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https://upload.orthobullets.com/topic/4066/images/clinical photo - courtesy Miller_moved.png
https://upload.orthobullets.com/topic/4066/images/Neutral lateral xray - courtesy Miller_moved.png
https://upload.orthobullets.com/topic/4066/images/plantar flexion lateral xray - courtesy Miller_moved.png
https://upload.orthobullets.com/topic/4066/images/Meary's angle_moved.png
Introduction
  • Irreducible dorsal dislocation of the navicular on the talus producing a rigid flatfoot deformity present at birth
  • Epidemiology:
    • Rare, 1:150,000 births
    • 50% associated with neuromuscular disease or chromosomal aberrations  
      • Myelomeningocele
      • Arthrogryposis
      • Diastematomyelia
    • 50% bilateral
    • M:F ratio of 2:1
  • Pathoanatomy
    • rigid foot deformity
      • irreducible dorsolateral navicular dislocation
      • vertically oriented talus
      • calcaneal eversion with attenuated spring ligament
    • soft tissue contractures
      • displacement of peroneal longus and posterior tibilais tendon so they function as dorsiflexors rather than plantar flexors
      • contracture of the Achilles tendon
  • Genetics
    • a positive family history is present in up to 20% of patients
    • HOXD10 gene mutation (transcription factor)
  • Prognosis 
    • poor in untreated cases and associated with significant disability
  • Differential diagnosis
    • oblique talus
      • anatomic variant
        • talonavicular subluxation that reduces with forced plantarflexion of the foot
      • treatment 
        • typically consists of observation and shoe inserts
        • some require surgical pinning of the talonavicular joint and achilles lengthening for persistent subluxation
Presentation
  • Physical exam
    • rigid rockerbottom deformity
      • fixed hindfoot equinovalgus 
        • due to contracture of the Achilles and peroneal tendons
      • rigid midfoot dorsiflexion
        • secondary to the dislocated navicular
      • forefoot abducted and dorsiflexed
        • due to contractures of the EDL, EHL and tibialis anterior tendons
    • prominent talar head
      • can be palpated in medial plantar arch on exam
        • produces a convex plantar surface
    • gait abnormality
      • patient may demonstrate a "peg-leg" or a calcaneal gait due to poor push-off power 
      • limited forefoot contact, excessive heel contact
    • neurologic deficits
      • a careful neurologic exam needs to be performed due to frequent association with neuromuscular disorders
Imaging
  • Radiographs
    • recommended views
      • AP, oblique and lateral foot 
    • findings
      • lateral
        • vertically positioned talus & dorsal dislocation of navicular  q
          • line along long axis of talus passes below the first metatarsal-cuneiform axis
            • before ossification of navicular at age 3, the first metatarsal is used as a proxy for the navicular on radiographic evaluation
      • AP
        • talocalcaneal angle > 40° (20-40° is normal) 
    • alternative views
      • forced plantar flexion lateral radiograph is diagnostic 
        • shows persistent dorsal dislocation of the talonavicular joint 
          • oblique talus reduces on this view
          • Meary's angle > 20° (between line of longitudinal axis of talus and longitudinal axis of 1st metatarsal)  
      • forced dorsiflexion lateral
        • reveals fixed equinus
  • MRI 
    • neuraxial imaging should be performed to rule out neurologic disorder
Differential Diagnosis
  • Oblique talus 
    • reduces with forced plantar flexion
    • treatment is observation vs casting
  • Calcaneovalgus foot deformity
  • Posteromedial tibial bowing
  • Tarsal coalition
  • Paralytic pes valgus
  • Pes planovalgus
Treatment
  • Nonoperative
    • serial manipulation and casting
      • indications
        • indicated preoperatively to stretch the dorsolateral soft-tissue structures q
        • foot is manipulated into inversion and plantarflexion
      • typically still requires closed vs open pinning of the talonavicular joint with percutaneous achilles tenotomy
  • Operative
    • surgical release and talonavicular reduction and pinning  q
      • indications
        • indicated in most cases
        • performed at 6-12 months of age
      • technique
        • involves pantalar release with concomitant lengthening of peroneals, Achilles, and toe extensors 
        • talonavicular joint is reduced and pinned while reconstruction of the plantar calcaneonavicular (spring) ligament is performed 
        • concomitant tibialis anterior transfer to talar neck
    • minimally invasive correction
      • indications
        • new technique performed in some centers to avoid complications associated with extensive surgical releases
      • technique
        • principles for casting are similar to the Ponseti technique used clubfoot
        • serial casting utilized to stretch contracted dorsal and lateral soft tissue structures and gradually reduced talonavicular joint
        • once reduction is achieved with cast, closed or open reduction is performed and secured with pin fixation 
        • percutaneous achilles tenotomy is required to correct the equinus deformity
    • talectomy
      • indicated in resistant case
    • triple arthrodesis
      • as salvage procedure
Complications
  • Missed vertical talus
    • reconstructive options are less predictable after age 3, and patients may require triple arthrodesis as salvage procedure
 

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(OBQ04.115) A 2-month old infant is born with a rocker-bottom foot deformity. A radiograph is shown in figure A. Why is the initial treatment manipulation and casting? Review Topic

QID: 1220
FIGURES:
1

to help stretch the dorsolateral soft-tissue before surgery

70%

(686/977)

2

the deformity usually corrects with non-operative treatment

24%

(233/977)

3

surgery is usually deferred until 5 years of age

4%

(38/977)

4

surgery is usually deferred until 10 years of age

0%

(3/977)

5

surgery does not help this condition

1%

(9/977)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(OBQ07.154) Which of the following is not characteristic of the pathologic process displayed in Figure A. Review Topic

QID: 815
FIGURES:
1

Dislocation of the talonavicular joint

5%

(135/2654)

2

Associated with posteromedial tibia bowing

58%

(1538/2654)

3

Associated with neural tube defects

15%

(397/2654)

4

Associated with arthrogryposis

9%

(245/2654)

5

Rigid rocker bottom deformity

12%

(320/2654)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(OBQ06.127) An 13-month-old boy is evaluated for a foot deformity and asymmetric gait. A clinical photo is shown in Figure A. A plantarflexion lateral radiograph is shown in Figure B. What is the most likely diagnosis? Review Topic

QID: 313
FIGURES:
1

Talipes equinovarus

4%

(65/1483)

2

Congenital vertical talus

60%

(885/1483)

3

Congenital oblique talus

31%

(461/1483)

4

Skewfoot

1%

(16/1483)

5

Normal radiographic findings

3%

(46/1483)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ09.29) What is the preferred treatment for newly diagnosed irreducible congenital vertical talus in a toddler? Review Topic

QID: 2842
1

Casting followed by open reduction and Achillies lengthening

83%

(1583/1900)

2

Serial Ponseti method casting

8%

(146/1900)

3

Percutaneous achillies lengthening

2%

(35/1900)

4

Talectomy with tendon interposition

4%

(79/1900)

5

Subtalar fusion with soft tissue release

3%

(50/1900)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1
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