SLR - October 2021 - Olesya Palko

Prospective Evaluation of Tarsal Coalition Excision Show Significant Improvements in Pain and Function

Reference: Mahan ST, Miller PE, Kasser JR, Spencer SA. Prospective Evaluation of Tarsal Coalition Excision Show Significant Improvements in Pain and Function. J Pediatr Orthop. 2021 Aug 19. 

Level of Evidence: Level II-prospective cohort study

Scientific Literature Review

Reviewed By: Olesya Palko, DPM
Residency Program: Montefiore Medical Center – Bronx, NY 

Podiatric Relevance: Symptomatic flatfoot deformity is a common complaint among adults and children that present to a podiatric office. Tarsal coalitions that present as a severe painful flatfoot usually become symptomatic in preadolescence and adolescence. Surgical correction is indicated for patients who failed conservative treatment. Surgical correction can include resection of a coalition, or foot deformity correction with or without resection. There is still a debate about the best treatment method as many patients still experience pain even after the excision. This study was conducted with 55 patients who had symptomatic coalition excision and assessed their patient based clinical outcome and radiographic outcome. 

Methods: This is a level II prospective cohort study that included 55 patients under the age of 18, who were surgically treated for tarsal coalition with excision. At the time of enrollment, patients had to complete pre-operative questionnaires including UCLA activity score, mAOFAS hindfoot score, and then patient completed similar questionnaires at 6, 12 and 24 months post operatively. Other data was collected: demographics, pre-op CT images, laterality, coalition type and location, interposition material, postoperative complications, the duration of days until range of motion was restored, weeks to full weightbearing, weeks to return to sports, and use of physical therapy. 
Results: A total of 55 patients were treated for tarsal coalition, 60 percent male, average age 13.3 years, talocalcaneal coalition (TC) was present in 22 patients and calcaneonavicular (CN) was present in 28. No differences were found across TC and CN coalitions with respect to demographics, coalition, or treatment characteristics. There was also no difference in the change of UCLA score and mAOFAS, or limitations from pre-op to 24-month follow up across groups. Also, by evaluating heel valgus by imaging, no difference was detected among groups. The data showed more rapid post-operative improvement in CN coalition vs TC coalition and decrease in pain limiting activities at month six and 12, however by two years both groups had similar outcomes. 

Conclusions: Pediatric patients benefited significantly from excision of the coalition. The outcomes from CN and TC coalitions were very similar, especially two years after the surgery. Previous studies showed that in TC coalition that is more than 50 percent the size of posterior facet is unresectable; however, current study found no statistical difference between the patients with the coalition that is more than 50 percent and the one with less than 50 percent. The weakness of the study is relatively small sample size, lack of complete pre-operative imaging. However, this is a prospective study, and it was able to demonstrate significant improvement in patients after excision of their coalition regardless of the type of coalition, although CN coalitions recovered faster. 

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