Congenital vertical talus BY DR.NAVEEN RATHOR

CVT is a rare foot deformity characterised by calacaneovalgus deformity.

1. BY: DR.NAVEEN RATHOR DEPT. OF ORTHOPAEDICS R .N.T. MEDICAL COLLEGE CONGENITAL VERTICAL TALUS

2. CVT- Rare defomity Term-1 st used by:Henken in 1914. Several Synonyms- Congenital convex pes valgus (CCPV) Reverse club foot congenital valgus flatfoot Rocker bottom foot Talipes convex pes valgus

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

4. Talus-

5. 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

6. 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

7. 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

8. AD inheritance 12-20% Mutation in HOXD10 Mutation in GDF5 Syndromes-1.De barsy syndrome 2.Prune Belly syndrome 3.Costello syndrome 4.Rasmussen syndrome

9. Ogata and schoenecker – Three group- 1-Idiopathic 2-A/W other abnormality but no neurological defecit 3.A/W neurological defecit Clinical Orthopaedics (1979 )139:128–132

10. 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

11. 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 :

12. 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

13. Clinical presentation- Forefoot-abduction ; dorsiflexion Hindfoot-equinus and valgus

14. Plantar surface is convex- Rocker bottom appearance Deep creases on anterolateral aspect of foot Foot is everted into valgus and externally rotated position

15. 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

16. 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 .

17. 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

18. 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)

19. Talocalcaneal angle is increased Middle and anterior subtalar facet- hypoplastic

20. Hamanishi described 2 radiographic angles: the talar axis–first metatarsal base angle (TAMBA) and the calcaneal axis–first metatarsal base angle (CAMBA).

21. 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.

22. Differentials- Calcaneovalgus foot deformity: -foot is dorsiflexed - no equinus contracture of calcaneus -flexible foot -forced plantar flexion lateral x-ray-normal Posteromedial bow of the tibia:calcaneovalgus foot,a shortened and bowed tibia Oblique talus

23. Oblique talus- less rigid,navicular will reduce on plantiflexion observation and /or casting

24. 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.

25. 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

26. Final cast – Maximum plantar flexion,inversion Foot simulates –clubfoot Lateral radigraph in PF;TAMBA<30’

27. 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

28. 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.

29. 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

30. 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. 

31. 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

32. 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

33. 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

34. Modified cincinnati incision-

35. Single stage repair- Three incisions-

36. 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

37. Matthew B Dobbs, MD Recognized for his skill at treating all paediatric foot disorders. Minimally invasive approach toward the treatment of CVT.

38. 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 .

39. 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

40. 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.

41. 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.

42. Once talonavicular joint reduced and fixed with k-wire percutaneous tenotomy was done.

43. 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

44. Dobbs Post op protocol After tenotomy,a long leg cast :foot –neutral Ankle 5’ DF Cast 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

45. 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 yrs After 7,once every 2 yr until skeletal maturity is reached

46. 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

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

48. 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 .

49. Bony procedures - 1)Wedge from navicular (WN), 2) Naviculectomy (NE), 3) Naviculectomy,extensive release and tendon transfer procedures (NERTT), 4) Subtalar / triple arthrodesis (STA).

50. 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