Congenital Vertical Talus(CVT)

CONGENITAL VERTICAL TALUSSAIKRISHNA

Objectives-Anatomy of footIntroduction Etiology Pathoanatomy Clinical presentation Treatment modalities

Anatomy-Foot-bones:Tarsals-7 Metatarsals-5 Phalanges-14Foot-hind foot mid foot fore footJoints-Ankle joint:15DF,55PF -subtalar joint:inv 30,ev-10 -mid tarsal joint:Abd 10;Add 15

Talus-

CVT-Congenital + vertical + talus

Term-1st used by:Heineken in 1914.

Several Synonyms- Congenital convex pes valgus(CCPV) Reverse club foot congenital valgus flat foot Rocker buttom foot Talipes convex pes valgus

Ccpv by lamy and weissman5

Tachdjian describes as the teratologic dorsolateral dislocation of the talocalcaneonavicular joint.

Incidence 1 in 10,000

Male=female

B/L -50%

TachdjianM:Pediatric Orthopedics,vol 4.2nd ed.Philadelphia,WB Saunders,1990.Jacob sen ST,Crawford AH(1983)Congenital vertical talus. J Pediatr Orthop 3:306310

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

Left untreaed causes significant disability.

Heel doesnt touch the ground-pt forced to bear wt on talar head;later on develop painful callosities and have awkward gait with difficulty balancing .

Etiology-Exact etiology :unknown.Possible causes-Muscle imbalance; Intrauterine compression Arrest in fetal development betn 7th -12th wk of POG

Idiopathic-50%

Verticaltalus is a heterogeneous birth defectResulting from many diverse etiologiesNeurolo-distal arthrogyposis,myelomeningocoele,sacral agenesis,-muscle imbalance,Neuromuscular-arthgryposis,sma,neurofibromatosisGen syn-trisomy 13 n trisomy 189

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 GDF5Syndromes-1.De barsy syndrome 2.Prune Belly syndrome 3.Costello syndrome 4.Rasmussen syndromeIatrogenic

HOXD10geneencoding,ahomeobox transcription factorGene expressed early in limb developmentGDF5-CARTILAGE DERIVED MORPHOGENIC PROTEIN-1Avarietyofsyndromeshavealsobeendescribedinwhichverticaltalusisaclinicalmanifestation.11

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

dorsolateral subluxation or dislocation of the calcaneocuboid joint.All dese deformities leads to elongation of the medial column and shortening of the lateral column12

The medial tendons,the calcaneo navicular ligament and the anterior bres of the delta ligament are elongated.

Contractures are on the dorsolateral side and include the peroneal tendons,the extensor tendons,the calcaneobular 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 Am77:19161923

Contracture of the TA,EHB,PL,PT,and AT

Posterior tibial tendon and PB,PL-act as dorsiflexors rather than plantiflexors.

Ligamentous abnormalities mirror the bony deformity15

Vascular supply-dominated by DPA and ATA ;deficient PTA.

Vascular supply at risk-extensive ant dissection and foot in plantar flexed16

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

Plantar surface is convex-Rocker bottom appearance

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

Palpable gap dorsally between navicular and talar neck

Left untreated more rigid deformity and adaptive changes in tarsal bones

Callosities around the head of talus

Heel doesnt touch the ground ;shoewear becomes difficult and pain is inevitable.

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 p70:6272

There has been several classification schemes proposed for vertical talus based either on anatomical abnormalities or associated diagnoses. Incontrasttocongenitalclubfoot,thereiscurrentlynoclini-calclassicationforCVTwhichassessestheseverityofthedeformity;currentclassicationsaremorefocusedonassociateddisorders21

2.Ogata and schoenecker -Three group-1-Idiopathic2-A/W other abnormality but no neurological defecit3.A/W neurological defecit

Clinical Orthopaedics (1979 )139:128132

Oblique talus-less rigid,navicular will reduce on plantiflexionobservation and /or casting

Less severe variant of vertical talus,23

Radiographic features-Ossification cuboid 1st month cuneiform-2nd year navicular-3rd yearAP and lateral radiographs of foot in neutral position

Lateral x-ray in forced dorsi and planti flexion of foot

Since most children with vertical talus are seen in the newborn period, the radiographic 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.24

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

Diagnosis :confirmed by-

Differentials-Calcaneovalgus foot deformity: -foot is dorsiflexed -no equinus contracture of calcaneus -flexible foot -forced plantar flexion lateral x-ray-normalPosteromedial bow of the tibia:calcaneovalgus foot,a shortened and bowed tibiaOblique talus

To such degree dorsal surface of foot touching ant surface of lower leg.28

Treatment-Goal:restore and maintain normal anatomic relationship.

As with the ponseti method of treatment of clubfoot deformity

Serial manipulations and casting-all deformities corrected simultaneously except heel equinus

stretching the foot into plantar exion and inversion with one hand while counter pressure is applied with the thumb of the opposite hand to the medial aspect of the head of the talus 30

Manipulation-Reverse ponseti technique

In the OPD settings

One parent beside the baby to offer a pacifier or bottle of milkOne 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

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 inversion2nd stage-cast extended to A/K cast

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

Final cast Maximum plantar flexion,inversionFoot simulates clubfoot Lateral radigraph in PF;TAMBA30) 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.

Dobbs minimally invasive techniqueIf 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.

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

A Beaver eye blade (Becton Dickinson, Franklin Lakes,New Jersey) is introduced through the skin onto the medialedge of the Achilles tendon about 1 cm above its calcaneal in-sertion with the cutting surface of the blade pointed proxi-mally. The undersurface of the tendon is palpated with the tipof the blade, which is then rotated 45 to allow the tendon tobe severed from ventral to dorsal.62

Dobbs Post op protocolAfter tenotomy,a long leg cast :foot neutral Ankle 5 DFCast changed at 2 weeks (Mold is made for solid AFO with 15 of PF at midtarsal joint)A long leg cast ankle in 10-15DF x 3 weeks

After 5 wks;cast removed and k-wire pulled

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 yrsAfter 7,once every 2 yr until skeletal maturity is reached

range of ankle motion andfoot inversion, to be performed two or three times a day athome.64

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 valgus 2.TAMBA-forefoot abduction lateral: 1.talocalcaneal 2.tibiocalcaneal 3.TAMBA

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