In general tarsal coalition surgery is divided into three treatment options:
A. Removal of the Tarsal Coalition
B. Removal of the Tarsal Coalition combined with Flat foot Corrective Surgery
C. Fusion of the Rearfoot
The decision making process for which surgery is best indicated is determined by patient age, size and location of coalition, type of coalition, presence of a flat foot, and presence of arthritis.
Dr. Blitz’ 3 Point Approach To Tarsal Coalition
- Drastic fusion procedures of major rearfoot joints are a last resort!
- Removal (resection) of the tarsal coalition will free up the rearfoot joints to move, and can spare excessive biomechanical wear and tear on adjacent joints.
- Flatfoot reconstruction should be performed, when indicated, in the presence of a flat foot.
Dr. Blitz has revolutionized the surgical thought process as it relates to tarsal coalition surgery. While many surgeons simply fuse major rearfoot joints in children and young adults, Dr. Blitz’ believes fusion is something that should be avoided with tarsal coalition, and rather the coalition removed and any structural mal-alignment corrected. Dr. Blitz’ approach is modern and is at the forefront of tarsal coalition research. He has pioneered the method for “Tarsal Coalition Resection & Flatfoot Correction in a Single Stage Operation” in addition to developing a surgical treatment algorithm. His advanced methods have been published in the Journal of Foot & Ankle Surgery and have received awards. The benefit of Dr. Blitz’ technique is that it preserves much of normal anatomy of the foot, returns motion for proper foot function as well as structurally improving the alignment of the foot.
A. Tarsal Coalition Resection (Tarsal Coalition Removal)
Tarsal coalition resection is a surgery that removes the abnormal boney blockage, therefore allowing free unrestricted motion of the back part of the foot. It is important to resect ‘enough’ bone and tissue so that motion remains unimpeded. As part of the surgery, a soft tissue spacer is placed between the bones to act as a cushion and prevent regrowth. Tarsal Coalition Resection preserves rearfoot motion!
Calcaneonavicular Tarsal Coalition Resection
Resection of the calcaneonavicular coalition is the simpler surgery of the tarsal coalition resections, and this is because the coalition itself is NOT directly located within a joint and more easily accessed. Calcaneonavicular resection surgery involves removing the coalition and placing a local muscle within the resection site (as a spacer).
Technical Aspects of Calcaneonavicular Coalition Resection
The Calcaneonavicular coalition is located on the outside of the foot, and the incision is made directly over the coalition. The coalition lives right below a two muscles (extensor hallucis longus and extensor hallucis brevis). The coalition is often easily identified though the boundaries may need to be delineated with intra-operative xrays (fluoroscopy).
It is important to remove enough of the coalition, which, unfortunately is often not performed in many cases. The coalition itself is deep and angle into the foot, and too often many surgeons do not appreciate this and too little bone is removed. The calcaneonavicular coalition should ideally be removed as a cylinder and not like a cone. While this coalition is NOT located within a joint, its is adjacent to two joints (calcaneocuboid and talonavicular joint), and these joints can be easily damaged or invaded during surgery – which can lead to premature degenerative arthritis.
After the coalition is resected, a wax coating can be placed on the bone ends to seal off the area to limit regrowth, which can occur. Additionally, the local muscle that overlies the coalition is split and placed within the coalition site, also to prevent re-growth. Older techniques involve securing the muscle to a string that exits the bottom of the foot and is tied to sole overlying a button – which is cut off of the skin a few weeks after surgery.
Dr. Blitz uses a special technique that secures the muscle in place with modern INTERNAL fixation techniques, avoiding the entire EXTERNAL “button thing.”
Middle Facet Tarsal Coalition Resection
Resection of middle facet coalitions are the most complicated of the tarsal coalition to resect because they are located within a joint that is deep within the foot and located right next to the major nerve of the foot. It is because of this location and inexperience; many surgeons choose more drastic fusion procedures as to treat middle facet tarsal coalitions. Unlike other coalitions, there is no local soft tissue spacer to insert at the coalition resection site – which means other materials need to be used (fat or tendon) which need to be separately harvested. Both of which DO NOT call for drastic fusion procedures to be performed instead, rather call for an experienced surgeon to perform these techniques. Middle facet tarsal coalition should be considered removal of the boney blockage to create a pseudo-joint (or false joint) where motion can occur.
Technical Aspects of Middle Facet Tarsal Coalition Resection
The middle facet tarsal coalition is located on the inside of the back part of the foot, just below the ankle. The incision is made directly over the coalition. This coalition is deep, and several tendons must be identified and moved aside to gain access to the coalition. Additionally the major nerve of the foot passes just below and alongside the middle facet coalition and extreme care must be taken to protect this nerve.
Once the area to the middle facet is identified, the coalition itself may be challenging to delineate. Fibrous coalitions are easier to define the interval because of its soft tissue composition. Boney (Osseous) coalition, however, require the surgeon to create the boney interval. It is important to remove enough of the coalition, which, unfortunately is often not performed in many cases. Middle facet coalitions are deep within the foot, and surgeons remove the coalition with a combination of a bone saw, osteotomes and bone cutting instruments. Intra-operative xrays (fluoroscopy) are helpful when performing this surgery.
Because this coalition is located within a joint complex, it is critical to remove only the coalition and NOT invade the remaining aspect of the joint (posterior facet of the subtalar joint). The posterior facet can be easily damaged or invaded during surgery – which can lead to premature degenerative arthritis.
After the coalition is resected, a wax coating can be placed on the bone ends to seal off the area to limit regrowth, which can occur. An interpositional material should be placed within the resection site to limit regrowth and involve harvested fat (adipose tissue) and/or tendon.
Dr. Blitz has used advanced soft tissue spacers to limit regrowth.
B. Tarsal Coalition Resection AND Flat foot Corrective Surgery
Dr. Blitz has pioneered and popularized the philosophy of tarsal coalition resection PLUS correcting structural flatfoot problems (if present). Dr. Blitz’ published and award-winning method involves removing the coalition and correcting the flatfoot in a single operation. The objective of this surgery is to remove the boney restriction of motion AND structurally realign the foot – allowing the foot to function in an improved more ‘normal’ position.
Dr. Blitz believes this very important for children and young adults because more drastic fusion procedures cannot be undone and may result in degeneration of adjacent joints with time as those joints (example is ankle) bear a greater biomechanical burden.
Common Flat Foot Procedures Performed With Tarsal Coalition Resection
- Gastrocnemius Recession
- TendoAchilles Lengthening
- Medializing Calcaneal Osteotomy
- Evans Calcaneal Osteotomy
C. Fusion of the Rearfoot
Rearfoot fusion for the treatment of tarsal coalition is the most drastic surgical option because it involves permanently fusing one or all of the rearfoot joints. This translates into little or NO motion of the entire back of the foot. This is a surgery that is best indicated when severe arthritis of the rearfoot exists.
Dr. Blitz strongly tries to avoid rearfoot fusion, and his published award winning techniques are aimed at preventing fusion and realigning the foot. Though, in some cases fusion may be unavoidable, such as in any the following scenarios:
- Giant Middle Facet Tarsal Coalitions That Significantly Invade Subtalar joint
- Significant Rearfoot Arthritis
- Severe Flat Foot
The long-term effects of rearfoot fusion may result in compensational foot and ankle problems and/or premature arthritis.
How To Choose The Best Tarsal Coalition Surgery?
All tarsal coalitions cases are unique and choosing the best procedure for a tarsal coalition is not always straightforward. Decision-making depends on a combination of the following:
- patient age,
- bone age,
- extent of pain,
- location of pain,
- size of coalition,
- type of coalition,
- presence and severity of a flat foot, and
- presence of arthritis.
Historically, there were only two surgeries for tarsal coalition: remove the coalition OR perform drastic fusion type procedures of the rearfoot. Many surgeons performed tarsal coalition resection surgery as a first attempt and, if that failed , then fusion surgery or flat foot procedures may be attempted as a second surgery. Dr. Blitz’ revolutionary techniques call for coalition resection and flatfoot resection in a SINGLE operation.
Tarsal Coalition Surgery Recovery
Tarsal coalition surgery recovery depends on the procedure performed. In general simple resection often allows for patients to ambulate almost immediately after the surgery. If flat foot surgery and/or rearfoot fusion procedures are performed, the recovery often involves casting and non-weightbearing with crutches for 6-8 weeks.
What Anesthesia Is Needed For Tarsal Coalition Surgery
Tarsal coalition surgery is performed as outpatient surgery – which means you go home the same day. It may be performed in a hospital setting or ambulatory surgery center. More advanced procedures may require a short hospital stay. Tarsal Coalition surgery often requires regional, spinal or general anesthetic.
What Are The Risks Of Tarsal Coalition Surgery
There are general risks associated with tarsal coalition surgery, and/or any surgery and the use of any anesthesia. Complications may occur and are not necessarily your fault, or the fault of your surgeon. Nonetheless, you should understand the risks associated with surgery.
Tarsal coalition surgery complications include, but are not limited to: infection, pain (temporary or permanent), swelling, hematoma, bleeding, blood clot, poor wound healing, incision breakdown, poor bone healing (delayed union, nonunion), malunion, nerve injury, neuroma, pain syndrome, RSD, disability, recurrence, flail toe, hammer toe deformity, metatarsalgia, unsightly scar, stiffness, weakness in toe, loss of toe to purchase ground, hardware problems, weakness, recurrence, regrowth, need for revision surgery, and/or catastrophic loss.