The surgical treatment of children with congenital convex foot (vertical talus)

Abstract

In this study we evaluated the results of midtarsal release and open reduction for the treatment of children with convex congenital foot (CCF) (vertical talus) and compared them with the published results of peritalar release. Between 1977 and 2009, a total of 22 children (31 feet) underwent this procedure. In 15 children (48%) the CCF was isolated and in the remainder it was not (seven with arthrogryposis, two with spinal dysraphism, one with a polymalformative syndrome and six with an undefined neurological disorder). Pre-operatively, the mean tibiotalar angle was 150.2° (106° to 175°) and the mean calcaneal pitch angle was -19.3° (-72° to 4°). The procedure included talonavicular and calcaneocuboid joint capsulotomies, lengthening of tendons of tibialis anterior and the extensors of the toes, allowing reduction of the midtarsal joints. Lengthening of the Achilles tendon was necessary in 23 feet (74%). The mean follow-up was 11 years (2 to 21). The results, as assessed by the Adelaar score, were good in 24 feet (77.4%), fair in six (19.3%) and poor in one foot (3.3%), with no difference between those with isolated CCF and those without. The mean American Orthopaedic Foot and Ankle Society midfoot score was 89.9 (54 to 100) and 77.8 (36 to 93) for those with isolated CCF and those without, respectively. At the final follow-up, the mean tibiotalar (120°; 90 to 152) and calcaneal pitch angles (4°; -13 to 22) had improved significantly (p < 0.0001). Dislocation of the talonavicular and calcaneocuboid joints was completely reduced in 22 (70.9%) and 29 (93.6%) of feet, respectively. Three children (five feet) underwent further surgery at a mean of 8.5 years post-operatively, three with pes planovalgus and two in whom the deformity had been undercorrected. No child developed avascular necrosis of the talus. Midtarsal joint release and open reduction is a satisfactory procedure, which may provide better results than peritalar release. Complications include the development of pes planovalgus and persistent dorsal subluxation of the talonavicular joint.

Naviculectomy for two ambulatory children with intractable congenital vertical talus: redefining the indications of an old technique

“…The current literature does not allow for strong treatment recommendations on how to manage nonisolated, recurrent and/or late-presenting ambulatory CVT children above the age of two years. It is believed that the use of serial casting with or without minimal soft tissue release in such cases will only make the likelihood of recurrence or undercorrection greater [1][2][3]11]. Likewise, the use of extensive soft tissue release in such cases has a tremendous potential in developing perioperative and delayed complications [1][2][3]9,11,12].…”

“…It is believed that the use of serial casting with or without minimal soft tissue release in such cases will only make the likelihood of recurrence or undercorrection greater [1][2][3]11]. Likewise, the use of extensive soft tissue release in such cases has a tremendous potential in developing perioperative and delayed complications [1][2][3]9,11,12]. We believe that the scale of these complications may be underreported in the orthopaedic literature and it is likely attributed to publication bias.…”

“…On lateral radiographs, the talocalcaneal angle, talar-axis-first metatarsal base angle (TAMBA) and tibiocalcaneal angle can verify the diagnosis and confirm the rigidity of all components of the deformity [1]. Studies have demonstrated that the manipulative technique with minimally invasive surgery is superior to extensive soft tissue release in terms of surgical trauma inflicted and subsequent ankle range of motion and foot pain on the long term [1][2][3]. Although some have advocated the use of the manipulative technique with minimally invasive surgery as a first-line treatment irrespective of patient's age and subcategory, there is a universal agreement in the literature that this technique is most suited to children younger than two years [4][5][6][7].…”

“…Longstanding congenital dislocations are likely to undergo secondary adaptive bony changes, thus making anatomic reconstruction unachievable. Furthermore, the extensive surgical trauma required to achieve a plantigrade foot in postsurgical recurrence and certain neuromuscular subtypes of CVT and club feet alike is fraught with serious complications that usually compromise the overall functional outcome of surgery [1,3]. We postulate that naviculectomy as a salvage procedure may present a workable and surgically affordable option for a carefully selected subset of complex CVT, where the risks incurred through extensive surgical release are expected to overpower the potential benefits of surgery.…”

Naviculectomy as a Third Way Beyond Minimally Invasive and Extensive Soft Tissue Releases for Ambulatory Children with Complex Congenital Vertical Talus: A Technical Note

“…Its typical radioclinical findings include severe and rigid flatfoot with radiographic abnormalities of the talar axis-first metatarsal base angle [1,2]. It is acknowledged that the results of manipulative serial casting with or without minimally invasive surgery are better than extensive soft tissue release respecting surgical trauma inflicted, foot stiffness and pain on the long-term [1][2][3][4]. Nevertheless, the use of manipulative techniques is classically suited to children younger than two years regardless of CVT subtype.…”