CONGENITAL VERTICAL TALUS

Dr. Joydeep Mandal

CVT Rare deformity

Term-1st used by : Henken in 1914.

Several Synonyms-

Congenital convex pes valgus (CCPV) Reverse club footcongenital rigid flatfootRocker-buttom flatfoot

Must be distinguished from flexible pes planus commonly found in infants and children.

Incidence 1 in 10,000

Male=female

B/L -50%

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 development 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 GDF5 Syndromes-1.De barsy syndrome 2.Prune Belly syndrome 3.Costello syndrome 4.Rasmussen syndrome

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

neurological deficit3.A/W neurological deficit

Classification3.Hamanishi: five groups- 1.NTD or spinal anomalies 2.neuromuscular disorders 3.malformation syndromes 4.chromosomal aberrations 5.idiopathic

Pathoanatomy: Irreducible dorsal & lateral

dislocation of navicular over talus

Posteriorly, Contracture of tendoachillis creates equinus of calcaneus

Anteriorly,contracture of EDL,EHL,Tibialis Anterior

Laterally PL,PB ,calcaneofibular ligament contracted

Posterior tendons subluxation over malleolus.

Tibialis Posterior acting as dorsiflexor.

pathoanatomy Navicular – hypoplastic

wedge shaped

Talar head- flattened, extreme planter flexed & medially deviated

Calacaneum-plantar flexed & externally rotated

Angle between axis of talus & calcaneum is increased

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

Clinical presentation-Forefoot - abduction ; dorsiflexion

Hindfoot - equinus and valgus

CVT can be usually detected at birth by the presence of a rounded prominence of the medial and plantar surfaces of foot.

Plantar surface is convex-Rocker bottom appearance. Heel does not touch the ground.

After weight bearing begins, callosities develop beneath the anterior end of calcaneus and along the medial border of the foot superficial to the head of talus.

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

What happen if untreated?

Heel does not touches the ground, have poor push off

Wt bearing on talar head resulting in painful callosities

Ambulation is usually not delayed but gait is awkward with difficult in balancing

Forefoot become severely abducted Talus become like “hourglass” Abnormal shape of foot result in difficult

shoe wearing.

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 radiograph include

the talocalcaneal – Increased in both AP & lateral views.

tibiocalcaneal – Increased in lateral view. tibiotalar – Increased in lateral view. talar axis- first metatarsal base angles –

Disrupted in both AP and lateral views.

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-

normal Posteromedial bow of the tibia :

calcaneovalgus foot,a shortened and bowed tibia

Oblique talus

Treatment Goals 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.

Manipulation-Reverse ponseti technique

In the OPD settings

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

Manipulation 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

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

After a few minutes of manipulation,A/K cast applied in two sections,with knee in 90’ of flexion.

1st section-short leg cast extending from toes to just distal to knee with foot in plantar flexion and inversion.

2nd stage-cast extended to A/K level.

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

Carefully mold the malleoli, head of the talus, above the calcaneum and arch.

Avoid constant pressure at single point.

Cast changed on weekly basis.

Never do pronation of the foot.

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 but it reduces extension and complexity of the surgery.

Surgical Management 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 1 to 4 years are usually offered an open reduction of the talonavicular joint, which can be performed through either a one-stage or two-stage operation.

Occasionally, in children of 3yrs or old with severe deformity require excision of navicular during open reduction.

Children of 4 to 8 yrs require open reduction and soft tissue procedures combined with extra-articular subtalar arthrodesis.

Children of 12 yrs or older require triple arthrodesis.

Two Stage Procedure Several authors, beginning with Osmond-Clarke,

Herndon and Heyman, and Coleman and associates, described staged, 2-incision 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 and a posterior capsulotomy of the ankle and subtalar joint.

Trend changing 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 peroneals 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

Modified cincinnati incision-

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

Single stage repair- Three incisions- Described by Kumar ,

Cowell and Ramsey.

1st – Oblique incision over sinus tarsi.

2nd – Concave incision over prominent medial head of talus.

3rd – 2 inches long incision over medial side of TA.

Through DL approach - calcaneocuboid joint inspected and reduced.

Medially – Tibialis anterior tendon exposed, if contracted, lengthening done with Z plasty or transpose it into the planter aspect of the repaired talonavicular capsule.

dorsal talonavicular ligament (deltoid) released. Planter calcaneonavicular ligament is released. capsulotomy of talonavicular joint done reduced and transfixed with k-wire.

Posteriorly - Z-lengthening of Achilles tendon with distal transverse cut directed laterally.

Check lateral x-ray: 1st metatarsal axis should line up

exactly with long axis of talus

Open reduction and extra-articular subtalar fusion

Described by Coleman et al. for older children with severe or recurrent deformities.

It combines open reduction and realignment of talonavicular joint (by Kumar et al.) with Grice-Green fusion of talo-calcaneal joint performed 6 to 8 weeks later.

Modification done by Dennyson and Fulford using screws for talo-calcaneal fusion.

Post Operative Care Apply long leg cast with knee flexed and

ankle, foot in neutral position for 8 weeks.

Steinmann pin or k wire removed and new long leg cast applied for next 4 weeks.

Below knee cast for another 4 weeks.

Foot supported in ankle-foot orthosis for another 3 to 6 months.

ComplicationsCorrection 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 , 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

Minimally invasive approach to CVT

Described by Dobbs et al. 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

- percutaneous Achilles tenotomy.

Percutaneous Achilles tenotomy

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

Outcome measures As by Adellar et al- Comprises 10 point scale :6 clinical appearance 4 radiological

parameter Maximum 10 points –Excellent 7-9 -good 4-6 -fair <3 -poor

Bone Joint J 2014;96-B:274–8

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.

Early detection and methodical treatment in a more comprehensive manner is the key to success.