Studies have reported that casting produces symptomatic improvement in approximately 25 to 33 percent of patients.6,7 However, although symptoms may resolve with a course of immobilization and offloading, the symptoms may recur at any time in the future and may necessitate repeated immobilization and offloading, or surgical intervention.
Essential Considerations In Choosing A Surgical Procedure
Surgical treatment is essentially limited to either resection of the coalition or fusion of the involved joint complex. However, significant debate continues in regard to the indications and timing for the procedures, and the results to be expected with these two diverse surgical approaches. For this reason, I have proposed a classification system, which may be a framework for the construction of an appropriate treatment plan.8,9
While the Articular Classification System is not all inclusive, it does consider several important parameters used in the development of any treatment regimen. These parameters include patient age, articular involvement and the extent of secondary adaptive or arthritic changes. Since the introduction of the Articular Classification System over 20 years ago, I now advocate that one routinely consider the size of the coalition when developing a surgical treatment plan, especially with talocalcaneal coalitions.
Patient age is consistently a factor when one plans the surgical treatment of a tarsal coalition. Ideally, in all patients, the surgeon would like to resect the tarsal coalition and restore normal or nearly normal function to the involved tarsal joints. From a practical standpoint though, this is often not possible. The surgeon must balance the likelihood of success of resection of the coalition against the possible need for additional surgery (i.e., arthrodesing procedures) should this resection procedure fail.
In the juvenile patient who has not yet attained osseous maturity (i.e., open physeal growth plates), resection is favored for most tarsal coalitions. The remodeling potential of the growing juvenile patient is significant. For example, a child or adolescent is much more likely than an adult to achieve an acceptable subjective and objective return of function after a severe joint depression calcaneal fracture. Similarly, in the juvenile patient with a tarsal coalition, one anticipates that the increased joint motion achieved with resection of the coalition in combination with continued osseous growth and remodeling will result in a more normal, less painful midfoot and rearfoot joint complex. If symptoms and limited function remain or recur in this immature patient after resection, one can perform major arthrodesis procedures at a later date (i.e., after osseous maturity occurs).
When it comes to adult patients, surgeons may also consider resection of a tarsal coalition but this approach is more likely to fail. The reality of limited remodeling potential in the adult patient diminishes the probability of recovery to a reasonably functional, symptom free state. Therefore, mature patients who undergo coalition resection are at a greater risk for recurrent or increased joint limitation, and symptoms in the area of the excised tarsal coalition. If the adult patient is going to undergo attempted resection of a tarsal coalition, he or she should understand that arthrodesis might eventually be necessary to treat the condition and diminish the symptom complex.1