Talus verticalis

Congenital vertical talus is a rare condition which presents as an isolated deformity or in association with neuromuscular and/or genetic disorders. Pathoanatomically the deformity shows a dislocated talonavicular and subtalar joint. The etiology and pathogenesis are still not finally determined although in some cases a genetic basis has been identified. The clinical picture is that of a flat, convex longitudinal arch with abduction and dorsiflexion of the forefoot and an elevated heel. Clinical diagnosis is confirmed by plain radiographic imaging. Congenital vertical talus should not be confused with other deformities of the foot, such as congenital oblique talus, flexible flat feet or pes calcaneus. The object of treatment of congenital vertical talus is to restore a normal anatomical relationship between the talus, navicular and calcaneus to obtain a pain-free foot. Major reconstructive surgery has been reported to be effective but is associated with substantial complications. Good early results of a modified non-operative treatment using serial manipulation, cast treatment and minimally invasive surgery may change therapeutic concepts.     

Open reduction internal fixation of a pelvic malunion through an anterior approach

Whereas the initial treatment of pelvic fractures and their long-term outcomes have been well researched, little has been written concerning the surgical management of late pelvic malunions and nonunions causing residual pain and deformity. The available literature describes osteotomies usually done in multiple stages. The authors report the case of a progressive lateral compression pelvic disability treated in a unique one-stage procedure. This one-stage anterior approach allowed excellent correction of the deformity. In cases in which the deformity is purely one of internal or external rotation or medial or lateral displacement with no vertical migration, the authors think it is possible to adequately mobilize the pelvis to an anatomic reduction in a single-stage anterior approach. In cases in which vertical migration of the hemipelvis causes symptoms, it is probably necessary to approach the patient posteriorly to safely mobilize and adequately reduce the hemipelvis. With these factors in mind, the authors think a one-stage anterior approach can be an effective treatment for appropriately selected pelvic malunions.     

Management of foot deformity in children

This study describes the management of foot deformity in children. Severe congenital clubfeet treated using posteromedial release without talocalcaneal joint release were flexible and functional. Talectomy may be necessary for congenital clubfeet with arthrogryposis multiplex congenita. The diagnosis and severity of vertical talus were defined based on stress radiographs. For the deformity with spina bifida, a combination of talocalcaneal joint fusion and precise correction by soft tissue release and tendon transfer was performed. This combined surgery is effective, particularly in patients with equino-varus feet.     

Bilateral congenital vertical talus with severe lower extremity external rotational deformity: Treated by reverse Ponseti technique

Congenital vertical talus, also known as congenital convex pes valgus, is a complex, rare, foot deformity that is resistant to conservative treatment. We report a case of bilateral congenital vertical talus with severe lower extremity external rotational deformity that was treated by means of a method of serial manipulations and casts. Although the initial manipulation and casting before surgical treatment is the current concept of idiopathic congenital vertical talus, a good result can be obtained by a well-organized conservative treatment with the help of patient compliance, so routine surgical release of the Achilles tendon may not be necessary in all cases.     

Early results of a new method of treatment for idiopathic congenital vertical talus

BACKGROUND: The treatment of idiopathic congenital vertical talus has traditionally consisted of manipulation and application of casts followed by extensive soft-tissue releases. However, this treatment is often followed by severe stiffness of the foot and other complications. The purpose of this study was to evaluate a new method of manipulation and cast immobilization, based on principles used by Ponseti for the treatment of clubfoot deformity, followed by pinning of the talonavicular joint and percutaneous tenotomy of the Achilles tendon in patients with idiopathic congenital vertical talus. METHODS: The cases of eleven consecutive patients who had a total of nineteen feet with an idiopathic congenital vertical talus deformity were retrospectively reviewed at a minimum of two years following treatment with serial manipulations and casts followed by limited surgery consisting of percutaneous Achilles tenotomy (all nineteen feet), fractional lengthening of the anterior tibial tendon (two) or the peroneal brevis tendon (one), and percutaneous pin fixation of the talonavicular joint (twelve). The principles of manipulation and application of the plaster casts were similar to those used by Ponseti to correct a clubfoot deformity, but the forces were applied in the opposite direction. Patients were evaluated clinically and radiographically at the time of presentation, immediately postoperatively, and at the time of the latest follow-up. Radiographic measurements obtained at these times were compared. In addition, the radiographic data at the final evaluation were compared with normal values for an individual of the same age as the patient. RESULTS: Initial correction was obtained both clinically and radiographically in all nineteen feet. A mean of five casts was required for correction. No patient underwent extensive surgical releases. At the final evaluation, the mean ankle dorsiflexion was 25 degrees and the mean plantar flexion was 33 degrees . Dorsal subluxation of the navicular recurred in three patients, none of whom had had pin fixation of the talonavicular joint. At the time of the latest follow-up, there was a significant improvement (p < 0.0001) in all of the measured radiographic parameters compared with the pretreatment values, and all of the measured angles were within normal values for the patient's age. CONCLUSIONS: 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.     

Congenital vertical talus: classification with 69 cases and new measurement system

Sixty-nine cases of congenital vertical talus (CVT) were classified into five groups in association with (1) neural tube defects or spinal anomalies, (2) neuromuscular disorders, (3) malformation syndromes, (4) chromosomal aberrations, and (5) idiopathic CVT unassociated with any of the systemic conditions described above. Forty-four cases of idiopathic CVT were subclassified into four groups: (5A) intrauterine molded or deformed cases, (5B) cases of digitotalar dysmorphism associated with contractile finger abnormalities and genetic inheritance, (5C) patients whose close relatives had CVT or oblique talus (OT) deformity, and (5D) cases unassociated with any skeletal deformity or genetic inheritance. The talar and Calcaneal axis--first metatarsal base angles (TAMBA and CAMBA) are introduced, which enable us to describe not only the obliquity of the talus and calcaneus but also the severity of the dislocation of the talonavicular joint and the contracture of the tendo Achilli. The changing point from flexible OT to rigid CVT is TAMBA of about 60 degrees and CAMBA of 20 degrees, and there are many borderline cases of CVT that could be treated conservatively. For the typical CVT, open reduction should be carried out as promptly as possible if 3 months of corrective casting in extreme equinovarus fails to reduce the TAMBA to 50 degrees.     

Tibiotalocalcaneal nail failure in a 60-year-old male: Case report and surgical technique

Tibiotalocalcaneal (TTC) arthrodesis is a hindfoot fusion that can treat numerous conditions including osteoarthritis, Charcot arthropathy, avascular necrosis of the talus, and severe deformity. The goal of fusion is to create solid union across the joint while correcting deformity, leaving a shoeable plantigrade foot. Multiple biomechanical studies have demonstrated similar performance when comparing the properties of plate and nail constructs for TTC arthrodesis. Plate fixation and retrograde intramedullary nailing (IMN) are successful in achieving TTC fusion and favorable postoperative outcomes. Despite generally favorable outcomes, TTC arthrodesis carries the risk of complications including nonunion, infection, hardware failure, and revision surgery. We present a case of an individual who presented with a complete break of the IMN after TTC arthrodesis. We also describe the technique used for extraction of the broken nail.     

Ilizarov 技术矫治马蹄足畸形中胫距关节前脱位的治疗及预防

 目的 总结 Ilizarov 技术矫治马蹄足畸形中发生胫距关节前脱位的概率、治疗及预防方法。方法 回顾性分析 2011 年 10 月至 2012 年 4 月,应用 Ilizarov 技术矫治 38 例马蹄足畸形患者资料,其中 5 例于术后 14～28 d 发生胫距关节前脱位,男 4 例,女 1 例;年龄 19～30 岁,平均 23.8 岁;均为马蹄内翻足畸形患者。5 例患者初次手术采用 Ilizarov 技术矫治马蹄足畸形,同时行经皮跟腱延长术、经皮跖腱膜切断术、胫后肌松解、胫前肌移位,其中 4 例同期行距骨周围截骨术,1 例同期行第一跖骨基底截骨术,1 例同期行胫骨近端去旋转截骨术;发生胫距关节前脱位后,1 例经手法复位,4 例使用 Ilizarov 复位装置后继续按原计划牵伸调整外固定架矫形,直至满意。结果 5 例马蹄内翻足畸形患者在行 Ilizarov 技术矫形过程中发生胫距关节前脱位的概率为 13.2%（5/38）。5 例患者均获得随访,随访时间 6～12 个月,平均 10 个月,马蹄足畸形均完全矫正。末次随访时应用国际马蹄足畸形研究学组评分为 3～10 分,平均 4.8 分;其中优 2 例,良 3 例,优良率为 100%。无一例发生钉道感染、神经血管损伤、血栓等并发症。结论 胫距关节脱位是 Ilizarov 技术矫治马蹄足畸形中较常见的并发症,发生率约为 13%。发生胫距关节前脱位后,及时安装距骨复位装置可获得良好效果。围手术期管理应注意外固定铰链关节与踝关节瞬时旋转中心的匹配。     

Single stage surgical correction of congenital vertical talus by complete subtalar release and peritalar reduction by using the Cincinnati incision

Seventeen feet of 12 patients with congenital vertical talus, which were treated with a single-stage surgical correction of complete subtalar release and peritalar reduction by using the Cincinnati incision, were reviewed. Five of the feet were associated with neuromuscular disorders, four with neural tube defects, and eight were idiopathic. All patients were operated on by the same surgeon and all were available for clinical and radiographic follow-up averaging 42.9 months (range 19-81) from the time of surgery. There were no wound complications or avascular necrosis of the talus. None required subsequent reoperation. At final follow-up, results were based on clinical and radiographic outcomes and included five excellent, eight good, two fair, and two poor. All families were satisfied with the results and appearance of the feet. Radiographically, there was a significant improvement in the anteroposterior and lateral talocalcaneal and talo-first metatarsal angles, and at follow-up, the group averages for each of these angles were within the normal ranges. In the treatment of congenital vertical talus, good clinical and radiographic outcomes can be obtained, with a low incidence of complications, using this single-stage surgical correction procedure.     

Management of Tuberous Breast Deformity with Anatomic Cohesive Silicone Gel Breast Implants

Background  Tuberous breast deformity is a rare congenital condition that often requires surgical correction. Numerous surgical techniques have been described, reflecting the reconstructive challenge of this deformity. The anatomic cohesive gel breast implant is a powerful tool in both aesthetic and reconstructive breast surgery. In the authors’ experience, its use in treating tuberous breast deformity has provided the opportunity for a single-stage approach, with very good results. Methods  The senior author has managed more than 50 cases of single-stage reconstruction for tuberous breast deformity using anatomic cohesive gel breast implants. His surgical technique is described with suggestions for achieving optimal results. Representative case examples are provided. Conclusions  The anatomic cohesive silicone gel breast implant is an excellent device for treating tuberous breast deformity. It often can be used as a single-stage correction of the deformity with very good results. The authors strongly advocate consideration of its use in tuberous breast deformity reconstruction.     

Talus necrosis and its treatment

Aetiopathogenesis of the necrosis of the talus has not yet been definitely clarified, and neither has that of the other aseptic necroses. We were able to study the aetiopathogenesis, course of the disease and therapy in 20 of our own patients by follow-up; two of these developed necrosis of the talus in both feet. We definitely excluded patients suffering from osteochondrosis dissecans. Even though fracture of the talus is on the whole relatively rare, it remains the most frequent cause of necrosis of the talus. We also found talonecrosis after surgical correction of clubfoot, after Sudeck's disease (Sudeck-Leriche syndrome, Sudeck's atrophy or dystrophy), suppurative arthritis of the ankle joint, subtalar luxation and haematogenic osteomyelitis. Only few patients required surgery. In most cases a special boot constructed for arthrodesis patients proved sufficient. Each patient developed arthrodesis to a different degree. Depending upon the complaints and stiffening of the ankle joint or of the talo-calcanonavicular joint, the capacity of the patients to be gainfully employed was reduced by an amount between 20 and 30 per cent.     

Congenital convex pes valgus

Congenital convex pes valgus (congenital vertical talus) is a rare condition. We reviewed ten feet in seven patients who had had surgical correction. All had been operated on by the senior author (JF) and the same surgical technique was used throughout, incorporating transfer of the tibialis anterior to the neck of the talus. The mean age at surgery was 31 months and the mean follow-up was nine years (6 to 14). All patients completed a questionnaire and had clinical, radiological and photographic evaluation performed by an independent examiner. None had required further surgery. All but one were satisfied with the result, and had no functional limitations. They all wore normal shoes. The mean ankle dorsiflexion was 17 degrees and plantar flexion 21 degrees. The mean arc of subtalar motion was 27 degrees. All radiological parameters measured were within the normal range, although irregularity of the talonavicular joint was common. No avascular necrosis of the body of the talus was seen. We conclude that the medium-term results of this procedure are very satisfactory.     

Extra-articular deformity correction using Taylor spatial frame prior to total knee arthroplasty

A good long-term outcome following a total knee arthroplasty relies on restoration of the mechanical axis and effective soft tissue balancing of the prosthetic knee. Arthroplasty surgery in patients with secondary osteoarthritis of the knee with an extra-articular tibial deformity is a complex and challenging procedure. The correction of mal-alignment of the mechanical axis is associated with unpredictable result and with higher revision rates. Single-staged deformity correction and replacement surgery often result in the use of constraint implants. We describe our experience with staged correction of deformity using a Taylor Spatial Frame (TSF) followed by total knee arthroplasty in these patients and highlight the advantage of staged approach. The use of TSF fixator for deformity correction prior to a primary total knee arthroplasty has not been described in the literature. We describe three cases of secondary osteoarthritis of the knee associated with multiplanar tibial deformity treated effectively with a total knee arthroplasty following deformity correction and union using a TSF. All patients had an improved Knee Society score and Oxford Knee score postoperatively and were satisfied with their replacement outcome. Staged deformity correction followed by arthroplasty allows the use of standard primary arthroplasty implants with predicable results and flexible aftercare. This approach may also provide significant improvement of patient symptoms following correction of deformity resulting in deferment of the arthroplasty surgery.     

Peri-operative optimization in adult spinal deformity surgery

The population aged 65 and over is projected to double by the year 2050. As the population continues to age, the incidence of adult spinal deformity (ASD) will continue to rise. It is estimated that 30–50% of patients older than 65-years develop a degenerative scoliosis. Many of these patients have little to no symptoms as a result of their deformity and continue to lead active and healthy lives. A smaller subset of patients with degenerative scoliosis develops pain and disability as a result of their underlying deformity. The outcomes of surgery in this group are generally favorable but there is significant risk and potential morbidity associated with deformity correction surgery. The pre-operative planning and technical aspects of surgery are important but the peri-operative optimization of modifiable factors to minimize the risk of complications is even more important to achieve optimal outcomes. This paper will review the most up-to-date literature on the peri-operative optimization of patients undergoing adult spinal deformity surgery.     

Congenital vertical talus: surgical correction by a one-stage medial approach

A single stage procedure for correction of congenital vertical talus using a medial approach is described. The operation was performed on 14 feet with good initial anatomical results in all cases. No wound healing complications were observed.     

Pathology of congenital metatarsus varus and its relationship to other congenital deformities of the foot

Congenital metatarsus varus may be regarded as a deformity caused by a dislocation and in that respect is similar to congenital clubfoot and vertical talus but not to calcaneovalgus. The dislocation causes adaptive bone changes as well as secondary contracture of the soft tissues. That the dislocation in the forepart of the foot may occur in a maximally dorsiflexed foot also may explain the valgus position of the hindfoot. The secondary changes in bone and soft tissue may explain the lack of spontaneous recovery and the difficulties in effecting correction in severe cases. It is still not possible to explain why the dislocation arises.     

距骨损伤与距骨坏死及其治疗

目的　探讨距骨损伤对距骨缺血坏死的影响及其治疗方法。方法　本文通过 2 5例距骨重度骨折脱位、 3例距骨全脱位和 17例距骨周围脱位的治疗 ,并分别经平均 7年和 2年 5个月的随访观察 ,来分析三种不同类型的损伤对距骨缺血坏死的影响。结果　距骨重度骨折脱位和全脱位缺血坏死率和创伤性关节炎发生率达 10 0 % ,距骨周围脱位则无缺血坏死发生。作者比较重度距骨骨折脱位和全脱位采用切开复位内固定、距骨切除和关节融合术三种治疗方法的结果 ,仅融合术最为满意。结论　作者建议在距骨有发生缺血坏死高危损伤的病例 ,融合术应是首选的方法     

Posttraumatic deformity correction at the foot

Posttraumatic foot deformities requiring correction result from overlooked or inadequately treated injuries and, on the other hand, from protracted courses because of avascular necrosis, non-union or infection after primary surgery. To achieve a maximum benefit, corrective surgery has to be carried out early before arthritic involvement of adjacent joint becomes evident. As salvage procedures, arthrodeses should be restricted to the affected joints. Especially talus malunion and non-union should be corrected with preservation of the joints whenever possible to achieve favourable functional outcomes. In case of calcaneal malunion with consequential lateral translation a reorientating subtalar arthrodesis should be supplemented by corrective osteotomy of the fracture line. Corrections at the level of Chopart's and Lisfranc's (mid-tarsal and tarsometatarsal) joints must restore the exact relationship between the medial and lateral foot columns. Malunions of the metatarsals and toes are corrected in cases of symptomatic malalignment. This paper reviews corrective procedures for posttraumatic deformities at the different foot regions. A therapy-based classification for mal-unions of the talus and calcaneus is proposed.     

Flexor hallucis longus tendon transfer for hallux claw toe deformity and vertical instability of the metatarsophalangeal joint

BACKGROUND: Historically, operative treatment of hallux claw toe deformity has been the Jones procedure or one of its modifications. Review of the literature confirms its ability to maintain alignment and achieve patient satisfaction; however, several complications have been reported. Many of these are related to altered biomechanics across the metatarsophalangeal (MTP) joint. A similar approach to this clinical problem involves restoration of the flexion moment across the MTP joint without an interphalangeal (IP) joint arthrodesis. METHODS: We conducted a retrospective review of 10 patients who had a flexor hallucis longus (FHL) tendon transfer to the proximal phalanx of the great toe for hallux claw toe deformity, as well as for symptomatic vertical instability. Four patients had a positive drawer test indicating vertical instability without static deformity. Two patients with vertical instability were found to have a dynamic deformity. Mean followup was 24 (SD 15.2) months. RESULTS: All deformities were corrected and alignment was maintained at the time of followup. Pain under the first metatarsal head was reliably improved in symptomatic patients (p < 0.05). Patient satisfaction also was assessed. All six patients treated for hallux claw deformity were satisfied with their outcomes. Two of the four patients treated for vertical instability were satisfied. The other two patients expressed dissatisfaction because of persistent pain that occurred during strenuous exercise. Their symptoms during routine activity were improved, however. CONCLUSION: Based on initial results, the FHL transfer to the proximal phalanx appears to be a viable treatment option for hallux claw deformity in terms of deformity correction, pain relief, and patient satisfaction. Further evaluation is warranted regarding the indication of vertical instability.