SlideShare a Scribd company logo
1 of 99
Congenital Vertical Talus
ANISUDDIN BHATTI
Consultant Paediatric Orthopaedic Surgery
Dept. Orthopaedic, & Spine Surgery
Dr. Ziauddin Hospital Clifton, Karachi
Objectives
Patho-anatomy
Clinical presentation
Radiological Evaluation
Treatment modalities
Congenital Vertical Talus
Several Synonyms Termanology:
o Congenital Convex pes valgus (CCPV). Rocker bottom foot
o Congenital valgus flat foot. Talipes convex pes valgus.
Q. Pathoanotomy ?? Deformity Comopents??
•Teratologic dorso-lateral dislocation
of Talo-Calcaneo-Navicular joint.
•Navicular is dislocated dorsally on
the talar head and neck.
•Talus oriented vertically leading to
fixed equinus contracture of the
hindfoot and a Rocker bottom
deformity.. Tachdjian
Congenital Vertical Talus
Term 1st used by Henken in 1914
50% Idiopathic. 50% associated with Other diseases
PathoAnatomy:
Skeletal Abnormalities
Talus: head and neck flattened and deviated
medially & plantarward
Calcaneum: plantar flexed and externally
rotated
Navicular: Displaced dorsally and laterally
& hypoplastic
Cuboid: Deformed & laterally deviated
Dorsolateral subluxation or Dislocation of the Calcaneo-Cuboid
joint.
Soft Tissues abnormalities
•Elongation of Medial Structures: tendons,
calcaneo navicular ligament and anterior
fibers of the deltoid ligament.
•Contractures of dorsolateral structures:
peroneal tendons, extensor tendons,
calcaneo-fibular ligament, talo-navicular
ligaments and capsule of ankle and subtalar
joint
Contracture of Dorsolateral Structures
• Contracture of: TA,
EHB, PL, PT, and AT
•Planter flexors
displaced dorsally
and act as
Dorsiflexors:
Tibialis
Posterior, PB &
PL
Vascuar supply-dominated by DPA and ATA ,
deficient PTA.
Clinical presentation
(Reverse Clubfoot deformity)
•Fore foot: Abduction, Dorsiflexion
•Hind foot: Equinus and Valgus
•Plantar surface: convex:
Rocker bottom appearance
•Deep creases: on anterolateral aspect of
foot
•Foot: everted into valgus and externally
rotated position
Elongation of medial column and shortening of lateral column
Q. Radiological Evaluation ??
Q. Any special view Needed for DD ??
Normal foot:
long axis of first metatarsal
passes plantarward to long axis
of talus.
CVT:
long axis of first metatarsal remains
dorsal to long axis of talus, indicating
dorsal dislocation of midfoot and
forefoot.
Radiological Evaluation
Special View: Plantar flexion view
•maximum plantar flexion view
demonstrates irreducible
talonavicular joint:
oNavicular cannot be reduced on
the talus
oline drawn thru axis of talus
passes plantar to metatarsal axis.
•Plantar flexion fails to realign
talus & first metatarsal,
confirming diagnosis of a fixed
talonavicular dislocation
("vertical talus")
Radiographic Confirmation of CVT:
6 Wks old Baby
A. Lateral Planter flexion radiograph, showing persistent dorsal translation
of forefoot on hind foot
B. Lateral dorsiflexion radiograph of the same foot, showing persistant
planter flexion of Talus & Calcaneum
A B
Radiological Evaluation: Angles
AP VIEW:
Kite angle: (Talo-Calcaneal angle)
• Normal 20-400
• CVT >40
• Valgus of midfoot
LATERAL VIEW:
• Meary’s angle ( angle between long
axis of talus and first Metatarsal).
N=<40
VT >20
• Vertical position of Talus
• Shows Navicular dislocation
Lines drawn down the axis of
talus and calcaneus:
• The midtalar line should
pass through (or just
medial to) the base of
the 1st metatarsal
• The mid-calcaneal
line should pass
through the base of the
4th metatarsal.
• Hindfoot varus: <25
• Normal : 25-40
• Hindfoot valgus: >40
Kite Angle: Talo-Calcaneal Angle
12 yr old
• Normal Meary’s angle is 0, angle > 4 deg shows:
• Pes planus deformity: Mild: <15 deg , Moderate: 15-30 deg,
Severe: > 30 deg
Meary’ Angle
Meary’s angle, Talo 1st MT tarsal Angle: line drawn
through axis of the talus and axis of 1st MT ray
Meary’ Angle: Comparative
Left Pes Plano valgus
12 yrs old boy
Meary’s Angle:
Left 230 PPV
Rigt < 100 Normal
Q. Any Classification?
Q. On what basis CVT classified
Coleman’s Classification
Two Types
•Type 1: CVT with both talonavicular and
calcaneocuboid
•joint dislocations
•Type 2: CVT with isolated talonavicular dislocation
This distinction is important clinically because the
type 1 deformity is stiffer and particular attention
must be paid to releasing the calcaneo-cuboid joint.
Coleman Type 1
• Key feature of fixed dorsal
dislocation of navicular on
neck of talus, equinus
position of talus and
calcaneus, dorsiflexion of
forefoot, and abduction
contracture of the foot.
•In CVT line through talus is
plantar to navicular (cuboid)
in both resting lateral and
plantar flexed views
Ogata and Schoenecker
Three groups:
•Group 1: Idiopathic, no other associated
diagnoses.
•Group 2: Associated with other congenital
anomalies but no neurologic deficits.
•Group 3: Associated with neurologic
disorders.
Hamanishi’s Classification
Five groups based on association with:
(1)Neural tube defects or spinal anomalies,
(2)Neuromuscular disorders,
(3) Malformation syndromes,
(4) Chromosomal aberrations, and
(5) Idiopathic.
Q. What are the variants & DD?
Q. How they are Differentiated?
Variants
a. Pes Plano Rigidus: Navicular
never reduce on planter flexion:
CVT.
b. Pes Plano flexus: navicular
will reduce on planter flexion
c. Oblique Talus: Less sever
variant of VT.
Flexible to Rigid CVT
• Because the navicular may not be ossified, the
alignment of the first metatarsal to the talus
must be evaluated.
•Hamanishi described 2
radiographic angles: Talar axis–
first metatarsal base angle
(TAMBA) and Calcaneal
metatarsal base angle (CAMBA).
•The changing point from a
flexible oblique talus to rigid CVT
is a TAMBA of approximately 60°
and a CAMBA of 200
OBLIQUE TALUS
•A deformity that is somwhere between the sever
form of flexible pes planus and congenital convex
pes valgus.
•It differ from congenital convex pes valgus by
absence of dislocation of T-N jt (in Planter flexion)
•Maintaining these distictions prevents
overdiagnosis of cong convex ps valgus.
•Additionally, better evaluation of Rx for cong convex
pes valgus results because those case with better
prognosis and better response to non-surgical
intervention are not included in data for the
management of cong convex pes valgus.
Harris EJ. Clin Podiatr Med Sur. 2000 17(3):419-42
Oblique Talus
• Pes Plano Flexus.
• Head of talus palpable on plantar medial aspect
of midfoot. Correctable on planter flexion,
reducible T-N-J dislocation
• Radiological evaluation:
CVT Rigidus
oAP view: increased talocalcaneal angle
oLateral Plantarflexed view: fixed forefoot dorsal
dislocation
oDorsiflexed lateral view: fixed equinus of
hindfoot
Congenital Oblique Talus:
oLateral radiographs of the foot in maximal
plantarflexion can reveal if the navicular is
reducible.
A. Plantar flexion lateral radiograph showing
persistent dorsal translation of the forefoot on the
hindfoot. B. Dorsiflexion Lateral radiograph of
the same foot, showing persistent plantar flexion
of the talus and calcaneus
A 12- week-old male with
congenital vertical talus
Lateral radiograph of a 7-week-old male with an oblique
talus, A. demonstrating vertical position of the talus. B Lateral plantar
flexion radiograph, demonstrating restoration of the normal
relationship between the longitudinal axis of the talus and the first
metatarsal
vertical talus
Oblique talus
Late presentation
• Left Untreated:
o More rigid deformity and adaptive changes in
tarsal bones.
o Heel doesn’t touch the ground.
o Pt. forced to bear wt on talar head.
o Callosities around the head of talus..
• Disability:
o The painful callosities causes significant
disability with an awkward gait & difficulty in
balancing .
o Frequent abnormal Shoe wear & tear
https://link.springer.com/book/10.1007/978-1-84882-611-3 NMI Case: 7 yr age Male
Differential Diagnosis
• Calcaneo-valgus foot deformity (Dorsif-lexus) :
foot is dorsiflexed, to such degree dorsal surface
of foot touching ant. surface of lower leg. No
equinus contracture of calcaneus. Deformity is
often flexible.
o Forced plantar flexion lateral x-ray – normal
• Posterio medial bow of the tibia:
an apparent Calcaneo valgus foot with a
shortened and bowed tibia.
Flat Foot (Calcaneo Valgus) vs CVT
• 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 calcaneo-valgus
foot.
• Upon plantar flexing the congenital vertical talus foot
the gap remains and, in a calcaneo-valgus foot, the gap
disappears as the talonavicular joint reduces in plantar
flexion.
HAMANISHI’S ANGLES
•Hamanishi described 2
radiographic angles: the talar
axis–first metatarsal base angle
(TAMBA) and the calcaneal
metatarsal base angle (CAMBA).
•The changing point from a
flexible oblique talus to rigid CVT
is a TAMBA of approximately 60°
and a CAMBA of 200
Hamanishi’s TAMBA & CAMBA
TMT1- 1st metatarsal axis should line up
exactly with long axis of talus
(TAMBA<30) normal??
CAMBA < Normal
Congenital Vertical Talus
Management
Treatment
Goal:
Restore and maintain normal anatomic
relationships between the talus, the navicular, and
the calcaneus
Objective:
•to provide a normal weight distribution through the
foot.
Treatment
Methods:
o Manipulation & Casting
o Manipulation Casting & Minimal
Invasive Reduction
o Open reduction
o Fusion/ Osteotomies
Literature Review
Serial Manipulation & Casting
• A traditionally used method of improving deformity
and thereby decreasing the complexity of an
inevitable extensive soft-tissue release operation.
• Unlike casting for clubfoot, serial casting for CTV has not
been used until recently as a method of achieving
definitive correction.
• The serial casting with minimal surgery has been a
recent addition that in excellent correction in the
short-term.
• Since mini-invasive approach has been a less invasive
approach, it provide more favourable long-term
outcomes than more extensive surgery.
J Bone Joint Surg Br 67:117–121. J Bone Joint Surg Am(2006)88:1192–1200, Clin Orthop 70:62–72
Q. Describe Bobb’s Reverse
Ponseti Technique: Salient
Features?
Q. What is crutial step?
Serial Manipulation & Casting
Reverse Ponseti Technique
• All components of the deformity are
corrected simultaneously with the exception
of the hindfoot equinus, which is corrected
last.
• Methodology is similar to the Ponseti
method of treatment of clubfoot deformity
but in Reverse direction.
• Preparation & positions same as for CFD
Reverse Ponseti Technique
•Crucial to locate the head
of talus i.e lying at
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.
Reverse Ponseti
Manipulative Technique
•Illustrations of the direction
of the forces applied to
reduce a vertical talus
deformity.
•The foot is stretched into
plantar flexion and inversion
while counterpressure is
applied with the thumb to
the medial aspect of the
head of the talus.
The Journal of Bone and Joint Surger, Inc (J Bone Joint Surg
Am. (2007) 89:Pt 1 Suppl 2:111–121)
Right foot Left foot
With each Weakly, serial manipulation & successive cast,
the foot is brought into more equinus, hindfoot varus,
forefoot in maximum plantar flexion and inversion to
ensure adequate stretching of the contracted dorsolateral
tendons, joint capsules and skin.
Succesive Serial Casting
Lateral
Medial
Left Foot
Manipulation Casting & Molding
•Manipulation for 2 minutes,
•Hold knee in 90’ of flexion, foot in
plantar flexion and inversion
•Apply Cast A/K in two stages:
1st B/k, mold and Dry
•Carefully mold the malleoli, head of
the talus, above the calcaneum and
arch
•Avoid constant pressure at single
point
•Extend vast A/K
Serial Casts & Follow-up
• Cast changed weekly
• 4-6 plaster cast is usually enough to achieve
reduction of the Talo-navicular joint.
• A percutaneous TA tenotomy may be
required before applying a Final cast with
Maximum plantar flexion, inversion.
• At the last cast Foot simulates –clubfoot.
• Evaluation: Lateral radiograph in PF:
TAMBA<300
Since the navicular is not ossified in infants, reduction is confirmed indirectly by
the talar axis-first metatarsal base angle as measured on the lateral foot radiograph.
Q. How to proceed, In failure to
achieve T-N-J reduction in Non-
walking child.
Minimal Invasive Approach
Matthew B Dobbs Technique.
•In resistant cases, after Initial
correction with Reverse Ponseti
Serial manipulation and casting,
a mini-invasive approach is used
to achieve Talo Navicular joint
reduction.
•Reduction Stabilized with
retrograde K wire fixation
Indication:
Failure to
achieve T-N Jt
reduction even
after 6 cast
TAMBA>30
Farhang Alaee, Mathew Dobbs J Child Orthop (2007) 1:165–174
Dobbs Mini Open Technique
•A small medial incision is made, for dorsal
capsulectomy of T-N joint to reduce the T-N joint.
•Hold talonavicular joint in max flexion alignment,
may be with help of an elevator & pass the k-wire
retrograde from Navicular to Talus.
Farhang Alaee, Mathew Dobbs J Child Orthop (2007) 1:165–174
•Once talonavicular joint is reduced and fixed with k-
wire,, do TA percutaneous Tenotomy, with a Beaver
eye blade 1cm above TA insertion
PCAT
a. T-N jt. Reduction & fixation with K-wire. Note
residual equinus of Calcaneus.
b. After PCAT calcaneal equineous corrected
PC Joystick technique of T-N-J reduction &
Fixation
•Joystick technique
to lever the talus
into position
percutaneously
with a k-wire
J Child Orthop (2007) 1:165–174
Q. Any additional procedure (some
times required) required in age over 2
yr group?
Additional Procedures
MIS Technique
•In patients, older than 2 years at the time of open
reduction of T-N-J, the tibialis anterior tendon is
also transferred to the dorsal aspect of the neck of
the talus to provide a dynamic corrective force.
•If plantar flexion is limited to <25 (as assessed on
Xray), a fractional lengthening of extensor
digitorum communis is done at the level of the
musculotendinous junction.
•If passive forefoot adduction is <10, fractional
lengthening of the peroneal brevis tendon is
performed at the musculotendinous junction.
Farhang Alaee, Mathew Dobbs J Child Orthop (2007) 1:165–174
Tibialis Anterior Transfer
•Tibialis Anterior Tendon Transfer (TATT) to the head
or neck of the talus at the time of open reduction to
add a dynamic corrective force.
Grice DS (1952). J Bone Joint Surg Am 34 A:927–940. Grice DS (1955). J Bone Joint Surg Am 37-A:246–259
Dobbs Post Op Protocol
Mini Open Technique
• After tenotomy, an A/K cast
• 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.
• AFO / Reverse BD Shoes, till walking age.
• Parents advised exercise:
ankle ROM & foot inversion exercises
2-3 times a day.
Case Report: Mini Invasive Technique
Demonstrating location of
the incision over the medial
aspect of the talonavicular
joint, used for open reduction
of the talonavicular joint
Demonstrating a single-prong skin hook placed on the
navicular and a Freer elevator in the medial subtalar
joint being used to reduce the talus to a horizontal
position in relation to the navicular
Demonstrating
Kirschner wire
fixation of the
reduced talonavicular
joint
Dobbs MJ Child Orthop (2007) 1:165–174
Case Report: Mini Invasive Technique
Dobbs MJ Child Orthop (2007) 1:165–174
Lateral radiograph and clinical picture of the same child illustrated in A. & B. at the
age of 5 years after treatment with cast correction, percutaneous Kirschner wire
fixation, and percutaneous Achilles tendon tenotomy for congenital vertical talus of
the right foot
Literature Review
•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
Literature Review
•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.
Congenital Vertical Talus
in
Walking Age Children
> 2 years
Q. How to manage this group?
Traditional Surgical Rx: OR
Type of procedure
based on:
•Age of the patient,
•Severity of the
deformity
•Complexity /
Associated disorders
•Preference of the
surgeon.
Approach:
oTriple incision dorsal
approach.
oSingle incision
posterior approach.
Clin Orthop 139:128–132, J Bone Joint Surg Br 67:117–121. Clin Orthop 70:62–72
Traditional Surgical Rx vs Age group
Children <3 years:
• OR soft tissue release, realignment
T-N-J,
• Tendon lengthening & K wire
Fixation
• one-stage or two-stage operation.
Children >3 years:
• Extensive Soft tissue release,
• Tendon Lengthening & K wire fixation
• Tendon transfer.
Children 4 years &
Recurrent Deformity
• Naviculectomy with
extensive release
• tendon transfer, or
• Subtalar / triple
arthrodesis
Grice DS (1952). J Bone Joint Surg Am 34 A:927–940. Grice DS (1955). J Bone Joint Surg Am 37-A:246–259
Litrature Review
•The exact upper age limit for a successful open
reduction is not known.
•Age > 3 years: Some children require excision of the
navicular at the time of open reduction [51, 52].
•Age > 3 years: There is also concern that, an
untreated vertical talus results in permanent
deformity in the anterior and middle subtalar
facets.
•If there is not sufficient remodelling potential of the
articular surfaces present after an open reduction
of the talonavicular joint then a medial column
shortening and lateral column lengthening
procedure may be necessary.
Colton CL (1973) J Bone Joint Surg Br 55:566–574
Clark MW, et al (1977) J Bone Joint Surg Am 59:816–824
Litrature Review
•Ages of 4-8 years: with either a primary or a
recurrent deformity can be treated with open
reduction combined with extraarticular
arthrodesis.
•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.
Coleman SS, Stelling FH 3rd, Jarrett J (1970) Clin Orthop 70:62–72
Grice DS (1952). J Bone Joint Surg Am 34 A:927–940.
Grice DS (1955). J Bone Joint Surg Am 37-A:246–259
One stage OR Procedure
Three basic components:
First step: Reduction of Talo-N-J with release & transfer of Tibialis
Ant Tendon, and release of tibio-navicular and talonavicular
ligaments. The reduction is held by a Kirschner wire placed
across the talonavicular joint .
• Second step: lengthening toe Extensors and Peroneals, and
reduction of alcaneocuboid joint (if necessary), to improve
ankle plantar flexion and forefoot adduction).
• Third step: TA lengthening and releasing, posterior ankle and
subtalar capsulotomy, to correct ankle equinus contracture.
Single stage reconstruction
Three incisions approach
•1ST: concave downward over
the medial talonavicular joint;
•2nd oblique over the sinus tarsi
to expose the calcaneocuboid
joint and peroneal and
extensor tendons;
•3rd along the lateral border of
the Achilles tendon to allow
posterior release.
Single stage reconstruction:
Three incisions
•Medial side Reduction, dorsal talonavicular
ligament (deltoid) divided and capsulotomy of
talonavicular joint done reduced and transfixed
with k-wire.
•Dorso lateral elongation: calcaneocuboid joint
inspected and reduced
•Postrior Lengthenig: Achilles Z-Plasty
Lengthening
One Stage OR Procedure
Fig.1 Intraoperative photograph illustrating
Kirschner wire placed antegrade through the
talus to aid in reduction of the talonavicular
joint during a one-stage reduction procedure
(Courtesy of Perry L.
Schoenecker)
Fig.2 Intraoperative photograph
illustrating a posterior ankle and
subtalar release performed on the same
patient in Fig. 5 during a one stage
reduction of a vertical talus (Courtesy of
Perry L. Schoenecker)
Fig 1 Fig 2
Tibialis Anterior Transfer
Technique
•Origin of Anterior Tibial
tendon released and transfer
it to the mid talar neck using
a drill hole and sewing it to
itself.
•Similarly Posterior Tibial
Tendon, is sewed beneath
the talar head and neck to
assist in support.
Appearance after transferring
and
fixing the tendon of the anterior
tibial muscle to the head of talus
with a mini anchor.
Diagram showing the
anatomy of CVT
Ref: Z Zhu et al., Mini anchor for congenital vertical talus
Orthopaedic Surgery (2010), Volume 2, No. 3, 218–222
Female, 5 yr old, CVT 3 years ago. (a) The
appearance of the CVT. (b) Lateral view radiograph
showing a TAMBA of 57°(normal value is 3.3° ⫾ 6.4°)
12 Wks Post-op. & 2 years Post-op
Case Reoprt
Single stage Posterior Approach:
Modified Cincinnati Incision
The Cincinnati transverse incision extends from the anteromedial to the
anterolateral aspect of the foot over the back of the ankle at the level of the
tibiotaler joint.
The incision is a modified Cincinnati incision that passes beneath the medial
malleolus just past the Achilles tendon posteriorly and proceeds dorsally
over the navicular just past the extensor tendons
Single stage Posterior Approach
Modified Cincinnati Incision
Literature Review
Modified Cincinnati Approach
•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. et al. Journal of Pediatric Orthopaedics; 19(1) 1999: 42-48
Two stage operation Approach
1st stage (Anterolateral release):
•Lengthening of extensor tendons and tibialis
anterior tendon, Peronius Tertius and Dorsolateral
capsulotomy / reduction of talo navicular joint
2nd stage (Posterior release):
• Correcting equinus contracture by lengthening
Achilles tendon, peroneal tendon and posterior
ankle and subtalar release
Post Reduction Maintenance
•After hind foot correction,
•second k-wire from
plantar surface of heel
through the calcaneus and
talus into tibia
•Long leg above knee cast
for 6 weeks
•After 6 weeks ,remove 2 k-
wires and B/K cast for
further 6 weeks
Long Term Outcom
Literature Review
• Disorder should be recognized at birth and treated before
the age of 2.
• More aggressive procedures must be employed when Rx
delayed after 2 yrs.
• Both approaches have Good short-term success
• Single Incision dorsal approach:
oshorter operative time,
obetter clinical scores,
ofewer complications than the posterior approach
J Foot Ankle Surg 2001; 40:166-171. Mazzocca AD et al. J Pediatr Orthop 21:212–217
Complications
Literature Review
Significant short-term complications include:
•Wound necrosis,
•Under correction of the deformity,
•Stiffness of the ankle and subtalar joint,
•Eventual need for multiple operative procedures
such as subtalar and triple arthrodesis.
Long-term outcomes complicated by:
•Degenerative arthritis as is seen in many patients
with clubfoot treated with extensive soft-tissue
releases.
Acta Orthopædica Belgica, Vol.73 - 3 - 2007
Pes Plano Valgus
Flat Foot Deformity
Q. How this differ from CVT & to Evaluate?
Pes Plano Valgus, Flat Foot Deformity
• Defined as a deformity with a
flattened arch, of various degree
from a lowered arch to rocker
bottom deformity of foot.
• Unknown in pediatric population
• 20% to 25% in adults
• Majority associated with Generalized
ligamentous Laxity & Cerebral Palsy
• 25% are associated with
gastrocnemius-soleus contracture
• Most of the time resolves
spontaneously
Classification
•Hypermobile flexible pes planovalgus (most
common)
 familial
o associated with generalized ligamentous
laxity and lower extremity rotational problem
o usually bilateral
 associated with an accessory navicular
•Flexible pes planovalgus with a tight heel cord
•Rigid flatfoot & tarsal coalition (least common)
Clinical Presentation
•Appearance:
Flat foot deformity on
standing, that reconstitutes
with toe walking, hallux
dorsiflexion, or foot hanging,
•Components:
Hindfoot Valgus
Forefoot abduction
Clinical Presentation
Range of Motion
•Normal and painless
subtalar motion
•Hindfoot valgus corrects to
a varus position with toe
standing
•Evaluate for decreased
dorsiflexion and tight heel
cord
13 yrs Old, girl. Two sublings with
H/o recent onset of pain & Night
cramps
Radiological Evaluation
• Painful flexible flatfoot to rule out
other mimicking conditions
 tarsal coalition (sinus tarsi pain)
 congenital vertical talus (rocker bottom
foot)
 accessory navicular (focal pain at
navicular)
 Rigid flatfoot
Radiological Evaluation
Meary’s angle subtended from a line drawn through axis of the talus and axis of 1st ray
• Normal Meary’s angle is 0, angle > 4 deg shows: Pes planus deformity
• Mild: <15 deg , Moderate: 15-30 deg , Severe: > 30 deg
Kite angles
Treatment
NON OPERATIVE RX
• observation, stretching, shoe wear
modification, orthotics
• Indications
asymptomatic patients, as it almost always
resolves spontaneously
counsel parents that arch will redevelop with age
stretching for symptomatic patients with a tight
heel cord
Indications of Surgery
CLINICAL:
•Progressively
increasing pain at
Mid-Tarsal Joint
•Local Tenderness
•Fatiguibility
•Difficult to continue
sport activity
RADIOLOGICAL
INDICATIONTS:
•Maery Angle >40
•Kite angle >400
Treatment
•OPERATIVE:
•Achilles tendon or gastrocnemius fascia
lengthening
Indication
•flexible flatfoot with a tight heelcord with
painful symptoms refractory to stretching
•calcaneal lengthening osteotomy (with or
without cuneiform osteotomy)
Indications
•continued refractory pain despite use of
extensive conservative management
Case: 12 yr old Boy:
Pain (Left foot) - 1 year
Difficulty walking
1st Born via NSVD at 9 months of
gestation, achieved normal
developmental milestones; normal
cognitive functions;
Family noticed Left foot deformity
at birth;
Initially was advised physiotherapy
(somewhere else) and was improved
For 1 year, again complaining of left
foot pain which has limited his
walking time to 5-10 mins
PES PLANOVALGUS
DEFORMITY: Flat foot
Which Angles, needed to assess the Diagnose & Severity
Talocalcaneal angle
(Kite angle):
Lines drawn down the
axis of talus and
calcaneus.
The midtalar
line should pass
through (or just
medial to) the base
of the 1st metatarsal
and the mid-
calcaneal
line should pass
through the base of
the 4th metatarsal.
• Hindfoot varus: <25
• Normal : 25-40
• Hindfoot valgus:
>40
45
Meary’s angle subtended from a line drawn through axis of the talus and axis of 1st ray
• Normal Meary’s angle is 0, angle > 4 deg shows: Pes planus deformity
• Mild: <15 deg , Moderate: 15-30 deg , Severe: > 30 deg
23
Right Angles
Comparative angle difference
• Muyad Khadim. Surgical Rx of
Plano valgus foot deformity,
in CP. J. Children Orthop.
2012(3)217-227
Subtalar fusion with cuneo-navicular joint fusion and
proximal phalangeal osteotomy of the great toe.
Conclusions: Surgery is effective in the treatment of planovalgus deformity in
ambulatory children with cerebral palsy. Severe and rigid planovalgus feet can be
treated effectively with subtalar fusion.
Feet with milder deformity show good results, with calcaneal lengthening. Surgery
provides good correction in young patients, but there is a higher recurrence rate.
Muyad Khadim. Surgical Rx of Plano valgus foot deformity, in CP.
J. Children Orthop. 2012(3)217-227
Lateral Column Lengthening
References
• J Bone Joint Surg Am. (2007) 89:2:111–121
• Acta Orthopædica Belgica, (73)3,2007
• Hamanishi C. J Pediatr Orthop, 1984, 4: 318–326.
• Kumar SJ, Cowell HR, Ramsey PL. Instr Course Lect, 1982, 31: 235–251.
• Farhang Alaee, Stephanie Boehm, Matthew B. Dobbs.
• https://dx.doi.org/10.1007%2Fs11832-007-0037-1
• https://link.springer.com/book/10.1007/978-1-84882-611-3
• Ze-Xing Zhu, Wei lei, Lu-yu Huang. 2010. https://doi.org/10.1111/j.1757-
7861.2010.00090.x
• Ogata K, Schoenecker PL, Sheridan J (1979). Clin Orthop 139:128–132.
• Grice DS (1952). J Bone Joint Surg Am 34 A:927–940
• Grice DS (1955). J Bone Joint Surg Am 37-A:246–259
Thank you for patience

More Related Content

What's hot

What's hot (20)

Knee rthrodesis
Knee rthrodesisKnee rthrodesis
Knee rthrodesis
 
Total knee approaches
Total knee approachesTotal knee approaches
Total knee approaches
 
Tips, tricks and pitfalls of proximal femoral nailing (PFN)
Tips, tricks and pitfalls of proximal femoral nailing (PFN)Tips, tricks and pitfalls of proximal femoral nailing (PFN)
Tips, tricks and pitfalls of proximal femoral nailing (PFN)
 
TENS
TENSTENS
TENS
 
Perilunate dislocations
Perilunate dislocationsPerilunate dislocations
Perilunate dislocations
 
Patella fractures and extensor mechanism injuries
Patella fractures and extensor mechanism injuries Patella fractures and extensor mechanism injuries
Patella fractures and extensor mechanism injuries
 
Cavus foot
Cavus footCavus foot
Cavus foot
 
Radial head fracture
Radial head fractureRadial head fracture
Radial head fracture
 
limb length discrepancy
limb length discrepancylimb length discrepancy
limb length discrepancy
 
Equinus
EquinusEquinus
Equinus
 
Pes planus
Pes planusPes planus
Pes planus
 
Protrusio acetabuli
Protrusio acetabuliProtrusio acetabuli
Protrusio acetabuli
 
Sushil seminar ctev
Sushil seminar ctevSushil seminar ctev
Sushil seminar ctev
 
Posterolateral corner injuries of knee joint
Posterolateral corner injuries of knee joint Posterolateral corner injuries of knee joint
Posterolateral corner injuries of knee joint
 
Tibial plateau fractures
Tibial plateau fracturesTibial plateau fractures
Tibial plateau fractures
 
Septic arthritis sequelae.
Septic arthritis sequelae.Septic arthritis sequelae.
Septic arthritis sequelae.
 
Iliotibial band contracture
Iliotibial band contractureIliotibial band contracture
Iliotibial band contracture
 
Ankle arthrodesis
Ankle arthrodesisAnkle arthrodesis
Ankle arthrodesis
 
Implant Selection In Revision T.K.R
Implant Selection In Revision T.K.RImplant Selection In Revision T.K.R
Implant Selection In Revision T.K.R
 
congenital vertical talus BY Dr Nk singh
congenital vertical talus BY Dr Nk singhcongenital vertical talus BY Dr Nk singh
congenital vertical talus BY Dr Nk singh
 

Similar to Congenital vertical talus Pes Plano Valgus

Advanced radiographic positions for the lower extremities
Advanced radiographic positions for the lower extremitiesAdvanced radiographic positions for the lower extremities
Advanced radiographic positions for the lower extremities
mr_koky
 

Similar to Congenital vertical talus Pes Plano Valgus (20)

congenital vertical talus by DR.Girish motwani
congenital vertical talus by DR.Girish motwanicongenital vertical talus by DR.Girish motwani
congenital vertical talus by DR.Girish motwani
 
Radiographic assessment of pediatric foot alignment
Radiographic assessment of pediatric foot alignmentRadiographic assessment of pediatric foot alignment
Radiographic assessment of pediatric foot alignment
 
Ctev
CtevCtev
Ctev
 
Pediatric foot deformities
Pediatric foot deformitiesPediatric foot deformities
Pediatric foot deformities
 
Congenital vertical talus
Congenital vertical talusCongenital vertical talus
Congenital vertical talus
 
Fractures and Dislocations of Foot - Dr Sunkappa SR
Fractures and Dislocations of Foot - Dr Sunkappa SRFractures and Dislocations of Foot - Dr Sunkappa SR
Fractures and Dislocations of Foot - Dr Sunkappa SR
 
Ctev
CtevCtev
Ctev
 
Advanced radiographic positions for the lower extremities
Advanced radiographic positions for the lower extremitiesAdvanced radiographic positions for the lower extremities
Advanced radiographic positions for the lower extremities
 
Congenital vertical talus
Congenital vertical talusCongenital vertical talus
Congenital vertical talus
 
Vertical talus
Vertical talusVertical talus
Vertical talus
 
Clup foot
Clup footClup foot
Clup foot
 
Flat foot work up
Flat foot work upFlat foot work up
Flat foot work up
 
Ctev
CtevCtev
Ctev
 
X rays of pelvic limb
X rays of pelvic limbX rays of pelvic limb
X rays of pelvic limb
 
AJM Sheet: pes cavus
AJM Sheet: pes cavusAJM Sheet: pes cavus
AJM Sheet: pes cavus
 
VERTICA Talus AKU august2023.pptx
VERTICA Talus AKU august2023.pptxVERTICA Talus AKU august2023.pptx
VERTICA Talus AKU august2023.pptx
 
Pes planus seminar
Pes planus seminarPes planus seminar
Pes planus seminar
 
Pes planus and pes valgus
Pes planus and pes valgus Pes planus and pes valgus
Pes planus and pes valgus
 
Congenital vertical talus
Congenital vertical talusCongenital vertical talus
Congenital vertical talus
 
Orthopedics 5th year, 3rd lecture (Dr. Ali A.Nabi)
Orthopedics 5th year, 3rd lecture (Dr. Ali A.Nabi)Orthopedics 5th year, 3rd lecture (Dr. Ali A.Nabi)
Orthopedics 5th year, 3rd lecture (Dr. Ali A.Nabi)
 

More from Anisuddin Bhatti

More from Anisuddin Bhatti (20)

Why Ponseti Technique in Clubfoot management MARCH 2022.pptx
Why Ponseti Technique in Clubfoot management MARCH 2022.pptxWhy Ponseti Technique in Clubfoot management MARCH 2022.pptx
Why Ponseti Technique in Clubfoot management MARCH 2022.pptx
 
Principles, pitfalls & problems of Paediatrics Fractures AKU 2023.pptx
Principles, pitfalls & problems of Paediatrics Fractures AKU 2023.pptxPrinciples, pitfalls & problems of Paediatrics Fractures AKU 2023.pptx
Principles, pitfalls & problems of Paediatrics Fractures AKU 2023.pptx
 
Principles of Containment in PERTHES AKU August 2023.pptx
Principles of Containment in PERTHES AKU August 2023.pptxPrinciples of Containment in PERTHES AKU August 2023.pptx
Principles of Containment in PERTHES AKU August 2023.pptx
 
CLUBFOOT Rx Principles AKU.ppt
CLUBFOOT Rx Principles AKU.pptCLUBFOOT Rx Principles AKU.ppt
CLUBFOOT Rx Principles AKU.ppt
 
Mock Examination short case Club Foot.pptx
Mock Examination short case Club Foot.pptxMock Examination short case Club Foot.pptx
Mock Examination short case Club Foot.pptx
 
Mock Examination Short CKD to long case.pptx
Mock Examination Short CKD to long case.pptxMock Examination Short CKD to long case.pptx
Mock Examination Short CKD to long case.pptx
 
Mock ExaminationLong case Cerebral Palsy .pptx
Mock ExaminationLong case Cerebral Palsy  .pptxMock ExaminationLong case Cerebral Palsy  .pptx
Mock ExaminationLong case Cerebral Palsy .pptx
 
Mock Clinical Examination Long case Acetabulum frx.pptx
Mock Clinical Examination Long case Acetabulum frx.pptxMock Clinical Examination Long case Acetabulum frx.pptx
Mock Clinical Examination Long case Acetabulum frx.pptx
 
Mock Examination short case Club Foot.pptx
Mock Examination short case Club Foot.pptxMock Examination short case Club Foot.pptx
Mock Examination short case Club Foot.pptx
 
Mock Examination Short case CKD to long case.pptx
Mock Examination Short case CKD to long case.pptxMock Examination Short case CKD to long case.pptx
Mock Examination Short case CKD to long case.pptx
 
Mock Examination Long case Cerebral Palsy.pptx
Mock Examination Long case Cerebral Palsy.pptxMock Examination Long case Cerebral Palsy.pptx
Mock Examination Long case Cerebral Palsy.pptx
 
Bhatti's Functional Scoring System for Developmental Dysplastic Hips
Bhatti's Functional Scoring System for Developmental Dysplastic HipsBhatti's Functional Scoring System for Developmental Dysplastic Hips
Bhatti's Functional Scoring System for Developmental Dysplastic Hips
 
Pakistan Clubfoot Disability Prevention program
Pakistan Clubfoot Disability Prevention programPakistan Clubfoot Disability Prevention program
Pakistan Clubfoot Disability Prevention program
 
Post Polio residual Palsy & Deformities part3 Upper limb
Post Polio residual Palsy & Deformities part3 Upper limbPost Polio residual Palsy & Deformities part3 Upper limb
Post Polio residual Palsy & Deformities part3 Upper limb
 
PostPolio Residual Paralysis part2 lower limb
PostPolio Residual Paralysis part2 lower limbPostPolio Residual Paralysis part2 lower limb
PostPolio Residual Paralysis part2 lower limb
 
Post Polio Residual Palsy: Pathophysiology & Principles of Rx
Post Polio Residual Palsy: Pathophysiology & Principles of RxPost Polio Residual Palsy: Pathophysiology & Principles of Rx
Post Polio Residual Palsy: Pathophysiology & Principles of Rx
 
LCPD Perthes'_ management
LCPD Perthes'_ managementLCPD Perthes'_ management
LCPD Perthes'_ management
 
1 perthese diagnosis &amp; classification
1 perthese diagnosis &amp; classification1 perthese diagnosis &amp; classification
1 perthese diagnosis &amp; classification
 
4 ddh principles &amp; protocols 3 &amp; above
4 ddh principles &amp; protocols 3 &amp; above4 ddh principles &amp; protocols 3 &amp; above
4 ddh principles &amp; protocols 3 &amp; above
 
3a ddh open reduction principles &amp; protocols
3a ddh open reduction principles &amp; protocols3a ddh open reduction principles &amp; protocols
3a ddh open reduction principles &amp; protocols
 

Recently uploaded

Unit 4 Pharmaceutical Organic Chemisty 3 Quinoline
Unit 4 Pharmaceutical Organic Chemisty 3 QuinolineUnit 4 Pharmaceutical Organic Chemisty 3 Quinoline
Unit 4 Pharmaceutical Organic Chemisty 3 Quinoline
AarishRathnam1
 
Difference Between Skeletal Smooth and Cardiac Muscles
Difference Between Skeletal Smooth and Cardiac MusclesDifference Between Skeletal Smooth and Cardiac Muscles
Difference Between Skeletal Smooth and Cardiac Muscles
MedicoseAcademics
 
Unveiling Pharyngitis: Causes, Symptoms, Diagnosis, and Treatment Strategies.pdf
Unveiling Pharyngitis: Causes, Symptoms, Diagnosis, and Treatment Strategies.pdfUnveiling Pharyngitis: Causes, Symptoms, Diagnosis, and Treatment Strategies.pdf
Unveiling Pharyngitis: Causes, Symptoms, Diagnosis, and Treatment Strategies.pdf
NoorulainMehmood1
 
Connective Tissue II - Dr Muhammad Ali Rabbani - Medicose Academics
Connective Tissue II - Dr Muhammad Ali Rabbani - Medicose AcademicsConnective Tissue II - Dr Muhammad Ali Rabbani - Medicose Academics
Connective Tissue II - Dr Muhammad Ali Rabbani - Medicose Academics
MedicoseAcademics
 
Obat Aborsi Ampuh Usia 1,2,3,4,5,6,7 Bulan 081901222272 Obat Penggugur Kandu...
Obat Aborsi Ampuh Usia 1,2,3,4,5,6,7 Bulan  081901222272 Obat Penggugur Kandu...Obat Aborsi Ampuh Usia 1,2,3,4,5,6,7 Bulan  081901222272 Obat Penggugur Kandu...
Obat Aborsi Ampuh Usia 1,2,3,4,5,6,7 Bulan 081901222272 Obat Penggugur Kandu...
Halo Docter
 
Cytoskeleton and Cell Inclusions - Dr Muhammad Ali Rabbani - Medicose Academics
Cytoskeleton and Cell Inclusions - Dr Muhammad Ali Rabbani - Medicose AcademicsCytoskeleton and Cell Inclusions - Dr Muhammad Ali Rabbani - Medicose Academics
Cytoskeleton and Cell Inclusions - Dr Muhammad Ali Rabbani - Medicose Academics
MedicoseAcademics
 
Histology of Epithelium - Dr Muhammad Ali Rabbani - Medicose Academics
Histology of Epithelium - Dr Muhammad Ali Rabbani - Medicose AcademicsHistology of Epithelium - Dr Muhammad Ali Rabbani - Medicose Academics
Histology of Epithelium - Dr Muhammad Ali Rabbani - Medicose Academics
MedicoseAcademics
 

Recently uploaded (20)

Buy 5cladba from 5cl precursor supplier with strong effect
Buy 5cladba from 5cl precursor supplier with strong effectBuy 5cladba from 5cl precursor supplier with strong effect
Buy 5cladba from 5cl precursor supplier with strong effect
 
Top 15 Sexiest Pakistani Pornstars with Images & Videos
Top 15 Sexiest Pakistani Pornstars with Images & VideosTop 15 Sexiest Pakistani Pornstars with Images & Videos
Top 15 Sexiest Pakistani Pornstars with Images & Videos
 
Unit 4 Pharmaceutical Organic Chemisty 3 Quinoline
Unit 4 Pharmaceutical Organic Chemisty 3 QuinolineUnit 4 Pharmaceutical Organic Chemisty 3 Quinoline
Unit 4 Pharmaceutical Organic Chemisty 3 Quinoline
 
Creeping Stroke - Venous thrombosis presenting with pc-stroke.pptx
Creeping Stroke - Venous thrombosis presenting with pc-stroke.pptxCreeping Stroke - Venous thrombosis presenting with pc-stroke.pptx
Creeping Stroke - Venous thrombosis presenting with pc-stroke.pptx
 
Stereochemistry & Asymmetric Synthesis.pptx
Stereochemistry & Asymmetric Synthesis.pptxStereochemistry & Asymmetric Synthesis.pptx
Stereochemistry & Asymmetric Synthesis.pptx
 
CONGENITAL HYPERTROPHIC PYLORIC STENOSIS by Dr M.KARTHIK EMMANUEL
CONGENITAL HYPERTROPHIC PYLORIC STENOSIS  by Dr M.KARTHIK EMMANUELCONGENITAL HYPERTROPHIC PYLORIC STENOSIS  by Dr M.KARTHIK EMMANUEL
CONGENITAL HYPERTROPHIC PYLORIC STENOSIS by Dr M.KARTHIK EMMANUEL
 
Difference Between Skeletal Smooth and Cardiac Muscles
Difference Between Skeletal Smooth and Cardiac MusclesDifference Between Skeletal Smooth and Cardiac Muscles
Difference Between Skeletal Smooth and Cardiac Muscles
 
Unveiling Pharyngitis: Causes, Symptoms, Diagnosis, and Treatment Strategies.pdf
Unveiling Pharyngitis: Causes, Symptoms, Diagnosis, and Treatment Strategies.pdfUnveiling Pharyngitis: Causes, Symptoms, Diagnosis, and Treatment Strategies.pdf
Unveiling Pharyngitis: Causes, Symptoms, Diagnosis, and Treatment Strategies.pdf
 
Top 10 Most Beautiful Russian Pornstars List 2024
Top 10 Most Beautiful Russian Pornstars List 2024Top 10 Most Beautiful Russian Pornstars List 2024
Top 10 Most Beautiful Russian Pornstars List 2024
 
Drug development life cycle indepth overview.pptx
Drug development life cycle indepth overview.pptxDrug development life cycle indepth overview.pptx
Drug development life cycle indepth overview.pptx
 
TEST BANK For Nursing Leadership, Management, and Professional Practice for t...
TEST BANK For Nursing Leadership, Management, and Professional Practice for t...TEST BANK For Nursing Leadership, Management, and Professional Practice for t...
TEST BANK For Nursing Leadership, Management, and Professional Practice for t...
 
Connective Tissue II - Dr Muhammad Ali Rabbani - Medicose Academics
Connective Tissue II - Dr Muhammad Ali Rabbani - Medicose AcademicsConnective Tissue II - Dr Muhammad Ali Rabbani - Medicose Academics
Connective Tissue II - Dr Muhammad Ali Rabbani - Medicose Academics
 
Unlocking Holistic Wellness: Addressing Depression, Mental Well-Being, and St...
Unlocking Holistic Wellness: Addressing Depression, Mental Well-Being, and St...Unlocking Holistic Wellness: Addressing Depression, Mental Well-Being, and St...
Unlocking Holistic Wellness: Addressing Depression, Mental Well-Being, and St...
 
Signs It’s Time for Physiotherapy Sessions Prioritizing Wellness
Signs It’s Time for Physiotherapy Sessions Prioritizing WellnessSigns It’s Time for Physiotherapy Sessions Prioritizing Wellness
Signs It’s Time for Physiotherapy Sessions Prioritizing Wellness
 
Obat Aborsi Ampuh Usia 1,2,3,4,5,6,7 Bulan 081901222272 Obat Penggugur Kandu...
Obat Aborsi Ampuh Usia 1,2,3,4,5,6,7 Bulan  081901222272 Obat Penggugur Kandu...Obat Aborsi Ampuh Usia 1,2,3,4,5,6,7 Bulan  081901222272 Obat Penggugur Kandu...
Obat Aborsi Ampuh Usia 1,2,3,4,5,6,7 Bulan 081901222272 Obat Penggugur Kandu...
 
Cytoskeleton and Cell Inclusions - Dr Muhammad Ali Rabbani - Medicose Academics
Cytoskeleton and Cell Inclusions - Dr Muhammad Ali Rabbani - Medicose AcademicsCytoskeleton and Cell Inclusions - Dr Muhammad Ali Rabbani - Medicose Academics
Cytoskeleton and Cell Inclusions - Dr Muhammad Ali Rabbani - Medicose Academics
 
Top 10 Most Beautiful Chinese Pornstars List 2024
Top 10 Most Beautiful Chinese Pornstars List 2024Top 10 Most Beautiful Chinese Pornstars List 2024
Top 10 Most Beautiful Chinese Pornstars List 2024
 
Histology of Epithelium - Dr Muhammad Ali Rabbani - Medicose Academics
Histology of Epithelium - Dr Muhammad Ali Rabbani - Medicose AcademicsHistology of Epithelium - Dr Muhammad Ali Rabbani - Medicose Academics
Histology of Epithelium - Dr Muhammad Ali Rabbani - Medicose Academics
 
TEST BANK For Guyton and Hall Textbook of Medical Physiology, 14th Edition by...
TEST BANK For Guyton and Hall Textbook of Medical Physiology, 14th Edition by...TEST BANK For Guyton and Hall Textbook of Medical Physiology, 14th Edition by...
TEST BANK For Guyton and Hall Textbook of Medical Physiology, 14th Edition by...
 
Anti viral drug pharmacology classification
Anti viral drug pharmacology classificationAnti viral drug pharmacology classification
Anti viral drug pharmacology classification
 

Congenital vertical talus Pes Plano Valgus

  • 1.
  • 2. Congenital Vertical Talus ANISUDDIN BHATTI Consultant Paediatric Orthopaedic Surgery Dept. Orthopaedic, & Spine Surgery Dr. Ziauddin Hospital Clifton, Karachi
  • 4. Congenital Vertical Talus Several Synonyms Termanology: o Congenital Convex pes valgus (CCPV). Rocker bottom foot o Congenital valgus flat foot. Talipes convex pes valgus. Q. Pathoanotomy ?? Deformity Comopents??
  • 5. •Teratologic dorso-lateral dislocation of Talo-Calcaneo-Navicular joint. •Navicular is dislocated dorsally on the talar head and neck. •Talus oriented vertically leading to fixed equinus contracture of the hindfoot and a Rocker bottom deformity.. Tachdjian Congenital Vertical Talus Term 1st used by Henken in 1914 50% Idiopathic. 50% associated with Other diseases
  • 6. PathoAnatomy: Skeletal Abnormalities Talus: head and neck flattened and deviated medially & plantarward Calcaneum: plantar flexed and externally rotated Navicular: Displaced dorsally and laterally & hypoplastic Cuboid: Deformed & laterally deviated Dorsolateral subluxation or Dislocation of the Calcaneo-Cuboid joint.
  • 7. Soft Tissues abnormalities •Elongation of Medial Structures: tendons, calcaneo navicular ligament and anterior fibers of the deltoid ligament. •Contractures of dorsolateral structures: peroneal tendons, extensor tendons, calcaneo-fibular ligament, talo-navicular ligaments and capsule of ankle and subtalar joint
  • 8. Contracture of Dorsolateral Structures • Contracture of: TA, EHB, PL, PT, and AT •Planter flexors displaced dorsally and act as Dorsiflexors: Tibialis Posterior, PB & PL Vascuar supply-dominated by DPA and ATA , deficient PTA.
  • 9. Clinical presentation (Reverse Clubfoot deformity) •Fore foot: Abduction, Dorsiflexion •Hind foot: Equinus and Valgus •Plantar surface: convex: Rocker bottom appearance •Deep creases: on anterolateral aspect of foot •Foot: everted into valgus and externally rotated position Elongation of medial column and shortening of lateral column
  • 10. Q. Radiological Evaluation ?? Q. Any special view Needed for DD ??
  • 11. Normal foot: long axis of first metatarsal passes plantarward to long axis of talus. CVT: long axis of first metatarsal remains dorsal to long axis of talus, indicating dorsal dislocation of midfoot and forefoot. Radiological Evaluation
  • 12. Special View: Plantar flexion view •maximum plantar flexion view demonstrates irreducible talonavicular joint: oNavicular cannot be reduced on the talus oline drawn thru axis of talus passes plantar to metatarsal axis. •Plantar flexion fails to realign talus & first metatarsal, confirming diagnosis of a fixed talonavicular dislocation ("vertical talus")
  • 13. Radiographic Confirmation of CVT: 6 Wks old Baby A. Lateral Planter flexion radiograph, showing persistent dorsal translation of forefoot on hind foot B. Lateral dorsiflexion radiograph of the same foot, showing persistant planter flexion of Talus & Calcaneum A B
  • 14. Radiological Evaluation: Angles AP VIEW: Kite angle: (Talo-Calcaneal angle) • Normal 20-400 • CVT >40 • Valgus of midfoot LATERAL VIEW: • Meary’s angle ( angle between long axis of talus and first Metatarsal). N=<40 VT >20 • Vertical position of Talus • Shows Navicular dislocation
  • 15. Lines drawn down the axis of talus and calcaneus: • The midtalar line should pass through (or just medial to) the base of the 1st metatarsal • The mid-calcaneal line should pass through the base of the 4th metatarsal. • Hindfoot varus: <25 • Normal : 25-40 • Hindfoot valgus: >40 Kite Angle: Talo-Calcaneal Angle 12 yr old
  • 16. • Normal Meary’s angle is 0, angle > 4 deg shows: • Pes planus deformity: Mild: <15 deg , Moderate: 15-30 deg, Severe: > 30 deg Meary’ Angle Meary’s angle, Talo 1st MT tarsal Angle: line drawn through axis of the talus and axis of 1st MT ray
  • 17. Meary’ Angle: Comparative Left Pes Plano valgus 12 yrs old boy Meary’s Angle: Left 230 PPV Rigt < 100 Normal
  • 18. Q. Any Classification? Q. On what basis CVT classified
  • 19. Coleman’s Classification Two Types •Type 1: CVT with both talonavicular and calcaneocuboid •joint dislocations •Type 2: CVT with isolated talonavicular dislocation This distinction is important clinically because the type 1 deformity is stiffer and particular attention must be paid to releasing the calcaneo-cuboid joint.
  • 20. Coleman Type 1 • Key feature of fixed dorsal dislocation of navicular on neck of talus, equinus position of talus and calcaneus, dorsiflexion of forefoot, and abduction contracture of the foot. •In CVT line through talus is plantar to navicular (cuboid) in both resting lateral and plantar flexed views
  • 21. Ogata and Schoenecker Three groups: •Group 1: Idiopathic, no other associated diagnoses. •Group 2: Associated with other congenital anomalies but no neurologic deficits. •Group 3: Associated with neurologic disorders.
  • 22. Hamanishi’s Classification Five groups based on association with: (1)Neural tube defects or spinal anomalies, (2)Neuromuscular disorders, (3) Malformation syndromes, (4) Chromosomal aberrations, and (5) Idiopathic.
  • 23. Q. What are the variants & DD? Q. How they are Differentiated?
  • 24. Variants a. Pes Plano Rigidus: Navicular never reduce on planter flexion: CVT. b. Pes Plano flexus: navicular will reduce on planter flexion c. Oblique Talus: Less sever variant of VT.
  • 25. Flexible to Rigid CVT • Because the navicular may not be ossified, the alignment of the first metatarsal to the talus must be evaluated. •Hamanishi described 2 radiographic angles: Talar axis– first metatarsal base angle (TAMBA) and Calcaneal metatarsal base angle (CAMBA). •The changing point from a flexible oblique talus to rigid CVT is a TAMBA of approximately 60° and a CAMBA of 200
  • 26. OBLIQUE TALUS •A deformity that is somwhere between the sever form of flexible pes planus and congenital convex pes valgus. •It differ from congenital convex pes valgus by absence of dislocation of T-N jt (in Planter flexion) •Maintaining these distictions prevents overdiagnosis of cong convex ps valgus. •Additionally, better evaluation of Rx for cong convex pes valgus results because those case with better prognosis and better response to non-surgical intervention are not included in data for the management of cong convex pes valgus. Harris EJ. Clin Podiatr Med Sur. 2000 17(3):419-42
  • 27. Oblique Talus • Pes Plano Flexus. • Head of talus palpable on plantar medial aspect of midfoot. Correctable on planter flexion, reducible T-N-J dislocation • Radiological evaluation: CVT Rigidus oAP view: increased talocalcaneal angle oLateral Plantarflexed view: fixed forefoot dorsal dislocation oDorsiflexed lateral view: fixed equinus of hindfoot Congenital Oblique Talus: oLateral radiographs of the foot in maximal plantarflexion can reveal if the navicular is reducible.
  • 28. A. Plantar flexion lateral radiograph showing persistent dorsal translation of the forefoot on the hindfoot. B. Dorsiflexion Lateral radiograph of the same foot, showing persistent plantar flexion of the talus and calcaneus A 12- week-old male with congenital vertical talus Lateral radiograph of a 7-week-old male with an oblique talus, A. demonstrating vertical position of the talus. B Lateral plantar flexion radiograph, demonstrating restoration of the normal relationship between the longitudinal axis of the talus and the first metatarsal vertical talus Oblique talus
  • 29. Late presentation • Left Untreated: o More rigid deformity and adaptive changes in tarsal bones. o Heel doesn’t touch the ground. o Pt. forced to bear wt on talar head. o Callosities around the head of talus.. • Disability: o The painful callosities causes significant disability with an awkward gait & difficulty in balancing . o Frequent abnormal Shoe wear & tear https://link.springer.com/book/10.1007/978-1-84882-611-3 NMI Case: 7 yr age Male
  • 30. Differential Diagnosis • Calcaneo-valgus foot deformity (Dorsif-lexus) : foot is dorsiflexed, to such degree dorsal surface of foot touching ant. surface of lower leg. No equinus contracture of calcaneus. Deformity is often flexible. o Forced plantar flexion lateral x-ray – normal • Posterio medial bow of the tibia: an apparent Calcaneo valgus foot with a shortened and bowed tibia.
  • 31. Flat Foot (Calcaneo Valgus) vs CVT • 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 calcaneo-valgus foot. • Upon plantar flexing the congenital vertical talus foot the gap remains and, in a calcaneo-valgus foot, the gap disappears as the talonavicular joint reduces in plantar flexion.
  • 32. HAMANISHI’S ANGLES •Hamanishi described 2 radiographic angles: the talar axis–first metatarsal base angle (TAMBA) and the calcaneal metatarsal base angle (CAMBA). •The changing point from a flexible oblique talus to rigid CVT is a TAMBA of approximately 60° and a CAMBA of 200
  • 33. Hamanishi’s TAMBA & CAMBA TMT1- 1st metatarsal axis should line up exactly with long axis of talus (TAMBA<30) normal?? CAMBA < Normal
  • 35. Treatment Goal: Restore and maintain normal anatomic relationships between the talus, the navicular, and the calcaneus Objective: •to provide a normal weight distribution through the foot.
  • 36. Treatment Methods: o Manipulation & Casting o Manipulation Casting & Minimal Invasive Reduction o Open reduction o Fusion/ Osteotomies
  • 37. Literature Review Serial Manipulation & Casting • A traditionally used method of improving deformity and thereby decreasing the complexity of an inevitable extensive soft-tissue release operation. • Unlike casting for clubfoot, serial casting for CTV has not been used until recently as a method of achieving definitive correction. • The serial casting with minimal surgery has been a recent addition that in excellent correction in the short-term. • Since mini-invasive approach has been a less invasive approach, it provide more favourable long-term outcomes than more extensive surgery. J Bone Joint Surg Br 67:117–121. J Bone Joint Surg Am(2006)88:1192–1200, Clin Orthop 70:62–72
  • 38. Q. Describe Bobb’s Reverse Ponseti Technique: Salient Features? Q. What is crutial step?
  • 39. Serial Manipulation & Casting Reverse Ponseti Technique • All components of the deformity are corrected simultaneously with the exception of the hindfoot equinus, which is corrected last. • Methodology is similar to the Ponseti method of treatment of clubfoot deformity but in Reverse direction. • Preparation & positions same as for CFD
  • 40. Reverse Ponseti Technique •Crucial to locate the head of talus i.e lying at 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.
  • 41. Reverse Ponseti Manipulative Technique •Illustrations of the direction of the forces applied to reduce a vertical talus deformity. •The foot is stretched into plantar flexion and inversion while counterpressure is applied with the thumb to the medial aspect of the head of the talus. The Journal of Bone and Joint Surger, Inc (J Bone Joint Surg Am. (2007) 89:Pt 1 Suppl 2:111–121)
  • 42. Right foot Left foot With each Weakly, serial manipulation & successive cast, the foot is brought into more equinus, hindfoot varus, forefoot in maximum plantar flexion and inversion to ensure adequate stretching of the contracted dorsolateral tendons, joint capsules and skin. Succesive Serial Casting Lateral Medial Left Foot
  • 43. Manipulation Casting & Molding •Manipulation for 2 minutes, •Hold knee in 90’ of flexion, foot in plantar flexion and inversion •Apply Cast A/K in two stages: 1st B/k, mold and Dry •Carefully mold the malleoli, head of the talus, above the calcaneum and arch •Avoid constant pressure at single point •Extend vast A/K
  • 44. Serial Casts & Follow-up • Cast changed weekly • 4-6 plaster cast is usually enough to achieve reduction of the Talo-navicular joint. • A percutaneous TA tenotomy may be required before applying a Final cast with Maximum plantar flexion, inversion. • At the last cast Foot simulates –clubfoot. • Evaluation: Lateral radiograph in PF: TAMBA<300 Since the navicular is not ossified in infants, reduction is confirmed indirectly by the talar axis-first metatarsal base angle as measured on the lateral foot radiograph.
  • 45. Q. How to proceed, In failure to achieve T-N-J reduction in Non- walking child.
  • 46. Minimal Invasive Approach Matthew B Dobbs Technique. •In resistant cases, after Initial correction with Reverse Ponseti Serial manipulation and casting, a mini-invasive approach is used to achieve Talo Navicular joint reduction. •Reduction Stabilized with retrograde K wire fixation Indication: Failure to achieve T-N Jt reduction even after 6 cast TAMBA>30 Farhang Alaee, Mathew Dobbs J Child Orthop (2007) 1:165–174
  • 47. Dobbs Mini Open Technique •A small medial incision is made, for dorsal capsulectomy of T-N joint to reduce the T-N joint. •Hold talonavicular joint in max flexion alignment, may be with help of an elevator & pass the k-wire retrograde from Navicular to Talus. Farhang Alaee, Mathew Dobbs J Child Orthop (2007) 1:165–174
  • 48. •Once talonavicular joint is reduced and fixed with k- wire,, do TA percutaneous Tenotomy, with a Beaver eye blade 1cm above TA insertion PCAT a. T-N jt. Reduction & fixation with K-wire. Note residual equinus of Calcaneus. b. After PCAT calcaneal equineous corrected
  • 49. PC Joystick technique of T-N-J reduction & Fixation •Joystick technique to lever the talus into position percutaneously with a k-wire J Child Orthop (2007) 1:165–174
  • 50. Q. Any additional procedure (some times required) required in age over 2 yr group?
  • 51. Additional Procedures MIS Technique •In patients, older than 2 years at the time of open reduction of T-N-J, the tibialis anterior tendon is also transferred to the dorsal aspect of the neck of the talus to provide a dynamic corrective force. •If plantar flexion is limited to <25 (as assessed on Xray), a fractional lengthening of extensor digitorum communis is done at the level of the musculotendinous junction. •If passive forefoot adduction is <10, fractional lengthening of the peroneal brevis tendon is performed at the musculotendinous junction. Farhang Alaee, Mathew Dobbs J Child Orthop (2007) 1:165–174
  • 52. Tibialis Anterior Transfer •Tibialis Anterior Tendon Transfer (TATT) to the head or neck of the talus at the time of open reduction to add a dynamic corrective force. Grice DS (1952). J Bone Joint Surg Am 34 A:927–940. Grice DS (1955). J Bone Joint Surg Am 37-A:246–259
  • 53. Dobbs Post Op Protocol Mini Open Technique • After tenotomy, an A/K cast • 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. • AFO / Reverse BD Shoes, till walking age. • Parents advised exercise: ankle ROM & foot inversion exercises 2-3 times a day.
  • 54. Case Report: Mini Invasive Technique Demonstrating location of the incision over the medial aspect of the talonavicular joint, used for open reduction of the talonavicular joint Demonstrating a single-prong skin hook placed on the navicular and a Freer elevator in the medial subtalar joint being used to reduce the talus to a horizontal position in relation to the navicular Demonstrating Kirschner wire fixation of the reduced talonavicular joint Dobbs MJ Child Orthop (2007) 1:165–174
  • 55. Case Report: Mini Invasive Technique Dobbs MJ Child Orthop (2007) 1:165–174 Lateral radiograph and clinical picture of the same child illustrated in A. & B. at the age of 5 years after treatment with cast correction, percutaneous Kirschner wire fixation, and percutaneous Achilles tendon tenotomy for congenital vertical talus of the right foot
  • 56. Literature Review •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
  • 57. Literature Review •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.
  • 58. Congenital Vertical Talus in Walking Age Children > 2 years Q. How to manage this group?
  • 59. Traditional Surgical Rx: OR Type of procedure based on: •Age of the patient, •Severity of the deformity •Complexity / Associated disorders •Preference of the surgeon. Approach: oTriple incision dorsal approach. oSingle incision posterior approach. Clin Orthop 139:128–132, J Bone Joint Surg Br 67:117–121. Clin Orthop 70:62–72
  • 60. Traditional Surgical Rx vs Age group Children <3 years: • OR soft tissue release, realignment T-N-J, • Tendon lengthening & K wire Fixation • one-stage or two-stage operation. Children >3 years: • Extensive Soft tissue release, • Tendon Lengthening & K wire fixation • Tendon transfer. Children 4 years & Recurrent Deformity • Naviculectomy with extensive release • tendon transfer, or • Subtalar / triple arthrodesis Grice DS (1952). J Bone Joint Surg Am 34 A:927–940. Grice DS (1955). J Bone Joint Surg Am 37-A:246–259
  • 61. Litrature Review •The exact upper age limit for a successful open reduction is not known. •Age > 3 years: Some children require excision of the navicular at the time of open reduction [51, 52]. •Age > 3 years: There is also concern that, an untreated vertical talus results in permanent deformity in the anterior and middle subtalar facets. •If there is not sufficient remodelling potential of the articular surfaces present after an open reduction of the talonavicular joint then a medial column shortening and lateral column lengthening procedure may be necessary. Colton CL (1973) J Bone Joint Surg Br 55:566–574 Clark MW, et al (1977) J Bone Joint Surg Am 59:816–824
  • 62. Litrature Review •Ages of 4-8 years: with either a primary or a recurrent deformity can be treated with open reduction combined with extraarticular arthrodesis. •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. Coleman SS, Stelling FH 3rd, Jarrett J (1970) Clin Orthop 70:62–72 Grice DS (1952). J Bone Joint Surg Am 34 A:927–940. Grice DS (1955). J Bone Joint Surg Am 37-A:246–259
  • 63. One stage OR Procedure Three basic components: First step: Reduction of Talo-N-J with release & transfer of Tibialis Ant Tendon, and release of tibio-navicular and talonavicular ligaments. The reduction is held by a Kirschner wire placed across the talonavicular joint . • Second step: lengthening toe Extensors and Peroneals, and reduction of alcaneocuboid joint (if necessary), to improve ankle plantar flexion and forefoot adduction). • Third step: TA lengthening and releasing, posterior ankle and subtalar capsulotomy, to correct ankle equinus contracture.
  • 64. Single stage reconstruction Three incisions approach •1ST: concave downward over the medial talonavicular joint; •2nd oblique over the sinus tarsi to expose the calcaneocuboid joint and peroneal and extensor tendons; •3rd along the lateral border of the Achilles tendon to allow posterior release.
  • 65. Single stage reconstruction: Three incisions •Medial side Reduction, dorsal talonavicular ligament (deltoid) divided and capsulotomy of talonavicular joint done reduced and transfixed with k-wire. •Dorso lateral elongation: calcaneocuboid joint inspected and reduced •Postrior Lengthenig: Achilles Z-Plasty Lengthening
  • 66. One Stage OR Procedure Fig.1 Intraoperative photograph illustrating Kirschner wire placed antegrade through the talus to aid in reduction of the talonavicular joint during a one-stage reduction procedure (Courtesy of Perry L. Schoenecker) Fig.2 Intraoperative photograph illustrating a posterior ankle and subtalar release performed on the same patient in Fig. 5 during a one stage reduction of a vertical talus (Courtesy of Perry L. Schoenecker) Fig 1 Fig 2
  • 67. Tibialis Anterior Transfer Technique •Origin of Anterior Tibial tendon released and transfer it to the mid talar neck using a drill hole and sewing it to itself. •Similarly Posterior Tibial Tendon, is sewed beneath the talar head and neck to assist in support.
  • 68. Appearance after transferring and fixing the tendon of the anterior tibial muscle to the head of talus with a mini anchor. Diagram showing the anatomy of CVT Ref: Z Zhu et al., Mini anchor for congenital vertical talus Orthopaedic Surgery (2010), Volume 2, No. 3, 218–222 Female, 5 yr old, CVT 3 years ago. (a) The appearance of the CVT. (b) Lateral view radiograph showing a TAMBA of 57°(normal value is 3.3° ⫾ 6.4°) 12 Wks Post-op. & 2 years Post-op Case Reoprt
  • 69. Single stage Posterior Approach: Modified Cincinnati Incision The Cincinnati transverse incision extends from the anteromedial to the anterolateral aspect of the foot over the back of the ankle at the level of the tibiotaler joint. The incision is a modified Cincinnati incision that passes beneath the medial malleolus just past the Achilles tendon posteriorly and proceeds dorsally over the navicular just past the extensor tendons
  • 70. Single stage Posterior Approach Modified Cincinnati Incision
  • 71. Literature Review Modified Cincinnati Approach •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. et al. Journal of Pediatric Orthopaedics; 19(1) 1999: 42-48
  • 72. Two stage operation Approach 1st stage (Anterolateral release): •Lengthening of extensor tendons and tibialis anterior tendon, Peronius Tertius and Dorsolateral capsulotomy / reduction of talo navicular joint 2nd stage (Posterior release): • Correcting equinus contracture by lengthening Achilles tendon, peroneal tendon and posterior ankle and subtalar release
  • 73. Post Reduction Maintenance •After hind foot correction, •second k-wire from plantar surface of heel through the calcaneus and talus into tibia •Long leg above knee cast for 6 weeks •After 6 weeks ,remove 2 k- wires and B/K cast for further 6 weeks
  • 74. Long Term Outcom Literature Review • Disorder should be recognized at birth and treated before the age of 2. • More aggressive procedures must be employed when Rx delayed after 2 yrs. • Both approaches have Good short-term success • Single Incision dorsal approach: oshorter operative time, obetter clinical scores, ofewer complications than the posterior approach J Foot Ankle Surg 2001; 40:166-171. Mazzocca AD et al. J Pediatr Orthop 21:212–217
  • 75. Complications Literature Review Significant short-term complications include: •Wound necrosis, •Under correction of the deformity, •Stiffness of the ankle and subtalar joint, •Eventual need for multiple operative procedures such as subtalar and triple arthrodesis. Long-term outcomes complicated by: •Degenerative arthritis as is seen in many patients with clubfoot treated with extensive soft-tissue releases.
  • 76.
  • 77. Acta Orthopædica Belgica, Vol.73 - 3 - 2007
  • 78. Pes Plano Valgus Flat Foot Deformity Q. How this differ from CVT & to Evaluate?
  • 79. Pes Plano Valgus, Flat Foot Deformity • Defined as a deformity with a flattened arch, of various degree from a lowered arch to rocker bottom deformity of foot. • Unknown in pediatric population • 20% to 25% in adults • Majority associated with Generalized ligamentous Laxity & Cerebral Palsy • 25% are associated with gastrocnemius-soleus contracture • Most of the time resolves spontaneously
  • 80. Classification •Hypermobile flexible pes planovalgus (most common)  familial o associated with generalized ligamentous laxity and lower extremity rotational problem o usually bilateral  associated with an accessory navicular •Flexible pes planovalgus with a tight heel cord •Rigid flatfoot & tarsal coalition (least common)
  • 81. Clinical Presentation •Appearance: Flat foot deformity on standing, that reconstitutes with toe walking, hallux dorsiflexion, or foot hanging, •Components: Hindfoot Valgus Forefoot abduction
  • 82. Clinical Presentation Range of Motion •Normal and painless subtalar motion •Hindfoot valgus corrects to a varus position with toe standing •Evaluate for decreased dorsiflexion and tight heel cord
  • 83. 13 yrs Old, girl. Two sublings with H/o recent onset of pain & Night cramps
  • 84. Radiological Evaluation • Painful flexible flatfoot to rule out other mimicking conditions  tarsal coalition (sinus tarsi pain)  congenital vertical talus (rocker bottom foot)  accessory navicular (focal pain at navicular)  Rigid flatfoot
  • 85. Radiological Evaluation Meary’s angle subtended from a line drawn through axis of the talus and axis of 1st ray • Normal Meary’s angle is 0, angle > 4 deg shows: Pes planus deformity • Mild: <15 deg , Moderate: 15-30 deg , Severe: > 30 deg
  • 87. Treatment NON OPERATIVE RX • observation, stretching, shoe wear modification, orthotics • Indications asymptomatic patients, as it almost always resolves spontaneously counsel parents that arch will redevelop with age stretching for symptomatic patients with a tight heel cord
  • 88. Indications of Surgery CLINICAL: •Progressively increasing pain at Mid-Tarsal Joint •Local Tenderness •Fatiguibility •Difficult to continue sport activity RADIOLOGICAL INDICATIONTS: •Maery Angle >40 •Kite angle >400
  • 89. Treatment •OPERATIVE: •Achilles tendon or gastrocnemius fascia lengthening Indication •flexible flatfoot with a tight heelcord with painful symptoms refractory to stretching •calcaneal lengthening osteotomy (with or without cuneiform osteotomy) Indications •continued refractory pain despite use of extensive conservative management
  • 90. Case: 12 yr old Boy: Pain (Left foot) - 1 year Difficulty walking 1st Born via NSVD at 9 months of gestation, achieved normal developmental milestones; normal cognitive functions; Family noticed Left foot deformity at birth; Initially was advised physiotherapy (somewhere else) and was improved For 1 year, again complaining of left foot pain which has limited his walking time to 5-10 mins
  • 92. Which Angles, needed to assess the Diagnose & Severity
  • 93. Talocalcaneal angle (Kite angle): Lines drawn down the axis of talus and calcaneus. The midtalar line should pass through (or just medial to) the base of the 1st metatarsal and the mid- calcaneal line should pass through the base of the 4th metatarsal. • Hindfoot varus: <25 • Normal : 25-40 • Hindfoot valgus: >40 45
  • 94. Meary’s angle subtended from a line drawn through axis of the talus and axis of 1st ray • Normal Meary’s angle is 0, angle > 4 deg shows: Pes planus deformity • Mild: <15 deg , Moderate: 15-30 deg , Severe: > 30 deg 23
  • 96. • Muyad Khadim. Surgical Rx of Plano valgus foot deformity, in CP. J. Children Orthop. 2012(3)217-227
  • 97. Subtalar fusion with cuneo-navicular joint fusion and proximal phalangeal osteotomy of the great toe. Conclusions: Surgery is effective in the treatment of planovalgus deformity in ambulatory children with cerebral palsy. Severe and rigid planovalgus feet can be treated effectively with subtalar fusion. Feet with milder deformity show good results, with calcaneal lengthening. Surgery provides good correction in young patients, but there is a higher recurrence rate. Muyad Khadim. Surgical Rx of Plano valgus foot deformity, in CP. J. Children Orthop. 2012(3)217-227 Lateral Column Lengthening
  • 98. References • J Bone Joint Surg Am. (2007) 89:2:111–121 • Acta Orthopædica Belgica, (73)3,2007 • Hamanishi C. J Pediatr Orthop, 1984, 4: 318–326. • Kumar SJ, Cowell HR, Ramsey PL. Instr Course Lect, 1982, 31: 235–251. • Farhang Alaee, Stephanie Boehm, Matthew B. Dobbs. • https://dx.doi.org/10.1007%2Fs11832-007-0037-1 • https://link.springer.com/book/10.1007/978-1-84882-611-3 • Ze-Xing Zhu, Wei lei, Lu-yu Huang. 2010. https://doi.org/10.1111/j.1757- 7861.2010.00090.x • Ogata K, Schoenecker PL, Sheridan J (1979). Clin Orthop 139:128–132. • Grice DS (1952). J Bone Joint Surg Am 34 A:927–940 • Grice DS (1955). J Bone Joint Surg Am 37-A:246–259
  • 99. Thank you for patience

Editor's Notes

  1. Ccpv by lamy and weissman
  2. Ligamentous abnormalities mirror the bony deformity