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congenital vertical talus BY Dr Nk singh

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congenital vertical talus

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congenital vertical talus BY Dr Nk singh

  1. 1. Presenter-Dr Navin Singh Co-Moderator- Dr Gajanand Moderator-Dr.Shah Alam Khan All India Institute of Medical Sciences , New Delhi
  2. 2. Objectives- Anatomy of foot Introduction Etiology Pathoanatomy Clinical presentation Treatment modalities
  3. 3. Anatomy-  Foot-bones:Tarsals-7 Metatarsals-5 Phalanges-14 Foot-hind foot mid foot fore foot Joints-Ankle joint:15’DF,55’PF -subtalar joint:inv 30’,ev-10’ -mid tarsal joint:Abd 10’;Add 15’
  4. 4. Talus-
  5. 5. CVT- Congenital + vertical + talus Term-1st 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
  6. 6.  Tachdjian describes as the “teratologic dorsolateral dislocation of the talocalcaneonavicular joint.”  Incidence 1 in 10,000  Male=female  B/L -50%  Tachdjian M: Pediatric Orthopedics, vol 4. 2nd ed. Philadelphia, WB Saunders, 1990.  Jacob sen ST,Crawford AH(1983)Congenital vertical talus. J Pediatr Orthop 3:306–310
  7. 7.  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.  Lamy L,Weissman L(1939)Congenital convex pes valgus. J Bone Joint Surg Am21:79
  8. 8.  Left untreared –causes significant disability.  Heel doesn’t touch the ground-pt forced to bear wt on talar head;later on develop painful callosities and have awkward gait with difficulty balancing .
  9. 9. Etiology-  Exact etiology :unknown.  Possible causes-Muscle imbalance; Intrauterine compression Arrest in fetal development betn 7th -12th wk of POG  Idiopathic-50%
  10. 10.  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
  11. 11.  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  Iatrogenic
  12. 12. Patho-anatomy:  “Kinematic coupling”  Skeletal : Talus-head and neck flattened and medially deviated - plantar flexed position Calcaneum-plantar flexed and externally rotated Navicular- Displaced dorsally and laterally;hypoplastic Cuboid- in severe deformity displaced laterally
  13. 13.  Talocalcaneal angle is increased  Middle and anterior subtalar facet-hypoplastic
  14. 14.  The medial tendons,the calcaneo navicular ligament and the anterior fibres of the delta 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.  Drennan JC(1995)Congenital vertical talus.J Bone Joint Surg Am77:1916–1923
  15. 15.  Contracture of the TA,EHB,PL,PT,and AT  Posterior tibial tendon and PB,PL-act as dorsiflexors rather than plantiflexors.
  16. 16.  Vascuar supply-dominated by DPA and ATA ;deficient PTA.
  17. 17. Clinical presentation-  Characterized by: Forefoot-abduction ;dorsiflexion Hindfoot-equinus and valgus
  18. 18.  Plantar surface is convex-Rocker bottom appearance  Deep creases on anterolateral aspect of foot  Foot is everted into valgus and externally rotated position
  19. 19.  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
  20. 20.  Callosities around the head of talus  Heel doesn’t touch the ground ;shoewear becomes difficult and pain is inevitable.
  21. 21. Classification- 1.Coleman-1st:isolated talonavicular dislocation 2nd-both talonavicular and calcaneocuboid dislocation Coleman SS,Stelling FH 3rd,Jarrett J(1970)Pathomechanics and treatment of congenital vertical talus .Clin Ortho p70:62–72
  22. 22. 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
  23. 23. 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
  24. 24. Oblique talus-  less rigid,navicular will reduce on plantiflexion  observation and /or casting
  25. 25. Radiographic features-  Ossification –cuboid 1st month cuneiform-2nd year navicular-3rd year  AP and lateral radiographs of foot in neutral position  Lateral x-ray in forced dorsi and planti flexion of foot
  26. 26.  Measurements:-on lateral x-ray – talocalcaneal; tibiocalcaneal, tibiotalar,talar axis 1st metatarsal base angle(TAMBA) In CVT-talar axis vertical,calcaneus in equinus and increased talocalcaneal angle
  27. 27. Diagnosis :confirmed by-
  28. 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. 29. Treatment-  Goal:restore and maintain normal anatomic relationship.
  30. 30.  As with the ponseti method of treatment of clubfoot deformity  Serial manipulations and casting-all deformities corrected simultaneously except heel equinus
  31. 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. 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. 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. 34.  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 cast  4-6 plaster cast is usually enough to achieve reduction of the talonavicular joint
  35. 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. 36.  Final cast –Maximum plantar flexion,inversion  Foot simulates –clubfoot  Lateral radigraph in PF;TAMBA<30’
  37. 37. Caring for casts-instruction for parents  Don’t get the cast wet  Don’t let the cast get damaged  Look out for potential problems- The cast slips down –cant see babies toes The cast fall off Bad smell coming from cast Toes are red white or black Baby appears very distressed
  38. 38.  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
  39. 39.  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.
  40. 40.  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
  41. 41.  Major reconsructive surgeries- -single stage releases -two stage releases -soft tissue releases with navicular excision -Grice –green subtalar fusion after release
  42. 42.  Complications-talar necrosis -wound necrosis -stiffness of the ankle and subtalar joint - undercorrection of the deformity -pseudoarthrosis -needs of multiple surgeries J Pediatr Orthop B. 2002;11:60-7 J Pediatr Orthop. 2001;21:212-7. J Bone Joint Surg Am. 1952;34:927-40.
  43. 43.  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
  44. 44. Two stage operation-  1st stage-lengthening of extensor tendons and tibialis anterior tendon and reduction of talo navicular joint  2nd stage -correcting equinus contracture by lengthening Achilles tendon,peroneal tendon and posterior ankle and subtalar release  Complication –AVN of talus
  45. 45. Dorsolateral approach-  The extensor digitorum longus and peroneus tertius tendons are lengthened  The dorsal and lateral talonavicular joint capsule are divided and talonavicular joint reduced and fixed using k-wire
  46. 46.  Achilles tendon lengthened percutaneously  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
  47. 47. Single stage repair-  Three incisions-
  48. 48.  Through DL approach-calcaneocuboid joint inspected and reduced  Medially,dorsal talonavicular ligament (deltoid)divided and capsulotomy of talonavicular joint done; reduced and transfixed with k-wire.
  49. 49.  Postriorly,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
  50. 50.  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.
  51. 51. Modified cincinnati incision-
  52. 52.  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
  53. 53.  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)
  54. 54. Bony procedures- 1)Wedge from navicular (WN), 2)Naviculectomy (NE), 3)Naviculectomy,extensive release and tendon transfer procedures (NERTT), 4)Subtalar / triple arthrodesis (STA).
  55. 55.  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
  56. 56. Acta Orthopædica Belgica, Vol.73 - 3 - 2007
  57. 57.  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.
  58. 58. Matthew B Dobbs, MD  Recognized for his skill at treating all paediatric foot disorders.  Minimally invasive approach toward the treatment of CVT.
  59. 59.  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.
  60. 60. 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
  61. 61. 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.
  62. 62. 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.
  63. 63.  Once talonavicular joint reduced and fixed with k-wire percutaneous tenotomy was done.
  64. 64. Dobbs Post op protocol  After tenotomy,a long leg cast :foot –neutral Ankle 5’ DF  Cast changed at 2 weeks (Mold is made for solid AFO with 15’ of PF at midtarsal joint)  A long leg cast –ankle in 10-15’DF x 3 weeks  After 5 wks;cast removed and k-wire pulled
  65. 65.  The solid orthoses is applied and parents are instructed regarding exercise and ankle ROM.  Orthoses is worn for 23 hrs a day until walking age.  Then 12-14 hrs a day until the age of 2 years.  After bracing every 3 monthly until age of 2 yrs  Then every 6 month-1 yr until age of 7 yrs  After 7,once every 2 yr until skeletal maturity is reached
  66. 66. 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
  67. 67.  Radiological –anteroposterior: 1.talocalcaneal –hindfoot algus 2.TAMBA-forefoot abduction lateral: 1.talocalcaneal 2.tibiocalcaneal 3.TAMBA
  68. 68. 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
  69. 69.  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. J Child Orthop 2007;1:165–174 J Bone Joint Surg [Am] 2012;94-A:73. J Bone Joint Surg [Am] 2006;88- A:1192–1200.
  70. 70. Pitfalls  Kinematics and pathoanatomy of deformity  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
  71. 71. Thank you!!!!!!!!

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