon, fascia, tendons from the area or fat graft.

Resection of the bar with a placement of fat graft

was performed, eventually leading to good results.

REFERENCES

1 .

2 .

3 .

4 .

5 .

6 .

I.

8 .

9.

ORahil ly R. A survey of carpal and tarsal anomalies. J Bone

Joint Surg 1953; 35A: 626-642.

ORahil ly R. Developmental deviat ions in the carpus and the

tarsus. Clin Orthon Rel Res 1957: 10: 9-18.

Scranton P E. Treatment of symptom atic talocalcaneal

coalit ion. J Bone Joint Surg 1987; 69A: 533-539.

Harris R I . Rigid valgus foot due to talocalcaneal bridge.

J Bone Joint Surer 1955: 37A: 169-183.

Moisher K M, her M. Tarsal coali tion and peroneal spast ic

f lat foot. A review . J Bone Joint Surg 1 984; 66A: 976984.

Salomao 0, Napoli M M M , De Ca alho A E Fernandes T D,

Maraues J . Hernandez A J. Talocalcaneal coal on: diagnosis

and surgical managem ent. Fo ot and Ankle 1992; 5: 251:256.

Harris R I . Follow-up notes on art ic les previously published

in the journal. J Bone Joint S urg 1965; 47A: 1657-1667.

Nysk a M, Deke l S. Tarsal coalit ion: a review. Hareffuah 1989;

117: 454457.

Deutch A L, Resnick D, Campbell G. Compu ted tomography

and bone scintigraphy in the evaluation of tarsal coalition.

Radio1 1982; 144: 137.

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Nyska Et Al. (1996) - Posterior Talocalcaneal Coalition