rocker bottom foot deformity vertical talus.pptx

congenital vertical talus

1. CONGENITAL VERTICAL TALUS - Dr. Pooja Suratwala

2. Introduction It is congenital dorsolateral dislocation of the navicular on the talus with severe eversion of the subtalar joint and rigid plantar flexion of the talus, creating a rocker - bottom appearance of the foot.

3. ETIOLOGY The exact etiology of vertical talus is unknown. Possible causes include : muscle imbalance; ( overpull of tibialis anterior). Autosomal dominant transmission Arrest in fetal development of the foot occurring between the 7th and 12th weeks of gestation.

4. Lichtblau defined three groups: Group I : teratogenic , associated with developmental dysplasia of the hip and mental retardation. A rigid deformity was present at birth, with very tight extensors and heel cords. Group II : neurogenic type accompanied by muscle imbalance. associated with myelomeningocele or neurofibromatosis Group III :acquired type / idiopathic

5. The classic appearance is a rocker-bottom foot (Persian slipper) Clinical features

6. a. Forefoot — supinated b. Midfoot — i. Abducted ii. Medial column—dislocated • dorsolateral dislocation of the navicular on the talus iii. Lateral column—subluxated • dorsolateral subluxation of calcaneocuboid joint c. Hindfoot —valgus/everted d. Ankle —plantar flexed (equinus)

7. Calcaneovalgus deformity Oblique talus At walking age flat foot Differential diagnosis

8. The term oblique talus is given to an intermediate deformity, neither a true vertical talus nor yet a flexible flatfoot. The diagnostic finding is subluxation of the navicular on the talus in a standing position, with reduction of the navicular in maximum plantar flexion.

9. RADIOGRAPHICAL FINDINGS X-ray- AP radiograph Lateral view in maximum plantar flexion and maximum dorsiflexion. before ossification of navicular at age 3, the first metatarsal is used as a proxy for the navicular on radiographic evaluation

10. The maximum dorsiflexion: persistent plantar flexion of the talus and calcaneus

11. Maximum olantarflexion: line along long axis of talus passes below the first metatarsal-cuneiform axis

12. Meary's angle > 20° (between line of longitudinal axis of talus and longitudinal axis of 1st metatarsal)

13. AP talocalcaneal angle > 40° (20-40° is normal)

14. The goals of treatment : 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. TREATMENT

15. A d orsally directed force is applied to the talar head to correct the plantar-flexed position. The forefoot is inverted and adducted No attempt is made to correct the hind foot equinus. Reverse Ponseti Technique

16. This procedure is repeated weekly. Once the talus is in line with the first metatarsal, closed pinning of the TN joint from the dorsum of the forefoot in line with the first ray (metatarsal) is performed. Percutaneous tendoachilles tenotomy is performed to correct the hind foot equnius and valgus.

17. Open soft tissue release

18. If closed reduction is unsuccessful then the talo-navicular joint can be reduced under vision. A small, 2-cm medial incision is made over the talonavicular joint in the operating roo m. The talonavicular joint capsule is opened as well as the medial subtalar joint.

19. Fractional lengthening of the EDC ( If plantar flexion is limited to <25°) Fractional lengthening of the peroneal brevis tendon ( If passive forefoot adduction is <10°) Z-lengthen the anterior tibialis and the EHL tendons

20. The vascular supply to the foot in vertical talus has been shown to be dominated by the dorsalis pedis and anterior tibial arteries. The posterior tibial artery has been noted to be deficient in a study of seven limbs in four patients. This configuration places the vascular supply at risk when extensive anterior dissection is performed and the forefoot is plantar flexed

21. An elevator is then used to gently lift the talus completing the reduction . With the talus held in the reduced position, a Kirschner wire is then placed in a retrograde manner across the talonavicular joint.

22. A percutaneous tenotomy of the Achilles tendon is used to correct the residual equinus deformity. Apply a long-leg cast with slight inversion molding of the subtalar joint Change to a new long-leg cast in clinic in 3 weeks Remove the cast and the two buried pins in the OR, or the exposed pins in the clinic, 6 weeks postoperatively

23. Several authors have reported the addition of a full or split transfer of the tibialis anterior to the head or neck of the talus .

24. Chronically unreduced CVT : manifests as either as an inability to fully reduce the deformity or as residual deformity despite full reduction of the talonavicular joint. Shortening the medial column and lengthening the lateral column of the foot are two approaches to management. A posterolateral release is combined with naviculectomy for full deformity correction in this group of slightly older children

25. Tripple arthrodesis is a salvage procedure for the adolescent and adult who have painful recurrent deformity or painful degenerative arthritis.

26. Thankyou