MASTERCLASS

Tarsal coalition
E. Fopma and M. F. Macnicol
Orthopaedic Department, Royal Hospital for Sick Children, Sciennes Road, Edinburgh, EH9 ILF, UK
INTRODUCTION
A tarsal coalition is an abnormal connection between
two or more of the four tarsal bones.The FrenchmanLe-
clerc, Count of Buon,
1
rst described the condition in
1750. In the pre-radiograph era, the anatomists Zucker-
kandl
2
and Holl
3
were the rst to describe a talocalcaneal
coalition(1877) andcalcaneonavicular coalition(1880), re-
spectively, and the latter suggested a link between the
coalition and a atfoot. This disorder must have plagued
some members of homo sapiens since ancient times as
evidenced by the ndings of bilateral tarsal coalition in a
pre-Columbian Indian skeleton in Ohio in 1966.
4
Sir
Robert Jones
5
was the rst to describe the peroneal
spastic atfoot in 1897. In 1920, after the invention of
roentgenographs, Slomannwas the rst tovisualize a cal-
caneonavicular coalition (CNC) on aninternal oblique lat-
eral lmof the ankle.
6
This nding enabledhimto explain
the association of a rigid pes planus and peroneal spasm
with a CNC. These assumptions were later supported
by the clinical ndings of Badgely,
7
who successfully
removed a CNC surgically, and the link between the
peroneal spastic atfoot and a CNC was conrmed.
Robert Harris,
8
a Toronto orthopaedic surgeon, recog-
nized that a talocalcaneal coalition (TCC) produced a
painful rigid pes planovalgus. In their classic paper, Harris
and Beath published the rst series of peroneal spastic
atfoot in association with a tarsal coalition.
8
The term
is no longer used, because it describes onlyone of several
clinical presentations of tarsal coalitions and the
condition may exist without a tarsal coalition.
EPIDEMIOLOGY
The true prevalence of tarsal coalitions in the general
population is unknown, because it is thought that the
majority of patients are asymptomatic. The same may
be said about the incidence of symptomatic ones. How-
ever, based on several studies on cadavers, army person-
nel, patients with painful atfeet and an osteological
collection, the estimated prevalence varies between 1
and 2%.
8^10
CNC (53^77%) is reported to be the most
common type followed by the TCC (23^47%).
11,12
How-
ever, in their review of the literature from 1927 to 1981,
Stormont and Peterson
11
found the relative frequencies of
coalitions to be 48.1% for TCC, 43.6% for CNC, 1.3% for
talonavicular (TNC) and 1.3% for calcaneocuboid (CCC)
coalitions. Together, CNC and TCC are assumed to ac-
count for over 90% of all symptomatic cases. Varner and
Michelson
13
(27 cases) found a reverse relationship of 55%
TCCvs 42% CNC. Takakura et al.
14
from Japan found 83%
TCCvs14% CNCin a series of 52 cases (81feet) and state
that these dierences may be explained by racial peculia-
rities. TNCis thought tobe thirdcommonest type.Other
forms of coalitions are reportedincidentally (Table1).
Multiple coalitions were thought to be very rare, until
the advent of CTandlater MRI.With these imaging mod-
alities, coalitions that are either dicult to detect with
conventional radiographs or have not yet ossied, can
be visualized.
15
Multiple coalitions can occur ipsilaterally
or bilaterally (Table1). They may be part of a syndrome,
existing concurrently with other congenital anomalies,
16
or may be found in otherwise healthy children.
15,17,18
Iso-
lated, bilateral CNC
15,17
and TCC
15,19
have beenreported.
Again, the true frequency of bilaterality is unknown be-
cause gures are usually calculated from small subgroups
of patients. They are estimated to be 25^57% for
CNC
10,12,14,17,20
and 30^64% for TCC
10,14,16,19,21
(Table 1).
Dierent types of coalitions seem to ossify at dierent
ages, CNC at 8^12 years and TCC at 12^16 years.
22,23
There does not seemto be a racial preference, and coali-
tions are reported in Caucasian, African and Asian chil-
dren.
24
In their study of presumed CNCin the skeletons
of the Hamann^Todd Osteological Collection, Cooper-
man et al.
10
found a predominance in blacks. We calcu-
lated the female to male ratio for TCC from three
articles totalling 43 patients and found it approximately
1^1.3.
19,21,25
AETIOLOGY
Tarsal coalitions are either congenital of acquired. In the
context of this article, only the congenital form is
discussed. Correspondence to: MFM
Current Orthopaedics (2002) 16, 65^73
c 2002 Publishedby Elsevier Science Ltd.
doi:10.1054/ycuor.244, available online at http://www.idealibrary.com on
Histopathology
Themost widelyaccepted theory for congenital coalitions
is that they are the result of a segmentation defect of the
primitive mesenchyme preventing the formation of a nor-
mal joint.
26^28
Leboucq
29
is credited with postulating this
theory for the rst time in1890. Harris
26
conrmed this
theory in1955 when he demonstrated a failure in segmen-
tationinembryos.Others like Harris and Beath,
8
believed
that an accessory ossustentaculi resulted in a fusion be-
tween the talus and calcaneus. Based on their histological
study of fetal feet at dierent stages of development, Ka-
washima andUhtho
27
subscribe to the segmentationfail-
ure theory as the pathomechanism of tarsal coalitions.
They believe that the mesenchymal tissue between the
cartilaginous anlagen of the posterior part of the susten-
taculum tali and the corresponding part of the talus fails
to dierentiate into brous tissue at the 7
1
2
to 8
1
2
week of
embryonic development. Instead, cartilaginous tissue de-
velops, leading to a bridge between the talus and calca-
neus.
27
Kumai et al.
28
found brocartilaginous tissue in all
specimens with varying percentages of the two compo-
nents in dierent patients. In juveniles, the coalition con-
sisted of almost100% cartilaginous tissue.
Genetics
Coalitions have been described in twins and successive
generations within a family suggesting a genetic basis for
their existence. The high frequency of bilaterality sup-
ports this view. Dierent patterns of inheritance have
been proposed. Wray and Herndon
30
reported a CNC
in three successive generations of men from the same fa-
mily andconcluded that this type of coalitionis causedby
a gene mutation, which behaves as an autosomal domi-
nant gene with reduced penetrance. Leonard
31
studied
31patients (27 with CNC and four withTNC) and 98 of
their rst-generation relatives and found that almost
40% of these relatives had a tarsal coalition. Moreover,
relatives from a patient with a CNC could possess a dif-
ferent type of coalition, mostly a TCC. This led him to
conclude that tarsal coalitions areinheritedas autosomal
dominant with almost full penetration. Plotkin
32
de-
scribed a case of monozygotic twins with bilateral
CNC. Basedon this case andthe ndings of other studies
he considered that coalitions were caused by a mutation
in a general joint developmental gene without a multi-
gene system.
Associateddisorders
Tarsal coalitions can be, infrequently, associated with idio-
pathic or arthrogrypotic (teratologic) clubfeet and tibial
dysplasia, hemimelia or pseudarthrosis.
15,16
They may also
occur in certain syndromes, such as multiple synostosis
andsymphalangismor ankylosis of thephalangeal joints.
15,23
Pain
It is generally thought that an inammatory process is
responsible for the pain. However, Kumai et al.
28
in a his-
topathological study of non-osseous coalitions in 55 feet
demonstrated that there are no inammatory cell inl-
tration or nerve elements present at the coalition site,
or at its boundary with normal bone tissue. Instead, free
nerve endings (pain receptors) were foundin the perios-
teum and articular capsules of the aected tarsal bones.
This suggests that abnormal mechanical stress occurs at
the site of the coalition inducing pain via these pain re-
ceptors. Abnormal posture within the rest of the hind-
foot and midfoot may also induce a chronic sprain
within the mobile joints in proximity to the coalition.
NATURALHISTORY
The natural history of tarsal coalition can probably be
dened as follows: an unknown percentage of initially
Table 1 Types of coalitions andcombinations of coalitions reported andtheir frequency(%)
Multiple non-symmetrical
Unilateral Bilateral symmetrical Ipsilateral Bilateral
CNC (43^75) CNC (25^47) CNC+TCC (3) Bilat.CNC+Ipsilat.TCC
w
TCC (50^70) TCC (30^50) Bilat.CNC+Ipsilat. NCC
w
TNC (715) TNC (7.5)*
w
CCC (71.5) CCC (10)*
w
NCC (2^5) NCC
w
NCfC (3^6) TNC+CCC
w
CNC=Calcaneonavicularcoalition;TCC=Talocalcaneal coalition:TNC=Talonavicularcoalition; CCC=Calcaneocuboidcoalition;
NCC=Naviculocuboid; NCfC=Naviculocuneiformcoalition.
*With other coalitions present in one or bothfeet.
wincidentallyreported.
66 CURRENT ORTHOPAEDICS
cartilaginous bars will gradually ossify as the patient ma-
tures, becoming completelyosseous at some stagein the
second decade of life. The aected foot may become
symptomatic due to stiening of the subtalar joint, lack
of adaptability onuneven terrain and a resultant strainin
mobile segments of the foot. Braddock
33
published on a
series of untreatedpatients after an average follow-up of
21 years. He found that 50% of the patients with CNC
and 20% of those withTCC were asymptomatic. In the
CNC group, none had osteoarthritis and one-third a
good range of inversion, as opposed to theTCC group
where 90% had a sti-subtalar joint and 20% had
osteoarthritis.
CLASSIFICATION
Tarsal coalitions can be classied according to aetiology,
histological characteristics or anatomical location. Con-
genital coalitions are present at birth as brous or carti-
laginous bridges. Infection, intra-articular fracture,
osteonecrosis or malignancy can lead to secondary sy-
nostosis between aected tarsal bones. Histologically,
the coalition may be brous (syndesmosis), cartilaginous
(synchondrosis) or bony (synostosis). The subtalar joint
has two compartments divided by the interosseous
membrane. Therefore, the TCC can be further subdi-
vided into middle facet (sustentacular) and posterior
facet (thalamic) coalitions. In the vast majority, the
sustentaculum is aected; coalitions of the posterior
facet are seldomreported.
12,19,21,34
CLINICALPRESENTATION
It is assumed that most patients remain asymptomatic.
The average age of onset of symptoms of CNC is in the
rst decade of life,
17
whereas, the TCC presents in the
second decade.
19
The reported pre-diagnosis symp-
tomatic period varies considerably from a couple of
months
25,35,36
to several years,
19,25,36
being longer in
cases of a brous bar.
19,25
The history is often vague and
symptoms non-specic at the outset. Typically, an activ-
ity-related pain develops insidiously around the foot and
ankle. In some, a sprained ankle may be the trigger.
21,25
The pain gradually worsens over time and occasionally
night painis reported. At a later stage, the patient starts
to limp because of increasingly restricted movement in
the tarsus leading to a rigid atfoot deformity. In CNC,
the pain is located in the foot or subtalar region. InTCC,
the pain is located on the medial side of the ankle joint,
dorsally and distally to the medial malleolus.
The classically described appearance of childhood and
adolescent rigid pes plano-valgus deformity,
19
the so-
called peroneal spastic atfoot, is not to be found in
every single case (Fig.1).
21
Indeed, feet with progressive
pes cavo-varus deformity
36
and neutral position
21
have
been described in both CNC and TCC. As opposed to
the younger age group, the heel typically retains its neu-
tral position in adults. Varner and Michelson
13
reported
the clinical presentation of tarsal coalition in a group of
27 skeletally mature patients with an average age of 40
years. They found that only seven out of 32 feet (22%)
had the typical adolescent pes plano-valgus deformity.
Twenty-two feet had a neutral heel on standing. There
may be a bony prominence in the region of the sustenta-
culum tali inTCC and disuse atrophy of the calf muscles.
Mobility in the subtalar joint will be signicantly reduced
or absent (50%of cases). Passivemovement is painful and
a click may be felt.
DIAGNOSIS
Tarsal coalitions can be dicult to diagnose clinically
when the presenting symptoms are still vague and non-
specic or the physical examination is equivocal. Unfor-
tunately, standard AP and lateral views of the ankle joint
are unreliable in demonstrating coalitions.
37
Moreover,
conventional radiographs are best suited to diagnose
an ossied or ossifying bar (synostosis). The 451 internal
oblique radiograph of the ankle described by Slomann
in 1920 is the classical view taken to visualize a CNC
(Fig.2).
6
Harris and Beath
8
described the posterior^
superior oblique projection for demonstrating a TCC of
the middle facet, which is commonly known as the Har-
ris or axial calcaneal (ski jump) view (Fig. 3). In cases of
suspected tarsal coalition, four views are recommended:
standing dorso-plantar and lateral ankle/foot, Slomanns
oblique foot and the Harris calcaneal view.
23
Theprimaryradiological sign tolook for in CNCis the
bar on the obliqueview.Theprimaryradiological signs on
a conventional standing lateral viewof the ankle in aTCC
are narrowing and subchondral sclerosis of the posterior
facet and absence of the middle facet and sinus tarsi.
These signs may be subtle or absent in 50% of the cases.
Non-specic secondary signs (i.e. dorsal talar beaking,
Figure 1 Peroneal spastic atfoot
TARSAL COALITION 67
ball-and-socket ankle deformity, broadening of the talar
lateral process, hypoplastic sustentaculum) may also be
absent.
23,37,38
However, there are a couple of helpful fea-
tures that may be seen on these standards lms, which
will aid in the diagnosis of both types of coalitions. In the
case of a CNC, the lateral ankle lmwill show a protru-
sion of the antero-superior aspect of the os calcis
approaching or overlapping the mid-portion of the navi-
cular, resembling the nose of an anteater (Fig. 4). Oes-
treich et al.
39
found the anteater nose sign in all 30
cases of CNC, compared to none in 100 non-CNC
controls.
In the case of aTCC, the lateral lm may show the C
sign.This sign was rst described by Lateur et al. in1994,
and describes a C-shaped line (C stands for the shape of
the line and the rst letter of the word coalition) formed
by the medial outline of the talar dome and the postero-
inferior outline of the sustentaculum tali (Fig. 5).
38
In a
prospective study using CTas a reference, the sensitivity
and specicity were found to be 86.6 and 93.3%, respec-
tively. There was one false-negative C sign in an achon-
droplastic patient with aplasia of the sustentaculum
tali. The C sign was graded as clear or faint depending
upon its visibility, and this seems to correlate with the
extent of the subtalar fusion. It may be continuous or
interrupted, secondary to the presence of a synostosis
or a synchondrosis/syndesmosis, rspectively.
38
Brown
et al.
40
believe that the C sign is related to the altered
talocalcaneal alignment in a atfoot deformity, which
may or may not be caused by aTCC. In their retrospec-
tive study, they found a sensitivity of 40% and a speci-
city of 89%. It should be remembered that many
patients with tarsal coalition present before skeletal
maturity or with a non-osseous brous or cartilaginous
coalition.
Therefore in a suspicious case, an MRI is recom-
mended. Wechsler et al.
37
found MRI superior to CT in
diagnosing and characterizing coalitions, for all brous
Figure 2 Slomanns 451 internal oblique view, showing a left-
sided CNC.
Figure 3 Harris (skijump) axial calcaneal view, showingmid-
dle facet TCC.
Figure 4 Anteater nosesign of CNC.
68 CURRENT ORTHOPAEDICS
coalitions were missed and interpreted as normal on
CT. If an osseous bar is suspected, a CTscan (axial and
coronal views) will suce (Fig. 6). In non-diagnostic,
painful ankles, an MRI (axial, coronal and sagittal views)
should be requested. Both CTand MRI can be used for
preoperative planning for the resection of multiple
coalitions.
15,37
TREATMENT
Conservative treatment
It is generally agreed that patients with symptomatic
tarsal coalition should receive a trial of conserva-
tive treatment before any operative intervention is
undertaken.
13,17,20,21,23,25
There are, however, no
evidence-based studies comparing the outcome of
dierent conservative treatment regimens in the two
most common types of tarsal coalition. In addition, no
attempt has been made to identify patient or coalition
characteristics that will predict a favourable outcome
of conservative treatment.
The goal of conservative treatment is to reduce the
movement of the subtalar joint, therebydiminishingpain.
Recommended methods include: modications in activ-
ity levels and shoes, the use of orthoses, casts and
non-steroidal anti-inammatory drugs (NSAIDs). Vary-
ing success rates arereported.
13,19,20
Scranton
21
reported
a successful outcome following a period of 3 weeks of
cast immobilization in combination with a local corti-
costeroid injection in three patients with isolated TCC,
two of whom had bilateral middle and posterior
Figure 5 CSignof TCC. Alsovisibleis dorsal talar beaking.
Figure 6 Coronal CTscan of bilateral TCC.
TARSAL COALITION 69
facet osseous bars. All threeledsedentarylives andwere
between 35 and 55 years of age. On examination, their
heels were in neutral position and subtalar motion was
absent. The average age in the 11 failures was 18 years.
Seven of them (11 feet) had typical pes plano-valgus
deformity, and six patients (9 feet) had brous, cartila-
ginous or incomplete bony coalitions.
21
ONeill and
Micheli
20
reported a100% failure rate following a below-
knee weight-bearing cast for 4^6 weeks in12 adolescent
athletes with congenital osseous CNC. Nine had a unilat-
eral bar and three had bilateral bars. In only three of
these 15 feet was the subtalar joint clinically ankylosed;
in the remainder, the average inversion and eversion
were 101 and 8.21, respectively. Varner and Michelson,
13
reporting on nine asymptomatic (11feet) and18 sympto-
matic (21 feet) adults with an average age of 40 years,
managed with a trial of activity modication in combina-
tion with a NSAID, shoe modication or orthosis. If that
failed, they continued with 6 weeks below-knee weight-
bearing cast support before embarking on surgery. Mod-
ifying activity and using a NSAID successfully treated
eight patients (44%). Another three patients were still
being casted with unknown results at the time of publi-
cation. Only one out of11asymptomatic feet (9%) and six
out of 19 symptomatic feet (31%) presented with a pes
plano-valgus deformity. The remainder of the asympto-
matic and 12 of the symptomatic feet had a neutral
posture. Interestingly, TCC occurred twice as frequently
as CNCin the asymptomatic group, seven and four feet,
respectively.
13
Takakura et al.
14
reported on the conservative treat-
ment of a group of 24 Japanese patients with 31 TCC.
Nine patients (12 feet) were treated with cold com-
presses and ointments, the remaining 15 (19 feet) using
various shoemodications andcasts.Theyreportedper-
sisting pain in only eight (26%) of the 31feet. The overall
success rate for conservative treatment in their series
was 68% (21feet). Interestingly, the 32% failures (10 feet)
did not receive further treatment. Unfortunately, it is
not clear from their study what kind of treatment bene-
ted their patients most, or what theinuencewas of an
osseous bar. Comfort and Johnson
19
reported a satisfac-
tory response to conservative treatment of 13% of cases
withTCC. Our analysis of the literature on conservative
treatment failed to reveal denitive factors that produce
a satisfactory prognosis. Characteristics that may help
are listedinTable 2.
Surgical treatment
In cases with persistent pain and functional impairment,
refractory to conservative treatment, a surgical solution
should be considered for both CNC
12,17,20,41
and
TCC.
12,14,19,21,25,42
Dierent operations for dierent types
of coalitions have been described: simple resection, var-
ious forms of arthrodesis and osteotomies. According to
theliterature, patients withdegenerative changes should
be dierentiated from those without, since only the lat-
ter will improve following a generous resection of the
osseous bar with or without an interposition graft.
12,14,43
However, thereremains someuncertainty whether a re-
section shouldbeperformedwhen there areradiological
signs present of early degenerative changes, such as talar
beaking, talonavicular spur formation or narrowing of
the posterior facet of the subtalar joint. Talar beaking is
now thought to represent a traction phenomenon, sec-
ondary to repeated, minute elevations of the talonavicu-
lar capsule and periosteum fromincreased stress at that
joint, rather than evidence of osteoarthritic change
(Fig. 5). Its evidence therefore does not preclude a good
result.
12,19^21,25
Calcaneonavicularcoalition
An oblique anterolateral incision, centred over the sinus
tarsi, allows access to the calcaneonavicular joint. The
technique is described in detail in Campbells operative
orthopaedics.
44
The coalitionis excisedsquare toensure
complete separation between the two bones (Figs 7
and 8). After excision, the bare cancellous bone is cov-
ered with bone wax, and the resultant gap is lled with
an extensor digitorum brevis interposition graft or
fat.
13,20,23,36.
The foot is kept mobile, allowing partial
weight bearing using elbowcrutches for 4^6 weeks.
Mitchell and Gibson
45
were the rst to undertake a
successful series of excisions. They reported complete
relief of symptoms in 28 of 41 feet (68%) after an
average follow-up of 6 years. In 58% of the feet, the sub-
talar inversion was restored to 251 to more.
Swiontkowski et al.
12
reported a 90% success following
simple resection in 44 feet, with restoration of
subtalar motion, improved subjective foot function
and no long-term degenerative changes at an average
follow-up of 4.6 years. All four failures had signicant
secondary degenerative changes in the talonavicular
joint at the time of surgery. The presence of a talar beak
had no adverse eect on outcome. There were no
recurrences.
ONeill and Micheli
20
reported 13 excellent or good
subjective results (87%) in15 feet of young athletes after
Table 2 Factors which may predict a favourable outcome
of conservativetreatment of tarsal coalition
Patientcharacteristics Coalitioncharacteristics
Sedentarylifestyle Synostosis
Skeletallymature/middle aged Ankylosed subtalarjoint
Neutral heel position
70 CURRENT ORTHOPAEDICS
resection of an osseous CNC at an average follow-up
of 5.1 years (range 2^10 years). All six males and six of
eight females returned to their preoperative level of
athletic activity. Two failures were due to post-operative
complications, one case of Sudecks dystrophy and one of
incisional neuroma possibly secondary to aninjury to the
lateral branch of the supercial peroneal nerve. One pa-
tient, with bilateral involvement, had bilateral recur-
rences of which one side was successfully re-excised. All
ve patients presenting with talar beaks had excellent or
good results at follow-up. There were no degenerative
changes. Inglis et al.
17
reported 69%excellent or good re-
sults after excision in16 symptomatic feet after an aver-
age follow-up of 23 years.Three failedresections treated
with early triple arthrodesis within12 months after the
index operation remained pain-free, with no restriction
of activities. The one patient who underwent repeated
excisions for recurrence of bilateral bars remained sti
and painful and was dissatised. The recurrence rate
was 25% (4 of 16 feet), the other two feet remaining
asymptomatic. In contrast to the ndings of others, talar
beakingledto a poor result. If resectionis unsuccessful, a
triple arthrodesis should be considered since outcome is
then reasonably satisfactory.
12,17
Subtalar Coalition
The recommended surgical procedure has shifted from
subtalar or triple arthrodesis to isolated resection of
the bar, the former procedures being reserved for failed
resection or concomitant osteoarthritis of the rest of
the subtalar or the talonavicular joint.
12,14,19,21,25
The coa-
lition is exposed through a straight or curvilinear medial
incision centred over the sustentaculum tali as described
by Olney and Asher in1987 (Figs 9 and10).
25
The abduc-
tor hallucis muscle is detached from its retinacular and
calcaneal origin and reected plantarwards. The exor
retinaculum is divided. The exor digitorum longus ten-
don and the neurovascular bundle are identied, mobi-
lized and individually protected with a vascular loop and
reected dorsally and ventrally, respectively. Next, the
exor hallucis longus tendon should be identied as it
passes under the sustentaculumtali andwill help toiden-
tify the locally abnormal anatomy. The periosteum over-
lying the coalition is incised and, if possible, intact aps
should be retracted dorsally and plantarwards. The ex-
tent of the coalitionis assessed, by inserting needles into
the normal anterior and posterior parts of the subtalar
joint. If the coalition is not extensive (more than 1/3 of
the joint surface), it is resected using an osteotome and
curette. After removal of the coalition, the exposed
bony surfaces are covered with bone wax to prevent ex-
cessive bleeding. The periosteum is closed over the re-
sected area if possible. The exor retinaculum is then
repaired including the origin of the abductor hallucis
muscle. Subcutaneous fat is approximated and the skin
closed subcuticularly. Post-operatively, the leg is immobi-
lized in a below- knee plaster-of-Paris for 3 weeks and
Figure 7 Photograph of resected CNC. Figure 8 Photograph of resected CNC.
Figure 9 Photograph of resectedmiddle facet TCC. Figure 10 Photograph of resectedmiddle facet TCC.
TARSAL COALITION 71
weight bearing is allowed as tolerated. Although some
argue that the resultant defect should be lled with a
fat issue graft to prevent recurrence of the bar,
12,21,25
Ta-
kakura et al.
14
found no recurrences in 30 feet after an
average follow-up of 5.3 years without interposition
grafting.
Several authors have published favourable results
of simple resection of the coalition with percentages of
excellent and good results varying from 77% to
100%.
12,14,19,21,25
Failures result from not appreciating sig-
nicant degenerative changes, inadequate resection, and
a relative coalition area of greater than 50%.
46
No recur-
rences are reported. As to the extent of the excision ne-
cessary to achieve a satisfactory outcome, the literature
is inconclusive. However, in a recent interesting article
by Comfort and Johnson,
19
who analysed their results
after simple resection by using the CT mapping techni-
que describedby Wilde et al,
46
it is clear that the success
of excision depends upon the size of the coalition in rela-
tion to the total subtalar joint surface. TCC involving
one-third or less of the total joint surface had a 77%like-
lihood of a good or excellent result. Therefore, it is wise
to request a CT scan to assess the surface area of the
coalition and to restrict resection to those cases with
limited involvement. Subtalar fusion should be consid-
eredin the patients with more extensive involvement.
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