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Interposition of the Split Flexor Hallucis Longus Tendon After Resection of a Coalition of the Middle Facet of the Talocalcaneal Joint*

STEVEN RAIKIN, M.D., DANIEL R. COOPERMAN, M.D. and GEORGE H. THOMPSON, M.D., CLEVELAND, OHIO

Investigation performed at the Division of Pediatric Orthopaedics, Department of Orthopaedics, Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland

	Abstract

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Ten consecutive patients (fourteen feet) who had a painful coalition of the middle facet of the talocalcaneal joint with restricted motion of that joint were managed with a resection of the coalition and interposition of a split flexor hallucis longus tendon in 1992, 1993, or 1994. Initial nonoperative treatment of all of the feet had failed. According to the ankle-hindfoot clinical rating system of the American Orthopaedic Foot and Ankle Society, there were eleven excellent results and one good, one fair, and one poor result at a mean of fifty-one months (range, thirty-two to sixty months) after the procedure. Thirteen of the fourteen procedures resulted in considerable relief of pain, an improved range of motion of the talocalcaneal joint, and improved function of the foot. No patient had symptoms or functional impairment of the great toe secondary to the interposition of the split flexor hallucis longus tendon. On the basis of these early results, tendon interposition appears to be an excellent procedure for the treatment of a symptomatic coalition of the middle facet of the talocalcaneal joint after initial nonoperative treatment has failed. The presence of degenerative osteoarthritis in the other facets of the talocalcaneal joint is a contraindication to this procedure. The long-term results have yet to be determined. However, the standardized rating system used in the present study will allow accurate comparison of our results with those of subsequent studies.

	Introduction

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There is general agreement that the initial treatment of a symptomatic coalition of the middle facet of the talocalcaneal joint should be nonoperative^{7,8,17,18,21,22,24,26,37,41,45}. Operative management is usually recommended only after nonoperative management has failed. Unfortunately, fewer than 50 percent of involved feet (approximately one-third in one series²² [no numbers reported], five of twenty-three in another series⁴⁵, and thirty-one of sixty-seven in another⁵²) have had lasting relief of symptoms after nonoperative treatment. Thus, most patients who have symptoms ultimately need operative management.

Operative treatment of this condition previously involved a subtalar or triple arthrodesis^{7,8,16-18,21,32,37,41,48,50}. These procedures are now usually restricted to feet that have an extensive coalition, a valgus deformity of the hindfoot, or radiographic evidence of degenerative osteoarthritis^11,45,50,52. Resection of a symptomatic coalition of the middle facet of the talocalcaneal joint has been shown to relieve pain, to increase the range of motion of the talocalcaneal joint, and to improve function^{9,11,13,15,22,24,26,30,36,44,45,50,56}. Resection is usually associated with the use of bone wax or an autologous free fat graft (or both) or other material. These substances have been used in an attempt to prevent reformation of the coalition, but no conclusive data on their effectiveness are available. Scranton⁴⁵ and Salomão et al.⁴⁴ reported the use of local fat obtained from behind the calcaneus through the same incision, but in most patients a separate incision in the gluteal region is made to obtain enough fat to fill the gap that is created by the resection. However, Takakura et al. noted that the coalition did not reform in thirty-three feet that had been treated with excision without the use of an interposition material⁵². Kitaoka et al. reported similar findings, in nine feet²⁴. De Vriese et al. used a sinus tarsi spacer after resection in six feet¹¹. However, the results were generally unsatisfactory and three spacers had to be removed at a mean of eight months postoperatively.

In 1992, Kumar et al. introduced a technique involving interposition of a split flexor hallucis longus tendon²⁶. In a study of nine feet, they reported five excellent results, three good results, and one fair result according to their own clinical rating system. Thus, a satisfactory (excellent or good) result was achieved in eight of the nine feet. To the best of our knowledge, no other reports on the efficacy of this procedure have been published. Kitaoka et al. used this procedure on two feet, but the results were combined with those for three feet that had been treated with a fat graft²⁴. Concerns regarding this procedure have included the possible rupture of the flexor hallucis longus tendon, the potential loss of active motion of the interphalangeal joint of the great toe, and the loss of muscle strength postoperatively. The purpose of this study was to review our clinical results with this procedure and to assess the function of the great toe at a minimum of two years postoperatively.

	Materials and Methods

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Ten adolescents (fourteen feet) had a resection of a symptomatic coalition of the middle facet of the talocalcaneal joint and interposition of a split flexor hallucis longus tendon; the procedures were performed in 1992, 1993, and 1994. There were seven boys and three girls, and their mean age was twelve years (range, nine to sixteen years) at the time of the onset of symptoms. Eight left feet and six right feet were involved. Six of the patients had a bilateral coalition of the middle facet: two had the onset of pain in both feet simultaneously, two had an interval of approximately two years between the onset of symptoms in the two feet, and two had unilateral symptoms only (the asymptomatic feet were not treated). Three of the four patients who had a symptomatic coalition bilaterally had both feet operated on simultaneously. The remaining patient (Case 4), a twelve-year-old girl who had an increase in the symptoms in the right foot after resection of the coalition in the left foot, had staged procedures, four months apart. Nonoperative treatment of the right foot (including a six-week period of immobilization) had failed.

All of the index operations were performed after nonoperative treatment had failed. The mean duration of the nonoperative treatment was fifteen months (range, six weeks to seventy-five months). The patient (Case 5) who was managed nonoperatively for more than six years was first seen at the age of nine years, at which time she had moderate exercise-induced pain and a radiographically evident coalition of the middle facet of the talocalcaneal joint in both feet. Although she had increasingly severe pain despite immobilization in below-the-knee casts and treatment with various orthoses on multiple occasions, her orthopaedist did not want to perform a triple arthrodesis because of her young age. At fifteen years of age, the patient was referred to our institution and resection of the coalition and interposition of the tendon was performed.

Six of the fourteen feet were treated with at least one period of immobilization in a below-the-knee weight-bearing cast. None of these feet caused any pain while they were immobilized, but the symptoms rapidly recurred after removal of the cast. The remaining eight feet were treated with various orthoses. Only feet for which nonoperative treatment had failed were considered for operative intervention. Nonoperative management was not successful in any of the patients who were seen during the time-period of the study. Also, no patient was managed for an asymptomatic coalition of the middle facet. Thus, nonoperative treatment did not achieve lasting success in any symptomatic foot.

When the patients were first seen, they had progressive pain in the hindfoot (eleven feet) or recurrent ankle sprains (three feet). Four of the fourteen feet had a long-standing pes planus deformity. In all of the patients, the pain was aggravated by vigorous activity. All ten adolescents had been active in sports, and nine of them had discontinued their sporting activities because of the pain in the foot. The range of motion of the talocalcaneal joint was assessed with the technique described by Buckley and Hunt². Inversion and eversion were measured with the foot in the simulated weight-bearing position and the knee extended. All fourteen feet had limited motion of the talocalcaneal joint. Eight feet had a rigid valgus deformity of the hind part, and the remaining six had 10 degrees of joint motion or less.

In thirteen of the fourteen feet, the coalition was suspected on the basis of anteroposterior, lateral, or Harris-Beath¹⁶ axial weight-bearing radiographs. A beak on the anterior aspect of the talus was seen on the lateral radiographs of twelve feet. An angle of greater than 20 degrees between the middle and posterior facets (which are usually parallel) indicates a high probability of a coalition, even if the facets appear to be normal⁷. The C-sign, which was described by Lateur et al. and is seen on the lateral radiograph, is also indicative of a coalition of the middle facet²⁷. It is represented by a continuous line that is formed by the medial aspect of the talar dome and the inferior border of the sustentacalum tali. These two radiographic findings were seen in thirteen feet. The only foot for which the plain radiographs were not suggestive of a coalition was that of a twelve-year-old boy (Case 6) who had a severe pes planus deformity, which made it difficult to visualize the talocalcaneal joint.

Thirteen feet were studied with computed tomography to provide a more detailed view of the cross-sectional anatomy of the talocalcaneal joint and to determine the extent and nature (fibrous, cartilaginous, or osseous) of the coalition. Computed tomography is important for preoperative assessment of the size of the coalition and for the detection of other coalitions, including those of the anterior or posterior facet. The fourteenth foot had been evaluated with magnetic resonance imaging, which had been ordered by the patient's primary-care physician. The coalition was evident, and computed tomography was not believed to be necessary. Magnetic resonance imaging was also performed on a foot for which the diagnosis had been equivocal on the basis of the computed tomography scan. A fibrous coalition was clearly evident on the magnetic resonance image. In total, five feet had a fibrous coalition, and nine had an osseous coalition.

The patients were followed for a mean of fifty-one months (range, thirty-two to sixty months) postoperatively. At the most recent follow-up evaluation, a clinical assessment of pain, function, range of motion, and alignment was performed. This information allowed a detailed assessment of pain, calculation of the ankle-hindfoot clinical rating according to the system of the American Orthopaedic Foot and Ankle Society (developed by Kitaoka et al.²³ in 1994), and evaluation of the function of the great toe. These data were compared with the preoperative data as retrospectively determined from the medical records and the patient's recall of symptoms and function before the operation. Standard weight-bearing radiographs of the involved feet were made at the most recent follow-up evaluation to check for degenerative changes.

Because pain is a major problem associated with tarsal coalition, each patient completed a separate questionnaire regarding preoperative and current levels of pain. The patients were asked to rate pain according to a 10-point scale, with 1 point representing no pain or limitation of activities and 10 points representing constant pain at rest (Table I). This questionnaire was useful because the pain category of the ankle-hindfoot clinical rating system is not specific.

Operative Technique and Postoperative Management
The procedure was performed as described by Kumar et al.²⁶. The coalition of the middle facet of the talocalcaneal joint is identified through a slightly oblique incision on the medial side of the foot. Care is taken to preserve the periosteum and soft tissue around the sustentaculum tali. The coalition is resected with a rongeur until normal articular cartilage is seen. More bone is removed from the talus than from the sustentaculum tali. There should be a relatively full range of motion of the talocalcaneal joint after resection. After satisfactory resection, bone wax is applied to the raw bone surfaces to prevent bleeding. The superior one-half of the longitudinally split flexor hallucis longus tendon is then interposed from beneath the sustentaculum tali into the area of the resection in the middle facet. After interposition, the interphalangeal joint of the great toe must have full passive flexion and extension to ensure that the longitudinal split is long enough and will not later impair active motion. The soft tissue between the talus and the sustentaculum tali is sutured to hold the transferred tendon in place.

Postoperatively, the patient is non-weight-bearing for six weeks. Approximately ten days after the operation, a molded ankle-foot orthosis that allows dorsiflexion and plantar flexion of the ankle is applied. Range-of-motion exercises of the ankle are performed three or four times per day. At six weeks, progressive weight-bearing is allowed. The orthosis is used during weight-bearing for approximately four to six months.

	Results

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Nine adolescents (twelve involved feet) were personally examined by us both clinically and radiographically for this study. The remaining patient (Case 4), who no longer lived locally and had been evaluated clinically and radiographically one year earlier, was interviewed by telephone; she reported no new symptoms and no change in the function of the feet.

Clinical Results
There was considerable relief of pain at the time of the most recent follow-up (Table III). Preoperatively, the mean pain score was 8.1 points (range, 6 to 10 points). Postoperatively, the mean pain score was 1.6 points (range, 0 to 7 points), a decrease of 6.5 points.

The mean combined arc of motion of the talocalcaneal joint was 3 degrees (range, 0 to 10 degrees) preoperatively compared with 20 degrees (range, 5 to 30 degrees) at the latest follow-up evaluation, indicating a notable improvement. Although clinical assessment of the range of motion of the talocalcaneal joint is difficult, there seemed to be an association between the amount of motion and the clinical outcome in our study.

Preoperatively, nine of the ten patients had discontinued sporting activities as a result of pain in the foot and the remaining patient had decreased the level of participation. At the latest follow-up evaluation, all ten patients reported that they were actively involved in sporting activities as diverse as hiking, soccer, and basketball. Only one patient (Case 4) reported any difficulty with walking on uneven surfaces.

No patient had noticed any loss of motion of the great toe, and no weakness in toe-off was detected manually or during observation of the patient's gait. The mean active and passive ranges of motion of the interphalangeal joint of the uninvolved great toe were 50 degrees (range, 45 to 60 degrees). The range of motion of the interphalangeal joint of the involved great toe was within 5 degrees of that on the uninvolved side in eleven of fourteen feet. Three great toes had limited motion: one patient (Case 5) had 15 degrees of active motion and 45 degrees of passive motion, and another (Case 7) had only 5 to 10 degrees of active motion bilaterally but 45 degrees of passive motion. The three feet that had a limited range of motion of the interphalangeal joint of the great toe were asymptomatic, and the patients had been unaware of the limited motion until it was demonstrated to them on physical examination. No weakness of toe-off could be detected clinically during observation of gait. Manual muscle-testing of the flexor hallucis longus revealed normal findings in all patients (including Case 7).

Radiographic Results
Anteroposterior, lateral, and Harris-Beath¹⁶ axial weight-bearing radiographs of the feet of each patient were made at the most recent follow-up evaluation. There was no evidence of reformation of the coalitions, and there were no degenerative changes in the talocalcaneal or adjacent joints. Computed tomography or other studies were not routinely performed.

Discussion of Individual Results
The patient who had a fair result (Case 10) was a boy who had been operated on at the age of seventeen years, after eight months of nonoperative management. He had had severe pain in the left foot that had prevented him from engaging in any sporting activities before the operation. The initial radiographic evaluation confirmed an osseous coalition of the middle facet of the talocalcaneal joint with mild degenerative changes of the posterior facet. Two years after the operation, the patient had no pain and had full function of the foot. Over the next three years, some pain recurred in the foot, for which he took anti-inflammatory medication two or three times a week. Clinically, the talocalcaneal joint had a painless 15-degree arc of motion. The patient was able to ride a bicycle for thirty-three kilometers four times a week, but this produced moderate discomfort in the foot. He considered the result to be good.

The patient who had a poor result (Case 3; Figs. 1-A, 1-B, 1-C, 1-D through 1-E) was operated on at the age of sixteen years, after two years of nonoperative management. He had had severe pain in the left foot that had substantially limited activities of daily living. Computed tomography showed an ossified coalition of the middle facet bilaterally (the contralateral foot was minimally symptomatic) with evidence of mild degenerative changes in the left ankle and talocalcaneal joints that were thought to be secondary to recurrent sprains of the ankle. Resection of the coalition and interposition of the flexor hallucis longus tendon was performed on the left foot, but it provided only moderate relief of pain. Computed tomography scans that were made one year postoperatively revealed additional degenerative changes in the posterior facet, and a subtalar arthrodesis was performed. The operative site healed uneventfully. Twenty-nine months postoperatively, the patient played basketball even though he had occasional pain in the ankle, for which he took anti-inflammatory medication. At the most recent follow-up evaluation, the left foot was less symptomatic than the right foot, which had not been treated operatively. The patient considered the result of the operation to be fair.

View larger version (63K): [in this window] [in a new window]   FIG1-A: Figs. 1-A through 1-E: Case 3. Radiographs of a sixteen-year-old boy who had a tarsal coalition of the left foot. Fig. 1-A: Anteroposterior weight-bearing radiograph of the symptomatic left foot. The first metatarsal is short, but there are no other abnormalities.

View larger version (59K): [in this window] [in a new window]   FIG1-B: Fig. 1-B: Oblique radiograph showing no evidence of a calcaneonavicular coalition.

View larger version (105K): [in this window] [in a new window]   FIG1-C: Fig. 1-C Lateral weight-bearing radiograph demonstrating the C-sign (arrows) as described by Lateur et al.27. This sign is indicative of a coalition of the middle facet of the talocalcaneal joint.

View larger version (97K): [in this window] [in a new window]   FIG1-D: Fig. 1-D: Computed tomography scan demonstrating a coalition of the middle facet of the talocalcaneal joint (white arrow) with mild narrowing of the joint space and sclerosis of the posterior facet (black arrow). Initially, the findings in the posterior facet were not believed to be clinically important. At the time of the operation, the coalition was primarily osseous.

View larger version (97K): [in this window] [in a new window]   FIG1-E: Fig. 1-E: Computed tomography scan, made one year postoperatively because of persistent symptoms, showing adequate resection of the coalition (white arrow) and no evidence of recurrence. Most of the resection was from the talus rather than from the sustentaculum tali. However, there is obvious degenerative osteoarthritis of the posterior facet (black arrow). This was believed to be the source of the symptoms at this time.

	Discussion

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Tarsal coalition occurs very infrequently but is one of the most common causes of a rigid pes planus deformity in children, adolescents, and adults^{5,8,12,16,17,21,22,25,37,48,53}. Talocalcaneal coalition is the most common tarsal coalition. Stormont and Peterson found that 314 tarsal coalitions had been reported in the literature over a period of fifty years⁴⁸. One hundred and fifty-one coalitions (48 percent) were talocalcaneal, and 137 (44 percent) were calcaneonavicular. The talocalcaneal coalitions most commonly involved the middle facet followed by the posterior facet. Coalitions of the middle facet can be osseous, cartilaginous, or fibrous^16,21,28. Approximately one-fourth to one-half of patients with coalition of the middle facet of the talocalcaneal joint have bilateral involvement^{6,21,24,26,44,45,48,50,52,56}. Technetium bone scans¹⁴ and lateral tomograms^4,6-8 can aid in the diagnosis, but coalitions are best evaluated with computed tomography scans^{10,16,20,28,31,33-35,42,46,47,49,52,54}. Magnetic resonance imaging can be helpful, especially in the evaluation of cartilaginous and fibrous coalitions^5,19,38,54. Leonard demonstrated that these coalitions are a unifactorial disorder of autosomal dominance with nearly full penetrance²⁹. Not all patients who have a talocalcaneal coalition of the middle facet have symptoms^16,21,22. However, when there is a valgus deformity of the hindfoot or a pes planus deformity, there is a greater effect on the biomechanics of the talocalcaneal joint. This results in abnormal stresses on the talonavicular, calcaneocuboid, and ankle joints^{3,22,31,37,40} and produces the talar beaking that is commonly associated with tarsal coalitions^1,43. Also, a large coalition may produce tarsal tunnel syndrome as a result of irritation of the medial plantar nerve^22,51,52.

Resection of a symptomatic coalition of the middle facet of the talocalcaneal joint after the failure of nonoperative treatment has been reported in a number of studies^{9,11,13,15,22,24,26,30,36,39,44,45,50,56}. Those studies have all demonstrated a high percentage of satisfactory postoperative results. Most authors have recommended interposition of a free fat graft to prevent reformation of the coalition. Others, however, have believed that no graft is necessary^24,52. The results of resection and interposition of a free fat graft do not appear to be quite as good as those of procedures in which the split flexor hallucis longus tendon is used as the interposition material. However, comparisons are difficult because a variety of classification systems were used in the previously reported series. Swiontkowski et al. assessed the clinical results for five patients (five involved feet) as improved or deteriorated⁵⁰. Four feet were reported as improved and one, as deteriorated. Scranton classified the results (nine patients [fourteen involved feet]) as good, satisfactory, or poor⁴⁵. He reported thirteen good results and one satisfactory result. Olney and Asher used a combination of pain and function to rate their results as excellent, good, fair, or poor³⁹. Of ten feet (nine patients), five had an excellent result; three, a good result; one, a fair result; and one, a poor result. Thus, eight feet had a satisfactory (excellent or good) result, and two had an unsatisfactory (fair or poor) result. Kumar et al. reported on six patients (six feet) who had had interposition of a free fat graft instead of a split flexor hallucis longus tendon²⁶. They found one excellent result, four good results, and one poor result. De Vriese et al.¹¹ used the scoring system of Mann and Baumgarten³² as well as clinical criteria to evaluate the preoperative and postoperative range of motion of the talocalcaneal joint. They evaluated four feet that had been treated with excision and interposition of a fat graft and found one excellent result, one fair result, and two poor results. Kitaoka et al.²⁴ used a hindfoot-ankle rating system similar to the one that he and others developed for the American Orthopaedic Foot and Ankle Society. They reported a satisfactory result for only one of five feet in which fat or a split flexor hallucis longus tendon had been used. They believed that the results of resection deteriorated with time. McCormack et al. reanalyzed the results for eight of nine patients (nine feet) who had been managed with resection and placement of a fat graft³⁰. At a mean of 11.2 years (range, ten to sixteen years), there was no deterioration of the results compared with the initial published results. They reported only one poor result. Other studies involving the use of fat grafts have been less specific, although the results have been uniformly satisfactory^9,13-15,44. Unfortunately, all of those studies (with the exception of that by McCormack et al.³⁰) had a relatively short follow-up period.

Interestingly, the results of resection without interposition of material have also been very satisfactory. In a study of thirty-three feet treated with excision without interposition of material, and using the same criteria as Olney and Asher³⁹, Takakura et al.⁵² reported an excellent result for twenty-four feet, a good result for seven, and a fair result for two. There were no poor results. Using their own rating system, Kitaoka et al. reported a satisfactory result in eight of nine patients²⁴.

In our study, twelve of fourteen feet that had been treated with interposition of a longitudinally split flexor hallucis longus tendon, as described by Kumar et al.²⁶, had a satisfactory (good or excellent) result according to a standardized, reproducible rating system. There were only two unsatisfactory (fair or poor) results. With the numbers available, we could detect no significant relationship between the result and the age or gender of the patient or the type of coalition (fibrous, cartilaginous, or osseous). The age distribution of the patients at the time of the operation was consistent with that of patients in other studies^{5,22,25,39,48}. Preoperative degenerative osteoarthritis of the posterior facet as seen on computed tomography scans appeared to be a risk factor for the only poor result in this study, and it has been identified as a risk factor by others^45,52,56. This was true even if the degenerative changes were mild. The presence of talar beaking was not associated with the results.

No patient had radiographic evidence of reformation of the coalition. However, computed tomography was not performed postoperatively.

Substantial loss of active motion of the interphalangeal joint of the great toe, loss of strength of the flexor hallucis longus muscle, and rupture of the flexor hallucis longus tendon immediately postoperatively were not seen in this study. Three feet in two patients had moderately impaired active flexion of the great toe. Neither patient was aware of this loss, and it did not pose any functional impairment. Both patients had an excellent clinical result and were active in sports.

We believe that excision of the coalition with interposition of the flexor hallucis longus tendon is an excellent procedure when nonoperative treatment fails. Although the rate of success of nonoperative treatment is low, we also believe that all patients should have an initial trial of nonoperative management before operative intervention is considered. If an operation is performed, we recommend the interposition of a split flexor hallucis longus tendon at the site of resection. However, as reported by Kitaoka et al., many patients have a residual loss of motion and spend less time in the stance phase of gait if the involved foot is the higher foot on a slope²⁴. This may contribute to the possibility of deteriorating results with longer follow-up periods. However, McCormack et al. did not find that the clinical results of resection with fat-grafting deteriorated or that degenerative osteoarthritis developed after a follow-up period of at least ten years³⁰.

Because our results were evaluated with use of standardized criteria, a more accurate comparison of the results of this and subsequent procedures will be possible in the future.

A longer follow-up period is required to determine whether degenerative osteoarthritis will develop in the weight-bearing middle facet over time. However, at three to five years postoperatively, the results of this study appeared to be stable and very encouraging.

	Footnotes

 
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

Mount Sinai Medical Center, One Mount Sinai Drive, Cleveland, Ohio 44106.

Division of Pediatric Orthopaedics, Department of Orthopaedics, Rainbow Babies and Children's Hospital, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, Ohio 44106.

	References

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