Orthopaedic management of spina bifida-part II: foot and ankle deformities

Abstract

Both congenital and acquired orthopaedic deformities are common in patients with spina bifida. Examples of congenital deformities, which are present at birth, include clubfoot and vertical talus. Acquired developmental deformities are related to the level of neurologic involvement and include calcaneus and cavovarus. Orthopaedic deformities may also result from postoperative tethered cord syndrome. The previously published Part I reviewed the overall orthopaedic care of a patient with spina bifida, with a focused review of hip, knee, and rotational deformities. This paper will cover foot and ankle deformities associated with spina bifida, including clubfoot, equinus, vertical talus, calcaneus and calcaneovalgus, ankle and hindfoot valgus, and cavovarus. In addition, this paper will address the issues surrounding skin breakdown in patients with spina bifida.

Keywords: Ankle deformity; Foot deformity; Spina bifida.

Fig. 1

a Rigid bilateral clubfoot in a patient with spina bifida. b Note the severity of the deformity and deep medial and posterior creases

Fig. 2

a Temporary Kirschner wire (K-wire) inserted into the posterolateral aspect of the talus to derotate the talus medially in the ankle mortise. b Malrotation of the talus before correction. c After derotation of the talus, showing corrected alignment. (Reprinted from de Carvalho et al. [11] with permission; reprint permission license #:2724320846255)

Fig. 3

Patient with spina bifida in a standing frame

Fig. 4

a “Double osteotomy” to correct forefoot adduction: closing wedge osteotomy of the cuboid, b with an opening wedge osteotomy of the medial cuneiform. (Reprinted from Lourenco et al. [19] with permission; reprint permission license #:2724320665380)

Fig. 5

a Intra-operative clinical photograph demonstrating the talus removed en bloc. b Radiograph demonstrating postoperative alignment and K-wire fixation

Fig. 6

a Vertical talus deformity in an infant with spina bifida. Clinical photograph demonstrating rigid rocker-bottom deformity. b Radiograph demonstrating dislocation of the talonavicular joint with vertical position of the talus

Fig. 7

a Appearance of the feet (same patient as in Fig. 6) after serial casting in plantar flexion and inversion. b Photograph demonstrating an open approach to the talonavicular joint with K-wire fixation of the talonavicular joint and subtalar joint in reduced alignment. c Clinical photograph taken 4 months postoperatively. d Radiograph taken 17 months postoperatively. Note the restoration of normal talonavicular alignment

Fig. 8

K-wire placed into the posterolateral aspect of talus and used as a joystick to elevate the talus into the reduced position while plantarflexing the navicular and forefoot. (Reprinted from Kodros and Dias [25] with permission; reprint permission license #:2724320267614)

Fig. 9

Radiograph of an ankle with valgus deformity. Note the extreme relative shortening of the fibula and the triangular shape of the distal tibial epiphysis with lateral wedging causing valgus inclination of the talus

Fig. 10

a Severe hindfoot and ankle valgus in an adolescent patient with spina bifida. b Medial view of the left ankle in the same patient demonstrating skin breakdown over the medial malleolus and callous over the talar head

Fig. 11

a Radiograph demonstrating distal tibia valgus deformity in a 9-year-old patient with spina bifida. b Intra-operative radiograph demonstrating the placement of a cannulated screw in the distal medial tibia. c Radiograph 19 months postoperatively demonstrating correction of the valgus alignment

Fig. 12

a Cavovarus deformity in a 14-year-old patient with spina bifida. Preoperative posterior view. b Preoperative side view. c Postoperative posterior view after bilateral calcaneus, medial cuneiform, first metatarsal osteotomies with soft-tissue releases. d Postoperative side view