Congenital vertical talus BY DR.NAVEEN RATHOR

BY:DR.NAVEEN RATHOR

DEPT. OF ORTHOPAEDICSR.N.T. MEDICAL COLLEGE

CONGENITAL VERTICAL TALUS

CVT- Rare defomity

Term-1st used by:Henken in 1914.

Several Synonyms-

Congenital convex pes valgus(CCPV) Reverse club footcongenital valgus flatfootRocker bottom foot Talipes convex pes valgus

Anatomy-

Foot-bones:Tarsals-7 Metatarsals-5 Phalanges-14Foot-hind foot mid foot fore footJoints-Ankle joint:15’DF,55’PF -subtalar joint:inv 30’,ev-10’ -mid tarsal joint:Abd 10’;Add 15’

Talus-

Talus is so distorted planterwaed and medially as to be almost vertical.

“ dorsolateral dislocation of the talocalcaneonavicular joint.” resulting in a rigid flatfoot deformity.

Incidence 1 in 10,000

Male=female

B/L -50%

Tachdjian M: Pediatric Orthopedics, vol 4. 2nd ed. Philadelphia, WB Saunders, 1990. Jacob sen ST,Crawford AH(1983)Congenital vertical talus. J Pediatr Orthop 3:306–310

Etiology

The exact etiology of vertical talus in most cases is not known.

Theories include increased intrauterine pressure and resultant tendon contractures,

or an arrest in fetal develop- ment occurring between the 7th and 12th week of gestation

50% idiopathic. Approximately one-half of all cases of

vertical talus occur in association with neurologic abnormalities or genetic syndromes

A/W -Neurological abnormalities-arthrogryposis,myelomeningocoele,spinal muscular atrophy,neurofibromatosis,cerebral palsy

-Genetic syndrome:trisomy 13,15 and 18

A thorough neurological and genetic work up

AD inheritance 12-20%

Mutation in HOXD10

Mutation in GDF5Syndromes-1.De barsy syndrome 2.Prune Belly syndrome 3.Costello syndrome 4.Rasmussen syndrome

Ogata and schoenecker –Three group-1-Idiopathic2-A/W other abnormality but no neurological

defecit3.A/W neurological defecit

Clinical Orthopaedics (1979 )139:128–132

Coleman classification

Coleman divided CVT into 2 types: type 1 was associated with a calcaneocuboid

dislocation, and type 2 was not. This distinction is important clinically

because the type 1 deformity is stiffer and particular attention must be paid to releasing the calcaneocuboid joint

Irreducible dorsal & lateral dislocation of navicular over talus

Posteriorly, Contracture of tendoachillis creates equinus of calcaneus

Anteriorly,contracture of EDL(EHL,TIB ANT)

Laterally PL,PB ,calcaneofibular ligament contracted

Posterior tendons subluxation over malleolus

Pathoanatomy:

Patho-anatomy:“Kinematic coupling”

Skeletal : Talus-head and neck flattened

and medially deviated - plantar flexed position Calcaneum-plantar flexed and

externally rotated Navicular- Displaced dorsally

and laterally;hypoplastic

Cuboid- in severe deformity displaced laterally

Clinical presentation-

Forefoot-abduction ;dorsiflexion

Hindfoot-equinus and valgus

Plantar surface is convex-Rocker bottom appearance

Deep creases on anterolateral aspect of foot

Foot is everted into valgus and externally rotated position

Head of talus plantar medial aspect of midfoot

Calcaneus is in equinus

The forefoot is dorsiflexed at the midtarsal joints creating a palpable gap dorsally between the navicular and where the talar neck should normally be located. This gap can be helpful in distinguishing congenital vertical talus from the more common calcaneovalgus foot

Radiological evaluation.

The lack of ossification of many of the bones in the foot at birth can make the diagnosis of congenital vertical talus challenging on plain radiographs

The talus, tibia, calcaneus, and metatarsals are ossified at birth.

The cuboid ossifies in the first month of life while the cuneiforms and navicular usually ossify around the ages of 2 and 3 years, respectively.

Since most children with vertical talus are seen in the newborn period, the radio- graphic evaluation is focused on the relationships of the ossified talus and calcaneus to the tibia as well as the relationship of the metatarsals to the hindfoot.

Forced plantar flexion and forced dorsiflexion lateral radiographs are necessary to confirm the diagnosis of vertical talus and rule out the oblique talus and calcaneovalgus foot as diagnoses. PLANTARFLEXED FILM:The forced plantar flexion lateral radiograph in a vertical talus foot shows persistent malalignment of the long axis of the talus and the first metatarsal.it show persistent dorsal translation of the forefoot on the hindfoot. DORSIFLEXED FILM: the forced dorsiflexion lateral radiograph demonstrates a persistently decreased tibiocalcaneal angle indicating fixed hindfoot equinus .OBLIQUE TALUS:In contrast, a forced plantar flexion lateral radiograph of an oblique talus will demonstrate restoration of a normal relationship between the long axis of the talus and the first metatarsal

Measurements that can be obtained on the lateral radiograph include

Increase talocalcaneal,(normal-20-40 degree)decreased tibiocalcaneal,(normal 60-90

degree) talar axis- first metatarsal base

angle(normally<30)

Talocalcaneal angle is increased

Middle and anterior subtalar facet-hypoplastic

Hamanishi described 2 radiographic angles: the talar axis–first metatarsal base angle

(TAMBA) and the calcaneal axis–first metatarsal base

angle (CAMBA).

Role of USG

 radiographs of an infant's foot particularly less than 6 months can be difficult to interpret. The use of dynamic ultrasound has been reported to be helpful in the evaluation of infants with vertical or oblique talus.

Differentials-

Calcaneovalgus foot deformity: -foot is dorsiflexed -no equinus contracture of

calcaneus -flexible foot -forced plantar flexion lateral x-ray-

normalPosteromedial bow of the

tibia:calcaneovalgus foot,a shortened and bowed tibia

Oblique talus

Oblique talus-

less rigid,navicular will reduce on plantiflexion

observation and /or casting

Treatment .

The goals of treatment are to restore the normal anatomic relationships between the talus, the navicular, and the calcaneus, in order to provide a normal weight distribution through the foot.

REVERSE PONSETI CASTING

The foot is stretched into plantar flexion and inversion while counter pressure is applied to the medial aspect of the head of the talus

4-6 plaster cast is usually enough to achieve reduction of the talonavicular joint

Final cast –Maximum plantar flexion,inversion

Foot simulates –clubfoot Lateral radigraph in PF;TAMBA<30’

However, unlike clubfoot, essentially 100% of reported vertical talus deformities have not been fully corrected with cast immobilization alone and have required major reconstructive surgery.

Dodge et al .Foot ankle .1987;7:326-32 Coleman et al clin orthop Relat Res 1970;70:62-72

J Bone Joint surg Br.1967;49:618-27

Serial cast treatment of the foot is viewed as beneficial for stretching the soft tissues and neurovascular structures on the dorsum of the foot and ankle,thereby decreasing the complexity of the operation.

J Pediatr Orthop. 1987;7:405-11 J Pediatr Orthop. 1983;3:306-10.

There are multiple surgeries described for the treatment of vertical talus.

The type of procedure used for an individual patient is based on

the age of the patient, severity of the deformity, and the preference of the surgeon.

Children up to the age of 3 years are usually offered an open reduction of the talonavicular joint, which can be performed through either a one-stage or two-stage operation

Traditional procedures.

Several authors, beginning with Osmond-Clarke, Herndon and Heyman, and Coleman and associates, described two staged,reconstructive surgery.

The first stage of the Coleman procedure consisted of lengthening the extensor digitorum longus (EDL), extensor hallucis longus (EHL), and tibialis anterior, with capsulotomies of the talonavicular and calcaneocuboid joints and release of the talocalcaneal interosseous ligament.

The second stage consisted of tendo-Achilles lengthening (TAL) and a posterior capsulotomy of the ankle and subtalar joints.

Coleman SS, Stelling FH 3rd, Jarrett J. Pathomechanics and treatment of congenital vertical talus. Clin Orthop Relat Res. 1970 May-Jun. 70:62-72.

Herndon CH, Heyman CH. Problems in the recognition and treatment of congenital pes valgus. J Bone Joint Surg Am. 1963. 45:413-29. Osmond-Clarke H. Congenital vertical talus. J Bone Joint Surg Br. 1956 Feb. 38-B(1):334-41. 

Then trend changed to single stage technique.

After noting a high incidence of complications with the 2-stage technique, Ogata and colleagues recommended a single-stage procedure with a medial approach

Kodros and Dias published results they derived using a single-stage approach with a Cincinnati incision.

Seimon described a single-stage dorsal approach

Three basic components

The first step is the reduction of the talonavicular joint which is aided by release of the anterior tibialis tendon and the tibionavicular and talonavicular ligaments. The reduction is held by a Kirschner wire placed across the talonavicular joint

. The second step is lengthening of the toe extensors and pero- neals which aids in improving ankle plantar flexion and forefoot adduction. The calcaneocuboid joint is also reduced if necessary.

The third step is correction of the ankle equinus contracture which is done by lengthening the Achilles tendon and releasing the ankle and subtalar joint capsules

. Some authors have recommended the addition of a tibialis anterior tendon transfer to the head or neck of the talus at the time of open reduction to add a dynamic corrective force

The Cincinnati incision provided excellent exposure to the pathoanatomy to allow complete correction of the plantarflexed vertical talus, reduction of the talonavicular dislocation, and realignment of the equinovalgus deformity of the calcaneus.

Kodros, Steven A. M.D.*; Dias, Luciano S. M.D. Single-Stage Surgical Correction of

Congenital Vertical Talus. Journal of Pediatric Orthopaedics; 19(1), January/February 1999, pp 42-48

Modified cincinnati incision-

Single stage repair-

Three incisions-

COMPLICATIONS.

Correction of vertical talus through an open reduction can be associated with significant short-term complications, including

wound necrosis undercorrection of the deformity , stiffness of the ankle and subtalar joint , and the eventual need for multiple operative

procedures such as subtalar and triple arthrodesis . Long-term outcomes are likely to be complicated by a

significant amount of degenerative arthritis as is seen in many patients with clubfoot treated with extensive soft-tissue releases

Matthew B Dobbs, MD

Recognized for his skill at treating all paediatric foot disorders.

Minimally invasive approach toward the treatment of CVT.

Between 2000 to 2003, at St. Louis Children’s Hospital & University of Iowa Hospitals and Clinics ;Dobbs et al treated 11 cases (19 feet) of idiopathic CVT by:

-serial manipulation and casting(reverse ponseti technique),

-percutaneous fixation of talonavicular joint using k- wire and

- percutaneous Achilles tenotomy.

Dobbs minimally invasive technique-

After the talonavicular joint has been reduced(after 5-6 casts),fixed percutaneously with k-wire.

Wire passed retrogade from the navicular into the talus with foot in maximum plantiflexion

Wire bent and cut outside skin

Dobbs minimally invasive technique

Even after 6 cast talonavicular joint is not seen to be reduced (TAMBA>30) then an attempt is made in the operating room to lever the talus into position percutaneously with a k-wire placed into the talus in a retrograde manner.

If this is successful, the talonavicular joint is held with k-wire.

Dobbs minimally invasive technique

If the talonavicular joint not reduced closed,a small medial incision is made and dorsal capsulectomy of talonavicular joint was done to reduce the joint.

Fractional lengthening of tibialis anterior and peroneus brevis tendon.

Once talonavicular joint reduced and fixed with k-wire

percutaneous tenotomy was done.

AFTER TA TENOTOMY …….

An assessment is made of the ankle plantar flexion and forefoot passive adduction at this point. If plantar flexion is limited to <25, a fractional lengthening of the extensor digitorum communis is done at the level of the musculotendinous junction.

If passive forefoot adduc- tion is <10, fractional lengthening of the peroneal brevis tendon is performed at the musculotendinous junction.

Lengthening of the peroneal brevis and extensor digitorum communis is not often needed since the preoperative casting usually stretches these structures enough

Dobbs Post op protocol

After tenotomy,a long leg cast :foot –neutral Ankle 5’ DFCast changed at 2 weeks (Mold is made for

solid AFO with 15’ of PF at midtarsal joint)A long leg cast –ankle in 10-15’DF x 3

weeks

After 5 wks;cast removed and k-wire pulled

The solid orthoses is applied and parents are instructed regarding exercise and ankle ROM.

Orthoses is worn for 23 hrs a day until walking age.

Then 12-14 hrs a day until the age of 2 years.

After bracing every 3 monthly until age of 2 yrs

Then every 6 month-1 yr until age of 7 yrsAfter 7,once every 2 yr until skeletal maturity is

reached

Routine follow up assessment

Both clinical and radiological parameter.Clinical-1.ankle and subtalar movement 2.cosmetic appearance 3.loss of the medial arch 4.medial prominence of the talar

head 5.hind foot valgus 6 .abnormal shoe wear

Radiological –anteroposterior: 1.talocalcaneal –hindfoot algus 2.TAMBA-forefoot abduction lateral: 1.talocalcaneal 2.tibiocalcaneal 3.TAMBA

Left untreared –causes significant disability.

Heel doesn’t touch the ground-pt forced to bear wt on talar head;later on develop painful callosities and have awkward gait with difficulty balancing .

Bony procedures-1)Wedge from navicular (WN),

2)Naviculectomy (NE),

3)Naviculectomy,extensive release and tendon transfer procedures (NERTT),

4)Subtalar / triple arthrodesis (STA).

WHAT ABOUT OLDER CVT?

• Some children after the age of 3 years require excision of the navicular at the time of open reduction.

• Children between the ages of 4 and 8 years with either a primary or a recurrent deformity can be treated with open reduction combined with extraarticular arthrodesis (GRICE GREEN )

• Those patients that are older than 8 years often require a triple arthrodesis . However, arthrodesis does result in painful degenerative arthritis of the ankle and midtarsal joints when the patients are followed long-term