Download to read offline
chapter 30 CCPV.ppt pes cavus, pes cavus
- 1. Congenital Convex PesValgus Michael D. Kotzen, D.P.M.
- 2. Overview âą Rare anddisabling condition âą Presents with rigid rocker-bottom flatfoot âą Differentiated from other valgus conditions by itâs rigidity âą Talonavicular joint dislocated on X-ray âą Navicular dorsally dislocated âą Talus is locked in plantarflexion âą Important to recognize condition as treatment is different from other flatfoot conditions
- 3. Incidence âą Less than1% of live births âą Osmond and Clark study states .76% incidence in 1,319 infants âą Buchanan and Greer .64% incidence in a study containing 22,000 children âą Equal distribution between genders âą Usually bilateral but if unilateral right foot is the most common
- 4. Etiology (theories) âą Exogenousforces create intrauterine pressure which forces foot into valgus âą Endogenous forces such as decreased amniotic fluid âą Increased pressure from the tibia on the foot âą Arrest in development of talus in 2nd intrauterine months âą Excessive action of peroneals in 4th stage intrauterine life âą Absence of plantar intrinsic muscles âą Neuromuscular imbalance between Tibialis Posterior and peroneals
- 5. Etiology (neuromuscular) âą Contractureof ankle dorsiflexors, Peroneal muscles, and Triceps Surae âą Shortened dorsiflexors and Peroneals pull forefoot into plantarflexion and valgus âą Triceps Surae holds Calcaneus in equinus âą Talus bound to Calcaneus by interosseous ligament so Talus follows Calcaneus into plantarflexion âą Ligamentous attachments prevent Talus from everting âą Talus protrudes medially and plantarly âą Possible hereditary trisomy 13,15, and 18
- 6. Associated conditions âą Congenitaldislocated hip âą Clubfoot âą Fusion of vertebrae âą Absence of patella âą Joint ankylosis âą Kyphosis âą Myelomengocele âą Ischiocalcaneus âą Whistling face syndrome âą Spina bifida âą Hernia âą Hypospadias âą Microcephalia âą Arthrogryphosis âą Cerebral palsy âą Endocrine disturbances âą Downâs syndrome âą Retardation of intellect
- 7. Clinical presentation âą Plantaraspect of foot is convex with severe rocker-bottom appearance âą Talar head is palpable at the plantar medial aspect of the foot âą Forefoot is abducted, dorsiflexed and everted âą Anterior and lateral muscles become tight and resist plantarflexion and inversion âą Rearfoot is in equinus âą Rigidity is seen after 2 months of age âą Gait is akward and difficult, but delay in ambulation is not noted because pain is not initially present
- 9. Radiographic evaluation âą Notall bones are visible in the newborn but x-rays still show characteristic findings âą On AP you will see abduction of the forefoot and increased Talo-Calcaneal angle âą On LAT you will see Talus vertical and parallel with the Tibia, Calcaneus in equinus âą Foot is dorsiflexed and laterally deviated âą Talar bisection is inferior to first metatarsal bisection âą Navicular is dislocated in dorsal aspect of the Talus
- 10.
- 11. Bone and jointchanges âą Navicular does not articulate with the Talus but lies on the dorsal aspect of the Talar head and neck âą Talar head is flattened superiorly and directed plantar medially âą Calcaneus is convex on the plantar surface and is locked in rigid equinus âą Anterior facet of the Calcaneus is absent and the Sustentaculum Tali is abnormal âą Lateral column is subluxed dorsolaterally at the Calcaneocuboid joint âą Cuboid and Navicular articulation with metatarsals and cuneiforms are normal
- 12. Tendon and musclechanges âą All anterior muscle group tendons are contracted across the ankle joint âą Only the proximal section of the extensor retinaculum is present âą Extensors are displaced laterally âą Tibialis posterior tendon is attenuated as it passes inferior to the navicular âą Peroneal tendons are subluxed anterior to the malleoli âą Peroneal and Tibialis posterior tendons can act as dorsiflexors
- 13. Ligamentous changes âą Tibionavicularband of the deltoid ligament is contracted âą Bifurcate, interosseous Talocalcaneal and Calcaneal fibular ligaments are shortened âą Distal band of the extensor retinaculum absent and the proximal part is thickened âą Ligaments along the medial plantar arch and long plantar ligament are attenuated âą Posterior ankle and subtalar joint capsules are contracted âą Plantar medial capsule of Talonavicular joint is elongated
- 14. Vascular and nervechanges âą To date there are no physical complaints of vascular and nerve abnormalities âą Some abnormal histological exams have been reported âą Congenital Convex Pes Valgus can be associated with chronic proliferation endarteritis and neurofibromatosis
- 15. Differential diagnosis âą TalipesCalcaneal Valgus - presents as flexible deformity âą Flexible vertical Talus âą Spastic flatfoot secondary to CP, and Myelmenigocele- can be reduced by using a nerve block to alleviate spasticity âą Flatfoot secondary to coalition
- 16. Conservative treatment âą Objectis to restore the anatomic relationship of Calcaneus and Navicular to the Talus âą Conservative treatment alone is considered inadequate and surgery is the mainstay of treatment âą Casting alone gets poor results, but can be beneficial in stretching and manipulating anterior capsule and contracted muscles pre-operatively
- 17. Surgical treatment âą Interventionis desired before 1 year of age âą Dodge proposed one stage open reduction and soft tissue release at ages less than 3 years old âą Grice arthrodesis is suggested for children ages 3 or greater âą Clark place bone block at the STJ at ages up to 3 years old, if greater than 3 years old perform STJ arthrodesis âą Griffen if surgery is delayed until 10-12 years old then perform triple arthrodesis âą Tachdijian ORIF if less than 4 years old and have failed casting and manipulation. If 4-6 years old, ORIF with TAL, posterior ankle and STJ capsule release, with STJ arthrodesis
- 18. Tendon procedures âą TransferTibialis anterior tendon to Talar neck. Peroneus Brevis tendon is anastomosed with Tibialis posterior tendon and attached at the medial Navicular âą Duckworth and Smith Tibialis anterior tendon is transferred to the neck of the Talus âą Goldner comprehensive release 4 incision approach for release of all contracted joints and capsules, Tibialis anterior and posterior tendons are transferred to the neck of the Talus, Peroneus Brevis tendon is run through the neck of the Talus, Talonavicular joint and STJ are released
- 20. Osseous procedures âą Talectomy(fallen out of favor) âą Removal of wedge from the Navicular under the Talar head to maintain elevation of the medial column âą Navicularectomy with release remains a very effective procedure âą Grice arthrodesis if less than 3 years of age âą Triple arthrodesis if 10-12 years of age
- 22. McGlamry preference âą Startmanipulation and casting ASAP, twice a week for 6-8 weeks âą At 6-8 weeks attempt to relocate Talocalcanealnavicular joint and pin if successful âą If not reducible by 4-6 months correct deformity by ORIF âą Medial incision is made from 1st metatarsal/cuneiform joint to distal aspect of the medial malleolus and proximally to overlie Achilles tendon âą Lengthen the Achilles tendon
- 23. McGlamry preference âą Lengthen:Tibialis anterior, and Peroneals âą Release: Talonavicular ligament, Tibionavicular ligament, Bifurcate ligament, Calcanealcuboid joint, Calcaneal Fibular liagament, Interosseous Talocalcaneal ligament âą Foot is distracted and manipulated and k-wire is placed from posterior Talar body through the Navicular and Cuneiform into IM space âą Reefing of the Spring ligament and placement of a 2nd k- wire from the plantar foot through the Calcaneus and into the Talus
- 24. McGlamry preference âą Closeincision sites according to surgeonâs preference âą AK cast for 3-4 months âą Remove k-wire at 6 weeks âą Night time splint for 1 to 2 years âą Physical therapy âą Excise Navicular if the child is between the ages of 3-6 or the deformity remains âą Triple arthrodesis if the child is 10-12 years of age
- 25. Post-op complications âą AVNof the Navicular or Talus âą Inadequate dorsiflexion âą Over correction of heel into Varus âą Development of bunion deformity âą Incomplete reduction âą Re-occurrence âą Continued Equinus âą Curly toes âą Stiffness
- 26.