Tarsal Coalition

What is tarsal coalition? even adulthood that symptoms develop. Pain A tarsal coalition is an unusual connection usually occurs below the around the (sometimes referred to as a “bar”) between middle or back half of the . 2 or more in the feet. The connecting Pain commonly starts when the bones stiffen tissue can be either , cartilage or fibrous. (a process known as ossification). This usually This condition normally occurs at the midfoot or occurs between the ages of 8-12 for talo- hindfoot (under the ankle ). calcaneal coalitions and 12-15 for talo-navicular. Its thought that around 1% of the population For adults, pain may be the result of trauma may have this condition. (e.g. an ankle sprain) or the development of arthritis in the . The most common coalitions are: The tarsal coalition may be associated with a • Talo-calcaneal (subtalar) coalition – a stiff flatfoot. Pain may come not only from the connection between the bone coalition itself, but from the peroneal tendons () and the talus bone (which sits (which sit around the outside of the ankle). on top of the heel bone) These tendons can shorten and go into spasm. • Calcaneo-navicular coalition – a connection Ligament strain and joint irritation may also between the heel bone (calcaneus) and the generate pain. bone in front of it (the navicular) Some people can present with frequent ankle • Talo-navicular coalition – a connection sprains, foot stiffness and difficulty walking on between the talus bone and the navicular – uneven surfaces. this is quite rare. Many patients have both feet affected, though X-ray of a talo-calcaneal often the symptoms are only on one side. coalition – How is the condition diagnosed? showing the uncommon The condition can be diagnosed through both joining between the a clinical examination (e.g. examining how the calcaneus (heel bone) and joints move) and with imaging (such as X-rays the (inside and MRI/CT scans). the circle) Findings in the clinical exam may include a flat foot with low arches, which is stiff (and doesn’t correct when you go up onto tip toe). What causes the condition? X-rays can help with the diagnosis, but often a high definition CT or MRI scan is required It is thought to be due to an inherited and to give more detail, such as the size of the genetic abnormality, which results in the failure coalition, and to help with surgical planning. of some bones in the foot to properly separate in the embryo. What are the non-operative treatment options? What are the symptoms? There are a number of non-operative Many people who have coalitions have no pain treatments, which can be tried before or other symptoms – they are asymptomatic. It considering surgery. is often not until late childhood, adolescence or

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These include: required alongside this resection procedure. • Activity modification e.g. Limiting high Calcaneo-navicular coalitions are generally impact sports for a few weeks. removed surgically and a graft placed between the bones. • Physiotherapy may help with stretching and strengthening muscles. After a resection (removal), younger patients will often make a full recovery. • Footwear changes, such as wearing an ankle boot (which limits joint movement) or A resection may not be viable if there is a large using a rocker bottom shoe. coalition and if arthritis present. In these cases, joint fusions (i.e. removing and stiffening the • Orthotic devices such as ankle braces or insoles may help some patients. joint(s)) may be indicated. The aim here is to sacrifice painful movement for pain reduction. • Pain relief, such as non-steroidal anti- inflammatory medication may give some It is important to note that surgery for this relief. condition will not result in a “normal” foot. As the articulations (joints) were abnormal to begin • Steroid injections (which acts as powerful with, the foot after surgery, will remain stiffer anti-inflammatory) can reduce pain in some than a normal foot. patients. What are the possible surgical • A period of immobilisation for a few weeks complications? can help settle the symptoms. As with any surgery there can be complications What are the operative options? with surgery. Some of these complications will Surgery is normally considered when non- be specific to the type of operation you have operative treatments fail and there is significant (e.g. fusion, resection, flatfoot correction). Your pain and functional limitation (e.g. you are general health, wellbeing and lifestyle can struggling to walk or play sports). impact on the success of the operation. Surgery normally involves either the removal Possible general complications: of the coalition (known as a resection) or These include infection (superficial, deep), fusion (stiffening) of the joint(s). The choice of nerve damage, blood vessel damage, tendon procedure(s) will depend on many factors and injury, wound healing issues, hypersensitive this will be discussed with your surgeon. scar, worse symptoms, increased pain, In general, a small surgical incision is made to recurrence (return of coalition), blood clot (DVT/ give the surgeon access the foot joints. Key PE), and anaesthetic risks. hole (“arthroscopic”) surgery may be possible Possible specific complications for depending on the size and location of the resection of the coalition: coalition. Incomplete resection (not taking away enough Talo-calcaneal coalitions are typically resected bone), recurrence (c.10%), over-resection if they are less than half of the joint surface and (taking too much bone away), worsening flat if there is limited joint arthritis. A graft (e.g. fat, foot and persistence pain. Ongoing symptoms or muscle) may be placed between the bones are more likely with a talo-calcaneal resection to stop it recurring. Re-alignment procedure(s) and in older patients. – for example a flat foot correction may be

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Possible specific complications for joint fusion: Can it be done as a day case operation Delayed union, malunion (bones fuse in wrong (returning home same day)? poison), non-union (bones don’t fuse together) It is usual to stay one night after the operation to allow adequate pain control. However, if What is the post-operative recovery? you are otherwise fit and there is someone Recovery will depend on the type of surgery who can collect you afterwards and stay with you have undergone and how well you heal. you overnight, the operation can be done as The information provided below is for resection a day case. This means that you are admitted surgery only. There are additional leaflets to hospital, operated on and discharged home available for fusion operations. on the same day. You may need to come back Can I walk after surgery? to plaster room the day after your operation to have your plaster changed. After a resection operation you will routinely be in a non-weightbearing cast for about 2 weeks. Will I have to go to sleep (general You should keep the foot elevated (foot above anaesthetic)? the knee) for about 95% of the time during this The operation is usually performed under period. After 2 weeks the wound(s) are checked general anaesthetic (asleep). Alternatively, and you may be placed into a special walking an injection in the back can be done to make boot. This is normally worn for about 4 weeks. the ankle numb while you remain awake. Your Physiotherapy may be organised at this stage. anaesthetist will advise about the best choice of Sometimes patients can mobilise more quickly anaesthetic for you. depending on the type of surgery and wound healing. Wellbeing advice - It is worth remembering that it can take a few Patients that have a healthy diet and weight, months for things to settle completely. Swelling take regular exercise and refrain from smoking and low-level discomfort may continue for 6-12 prior to surgery are more likely to experience months. quicker and better recovery and may also have a more successful outcome from their surgery. When Can I drive? If you have any concerns about your general Normally after 6 weeks. You can drive an health and wellbeing (diet, exercise, smoking automatic car before this if you had your left cessation) you are encouraged to discuss this foot operated on and things are progressing with your GP, who will be able to provide advice well. on the options available to you. When can I return to work? Literature references: American Academy of orthopaedic surgeons – Tarsal This will depend on a few things such as – what Coalitions https://orthoinfo.aaos.org/en/diseases-- work you do, how you are healing and what conditions/tarsal-coalition type of surgery you had. Overall as a guide, British Orthopaedic Foot and Ankle Society (BOFAS) this can vary from 3-4 weeks for a sedentary Round table document. Tarsal coalition. (2016) https:// type job to about 8-12 weeks for more manual/ www.bofas.org.uk/Portals/0/RoundTable_Booklets/ strenuous type job. Round%20Table%20-%202016%20-%20Munich. pdf?ver=2019-11-28-055157-923 Kothari et el (2020) Surgical treatment of tarsal coalition in children and adolescents. EFFORT. Vol 5, (2),pp.80- 89.

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