05 Congenital Vertical Talus (Dr Waqar Alam) (1)

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Congenital Vertical Talus:

Congenital Vertical Talus By Dr. Waqar Alam

Synonyms:

Synonyms Congenital Vertical Talus Congenital Convex Pes Valgus Teratological Dislocation of Talo-Calcaneo-Navicular Joint Rocker-bottom flatfoot Congenital rigid flatfoot Persian slipper foot

Definition:

Definition This is vertical placement of Talus with irreducible and rigid dorsal dislocation of the Navicular Bone and equinus of the calcaneus

Incidence:

Incidence Rare anomaly One in 10,000 live births Equal in both sex Bilateral in 50% cases

Etiology:

Etiology Exact cause is unknown In 60% of cases it is associated with other conditions such as Spina Bifida(most common) Trisomy 13 through 15 and 18 DDH Marfan,s Syndrome Thus a very careful musculoskeleal and Neurological assessment is needed in these patients

Etiological Classification:

Etiological Classification Hamanishi (1984) classsify this disorder into Five groups according to an association with one of the following five disorders A)Neural defect/spinal deformities B)Neuromuscular Disorder C)Malformation Syndromes D)Chromosomal aberrations E)Idiopathic

Coleman Classification:

Coleman Classification Type I: Congenital Vertical Talus associated with CalcaneoCuboid dislocation Type II: Congenital Vertical Talus without associated CalcaneoCuboid dislocation

Path physiology:

Path physiology It includes four basic abnormalities which involve bones, joints, ligaments and muscles. Following abnormalities are always present Navicular bone dislocation with vertical talus Tibialis posterior and Peroneus longus tendons displacement Talo-Calcaneal Joint subluxation Fixed equinus of heel

Clinical Presentation:

Clinical Presentation Rounded prominance on the medial and planter surfaces of foot by abnormal location of Talus Abnormalities are present in forefoot, midfoot and hindfoot

Forefoot abnormalities:

Forefoot abnormalities Abducted Pronated Dorsiflexed Clawing of lateral toes

Midfoot abnormalities:

Midfoot abnormalities Medial arch is not only flat but also the most prominent part of sole(Rocker Bottom Foot) A hollow in front of lateral Malleolus

Hindfoot abnormalities:

Hindfoot abnormalities Equinus Valgus

When child start wt. bearing:

When child start wt. bearing Talus become like hourglass and in same alignment with Tibia Calcaneus remain in equinus and displaced posteriorly Calosities on sole and medial aspect of foot

When child start full wt. bearing:

When child start full wt. bearing Forefoot severly abducted Heel does not touch the groung Adaptive changes occur in soft tissues Tibialis Posterior, Peroneal longus and brevis become anterior to malleoli

Investigations:

Investigations A) Radiology 1) A/P View 2) Lateral View(Eyre-Brook View) B) MRI C) Ultra Sound

A/P view shows following findings:

A/P view shows following findings A) Kite angle(TaloCalcaneal angle) >40 (20_40 is Normal) B) Valgus of midfoot

Lateral View(Eyre-Brook View):

Lateral View(Eyre-Brook View) Vertical position of Talus Mearry,s angle( angle between long axis of talus and first Metatarsal) is >20 Shows Navicular dislocation

MRI:

MRI Currently limited to research applications only It provides information about the cartilagenous and soft tissues structures

Ultra Sound:

Ultra Sound In the newborn the Navicular bone is not ossified and on plain X-Ray it is not visualized. For this reason it is best assessed with Ultra Sonography. (Violas, Philippe a ; Chapuis, Madeleine a et al Ultrasound: a helpful technique in the analysis of congenital vertical talus. A case report Journal of Pediatric Orthopaedics B: January 2006 - Volume 15 - Issue 1 - pp 70-72)

Differential Diagnosis:

Differential Diagnosis Congenital CalcaneoValgus Deformity Congenital absence of Fibula PlanoValgus foot Severe Pes Planus Paralytic Flat foot Flat foot in CP Rocker Bottom foot after treatment of Club Foot

Treatment:

Treatment Aim of treatment Restoration of bones to normal relationship and holding them there

Treatment:

Treatment Non-operative Treatment Operative Treatment

Non-Operative Treatment:

Non-Operative Treatment Gentle manipulation and Immobilization but the results are not good and the pt. needs surgery

Operative Treatment:

Operative Treatment Depends on A) Age B) Severity of disease

Patients 1-4 years:

Patients 1-4 years Open reduction and realignment of TaloNavicular and SubTalar joint If child age is >3 years and deformity is severe Navicular bone excission is indicated

Patients 4-8 years:

Patients 4-8 years Open reduction Soft tissue release Extra-articular SubTalar Arthrodesis

Patients 12 or >12 years:

Patients 12 or >12 years Triple arthrodesis

Resistant cases:

Resistant cases Talectomy

Different techniques:

Different techniques Kumar et al technique Grice-Green technique Dennyson and Fulford technique Coleman et al technique

New Technique:

New Technique Serial manipulation and cast immobilization followed by talonavicular pin fixation and percutaneous tenotomy of the Achilles tendon provides excellent results, in terms of the clinical appearance of the foot, foot function, and deformity correction as measured radiographically at a minimum two years, in patients with idiopathic congenital vertical talus. Matthew et al,Early Results of a New Method of Treatment for Idiopathic Congenital Vertical Talus The Journal of Bone and Joint Surgery (American) . 2006;88:1192-1200.

PowerPoint Presentation:

Q Bank

PowerPoint Presentation:

What is the preferred treatment for newly diagnosed irreducible congenital vertical talus in a toddler? 1. Open reduction and achillies release 2. Serial Ponseti method casting 3. Percutaneous achillies lengthening 4. Talectomy with tendon interposition 5. Subtalar fusion with soft tissue release

PowerPoint Presentation:

All of the following are known to be associated with the Congenital Vertical talus EXCEPT: 1. Chromosomal deletions 2. Arthrogryposis 3. Amoniotic band syndrome 4. Hip dysplasia 5. Spinal muscular atrophy

PowerPoint Presentation:

All of the following are seen in patients with the Congenital Vertical Talus EXCEPT: 1. dislocation of the talonavicular joint 2. dislocation of the subtalar joint 3. association with other congenital disorders 4. failure to reduce with plantar flexion 5. rigid rocker bottom deformity

PowerPoint Presentation:

A 2-month old infant is born with a rocker-bottom foot deformity. Why is the initial treatment manipulation and casting? 1. to help stretch the dorsolateral soft-tissue before surgery 2. the deformity usually corrects with non-operative treatment 3. surgery is usually deferred until 5 years of age 4. surgery is usually deferred until 10 years of age 5. surgery does not help this condition

Exam Question :

Exam Question Write down the Clinical features, Investigations, Differential Diagnosis, Treatment and Complications of Congenital Vertical talus

PowerPoint Presentation:

Thank you

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