ORIGINAL ARTICLE
Patient-reported Outcomes of Tarsal Coalitions Treated With Surgical Excision Susan T. Mahan, MD, MPH,*w Samantha A. Spencer, MD,*w Peter S. Vezeridis, MD,z and James R. Kasser, MDy8
Purpose: There are little patient-reported data on functional outcomes of tarsal coalition resection in children and adolescents. The purpose of this study is to evaluate the medium-term (> 2 y) outcomes in patients who have had surgical excision of their symptomatic tarsal coalition and to compare patient-based outcomes in patients who have calcaneonavicular (CN) coalitions to those with talocalcaneal (TC) coalitions. Methods: A billing query was conducted to identify patients who had surgical excision of their tarsal coalition between 2003 and 2008. Eligible patients were mailed questionnaires consisting of a modified American Orthopaedic Foot and Ankle Society (AOFAS) score and the University of California at Los Angeles (UCLA) activity scale. Patients were also specifically asked if their activity level was limited by their foot pain. Only patients who returned questionnaires were included. Demographics and diagnostic images were reviewed. A nonresponder analysis was completed. Complications such as infection and reoperation were reported. Results: Sixty-three patients (22 females, 41 males) who returned questionnaires were included in the analysis. Twenty-four patients had bilateral surgery. TC coalitions were present in 20 patients (32%); CN coalitions were present in 43 patients (68%). Overall, mean modified AOFAS score was 88.3 and mean UCLA activity score was 8.33 at an average of 4.62 years after surgery. Patients who had TC coalitions had similar modified AOFAS scores (88.4) and UCLA activity scores (8.4) when compared with those with CN coalitions (88.0 and 8.3, both not significant). Of the 73% (46/ 63) patients who reported that their activity levels were not limited by their foot pain, the mean AOFAS score was 93.9 and the mean UCLA activity score was 8.9; 32 of these were CN and 14 were TC coalitions. Of the 27% (17/63) patients who reported that their activity levels were limited by their foot pain, the mean AOFAS score was 72.9 and the mean UCLA activity score was 6.9; 11 of these were CN and 6 were TC coalitions. There was a statistically significant difference in these groups both in modified AOFAS From the Departments of *Orthopaedics; yOrthopaedic Surgery, Boston Children’s Hospital; wDepartment of Orthopaedic Surgery; 8Catharine Ormandy Professor of Orthopaedic Surgery, Harvard Medical School; and zHarvard Combined Orthopaedic Residency Program, Boston, MA. The authors have no financial disclosures related to this topic. The authors declare no conflicts of interest. Reprints: Susan T. Mahan, MD, MPH, Department of Orthopaedics, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115. E-mail: [email protected]. Copyright r 2014 Wolters Kluwer Health, Inc. All rights reserved.
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score (P < 0.0001) and UCLA activity score (P = 0.006). There was no difference in outcomes between those who were treated for a TC and CN coalition. Conclusions: Patient-reported outcomes after surgical excision of tarsal coalition reveal that >70% of patients’ activities are not limited by pain and their functional outcome is terrific. A few patients continue to have problems with ongoing foot pain and activity limitations. The type of coalition does not seem to be an indicative factor in determining outcome. Key Words: tarsal coalition, patient-reported outcomes, congenital foot (J Pediatr Orthop 2015;35:583–588)
T
arsal coalitions are often the cause of foot pain and rigid pes planovalgus deformity in children and adolescents, with an incidence of 50% involvement of the joint were recommended for fusion over excision.12,16–18 More recently, authors have demonstrated success with excision regardless of the extent of the coalition.14,15 At the present time, symptomatic tarsal coalitions (both CN and TC) are typically treated with coalition resection and interposition to prevent recurrence.11–13 Materials used for www.pedorthopaedics.com |
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interposition include fat, bone wax, and the extensor digitorum brevis muscle.19 Previous studies have examined the results after excision of symptomatic tarsal coalitions; however, patient-reported outcome data regarding functional outcomes of this procedure in children and adolescents has been uncommon until recently. Those that have reported patient-based outcomes in this population14,15,20 had some outcomes that were below normal values, and a conclusive understanding of which children will most benefit from this surgery remains elusive. This study examines clinical and patient-based outcomes of symptomatic tarsal coalition excisions through retrospective review and patient-reported outcome questionnaires. The purpose of this study was to determine whether patients who had symptomatic tarsal coalitions treated with excision and interposition were able to return to athletic activities with a pain-free functional foot. Secondary purposes were to determine whether location of the coalition (TC vs. CN) had any impact on success of treatment, as well as to assess for clinical and radiographic indicators of favorable outcomes.
METHODS Institutional Review Board approval was achieved before the initiation of this study. A search of surgical billing records was conducted to identify patients who underwent surgical excision of a tarsal coalition at our institution between 2003 and 2008. This search yielded 108 patients. Inclusion criteria consisted of surgical excision of tarsal coalition (CPT 28116), surgical treatment for a symptomatic TC or CN coalition, and an age of 18 years or younger at the date of surgery. Exclusion criteria consisted of treatment for an accessory tarsal bone, patients with a neuromuscular disorder, or the presence of clubfoot. Eight patients did not meet the inclusion criteria for the present study. The remaining 101 patients were mailed questionnaires consisting of (1) a modified American Orthopaedic Foot and Ankle Society (AOFAS) score,21 (score of 0 to 100 with higher number equivalent to better outcomes); (2) the University of California at Los Angeles (UCLA) activity scale22 (score 0 to 10 with higher score equivalent with greater level of athletic participation); and (3) the additional question “Is your activity limited by your foot pain?” (dichotomous yes/no answer). Of the 101 patients sent a questionnaire, 64 returned completed questionnaires for inclusion in the study (63.4%). Two patients had minorly incomplete questionnaires but were still able to be included. Chart review was conducted to identify patient demographics, including age, sex, type of coalition (CN or TC), details of the surgical procedure, and clinical and radiographic follow-up. Complications involving infection and reoperation were reported. All patients who returned questionnaires were included in the analysis except for 1— further review of imaging showed the patient had a coalition between the navicular and cuboid and was therefore excluded. Nonresponder analysis was performed.
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This was a retrospective study with patient contact for questionnaires. As such, the radiologic data were not standardized. As we were more interested in clinical, rather than imaging, outcomes we did not limit study participation based on the imaging available; therefore imaging data for study purposes was incomplete. Despite the incomplete imaging, computerized tomography (CT) scans were utilized in most patients (40/62) and were assessed for (1) percent involvement of the middle facet compared with the posterior facet as well as (2) heel valgus angle on coronal cuts, both as described initially by Wilde et al.23 This CT analysis was done by a pediatric orthopaedic surgeon (S.T.M.) who was not aware of the clinical results during the radiographic assessment. Statistical significance was set to P < 0.05 (2-tailed). Continuous data were age (y), UCLA activity score (linearity assumed), modified AOFAS score (linearity assumed), and time since surgery (y). Data were compared between groups using the Student t test or the Wilcoxon rank-sum test, as appropriate. Dichotomous data included sex, type of coalition (CN or TC), unilateral versus bilateral, and activity limited by foot pain (yes or no). Dichotomous data were then compared using the Fisher exact test. SAS software (SAS Institute Inc., Cary, NC) and Excel software (Microsoft, Redmond, WA) were utilized for all analyses.
RESULTS Sixty-three patients (22 females, 41 males) were analyzed. Thirty-seven patients had bilateral coalitions present, and of these 24 patients had bilateral surgery. Five different surgeons were involved. TC coalitions were present in 20 patients (32%) and 5 had bilateral excision; CN coalitions were present in 42 patients (68%) (Table 1). No postoperative infections were identified among these patients. Five patients had follow-up surgery after their initial coalition excision (other than for contralateral coalition excision): 3 patients required reoperation due to coalition recurrence (all were CN coalitions), 1 patient had accessory navicular excision, and 1 patient had excision of a talar bone spur. No patient in this group had subsequent hindfoot surgery for pes planovalgus correction. Analysis of all patients who returned questionnaires yielded a mean modified AOFAS score of 88.3 (SD 12.7; range, 39 to 100) and mean UCLA activity score of 8.3 (SD 2.2; range, 3 to 10) at an average of 4.62 years after surgery (SD 1.97; range, 1.8 to 10.6). Patients who had TC coalitions had similar modified AOFAS scores (88.4) and UCLA activity scores (8.4) when compared with those patients with CN coalitions who had a mean modified AOFAS score of 88.0 and mean UCLA activity score of 8.3 (Table 1). Neither score was significantly different between the TC and CN groups. Subgroup analysis was performed, comparing those patients who had activity limitations due to foot pain with those patients who had no activity limitations. For the 73% (46/63) of patients who reported that their activity levels were not limited by foot pain, mean modified AOFAS score Copyright
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TABLE 1. Comparison of Patient and Outcome Characteristics for Talocalcaneal and Calcaneonavicular Coalitions (N = 63) Frequency (%)
Patient characteristics Sex (male) Age at surgery (mean) (y) Bilateral surgery Length of follow-up (mean) (y) Outcomes Modified AOFAS score (mean ± SD) UCLA activity score (mean ± SD) Activity not limited by foot pain
Calcaneonavicular (n = 43)
Talocalcaneal (n = 20)
30 (70) 13.3 19 (44) 4.85
11 (55) 12.8 5 (25) 4.15
88.0 ± 2.13
88.4 ± 2.44
8.3 ± 0.32
8.4 ± 0.50
32 (74)
14 (70)
Characteristics were compared across groups using either Fisher exact test or Student t test at the 5% significance level. All P-values were not significant. AOFAS indicates American Orthopaedic Foot and Ankle Society; UCLA, University of California at Los Angeles.
was 93.9 and mean UCLA activity score was 8.9 (Table 2). Thirty-two patients had CN coalitions, whereas 14 patients had TC coalitions. Of the 27% (17/63) patients who reported that their activity levels were limited by foot pain, the mean modified AOFAS score was 72.9 and the mean UCLA activity score was 6.9. These 17 patients consisted of 11 with CN coalitions and 6 with TC coalitions. There was a statistically significant difference in these groups both in mean modified AOFAS score (P < 0.0001) and mean UCLA activity score (P = 0.006). CT imaging was available in 63.5% (40/63) of the patients, 24 with CN and 16 with TC coalitions. Mean UCLA score for this subgroup of patients was 8.2 (SD 2.1), mean modified AOFAS score was 88.4 (SD 11.8), and 65% (26/40) did not have foot pain limiting their activity. Of these patients, 28/40 had bilateral coalitions (18 CN and 10 TC, none were mixed); however, only 18 of those had bilateral surgery (13 CN and 5 TC). Of those patients who had surgical excision of their coalition, the average heel valgus was 9.7 degrees (SD 7.1 degrees; range, 0 to 27 degrees). There was no difference in average valgus in patients with CN coalitions (mean 9.6 degrees)
Patient-reported Outcomes of Tarsal Coalitions
compared with TC coalitions (mean 9.8 degrees). Using r16 degrees valgus as a cutoff,15 82.5% (33/40) patients had a maximum heel valgus (greatest of the 2 feet) r16 degrees, whereas 17.5% (7/40) had at least 17 degrees of heel valgus in 1 foot (Table 3). There was no difference in the mean modified AOFAS score, UCLA activity score, and no activity limiting foot pain when comparing those patients with 50%: 86.9, 7.5, and 50%). Bilateral coalitions were found in 59% (37/63) of the patients. In all cases the same type of coalition (CN or TC) was found in both feet (Table 4). However, of those patients with bilateral coalitions, surgery was only performed bilaterally in 59% (22/37). Patients who had surgery on both feet had a mean modified AOFAS score of 90.8, mean UCLA activity score of 8.5, and 81% (18/ 22) did not have foot pain that limited their activity; patients with surgery on only 1 foot had a mean AOFAS score of 84.1, mean UCLA activity score of 7.7, and 47% (7/15) did not have foot pain that limited their activity. Only foot pain limiting activity was statistically significant (P = 0.025 by Fisher exact test).
DISCUSSION Surgery for symptomatic tarsal coalitions has been widely reported in the literature with outcomes focused on a clinical-based assessment of foot alignment, function, and return to activity, as well as need for further surgery.10–13,20,23,24 However, patient-reported outcomes following tarsal coalition excision have been increasingly recognized for their importance13–15 in appreciating functional outcome of these patients after surgery. Our investigation sought to assess outcomes that are important to patients so we can better inform them about surgical expectations and outcomes in the preoperative
TABLE 2. Outcome Scores and Coalition Type Compared by Response to the Question: “Are Your Activities Limited by Your Foot Pain?” (N = 63) “Is Your Activity Limited By Foot Pain?” Modified AOFAS score (mean ± SD) UCLA activity score (mean ± SD) Coalition type [n (%)] Calcaneonavicular Talocalcaneal
No (n = 46)
Yes (n = 17)
P
93.9 ± 1.05 8.9 ± 0.24
72.9 ± 3.14 6.9 ± 0.66
< 0.001 0.006
32 (70) 14 (30)
11 (65) 6 (35)
NS
Outcomes were compared across groups using either Fisher exact test or Student t test at the 5% significance level. AOFAS indicates American Orthopaedic Foot and Ankle Society; NS, not significant; UCLA, University of California at Los Angeles.
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TABLE 3. Comparison of CT Data as Available for 63.5% of the Patients (40/63) With Surgically Treated Coalitions Heel Valgus Modified AOFAS score (mean ± SD) UCLA score (mean ± SD) Activity not limited by foot pain [frequency (%)] Involvement of medial facet (compared with posterior facet) Modified AOFAS score (mean ± SD) UCLA score (mean ± SD) Activity not limited by foot pain [frequency (%)]
r16 Degrees (n = 33)
>16 Degrees (n = 7)
88.3 ± 2.00
88.7 ± 5.57
8.3 ± 0.38 21 (73)
7.7 ± 0.78 5 (71)
r50% involvement (n = 8) 88.8 ± 4.34
> 50% involvement (n = 8) 86.9 ± 4.36
8.9 ± 0.64 6 (75)
7.5 ± 1.00 4 (50)
Outcomes were compared across groups using either Fisher exact test or Student t test at the 5% significance level. All P-values were not significant. When bilateral coalitions were treated surgically, the worst (greatest valgus or greatest % involvement of the medial facet) foot was chosen for comparison of outcomes. AOFAS indicates American Orthopaedic Foot and Ankle Society; CT, computerized tomography; UCLA, University of California at Los Angeles.
visits. In particular, our patients wanted to know the likelihood of improvement in their pain after surgery and whether unrestricted sports participation would be possible. This study aimed to assess outcomes by a patientbased questionnaire that utilized the modified AOFAS pain and function sections as well as the UCLA activity scale. We also asked a simple additional question: is your activity limited by your foot pain? We felt that this combination of questions would best assess: (1) how are these feet functioning postoperatively, (2) what level of activity are our patient participating in postoperatively, and (3) what is their motivation for their activity level (personal choice or foot pain)? Interestingly, our study found that 73% of patients reported no activity limitation following surgery. This correlated with high AOFAS and UCLA scores. Type of coalition (CN or TC) did not impact postoperative outcomes. Unfortunately, 27% of our patients found that even after surgery, their activity was limited by foot pain, and this correlated with lower AOFAS and UCLA scores. Interestingly, of the 17 patients who had ongoing foot pain limiting their activity, 47% (8/17) had known bilateral coalitions but only had surgery on 1 side. Unfortunately, we did not ask which foot was causing the pain.
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Many authors have advocated that patients with a TC coalition and >50% involvement of the joint and/or >16 degrees of heel valgus were recommended for fusion or osteotomy over simple excision.12,16–18 Mosca and Bevan16 advocate that any patient with hindfoot valgus of >16 degrees or large subtalar coalition should undergo a calcaneal lengthening osteotomy, and the average AOFAS score in their small series of 8 patients was 91.2. Other series are noting the success of simple excision of coalition in both CN and subtalar coalitions, and our findings are in line with other studies. Raikin et al20 reported on 10 patients (14 feet) using the AOFAS at least 2 years after surgery for subtalar coalitions with split flexor halluces longus tendon interposition. They had 11 feet with excellent results (score 90 to 100).20 Gantsoudes et al14 reported on a series of 32 patients with TC coalitions excisions with patient-based outcomes with at least 12-month follow-up and utilizing the AOFAS anklehindfoot score. They found that 85% of their patients had a good to excellent result (80 to 100 score on the AOFAS), which was very similar to our results. Twenty-two percent of their patients underwent subsequent procedures, mostly pes planovalgus deformity corrections and also revision coalition excisions. Although we are not averse to pes planovalgus correction osteotomies (eg, Evans16 or calcaneal-cuboid-cuneiform osteotomy14), no patient in our series underwent such a procedure. Khoshbin et al15 also reported on patient-based outcomes after tarsal coalition excision, including both TC and CN coalitions. They had a smaller series (24 patients) with longer follow-up (25 y) using the American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle Module and the Foot Function Index (FFI).15 They also found no difference in outcomes between the CN and TC coalitions and found that most patients were doing quite well but that some patients had ongoing issues with their feet. Only 2 of their patients underwent subsequent correction for pes planovalgus deformity (1 each of CN and TC types). In the literature discussing treatment for tarsal coalition, there is some debate about when pes planovalgus reconstruction should be utilized16,25 and how predictive the finding of increased valgus on preoperative CT is of subsequent outcomes.12 In the Khoshbin et al15 report of the Toronto experience, they did not find increased hindfoot valgus predictive of outcome, and did very few subsequent deformity-correcting osteotomies. Gantsoudes et al14 from San Diego report a higher rate of
TABLE 4. Comparison of Patients With Known Bilateral Coalitions Where Either 1 or Both Coalitions Underwent Surgical Excision (N = 37) Modified AOFAS score (mean ± SD) UCLA activity score (mean ± SD) Activity not limited by foot pain [frequency (%)]
Unilateral Excisions (n = 15)
Bilateral Excisions (n = 22)
P
84.1 ± 3.18 7.7 ± 0.69 7 (47)
90.8 ± 2.32 8.5 ± 0.36 18 (81)
NS NS 0.025
Outcomes were compared across groups using either Fisher exact test or Student t test at the 5% significance level. AOFAS indicates American Orthopaedic Foot and Ankle Society; NS, not significant; UCLA, University of California at Los Angeles.
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correction of hindfoot deformities after coalition excision. Mosca and Bevan16 advocate that any patient with hindfoot valgus over 16 degrees undergoes calcaneal lengthening osteotomy. We report no subsequent osteotomies in our series, with similar clinical outcomes to the San Diego, Toronto, and Seattle groups. Similarly, previous literature has suggested that TC coalitions where the coalition involves >50% of area of the posterior facet may have compromised outcomes and should be considered for fusion over coalition excision.12,18,23 We found that half of our patients with TC coalitions and CT scans had a coalition with >50% involvement of the area of the posterior facet; yet the outcomes were no different in this group than in the group with less involvement. This is in line with more recent studies14,15 suggesting that extent of coalition does not influence outcome after excision. Previously, other studies have reported TC excisions as having less satisfactory results23,26 when compared with CN coalitions. We found no significant difference between the TC and CN groups, which is similar to more recent reports.15 It is interesting to note that in the recently reported series of patient-based outcomes after surgical excision of tarsal coalition (including ours), most of the patients are doing quite well but a few still have ongoing pain in their feet.14–16,20 Our data dichotomizes these 2 groups by determining which patients have limitation of their activities due to foot pain. We found that 73% had no limitation of their activities due to foot pain and therefore had the expected high UCLA activity and AOFAS scores. Ultimately, further investigation needs to be done for the 27% of patients with ongoing foot pain that limits their activities, and we now have an ongoing prospective study evaluating this further. Finally, we found that in the patients with known bilateral coalitions, only about 60% had surgery on both feet. Just because a coalition is present does not mean that it causes symptoms, and many coalitions are asymptomatic.1 However, the group that had surgery on both feet in general is doing better than the group with unilateral surgery. It is not clear whether the foot that is causing activity-limiting pain is the postoperative foot or the foot with the persistent coalition (as we did not ask which side hurt in the questionnaire). Either the patients who had unilateral surgery are not happy with their surgical result and have chosen not to pursue the other side (ie, their postoperative foot still hurts) or they have chosen not to pursue surgery on their symptomatic contralateral coalition (ie, the foot with the persistent coalition is hurting). We anticipate looking into this further in a subsequent ongoing prospective study. One limitation of this study is its retrospective nature and limited uniformity of imaging. Unfortunately only 63.5% (40/63) of our patients had CT scans that could be evaluated, but we feel that this was a representative sample of our group of patients. However, this study showed our questionnaire to be useful and functional to assess patient outcomes in tarsal coalitions, and a follow-up prospective study is now underway. Another Copyright
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Patient-reported Outcomes of Tarsal Coalitions
limitation of our study is the number of nonresponders on initial mailing of our survey. Initially, 40 of 101 patients responded to our query. Nonresponders were mailed repeat questionnaires and reminded by phone, and 23 additional patients subsequently responded for a total response rate of 63.4%; however, an online survey or survey at the time of a clinic visit might increase response rates further. Nonresponder analysis of clinical charts found similar postoperative courses to responders; there did not seem to be increased rates of complications or prolonged postoperative pain and dysfunction in nonresponders; however, a formal analysis was not done. We hypothesize that our responder group is representative of our entire patient population, although we recognize that nonresponder bias is a possibility. In an era of increasing scrutiny of outcomes and quality improvement initiatives, the importance of measuring appropriate outcomes is clear. Although physicianbased outcomes such as foot alignment are important in tarsal coalition surgery, patient-reported outcomes of pain, daily function, and return to high-level sports are of paramount importance in assessing whether tarsal coalition surgery can reliably offer a high-quality result. In our study, 73% of patients reported unlimited activity. There was no difference in reported outcomes between the CN and TC groups. In conclusion, tarsal coalition surgery offered high rates of return to full activity based on patient reports.
REFERENCES 1. Olney BW. Tarsal coalition. In: McCarthy JJ, Drennan JC, eds. Drennan’s The Child’s Foot and Ankle. New York: Wolters Kluwer/ Lippincott Williams & Wilkins; 2010:160–173. 2. Gardner E, Gray DJ, O’Rahilly R. The prenatal development of the skeleton and joints of the human foot. J Bone Joint Surg Am. 1959;41-A:847–876. 3. Harris BJ. Anomalous structures in the developing human foot. Anat Rec. 1955;121:251–480. 4. O’Rahilly R, Gardner E, Gray DJ. The skeletal development of the foot. Clin Orthop. 1960;16:7–14. 5. Jayakumar S, Cowell HR. Rigid flatfoot. Clin Orthop Relat Res. 1977;122:77–84. 6. Conway JJ, Cowell HR. Tarsal coalition: clinical significance and roentgenographic demonstration. Radiology. 1969;92:799–811. 7. Stormont DM, Peterson HA. The relative incidence of tarsal coalition. Clin Orthop Relat Res. 1983;181:28–36. 8. Badgley CE. Coalition of the calcaneus and the navicular. Arch Surg. 1927;15:75–88. 9. Andreasen E. Calcaneo-navicular coalition. Late results of resection. Acta Orthop Scand. 1968;39:424–432. 10. Cowell HR, Elener V. Rigid painful flatfoot secondary to tarsal coalition. Clin Orthop Relat Res. 1983;177:54–60. 11. Gonzalez P, Kumar SJ. Calcaneonavicular coalition treated by resection and interposition of the extensor digitorum brevis muscle. J Bone Joint Surg Am. 1990;72:71–77. 12. Luhmann SJ, Schoenecker PL. Symptomatic talocalcaneal coalition resection: indications and results. J Pediatr Orthop. 1998;18: 748–754. 13. Mubarak SJ, Patel PN, Upasani VV, et al. Calcaneonavicular coalition: treatment by excision and fat graft. J Pediatr Orthop. 2009;29:418–426. 14. Gantsoudes GD, Roocroft JH, Mubarak SJ. Treatment of talocalcaneal coalitions. J Pediatr Orthop. 2012;32:301–307.
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15. Khoshbin A, Law PW, Caspi L, et al. Long-term functional outcomes of resected tarsal coalitions. Foot Ankle Int. 2013;34: 1370–1375. 16. Mosca VS, Bevan WP. Talocalcaneal tarsal coalitions and the calcaneal lengthening osteotomy: the role of deformity correction. J Bone Joint Surg Am. 2012;94:1584–1594. 17. Scranton PE. Treatment of symptomatic talocalcaneal coalition. J Bone Joint Surg Am. 1987;69:533–539. 18. Comfort TK, Johnson LO. Resection for symptomatic talocalcaneal coalition. J Pediatr Orthop. 1998;18:283–288. 19. Thometz J. Tarsal coalition. Foot Ankle Clin. 2000;5:103–118. vi. 20. Raikin S, Cooperman DR, Thompson GH. Interposition of the split flexor hallucis longus tendon after resection of a coalition of the middle facet of the talocalcaneal joint. J Bone Joint Surg Am. 1999;81:11–19.
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21. Kitaoka HB, Alexander IJ, Adelaar RS, et al. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int. 1994;15:349–353. 22. Amstutz HC, Thomas BJ, Jinnah R, et al. Treatment of primary osteoarthritis of the hip. A comparison of total joint and surface replacement arthroplasty. J Bone Joint Surg Am. 1984;66:228–241. 23. Wilde PH, Torode IP, Dickens DR, et al. Resection for symptomatic talocalcaneal coalition. J Bone Joint Surg Br. 1994;76:797–801. 24. McCormack TJ, Olney B, Asher M. Talocalcaneal coalition resection: a 10-year follow-up. J Pediatr Orthop. 1997;17:13–15. 25. Rathjen KE, Mubarak SJ. Calcaneal-cuboid-cuneiform osteotomy for the correction of valgus foot deformities in children. J Pediatr Orthop. 1998;18:775–782. 26. Kitaoka HB, Wikenheiser MA, Shaughnessy WJ, et al. Gait abnormalities following resection of talocalcaneal coalition. J Bone Joint Surg Am. 1997;79:369–374.
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Patient-reported Outcomes of Tarsal Coalitions Treated With Surgical Excision Susan T. Mahan, MD, MPH,*w Samantha A. Spencer, MD,*w Peter S. Vezeridis, MD,z and James R. Kasser, MDy8
Purpose: There are little patient-reported data on functional outcomes of tarsal coalition resection in children and adolescents. The purpose of this study is to evaluate the medium-term (> 2 y) outcomes in patients who have had surgical excision of their symptomatic tarsal coalition and to compare patient-based outcomes in patients who have calcaneonavicular (CN) coalitions to those with talocalcaneal (TC) coalitions. Methods: A billing query was conducted to identify patients who had surgical excision of their tarsal coalition between 2003 and 2008. Eligible patients were mailed questionnaires consisting of a modified American Orthopaedic Foot and Ankle Society (AOFAS) score and the University of California at Los Angeles (UCLA) activity scale. Patients were also specifically asked if their activity level was limited by their foot pain. Only patients who returned questionnaires were included. Demographics and diagnostic images were reviewed. A nonresponder analysis was completed. Complications such as infection and reoperation were reported. Results: Sixty-three patients (22 females, 41 males) who returned questionnaires were included in the analysis. Twenty-four patients had bilateral surgery. TC coalitions were present in 20 patients (32%); CN coalitions were present in 43 patients (68%). Overall, mean modified AOFAS score was 88.3 and mean UCLA activity score was 8.33 at an average of 4.62 years after surgery. Patients who had TC coalitions had similar modified AOFAS scores (88.4) and UCLA activity scores (8.4) when compared with those with CN coalitions (88.0 and 8.3, both not significant). Of the 73% (46/ 63) patients who reported that their activity levels were not limited by their foot pain, the mean AOFAS score was 93.9 and the mean UCLA activity score was 8.9; 32 of these were CN and 14 were TC coalitions. Of the 27% (17/63) patients who reported that their activity levels were limited by their foot pain, the mean AOFAS score was 72.9 and the mean UCLA activity score was 6.9; 11 of these were CN and 6 were TC coalitions. There was a statistically significant difference in these groups both in modified AOFAS From the Departments of *Orthopaedics; yOrthopaedic Surgery, Boston Children’s Hospital; wDepartment of Orthopaedic Surgery; 8Catharine Ormandy Professor of Orthopaedic Surgery, Harvard Medical School; and zHarvard Combined Orthopaedic Residency Program, Boston, MA. The authors have no financial disclosures related to this topic. The authors declare no conflicts of interest. Reprints: Susan T. Mahan, MD, MPH, Department of Orthopaedics, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115. E-mail: [email protected]. Copyright r 2014 Wolters Kluwer Health, Inc. All rights reserved.
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score (P < 0.0001) and UCLA activity score (P = 0.006). There was no difference in outcomes between those who were treated for a TC and CN coalition. Conclusions: Patient-reported outcomes after surgical excision of tarsal coalition reveal that >70% of patients’ activities are not limited by pain and their functional outcome is terrific. A few patients continue to have problems with ongoing foot pain and activity limitations. The type of coalition does not seem to be an indicative factor in determining outcome. Key Words: tarsal coalition, patient-reported outcomes, congenital foot (J Pediatr Orthop 2015;35:583–588)
T
arsal coalitions are often the cause of foot pain and rigid pes planovalgus deformity in children and adolescents, with an incidence of 50% involvement of the joint were recommended for fusion over excision.12,16–18 More recently, authors have demonstrated success with excision regardless of the extent of the coalition.14,15 At the present time, symptomatic tarsal coalitions (both CN and TC) are typically treated with coalition resection and interposition to prevent recurrence.11–13 Materials used for www.pedorthopaedics.com |
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interposition include fat, bone wax, and the extensor digitorum brevis muscle.19 Previous studies have examined the results after excision of symptomatic tarsal coalitions; however, patient-reported outcome data regarding functional outcomes of this procedure in children and adolescents has been uncommon until recently. Those that have reported patient-based outcomes in this population14,15,20 had some outcomes that were below normal values, and a conclusive understanding of which children will most benefit from this surgery remains elusive. This study examines clinical and patient-based outcomes of symptomatic tarsal coalition excisions through retrospective review and patient-reported outcome questionnaires. The purpose of this study was to determine whether patients who had symptomatic tarsal coalitions treated with excision and interposition were able to return to athletic activities with a pain-free functional foot. Secondary purposes were to determine whether location of the coalition (TC vs. CN) had any impact on success of treatment, as well as to assess for clinical and radiographic indicators of favorable outcomes.
METHODS Institutional Review Board approval was achieved before the initiation of this study. A search of surgical billing records was conducted to identify patients who underwent surgical excision of a tarsal coalition at our institution between 2003 and 2008. This search yielded 108 patients. Inclusion criteria consisted of surgical excision of tarsal coalition (CPT 28116), surgical treatment for a symptomatic TC or CN coalition, and an age of 18 years or younger at the date of surgery. Exclusion criteria consisted of treatment for an accessory tarsal bone, patients with a neuromuscular disorder, or the presence of clubfoot. Eight patients did not meet the inclusion criteria for the present study. The remaining 101 patients were mailed questionnaires consisting of (1) a modified American Orthopaedic Foot and Ankle Society (AOFAS) score,21 (score of 0 to 100 with higher number equivalent to better outcomes); (2) the University of California at Los Angeles (UCLA) activity scale22 (score 0 to 10 with higher score equivalent with greater level of athletic participation); and (3) the additional question “Is your activity limited by your foot pain?” (dichotomous yes/no answer). Of the 101 patients sent a questionnaire, 64 returned completed questionnaires for inclusion in the study (63.4%). Two patients had minorly incomplete questionnaires but were still able to be included. Chart review was conducted to identify patient demographics, including age, sex, type of coalition (CN or TC), details of the surgical procedure, and clinical and radiographic follow-up. Complications involving infection and reoperation were reported. All patients who returned questionnaires were included in the analysis except for 1— further review of imaging showed the patient had a coalition between the navicular and cuboid and was therefore excluded. Nonresponder analysis was performed.
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This was a retrospective study with patient contact for questionnaires. As such, the radiologic data were not standardized. As we were more interested in clinical, rather than imaging, outcomes we did not limit study participation based on the imaging available; therefore imaging data for study purposes was incomplete. Despite the incomplete imaging, computerized tomography (CT) scans were utilized in most patients (40/62) and were assessed for (1) percent involvement of the middle facet compared with the posterior facet as well as (2) heel valgus angle on coronal cuts, both as described initially by Wilde et al.23 This CT analysis was done by a pediatric orthopaedic surgeon (S.T.M.) who was not aware of the clinical results during the radiographic assessment. Statistical significance was set to P < 0.05 (2-tailed). Continuous data were age (y), UCLA activity score (linearity assumed), modified AOFAS score (linearity assumed), and time since surgery (y). Data were compared between groups using the Student t test or the Wilcoxon rank-sum test, as appropriate. Dichotomous data included sex, type of coalition (CN or TC), unilateral versus bilateral, and activity limited by foot pain (yes or no). Dichotomous data were then compared using the Fisher exact test. SAS software (SAS Institute Inc., Cary, NC) and Excel software (Microsoft, Redmond, WA) were utilized for all analyses.
RESULTS Sixty-three patients (22 females, 41 males) were analyzed. Thirty-seven patients had bilateral coalitions present, and of these 24 patients had bilateral surgery. Five different surgeons were involved. TC coalitions were present in 20 patients (32%) and 5 had bilateral excision; CN coalitions were present in 42 patients (68%) (Table 1). No postoperative infections were identified among these patients. Five patients had follow-up surgery after their initial coalition excision (other than for contralateral coalition excision): 3 patients required reoperation due to coalition recurrence (all were CN coalitions), 1 patient had accessory navicular excision, and 1 patient had excision of a talar bone spur. No patient in this group had subsequent hindfoot surgery for pes planovalgus correction. Analysis of all patients who returned questionnaires yielded a mean modified AOFAS score of 88.3 (SD 12.7; range, 39 to 100) and mean UCLA activity score of 8.3 (SD 2.2; range, 3 to 10) at an average of 4.62 years after surgery (SD 1.97; range, 1.8 to 10.6). Patients who had TC coalitions had similar modified AOFAS scores (88.4) and UCLA activity scores (8.4) when compared with those patients with CN coalitions who had a mean modified AOFAS score of 88.0 and mean UCLA activity score of 8.3 (Table 1). Neither score was significantly different between the TC and CN groups. Subgroup analysis was performed, comparing those patients who had activity limitations due to foot pain with those patients who had no activity limitations. For the 73% (46/63) of patients who reported that their activity levels were not limited by foot pain, mean modified AOFAS score Copyright
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TABLE 1. Comparison of Patient and Outcome Characteristics for Talocalcaneal and Calcaneonavicular Coalitions (N = 63) Frequency (%)
Patient characteristics Sex (male) Age at surgery (mean) (y) Bilateral surgery Length of follow-up (mean) (y) Outcomes Modified AOFAS score (mean ± SD) UCLA activity score (mean ± SD) Activity not limited by foot pain
Calcaneonavicular (n = 43)
Talocalcaneal (n = 20)
30 (70) 13.3 19 (44) 4.85
11 (55) 12.8 5 (25) 4.15
88.0 ± 2.13
88.4 ± 2.44
8.3 ± 0.32
8.4 ± 0.50
32 (74)
14 (70)
Characteristics were compared across groups using either Fisher exact test or Student t test at the 5% significance level. All P-values were not significant. AOFAS indicates American Orthopaedic Foot and Ankle Society; UCLA, University of California at Los Angeles.
was 93.9 and mean UCLA activity score was 8.9 (Table 2). Thirty-two patients had CN coalitions, whereas 14 patients had TC coalitions. Of the 27% (17/63) patients who reported that their activity levels were limited by foot pain, the mean modified AOFAS score was 72.9 and the mean UCLA activity score was 6.9. These 17 patients consisted of 11 with CN coalitions and 6 with TC coalitions. There was a statistically significant difference in these groups both in mean modified AOFAS score (P < 0.0001) and mean UCLA activity score (P = 0.006). CT imaging was available in 63.5% (40/63) of the patients, 24 with CN and 16 with TC coalitions. Mean UCLA score for this subgroup of patients was 8.2 (SD 2.1), mean modified AOFAS score was 88.4 (SD 11.8), and 65% (26/40) did not have foot pain limiting their activity. Of these patients, 28/40 had bilateral coalitions (18 CN and 10 TC, none were mixed); however, only 18 of those had bilateral surgery (13 CN and 5 TC). Of those patients who had surgical excision of their coalition, the average heel valgus was 9.7 degrees (SD 7.1 degrees; range, 0 to 27 degrees). There was no difference in average valgus in patients with CN coalitions (mean 9.6 degrees)
Patient-reported Outcomes of Tarsal Coalitions
compared with TC coalitions (mean 9.8 degrees). Using r16 degrees valgus as a cutoff,15 82.5% (33/40) patients had a maximum heel valgus (greatest of the 2 feet) r16 degrees, whereas 17.5% (7/40) had at least 17 degrees of heel valgus in 1 foot (Table 3). There was no difference in the mean modified AOFAS score, UCLA activity score, and no activity limiting foot pain when comparing those patients with 50%: 86.9, 7.5, and 50%). Bilateral coalitions were found in 59% (37/63) of the patients. In all cases the same type of coalition (CN or TC) was found in both feet (Table 4). However, of those patients with bilateral coalitions, surgery was only performed bilaterally in 59% (22/37). Patients who had surgery on both feet had a mean modified AOFAS score of 90.8, mean UCLA activity score of 8.5, and 81% (18/ 22) did not have foot pain that limited their activity; patients with surgery on only 1 foot had a mean AOFAS score of 84.1, mean UCLA activity score of 7.7, and 47% (7/15) did not have foot pain that limited their activity. Only foot pain limiting activity was statistically significant (P = 0.025 by Fisher exact test).
DISCUSSION Surgery for symptomatic tarsal coalitions has been widely reported in the literature with outcomes focused on a clinical-based assessment of foot alignment, function, and return to activity, as well as need for further surgery.10–13,20,23,24 However, patient-reported outcomes following tarsal coalition excision have been increasingly recognized for their importance13–15 in appreciating functional outcome of these patients after surgery. Our investigation sought to assess outcomes that are important to patients so we can better inform them about surgical expectations and outcomes in the preoperative
TABLE 2. Outcome Scores and Coalition Type Compared by Response to the Question: “Are Your Activities Limited by Your Foot Pain?” (N = 63) “Is Your Activity Limited By Foot Pain?” Modified AOFAS score (mean ± SD) UCLA activity score (mean ± SD) Coalition type [n (%)] Calcaneonavicular Talocalcaneal
No (n = 46)
Yes (n = 17)
P
93.9 ± 1.05 8.9 ± 0.24
72.9 ± 3.14 6.9 ± 0.66
< 0.001 0.006
32 (70) 14 (30)
11 (65) 6 (35)
NS
Outcomes were compared across groups using either Fisher exact test or Student t test at the 5% significance level. AOFAS indicates American Orthopaedic Foot and Ankle Society; NS, not significant; UCLA, University of California at Los Angeles.
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TABLE 3. Comparison of CT Data as Available for 63.5% of the Patients (40/63) With Surgically Treated Coalitions Heel Valgus Modified AOFAS score (mean ± SD) UCLA score (mean ± SD) Activity not limited by foot pain [frequency (%)] Involvement of medial facet (compared with posterior facet) Modified AOFAS score (mean ± SD) UCLA score (mean ± SD) Activity not limited by foot pain [frequency (%)]
r16 Degrees (n = 33)
>16 Degrees (n = 7)
88.3 ± 2.00
88.7 ± 5.57
8.3 ± 0.38 21 (73)
7.7 ± 0.78 5 (71)
r50% involvement (n = 8) 88.8 ± 4.34
> 50% involvement (n = 8) 86.9 ± 4.36
8.9 ± 0.64 6 (75)
7.5 ± 1.00 4 (50)
Outcomes were compared across groups using either Fisher exact test or Student t test at the 5% significance level. All P-values were not significant. When bilateral coalitions were treated surgically, the worst (greatest valgus or greatest % involvement of the medial facet) foot was chosen for comparison of outcomes. AOFAS indicates American Orthopaedic Foot and Ankle Society; CT, computerized tomography; UCLA, University of California at Los Angeles.
visits. In particular, our patients wanted to know the likelihood of improvement in their pain after surgery and whether unrestricted sports participation would be possible. This study aimed to assess outcomes by a patientbased questionnaire that utilized the modified AOFAS pain and function sections as well as the UCLA activity scale. We also asked a simple additional question: is your activity limited by your foot pain? We felt that this combination of questions would best assess: (1) how are these feet functioning postoperatively, (2) what level of activity are our patient participating in postoperatively, and (3) what is their motivation for their activity level (personal choice or foot pain)? Interestingly, our study found that 73% of patients reported no activity limitation following surgery. This correlated with high AOFAS and UCLA scores. Type of coalition (CN or TC) did not impact postoperative outcomes. Unfortunately, 27% of our patients found that even after surgery, their activity was limited by foot pain, and this correlated with lower AOFAS and UCLA scores. Interestingly, of the 17 patients who had ongoing foot pain limiting their activity, 47% (8/17) had known bilateral coalitions but only had surgery on 1 side. Unfortunately, we did not ask which foot was causing the pain.
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Many authors have advocated that patients with a TC coalition and >50% involvement of the joint and/or >16 degrees of heel valgus were recommended for fusion or osteotomy over simple excision.12,16–18 Mosca and Bevan16 advocate that any patient with hindfoot valgus of >16 degrees or large subtalar coalition should undergo a calcaneal lengthening osteotomy, and the average AOFAS score in their small series of 8 patients was 91.2. Other series are noting the success of simple excision of coalition in both CN and subtalar coalitions, and our findings are in line with other studies. Raikin et al20 reported on 10 patients (14 feet) using the AOFAS at least 2 years after surgery for subtalar coalitions with split flexor halluces longus tendon interposition. They had 11 feet with excellent results (score 90 to 100).20 Gantsoudes et al14 reported on a series of 32 patients with TC coalitions excisions with patient-based outcomes with at least 12-month follow-up and utilizing the AOFAS anklehindfoot score. They found that 85% of their patients had a good to excellent result (80 to 100 score on the AOFAS), which was very similar to our results. Twenty-two percent of their patients underwent subsequent procedures, mostly pes planovalgus deformity corrections and also revision coalition excisions. Although we are not averse to pes planovalgus correction osteotomies (eg, Evans16 or calcaneal-cuboid-cuneiform osteotomy14), no patient in our series underwent such a procedure. Khoshbin et al15 also reported on patient-based outcomes after tarsal coalition excision, including both TC and CN coalitions. They had a smaller series (24 patients) with longer follow-up (25 y) using the American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle Module and the Foot Function Index (FFI).15 They also found no difference in outcomes between the CN and TC coalitions and found that most patients were doing quite well but that some patients had ongoing issues with their feet. Only 2 of their patients underwent subsequent correction for pes planovalgus deformity (1 each of CN and TC types). In the literature discussing treatment for tarsal coalition, there is some debate about when pes planovalgus reconstruction should be utilized16,25 and how predictive the finding of increased valgus on preoperative CT is of subsequent outcomes.12 In the Khoshbin et al15 report of the Toronto experience, they did not find increased hindfoot valgus predictive of outcome, and did very few subsequent deformity-correcting osteotomies. Gantsoudes et al14 from San Diego report a higher rate of
TABLE 4. Comparison of Patients With Known Bilateral Coalitions Where Either 1 or Both Coalitions Underwent Surgical Excision (N = 37) Modified AOFAS score (mean ± SD) UCLA activity score (mean ± SD) Activity not limited by foot pain [frequency (%)]
Unilateral Excisions (n = 15)
Bilateral Excisions (n = 22)
P
84.1 ± 3.18 7.7 ± 0.69 7 (47)
90.8 ± 2.32 8.5 ± 0.36 18 (81)
NS NS 0.025
Outcomes were compared across groups using either Fisher exact test or Student t test at the 5% significance level. AOFAS indicates American Orthopaedic Foot and Ankle Society; NS, not significant; UCLA, University of California at Los Angeles.
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correction of hindfoot deformities after coalition excision. Mosca and Bevan16 advocate that any patient with hindfoot valgus over 16 degrees undergoes calcaneal lengthening osteotomy. We report no subsequent osteotomies in our series, with similar clinical outcomes to the San Diego, Toronto, and Seattle groups. Similarly, previous literature has suggested that TC coalitions where the coalition involves >50% of area of the posterior facet may have compromised outcomes and should be considered for fusion over coalition excision.12,18,23 We found that half of our patients with TC coalitions and CT scans had a coalition with >50% involvement of the area of the posterior facet; yet the outcomes were no different in this group than in the group with less involvement. This is in line with more recent studies14,15 suggesting that extent of coalition does not influence outcome after excision. Previously, other studies have reported TC excisions as having less satisfactory results23,26 when compared with CN coalitions. We found no significant difference between the TC and CN groups, which is similar to more recent reports.15 It is interesting to note that in the recently reported series of patient-based outcomes after surgical excision of tarsal coalition (including ours), most of the patients are doing quite well but a few still have ongoing pain in their feet.14–16,20 Our data dichotomizes these 2 groups by determining which patients have limitation of their activities due to foot pain. We found that 73% had no limitation of their activities due to foot pain and therefore had the expected high UCLA activity and AOFAS scores. Ultimately, further investigation needs to be done for the 27% of patients with ongoing foot pain that limits their activities, and we now have an ongoing prospective study evaluating this further. Finally, we found that in the patients with known bilateral coalitions, only about 60% had surgery on both feet. Just because a coalition is present does not mean that it causes symptoms, and many coalitions are asymptomatic.1 However, the group that had surgery on both feet in general is doing better than the group with unilateral surgery. It is not clear whether the foot that is causing activity-limiting pain is the postoperative foot or the foot with the persistent coalition (as we did not ask which side hurt in the questionnaire). Either the patients who had unilateral surgery are not happy with their surgical result and have chosen not to pursue the other side (ie, their postoperative foot still hurts) or they have chosen not to pursue surgery on their symptomatic contralateral coalition (ie, the foot with the persistent coalition is hurting). We anticipate looking into this further in a subsequent ongoing prospective study. One limitation of this study is its retrospective nature and limited uniformity of imaging. Unfortunately only 63.5% (40/63) of our patients had CT scans that could be evaluated, but we feel that this was a representative sample of our group of patients. However, this study showed our questionnaire to be useful and functional to assess patient outcomes in tarsal coalitions, and a follow-up prospective study is now underway. Another Copyright
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Patient-reported Outcomes of Tarsal Coalitions
limitation of our study is the number of nonresponders on initial mailing of our survey. Initially, 40 of 101 patients responded to our query. Nonresponders were mailed repeat questionnaires and reminded by phone, and 23 additional patients subsequently responded for a total response rate of 63.4%; however, an online survey or survey at the time of a clinic visit might increase response rates further. Nonresponder analysis of clinical charts found similar postoperative courses to responders; there did not seem to be increased rates of complications or prolonged postoperative pain and dysfunction in nonresponders; however, a formal analysis was not done. We hypothesize that our responder group is representative of our entire patient population, although we recognize that nonresponder bias is a possibility. In an era of increasing scrutiny of outcomes and quality improvement initiatives, the importance of measuring appropriate outcomes is clear. Although physicianbased outcomes such as foot alignment are important in tarsal coalition surgery, patient-reported outcomes of pain, daily function, and return to high-level sports are of paramount importance in assessing whether tarsal coalition surgery can reliably offer a high-quality result. In our study, 73% of patients reported unlimited activity. There was no difference in reported outcomes between the CN and TC groups. In conclusion, tarsal coalition surgery offered high rates of return to full activity based on patient reports.
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15. Khoshbin A, Law PW, Caspi L, et al. Long-term functional outcomes of resected tarsal coalitions. Foot Ankle Int. 2013;34: 1370–1375. 16. Mosca VS, Bevan WP. Talocalcaneal tarsal coalitions and the calcaneal lengthening osteotomy: the role of deformity correction. J Bone Joint Surg Am. 2012;94:1584–1594. 17. Scranton PE. Treatment of symptomatic talocalcaneal coalition. J Bone Joint Surg Am. 1987;69:533–539. 18. Comfort TK, Johnson LO. Resection for symptomatic talocalcaneal coalition. J Pediatr Orthop. 1998;18:283–288. 19. Thometz J. Tarsal coalition. Foot Ankle Clin. 2000;5:103–118. vi. 20. Raikin S, Cooperman DR, Thompson GH. Interposition of the split flexor hallucis longus tendon after resection of a coalition of the middle facet of the talocalcaneal joint. J Bone Joint Surg Am. 1999;81:11–19.
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21. Kitaoka HB, Alexander IJ, Adelaar RS, et al. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int. 1994;15:349–353. 22. Amstutz HC, Thomas BJ, Jinnah R, et al. Treatment of primary osteoarthritis of the hip. A comparison of total joint and surface replacement arthroplasty. J Bone Joint Surg Am. 1984;66:228–241. 23. Wilde PH, Torode IP, Dickens DR, et al. Resection for symptomatic talocalcaneal coalition. J Bone Joint Surg Br. 1994;76:797–801. 24. McCormack TJ, Olney B, Asher M. Talocalcaneal coalition resection: a 10-year follow-up. J Pediatr Orthop. 1997;17:13–15. 25. Rathjen KE, Mubarak SJ. Calcaneal-cuboid-cuneiform osteotomy for the correction of valgus foot deformities in children. J Pediatr Orthop. 1998;18:775–782. 26. Kitaoka HB, Wikenheiser MA, Shaughnessy WJ, et al. Gait abnormalities following resection of talocalcaneal coalition. J Bone Joint Surg Am. 1997;79:369–374.
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