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12 yo talipes pt

Discussion in 'Foot Surgery' started by CraigT, Aug 10, 2009.

  1. CraigT

    CraigT Well-Known Member


    Members do not see these Ads. Sign Up.
    Greetings all
    I hope to get some professional opinions regarding a case which presented here.
    It is hard to cover all of this here, but briefly...
    - 12 yo boy who had surgery in Germany for Talipes 10 years ago
    - Has had pain only for the last 18 months after playing football. Now has symptomatic L first MTPJ.
    - He has obvious limited STJ ROM with significant FF varus
    - Both 1st MTPJ are grossly plantar flexed
    - He cannot dorsiflex the L 1st and it appears the joint is subluxed plantarly and EHL may have translated laterally to the digit.
    - Obviously he is mechnically a bit of a mess, and his concerns are pain and he cannot wear enclosed shoes (not such an issue in the Middle East as othe parts of the world...). Also worried about progression.
    I expect this is a surgical case, but the question would be how far to go and how to proceed? Is this treated as a 1st MTPJ pathology or do we address all the alignment issues surgically also? Should this be done now or when he is older?
    We have excellent surgeons here, but I suspect this may need specialist foot and ankle man...
    I have attached xrays and can attach photos later.
    Many thanks
     

    Attached Files:

  2. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Craig

    The films are non weight-bearing, so difficult to assess with any meaningful mechanical accuracy.

    However, it appears there is an extrinsic metatarsus primus elevatus due to a lack of correction of the hindfoot varus component of the deformity.There appears to be a 'Z' (skew) foot component to this as well..but this is a little contradictory in the presence the extrinsic elevatus. Weight-bearing plain films will be a better way to assess the relaxed weight bearing status of the hindfoot, and will be mandatory before any surgical intervention.

    The bottom line (based on the chief complaint), to some degree irrespective of the hindfoot mechanics, is that there is an extrinsic met primus elevatus, with a resultant hallux equinus. The apex of the hallux has now become the main contact point for the medial column. Soft tissue contracture has just worsened the issue, and the 1st MTP joint is now jammed in plantarflexion.

    Conservatively, this could be managed in a similar manner to a supinatus - with a long, aggressive extrinsic forefoot varus post extending most of the way out under the hallux. This would allow the 1st MT head to become weight-bearing again, and reduce the symptoms.

    Surgically, there are a range of options. Correcting the hindfoot deformity deals with the underlying cause, but accurate advice is difficult to give here without correct imaging. Plantarflexing the 1st metatarsal is possible via a sagittal Z osteotomy (or similar), and this would get the first MT head back on the ground, but this may worsen any residual varus in the hindfoot.

    Ultimately there are a range of ways to tackle this quite complex deformity, and there would be a range of opinions - from relatively complex surgery, to more 'symptom' driven procedures. Dr Arbes may comment more here, and if you could post some weight bearing clinical images and films, so productive advice may ensue.

    LL
     
  3. CraigT

    CraigT Well-Known Member

    Cheers Lucky
    He is in tomorrow to see one of our surgeons, so will try and organise some more films...
     
  4. CraigT

    CraigT Well-Known Member

    Ok- so here are some WB films...
    It is a pretty rigid foot, and you can see the condyles of the 1st MT head distorting the dorsal skin on the left.
    At this stage orthotic management is not possible as he cannot wear closed shoes.
    Thanks for your thoughts LL and any other interested parties...
    Cheers
     

    Attached Files:

  5. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Wow. Good case. Only seen a couple of these.

    There are so many things to comment on in terms of mechanics. This is a powerful illustration of the fact that an equinus is truly the most deforming force that can affect the foot.

    Essentially this is heading towards probably a triple arthrodesis, with a variety of options to plantarflex the medial column. The equinus hasnt been fully corrected, so TAL or gastrocnemius recession may be indicated also, but once the bone is resected for the triple arthrodesis it may not be required...

    This really requires extensive clinical examination and consideration of suitability and realistic expectations for surgery and long term function.

    I am going to use these pictures for teaching!

    LL
     
  6. drsarbes

    drsarbes Well-Known Member

    Hi Craig:
    Tough case.
    At 2 years old when the previous surgery was performed they most likely did any of a variety of soft tissue releases then serial casted him and crossed their collective fingers.

    His present deformity is basically a dorsally subluxated talonavicular joint.

    With the talo navicular subluxed dorsally it results in functional dorsiflexion of the remaining portion of the first ray (Navicular to the MTPJ. They may have tenotomized the EHL (and EDL as well) and whatever muscle strength he has at the hallux in extension is from the EHB/EDB.

    (you "just" posted the weight bearing radiographs which demonstrates the TaloNavicular subluxation rather well)

    The correct surgical treatment (given these xrays) would be to wait for the epiphyses to close (or nearly closed) and perform a:
    1. TaloNaviclular fusion (plantarflectory) and most likely (depending on the amount of correction obtained intraoperatively)
    2. a 1st metcuneiform fusion.

    A CC joint fusion or lateral column lengthening may also be needed although on the lateral weight bearing it looks fairly good.

    As you may know, with the TaloNavicular fusion, he may in fact end up with a triple later in life if he remains active.

    I'd be interested in what others have to say about this case.

    Good luck

    Steve
     
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