Vertical talus

CONGENITAL VERTICAL TALUS

1. Congenital Vertical Talus(CVT) Dr ShyamGopal V

2. 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’

3. Talus-

4. CVT- Congenital + vertical + talus Term-1 st used by:Henken in 1914. Several Synonyms- Congenital convex pes valgus (CCPV) Reverse club foot congenital valgus flat foot Rocker buttom foot Talipes convex pes valgus

5. Tachdjian describes as the “ teratologic dorsolateral dislocation of the talocalcaneonavicular joint with rigid hind foot equinus ” Incidence 1 in 10,000 Male=female B/L -50%

6. CVT- fixed dorsal dislocation of the navicular on the talar head and neck and fixed equinus contracture of the hindfoot resulting in rigid flatfoot deformity. Idiopathic /or associated with other neuromuscular or genetic disorder.

7. Left untreated –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 .

8. Etiology- Exact etiology :unknown. Possible causes-Muscle imbalance; Intrauterine compression Arrest in fetal development betn 7 th -12 th wk Idiopathic-50%

9. 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

10. AD inheritance 12-20% Mutation in HOXD10 Mutation in GDF5 { GDF5-CARTILAGE DERIVED MORPHOGENIC PROTEIN-1 } Syndromes-1.De barsy syndrome 2.Prune Belly syndrome 3.Costello syndrome 4.Rasmussen syndrome

11. Patho -anatomy: 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

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

13. The medial tendons,the calcaneo navicular ligament and the anterior fibres of the deltoid ligament are elongated . Contractures are on the dorsolateral side and include the peroneal tendons,the extensor tendons,the calcaneofibular ligament,the talo-navicular ligaments and the capsule of the ankle and the subtalar joint.

14. Contracture of the TA,EHB,PL,PT,and AT Posterior tibial tendon and PB,PL-act as dorsiflexors rather than plantiflexors . Vascular supply-dominated by DPA and ATA deficient PTA.

15. Clinical presentation- Characterized by: Forefoot-abduction ; dorsiflexion Hindfoot-equinus and valgus

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

17. Head of talus plantar medial aspect of midfoot Calcaneus is in equinus Palpable gap dorsally between navicular and talar neck Left untreated –more rigid deformity and adaptive changes in tarsal bones

18. Callosities around the head of talus Heel doesn’t touch the ground ; shoewear becomes difficult and pain is inevitable.

19. Classification- 1. Coleman -1 st :isolated talonavicular dislocation 2 nd -both talonavicular and calcaneocuboid dislocation

20. 2.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

21. 3.Hamanishi :five groups- 1.NTD or spinal anomalies 2.neuromuscular disorders 3.malformation syndromes 4.chromosomal aberrations 5.idiopathic J Pediatric Orthopaedics (1984)4:318–326

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

23. Radiographic features- Ossification – cuboid 1 st month cuneiform-2 nd year navicular-3 rd year AP and lateral radiographs of foot in neutral position Lateral x-ray in forced dorsi and planti flexion of foot

24. Measurements:-on lateral x-ray – talocalcaneal ; tibiocalcaneal , tibiotalar , In CVT talar axis vertical calcaneus in equinus increased talocalcaneal angle

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

26. The changing point from flexible OT to rigid CVT is TAMBA of about 60 degrees and CAMBA of 20 degrees open reduction should be carried out as promptly as possible if 3 months of corrective casting in extreme equinovarus fails to reduce the TAMBA to 50 degrees.

27. Diagnosis :confirmed by-

28. 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

29. Treatment- Goal: restore and maintain normal anatomic relationship.

30. As with the ponseti method of treatment of clubfoot deformity Serial manipulations and casting-all deformities corrected simultaneously except heel equinus

31. Manipulation-Reverse ponseti technique In the OPD settings One parent beside the baby to offer a pacifier or bottle of milk One assistant to either hold the corrected foot or apply cast. If breastfeed-nursed before manipulation More relaxed the baby-better the cast that can be applied

32. Supine on the clinic table with feet at the end of the table Crucial-to palpate the head of talus: Plantar medial aspect of midfoot

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

34. After a few minutes of manipulation,A /K cast applied in two sections,with knee in 90’ of flexion 1 st section-short leg cast extending from toes to just distal to knee with foot in plantar flexion and inversion 2 nd stage-cast extended to A/K cast 4-6 plaster cast is usually enough to achieve reduction of the talonavicular joint

35. Carefully mold the malleoli,head of the talus,above the calcaneum and arch Avoid constant pressure at single point Cast changed on weekly basis

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

37. 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

38. 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.

39. However,unlike casting for clubfoot,serial casting for congenital vertical talus has not been used until recently as a method of achieving definitive correction. J Bone Joint Surg Am(2006)88:1192–1200

40. Major reconsructive surgeries- -single stage releases -two stage releases -soft tissue releases with navicular excision -Grice –green subtalar fusion after release

41. Complications- talar necrosis -wound necrosis -stiffness of the ankle and subtalar joint - undercorrection of the deformity - pseudoarthrosis -needs of multiple surgeries .

42. Type of procedure-age of child -severity of the deformity and -surgeon preference Upto age three open reduction of talonavicular joint. -one stage /or two stage operation

43. Two stage operation- 1 st stage -lengthening of extensor tendons and tibialis anterior tendon and reduction of talo navicular joint 2 nd stage -correcting equinus contracture by lengthening Achilles tendon,peroneal tendon and posterior ankle and subtalar release Complication –AVN of talus

44. STEPS Reduction of the talonavicular joint Lengthening of the toe extensors and peroneals Correction of the ankle equinus tibialis anterior tendon transfer

45. PRINCIPLE 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 peroneals which aids in improving ankle plantar flexion and forefoot adduction. The calcaneocuboid joint is also reduced if necessary

46. 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

47. The single-stage surgical correction resulted in good results with a low rate of complications. 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

48. In literature various surgical techniques have been described: two soft tissue and four bony procedures . Soft tissue procedures- 1)extensive release with lengthening of tendons and fixation procedures (ETLF) , 2)extensive release with tendon transfer procedures (ETT)

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. The technique of choice in a child younger than 2 years of age is -extensive release with lengthening of tendons and fixation procedures. In a child over 2 years of age,extensive release with tendon transfer is the preferred procedure. When this procedure has failed,naviculectomy with extensive release and tendon transfer,or subtalar / triple arthrodesis must be considered

51. Acta Orthopædica Belgica, Vol.73 - 3 - 2007

52. Most authors agree that the disorder should be recognised at birth and treated before the age of 2. If treatment is delayed beyond 2 years of age,more aggressive procedures must be employed. J Foot Ankle Surg 2001; 40:166-171.

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

54. 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 .

55. 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

56. 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.

57. 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.

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

59. Dobbs Post op protocol After tenotomy,a long leg cast :foot –neutral Ankle 5’ DF Cast changed at 2 weeks A long leg cast –ankle in 10-15’DF x 3 weeks After 5 wks;cast removed and k-wire pulled

60. 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.

61. 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

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

63. Excellent results, in terms of the clinical appearance of the foot, foot function, and deformity correction as measured radiographically , in patients with idiopathic and those associated with other genetic or neuromuscular disorder ;congenital vertical talus.

64. Pitfalls Failure to obtain maximum hindfoot varus,forefoot adduction in the last cast b/k cast application- a toe to groin cast :to prevent ankle and talus from rotating Failure to have perfect talonavicular reduction(role of x-ray) Achilles tenotomy before first securing talonavicular joint Failure of parents to do stretching exercises

65. Thank you!!!!!!!!