Single Stage Surgical Correction of Congenital Vertical Talus by Complete Subtalar Release Using Thr - PowerPoint PPT Presentation

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Single Stage Surgical Correction of Congenital Vertical Talus by Complete Subtalar Release Using Thr

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... multiplex congenita (AMC) and 2 cases (4 feet) have sacral agenesis. ... CVT associated with neuromuscular conditions, especially AMC or sacral agenesis , ... – PowerPoint PPT presentation

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Title: Single Stage Surgical Correction of Congenital Vertical Talus by Complete Subtalar Release Using Thr


1
Single Stage Surgical Correction of Congenital
Vertical Talus by Complete Subtalar Release Using
Three Incisions
  • 6-Foot and Ankle
  • By
  • Dr.Mostafa El Sherbini,M.D.
  • National Institute Of Neuromotor System ,Egypt
  • elsherbini58_at_hotmail.com
  • elsherbini58_at_yahoo.com

2
Introduction
  • Congenital vertical talus(CVT) is a rare disorder
    of the tarsal bone, more commonly
    associated with other neuromuscular condition
    which have more rigid deformity and less
    favorable outcome. The constant pathology is
    fixed dorsal dislocation of talonavicular joint,
    planter flexion of the talus and equinus
    position of the calcaneus.Untreated foot will end
    up with painful rocker bottom deformity
    (Drennan Sharrad,1971)
    (Drennan,1995) (Kordos Dias.1999).
  • Nonoperative treatment is ineffective the
    treatment of choice is surgical but the main
    debate is in the stages of operation and the type
    of incisions.
  • Most authors recommend one stage correction
    with reduction fixation of the
    talonavicular joint (Kordos Dias.1999)
    (Mazzoca et al,2001) (Zorer et al,2002).
  • Although single incision has fewer complications
    , still it is difficult to reach the dorsal
    anatomical structures for Cincinnati incision or
    the posterior structures for dorsal incision
    and additional separate incision may be
    needed (Fitton Nevelos,1979) (Mazzoca et
    al,2001) (Zorer et al,2002).

3
Aim of the work
  • This study evaluate the one stage correction of
    the CVT associated with neuromuscular conditions
    ,by complete subtalar release ( CSTR), through
    three incisions. The aim is to correct all the
    pathological components by direct approach
    through posteromedial ,lateral and anterior mid
    leg incisions to get painless plantigrade foot.

4
Material Method
  • 6 cases (10 feet) of severe CVT underwent CSTR by
    one stage surgical correction through three
    incisions in the period between june 2002 to
    march 2005.4 cases (6 feet) have arthrogryposis
    multiplex congenita (AMC) and 2 cases (4 feet)
    have sacral agenesis. There were 3 boys and 3
    girls. The age at the time of surgery ranged from
    9 months to 3 years ( average 14.5 months). The
    follow up ranged from 24 m to 51 months (average
    37 m) .
  • Preoperative evaluation depends on standing
    lateral view X-ray measuring Talocalcaneal angle
    (reflect the degree of valgus hinfoot),
    Tibiocalcaneal angle (reflect the degree of
    equinus foot ),Talo-first metatarsal
    angle(reflect the position of the talus) and the
    Talonavicular relation (reflect the degree of
    talonavicular dislocation. (Vanderwilde et
    al,1988)(Zorer et al,2002)

5
Operative technique
  • Peritalar reduction by CSTR through 3 incisions-
  • 1-Poseromedial (Z lengthening of
    tendoachilles,posterior capsulotomy of
    the ankle and subtalar,Tibialis posterior tendon
    is cut at its insertion for further distal
    advancement ,capslulotomy of the talonavicular
    joint (TNJ) and cutting of the spring
    ligament,posterior talofibular
    calcaneofibular ligaments).
  • 2-Lateral (cut of peroneus brevis , capsulotomy
    of
    calcaneocuboid joint and lengthening of
    peroneus longus).
  • 3-Anterior mid leg (lengthening of EDL EHL
    tendons).
  • A K.wire is inserted retrograde into the center
    of the talar head and used as a
    joystick to reduce the TNJ. Capsullorraphy of the
    TNJ and plication of the spring
    ligament were done. Split transfer of he Tibialis
    anterior tendon to the medial side of the
    talar neck was done.
  • Postoperatively (PO) a well padded long leg
    posterior slap is applied for 2 weeks
    then above knee cast is done . K.wire is removed
    6 weeks PO and below knee cast applied
    for 2 months then AFO was formed to
    keep correction at night and medical shoes at
    day.
  • .

6
Operative technique
7
Result
  • All feet are painless and Plantigrade,there
    was one case of avascular necrosis of the
    talus.
  • Evaluation system depending on both clinical and
    radiological examination, modified from
    Zorer et al,2002 .
  • The clinical parameters include wound
    complication, pain,Hindfoot alignment
    ,Longitudinal arch attainmed and Family
    satisfaction.
  • Radiological parameters include lateral Tal/cal
    angle ,Tib/cal angle, Tal /first
    metatarsal angle and Tal/nav relation. Each item
    has certain score ranged from 0 to 3 .
  • According to the total scores (clinical
    radiological) result were classified into good
    (score gt 13),fair (score between 8 and 13) and
    poor (score lt8).
  • There were 8 good feet and 2 fair results. There
    were 4 feet were not attained the longitudinal
    arch,2 feet had wound gap, 2 feet still had
    valgus hindfoot and 2 feet unsatisfied by the
    family.
  • There were significant improvement of all
    radiological parameters where the lateral
    Tal/cal angle improved from 62 average
    preoperatively to 33PO , the Tib/cal angle
    improved from average 94 to 74 , the Tal/first
    metatarsal angle improved from
    average 80 to 20 postoperatively and
    the Tal/navicular relation improved from G3
    preoperatively for all cases to 6 feet
    G1,2feet G2 and 2 feet G0 postoperatively.
  • .

8
Evaluation Scheme modified from Zorer et
al,2002 Clinical
Radiological
SD Standard deviation .
9
Illustrative Case
  • AMC Bilateral CVT
  • at birth
  • Preoperative X-ray at 9 m
  • R L
  • Tal/Cal.A 48 52
  • Tib/Cal A 125 92
  • Tal/1st met.A 94 85
  • Tal/Nav.rel. Gr3 Gr3
  • Last follow up 3y (score)



Tal/Cal.A 25(0) 30(1)
R Tib/Cal.A 91(1) 80(3) Tal/1st met .A
26(2) 4(3) Tal/Nav rel Gr0(3)
Gr2(1) Radiolog Score 6 8
L Clinical Score 8 7 Total
14 15 Result good good


10
Conclusion
  • Surgical correction of CVT associated with
    neuromuscular conditions, especially AMC
    or sacral agenesis , by complete subtalar
    release gave satisfactory results both
    clinically and radiographically.
  • The three incisions,posteromedial,lateral and
    anterior mid leg incisions allow direct
    approach to the pathological components of the
    deformity at one stage.
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