When does the flat-top talus lesion occur in idiopathic clubfoot: evaluation with magnetic resonance imaging at three months of age

Flat-top talus after clubfoot treatment: a literature review

Flat-top talus (FTT) is a complication well-known to those treating clubfoot. Despite this, it receives little attention in textbooks, so our knowledge and understanding can be limited to anecdote and hearsay. In particular, its association with different treatments, especially the Ponseti method, is not well understood. This review provides some clarity on the possible pathoanatomical, radiological and iatrogenic causes of FTT. It summarises its prevalence following different treatments. It is seen after surgery, 'pre-Ponseti' casting and the Ponseti method, and seems least common following Ponseti. Potential surgical management strategies are also discussed.

Surgical management of clubfoot overcorrection: a case series

INTRODUCTION

Overcorrection is a possible complication of clubfoot treatment, whose prevalence varies from 5 to 67%. Overcorrected clubfoot usually presented as a complex flatfoot with different degrees of hindfoot valgus, flat top talus, dorsal bunion, and dorsal navicular subluxation. The management of clubfoot overcorrection is challenging, and both conservative and surgical treatments are available. This study aims to present our experience in the surgical management of overcorrected clubfoot and to provide an overview of actual treatment options for each specific sub-deformity.

MATERIALS AND METHODS

A retrospective cohort study of patients surgically treated for an overcorrected clubfoot from 2000 to 2015 at our Institution was conducted. Surgical procedures were tailored to the type and symptomatology of the deformity. A medializing calcaneal osteotomy or subtalar arthrodesis was performed for hindfoot valgus. Subtalar and/or midtarsal arthrodesis were considered in cases of dorsal navicular subluxation. The first metatarsus elevatus was addressed through a proximal plantarflexing osteotomy, sometimes associated with a tibialis anterior tendon transfer. Clinical scores and radiographic parameters were obtained pre-operatively and at the last follow-up.

RESULTS

Fifteen consecutive patients were enrolled. The series included 4 females and 11 males, with a mean age at surgery of 33,1 (18-56) years, and a mean follow-up of 4,46 (2-10) years. Seven medializing calcaneal osteotomies, 5 subtalar arthrodesis, 11 first metatarsal plantarflexing osteotomies, and 7 anterior tibialis tendon transfers were performed. A statistically significant improvement in both clinical and radiographic scores was observed.

CONCLUSIONS

Management of overcorrected clubfoot involves many surgical techniques because of the high interpersonal variability of the deformities. The surgical approach showed positive results, as long as the indication is based on clinical symptoms and functional impairment rather than morphological alterations and radiographic findings.

Anterior Distal Tibial Guided Growth for recurrent equinus deformity in idiopathic Congenital Talipes Equinovarus treated with the Ponseti method

INTRODUCTION

Distal Anterior Tibial Guided Growth has been shown to be useful to correct recurrent equinus deformity after open surgical release for Congenital Talipes Equinovarus. This has not been evaluated in a recurrence after use of the Ponseti method, where soft tissue releases are currently understood as the mainstay of treatment.

METHODS

Patients with recurrence of equinus component of CTEV, who underwent DATGG with at least 6-month follow-up were identified retrospectively. The criteria for performing this procedure were (1) equinus not correctable to neutral passively (2) the feeling of a bony block to dorsiflexion clinically as evidenced by a supple Achilles' tendon at maximum dorsiflexion and (3)a finding of a flat-top talus radiologically. Successful treatment was defined by the achievement of heel strike on observation of gait. Details of the index procedure including concurrent procedures, any complications and their treatment, past and subsequent treatment episodes were retrieved from electronic patient records. Pre-op and last available post-op X-rays were evaluated for change in the anterior distal tibial angle and for flat-top talus deformity.

RESULTS

We identified 22 feet in 16 patients, with an average follow-up was 25 (8.8-47.3) months. The mean aDTA changed from 88.9 (82.3-94.5) to 77.0 (65.0-83.9) degrees, which was statistically significant (p < 0.0001) using the Paired t-test. Clinically, 17 feet (77 %) obtained a plantigrade foot with a normal heel strike. Complications were identified in 5 feet and include staple migration, oversized staple, superficial infection, iatrogenic varus deformity. Recurrence after completed treatment was noted in one foot.

CONCLUSION

This procedure should form a part of the armamentarium of procedures for treating equinus component of CTEV recurrences even in feet not treated previously by open procedures. When used in patients without significant surgical scarring it helps to address bony and soft-tissue factors, leading to effective treatment.

LEVEL OF EVIDENCE

Therapeutic Level IV.

Surgical Management of the Undercorrected and Overcorrected Severe Club Foot Deformity

Managing complications of clubfoot deformities can be very challenging. Some patients present with recurrent clubfoot and residual symptoms, and some present with overcorrection leading to a severe complex flatfoot deformity. Both can lead to long-term degenerative changes of the foot and ankle joints owing to deformity caused by unbalanced loading. This article only focuses on severe complications caused by recurrence and overcorrection in both children and adult patients.

Flat Top Talus: Complication of Ponseti Method or Overcorrection?

Purpose

Deformation of talus in idiopathic clubfoot is a common problem both surgically and after treatment with the Ponseti technique, although the cause of deformation and its clinical impact on the function of the ankle is not yet known. The goal of this research was to evaluate factors leading to talar dome deformation (flat-top talus) after the Ponseti technique

Methods

This was a single-center, cross-sectional study. Fifty patients with virgin idiopathic clubfoot were enrolled from our consecutive series of data from August 2017 to January 2018 from our clubfoot patients who completed their casting and bracing protocol. Weight-bearing lateral X-rays of the ankle were examined in patients to determine the flattening of the talus dome and its correlation with age, sex, BMI, number of casts, and casting period. In these patients, the frequency of tenotomy and its relationship to the flat top talus was also examined.

Results

The study included a total of 50 children, of which 36 (72%) were boys and 14 (28%) were girls. The mean age, height, weight, and BMI of the children were 5.06 ± 0.79 years, 101.6 ± 6.34 cm, and 19.7 ± 1.57 kg, respectively. No significant difference between the normal and flat top talus category was found in age and BMI (p=0.611 and 0.997, respectively). Whereas, relative to normal children, the children who had flat-top talus were on casts for a longer period of time (median: 9 vs. 6 weeks, p=0.026). In addition, a higher proportion of children with more than six casts developed flat-top talus than those with fewer than six casts (69.2% vs. 30.8%, p=0.005). After treatment, a total of 13 (26%) patients developed flat top talus, of which 11 (84.6%) were boys and two (15.4%) were girls (p=0.303). No substantial association between tenotomy and flat top talus (p=0.340) could be identified.

Conclusion

Flat top talus is a complication of improper manipulation specifically correlated with the number of Ponseti casts applied. Maintenance of cast treatment for more than three months may result in flat-top talus with no significant association with tenotomy of the tendoachilles.

Anterior Distal Hemiepiphysiodesis of Tibia for Treatment of Recurrent Equinus Deformity Due to Flat-Top Talus in Surgically Treated Clubfoot

Treatment of persistent or recurrent equinus after repeated surgical releases can be challenging in patients with clubfoot. Anterior distal tibial epiphysiodesis has recently been used in patients with recurrent progressive equinus deformity, with inconsistent outcomes. Herein, we used this technique in a carefully selected subgroup (8 children, 9 feet) of patients with a severe equinus deformity and a flat-top talus. The patients were followed up with radiological and clinical measures for 12 to 18 months. The mean angle of the ankle improved significantly (25.5°, p < .0001). The mean anterior distal tibial angle decreased from 86.3° to 69° (p < .0001). Plantigrade foot was obtained in all patients, except 1 with arthrogryposis. When applied to carefully selected patients, anterior distal hemiepiphysiodesis of the tibia is an effective method for management of recurrent equinus deformity.

Does an overcorrected clubfoot caused by surgery or by the Ponseti method behave differently?

BACKGROUND

Overcorrection is a recognized problem following surgical treatment of congenital clubfoot. Recently this complication has also been mentioned following Ponseti treatment.

RESEARCH QUESTION

Do overcorrected clubfeet (OCCF) caused by surgery behave differently from those caused by Ponseti treatment in terms of segmental motion of the feet and show differences in the severity of deformity on X-rays?

METHODS

Children between 7 and 12 years with OCCF were included in this study. Depending on the aetiology causing them, the feet were divided into 2 groups (Ponseti and peritalar release surgery). 25 typically developing children served as controls. All subjects were subjected to clinical and radiological examination and 3-Dimensional gait analysis using the Oxford Foot Model.

RESULTS

Thirty-two children with OCCF, of these 18 feet in the surgical and 14 feet in the Ponseti group, were included in the study. No radiological differences were seen in the flatfoot parameters between OCCF groups except in the calcaneal inclination angle that was more pathological in the Ponseti group. The clinical ankle plantar flexion was significantly reduced in the surgical group. During walking the range motion of the hindfoot in the frontal plane was significantly reduced in surgically treated feet compared to the Ponseti group. The other parameters did not show any significant difference between groups.

SIGNIFICANCE

The overcorrected clubfeet following surgery and Ponseti showed similar appearance and showed no significant differences in 11/12 radiological parameters. The segmental motion of the feet showed no significant differences between groups except the in the range of motion of the subtalar eversion. A considerable subtalar joint motion was present even in the surgical group. These findings might help plan the treatment of these feet.

Role of a tendon transfer as a dynamic checkrein reducing recurrence of equinus following distal tibial dorsiflexion osteotomy

Tibial dorsiflexion osteotomy for recalcitrant equinus in clubfeet is reported to have a high recurrence rate with growth. We present the results of closing wedge tibial dorsiflexion osteotomy and tendon transfers in 15 feet and 11 patients. The mean age at presentation was 7 (range: 3.98-12.38) years. At a mean follow-up of 4.16 (range: 2.09-6.87) years, 11 of the 15 feet remained corrected. Mean correction of the dorsiflexion was 24.5° and mean correction of anterior distal tibial angle was 10.9° at final review. Muscle rebalancing appears to influence bone remodeling and reduce recurrence of equinus.

Inferior results with unilateral compared with bilateral brace in Ponseti-treated clubfeet

PURPOSE

The Ponseti method for treating clubfoot was introduced in Norway in 2003, and a cohort of children has been followed for 8 to 11 years. In a previous study, we found good results after follow-up of two to five years, with 3% rate of extensive surgery (posterior release or posteromedial release). During 8 to 11 years of follow-up, the rate of extensive surgery increased to 11%. The children had been treated with a bilateral brace or a unilateral brace. In this multicentre study we aimed to compare these two post-corrective treatment methods.

METHODS

In all, 94 children (133 feet) were initially treated according to the Ponseti method, and had post-corrective treatment with either a bilateral foot abduction brace or a unilateral above-the-knee brace. The children were examined at a mean age of 9.3 years (8 to 11) regarding flexibility and deformity of the foot and ankle. Information including type of brace, brace compliance and surgical procedures was -obtained from the patient records. The parents answered questionnaires and radiographs were taken of the feet.

RESULTS

Feet treated with a bilateral brace had better dorsal flexion (p = 0.008), plantar flexion (p = 0.02), external rotation (p = 0.001) and less forefoot adduction (p = 0.04) than feet treated with a unilateral brace. Children using a bilateral brace had a better Functional Rating System score (p = 0.005) and Disease Specific Instrument score (p = 0.02).

CONCLUSION

Children treated with a bilateral brace had better parent-reported outcomes and more flexible feet than children treated with a unilateral brace. Our results do not support the use of a unilateral foot abduction brace in clubfoot treatment.

Evaluation and Surgical Management of the Overcorrected Clubfoot Deformity in the Adult Patient

Adult patients presenting with an overcorrected clubfoot often have had a posteromedial release. They present later in life and have compensated quite well despite the development of deformity. Minor trauma may lead to the onset of acute symptoms. A spectrum of deformity exists. Key features include a dorsally subluxated navicular, a dorsal bunion from overpull of the tibialis anterior tendon, valgus of the ankle or hindfoot or both, and a flattop talus. This article details the diagnostic approach to the overcorrected clubfoot patient and options for management of the various components of the deformity.

Persistent clubfoot deformity following treatment by the Ponseti method

The Ponseti method of clubfoot correction is now widely practiced worldwide. Initial correction rates are nearly 100%, but subsequent relapses may occur in up to one-third of patients. Very little has been written by anyone other than Dr Ponseti about the characterization and treatment of recurrent clubfoot deformity following use of the Ponseti method. This review paper is the first one which draws together the current literature on the topic.