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REVIEW ARTICLE Congenital Convex Pes Valgus

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REVIEW ARTICLE Congenital Convex Pes Valgus Acta Orthop. Belg., 2007, 73, 366-372 REVIEW ARTICLE Congenital convex pes valgus (congenital vertical talus) The condition and its treatment : A review of the literature Bart H. BOSKER, Jon H. M. GOOSEN, René M. CASTELEIN, Adriaan K. MOSTERT From the Isala Klinieken, Weezenlanden Hospital, Zwolle, The Netherlands and the University Medical Center Utrecht, Utrecht, The Netherlands Much discussion exists about the best operative tech- al dislocation of the talocalcaneonavicular joint” nique to treat congenital convex pes valgus. In this more accurately directs attention to pathogenesis article a table of surgical approaches and an algo- and therapeutic implications (13). Anatomical fea- rithm, based upon literature review, are presented. tures of the deformity are a dislocated talonavicular In our opinion the technique of choice in a child joint, with the navicular bone lying dorsally on the younger than 2 years of age is extensive release with neck of the talus. The talus itself lies in a plantar lengthening of tendons and fixation procedures. In a child over 2 years of age, extensive release with and medial position, almost vertically directed. The tendon transfer is the preferred procedure. When head of the talus produces a prominence on the this procedure has failed, naviculectomy with exten- medial side ; clinically the calcaneus produces a sive release and tendon transfer, or subtalar / triple rocker bottom on the sole of the foot. The forefoot arthrodesis must be considered. is dorsiflexed, abducted and everted at the mid- tarsal joint, and the hind foot is fixed in plantar Keywords : congenital convex pes valgus ; treatment ; flexion. algorithm ; literature review. Congenital convex pes valgus should not be con- fused with other deformities of the foot, such as INTRODUCTION Congenital convex pes valgus is a condition ■ Bart H. Bosker, MD, Resident Orthopaedic Surgery. characterised by multiple soft-tissue, joint and ■ Jon H. M. Goosen, MD, Resident Orthopaedic Surgery. osseous abnormalities which result in a severe rigid ■ Adriaan K. Mostert, MD, PhD, Orthopaedic Surgeon. flat-foot deformity. It was described first by Department of Orthopaedic Surgery, Isala Klinieken, Rocher (28) in 1913 who called it “foot in piole”. Weezenlanden Hospital, Zwolle, The Netherlands. Since then many authors published about this ■ René M. Castelein, MD, PhD, Professor in Orthopaedic deformity under various terminologies as “pied plat Surgery. Department of Orthopaedic Surgery, University Medical valgus congénital”, vertical talus, reverse club foot, Center Utrecht, The Netherlands. congenital valgus flatfoot, rocker-bottom foot and Correspondence : A. K. Mostert, MD, PhD, Department of talipes convex pes valgus (13, 18, 21). Although the Orthopaedic Surgery, Isala Klinieken, Weezenlanden Hospital, term congenital convex pes valgus, proposed by Zwolle, Groot Wezenland 20, P.O. box 10500, 8000 GM Lamy and Weissman (19), is currently preferred, Zwolle, The Netherlands. E-mail : [email protected]. © 2007, Acta Orthopædica Belgica. Tachdjian (32) believes that “teratologic dorsolater- Acta Orthopædica Belgica, Vol. 73 - 3 - 2007 No benefits or funds were received in support of this study CONGENITAL CONVEX PES VALGUS 367 clubfoot (talipes equino-cavo-varus). The displace- up. Fifty articles were found, of which 22 (including 212 ment of the talonavicular joint is indeed opposite in operated feet) could be used following the above men- the two conditions : in club foot it is displaced tioned criteria. downwards and medially, whereas in congenital After studying the various surgical techniques in the convex pes valgus the navicular bone moves articles, 6 main procedures were defined : 2 soft tissue upwards and laterally to lie on the dorsum of the and 4 bony procedures. Age at operation (+/- 2 years), associated congenital head of the talus. A further difference is that the abnormalities according to Hamanishi (17), surgical elevated heel in congenital convex pes valgus is not technique and its success rate are shown in tables I, II fixed, as it is in clubfoot (11). and III. Although many surgical procedures have been described for the correction of congenital convex pes valgus, the best operative technique to treat this RESULTS condition is often discussed (21, 29, 35). In this arti- cle an algorithm of surgical techniques, based upon Most patients up to two years of age were oper- a review of the literature is presented. ated by extensive release with tendon lengthening and fixation procedures. The average success rate MATERIAL AND METHODS with this technique was 71% (8, 10, 12, 13, 16, 22, 29, PubMed was used to search for articles on surgical 31, 33, 34). treatment of congenital convex pes valgus. Extensive release with tendon transfer was the Articles found and reporting about the following were second most performed procedure in this age included : number of affected feet ; other abnormalities ; group. The average success rate in these patients age at surgery ; surgical technique ; results and follow- was 74% (3, 5, 6, 8-10, 12, 15, 16, 34). Table I. — Results in feet treated with 6 different operative techniques, in children from 0-24 months of age 0-24 months Age at surgery Number of feet Follow-up Results in months in months (range) (range) ETLF* 9.6 78 59.3 55 good (0.25-24) (3-251) 8 fair 15 poor ETT* 15.6 43 53.7 32 good (5-24) (8-184) 5 fair 6 poor WN* 9.6 3 89 3 good (9-11) (72-120) 0 fair 0 poor NE* 14.5 4 30 2 good (5-24) (24-36) 2 fair 0 poor NERTT* 11.2 8 19.2 8 good (3-18) (12-48) 0 fair 0 poor STA* 14.6 4 30 4 good (3-24) (24-41) 0 fair 0 poor * extensive release with lengthening of tendons and fixation procedures (ETLF), extensive release with tendon transfer procedures (ETT), wedge from navicular (WN), naviculectomy (NE), naviculectomy, extensive release and tendon transfer procedures (NERTT), subtalar / triple arthrodesis (STA). Acta Orthopædica Belgica, Vol. 73 - 3 - 2007 368 B. H. BOSKER, J. H. M. GOOSEN, R. M. CASTELEIN, A. K. MOSTERT Table II. — Results in feet treated with 6 different operative techniques, in children older than 24 months of age >24 months Age at surgery in Number of feet Follow-up Results months in months (range) (range) ETLF* 40.4 13 76 6 good (25-72) (24-207) 3 fair 4 poor ETT* 42 22 67 16 good (26-84) (12-154) 3 fair 3 poor WN* 96 1 84 1 good NE* 37 4 57 1 good (32-42) (24-96) 2 fair 1 poor NERTT* 43.6 15 41.7 11 good (25-78) (18-65) 1 fair 3 poor STA* 75 17 78 12 good (36-156) (12-180) 3 fair 2 poor * extensive release with lengthening of tendons and fixation procedures (ETLF), extensive release with tendon transfer procedures (ETT), wedge from navicular (WN), naviculectomy (NE), naviculectomy, extensive release and tendon transfer procedures (NERTT), subtalar / triple arthrodesis (STA). The other four surgical procedures, all bony pro- The results of the soft tissue procedures com- cedures, were hardly used in this age group pared accordingly to the accompanying congenital (table I) (3, 5, 10, 11, 16, 27). abnormalities are listed in table III. In the group of children who had surgery over Bony procedures and operations performed on 24 months of age, extensive release with tendon children beyond 2 years of age were not included in transfer was the most used procedure. The average this table due to the lack of sufficient data for a success rate with this technique was 73% (3, 6, 8, 9, reliable analysis. 16, 25, 34). The most performed procedure was extensive Extensive release with tendon lengthening and release with tendon lengthening and fixation proce- fixation procedures scored an average success rate dures. Poor results were relatively more common in of 46% (8, 10, 23, 31, 33). children with chromosomal abnormalities. Of the bony procedures, naviculectomy with Extensive release with tendon transfer seemed to release procedures and tendon transfer, and the be a superior procedure in children with neural tube subtalar / triple arthrodesis, were the two most used defects, younger than 2 years of age. surgeries. The average success rate of naviculectomy with DISCUSSION release procedures and tendon transfer was 73% at a mean age of 43.6 months at surgery (5, 20, 27). The If left untreated the condition will result in a very subtalar / triple arthrodesis scored 71% at a mean painful and deformed foot in adolescence. Most age of 75 months at surgery (4, 10, 23, 24, 26). authors agree that the disorder should be recog- Excision of the navicular bone or excision of a nised at birth and treated before the age of 2. If wedge from the navicular was only done in five feet treatment is delayed beyond 2 years of age, more (table II) (3, 10, 35). aggressive procedures must be employed (20). Acta Orthopædica Belgica, Vol. 73 - 3 - 2007 CONGENITAL CONVEX PES VALGUS 369 Table III. — Results of the two soft tissue techniques in feet of children with congenital abnormalities, in the classification accord- ing to Hamanishi (17) 0-24 months Age at surgery Number of feet Follow-up Results in months in months (range) (range) Neural tube defects ETLF* 11 18 72 10 good (3-220) (3-220) 3 fair 5 poor ETT* 23 9 36 7 good (12-24) (12-60) 0 fair 2 poor Neuromuscular ETLF* 9.6 5 33 4 good (5-18) (12-62) 1 fair 0 poor ETT* 14 6 51.2 4 good (8-24) (12-94) 0 fair 2 poor Chromosomal ETLF* 8 5 92.6 2 good (6-12) (28-204) 1 fair 2 poor ETT* 5 2 16.5 1 good (8-25) 0 fair 1 poor Malformation ETLF* 11.3 20 58.3 14 good (1-22) (14-144) 2 fair 4 poor ETT* 16 5 79.6 4 good (11-22) (24-180) 0 fair 1 poor Idiopathic ETLF* 9.5 30 53.3 26 good (1week-24 months) (18-251) 1 fair 3 poor ETT* 10.3 11 47.9 9 good (6-24) (25-184) 2 fair 0 poor * extensive release with lengthening of tendons and fixation procedures (ETLF), extensive release with tendon transfer procedures (ETT).
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