Dr. Anisuddin Bhatti Paediatric Orthopaedic Surgeon DR. Ziauddin University Karachi presented talk on Congenital Vertical Talus at AKU karachi on August 2023 in Orthopaedic Review course. Acknowledged for some text material & photo taken from Published literature.

1. Congenital Vertical Talus (CVT)
ANISUDDIN BHATTI
HOD, Orthopaedic, Trauma & Reconstructive Surgery
Jinnah Postgradaute Medical Centre, Karachi

2. Objectives-
Patho-anatomy
Clinical presentation
Treatment modalities

3. CVT-
Congenital + Vertical + Talus
Term-1st used by: Henken in 1914.
Several Synonyms-
o Congenital convex pes valgus(CCPV)
o Reverse club foot
o Congenital valgus flat foot
o Rocker Buttom foot
o Talipes convex pes valgus

4. oTachdjian describes CVT as:
o “Teratologic dorso-lateral dislocation of
the talo-calcaneo-navicular joint.”
oNavicular is dislocated dorsally on the
talar head and neck, Talus oriented
vertically leading to fixed equinus
contracture of the hindfoot and a Rocker
bottom deformity..

5. Etiology-
• Exact etiology :unknown.
• Possible causes-Muscle imbalance;
Intrauterine compression
Arrest in fetal development b/w 7th -12th wk
• Idiopathic (50%) or Associated with other neuromuscular or genetic
disorder (50%)
• Incidence 1 in 10,000
• Male=female
• B/L -50%

6. 50% Associated with
• Neurological abnormalities- Arthrogryposis,
myelomeningocoele,
spinal musc atrophy,
neurofibromatosis,
cerebral palsy
Genetic syndrome: trisomy 13,15 and 18
• A thorough neurological and genetic work up

7. Patho-anatomy-Skeletal :
• Talus-head and neck flattened
and medially deviated
- plantar flexed position
Calcaneum-plantar flexed and
externally rotated
Navicular- Displaced dorsally
and laterally;hypoplastic
Cuboid- in severe deformity
displaced laterally All these deformities leads to
elongation of the medial column and
shortening of the lateral column

8. PathoAnatomy: Soft Tissues
• The medial tendons, the calcaneo navicular ligament and the
anterior fibres of the delta ligament are elongated.
• Contractures are on the dorsolateral side include the
peroneal tendons, the extensor tendons, the calcaneo-fibular
ligament, the talo-navicular ligaments and the capsule of the
ankle and the subtalar joint

9. PathoAnatomy: Soft Tissues
• Contracture of the TA, EHB, PL, PT, and AT
• Tibialis Posterior, PB & PL-act as dorsiflexors rather than
plantiflexors.
Vascuar supply-
dominated by DPA
and ATA ; deficient
PTA.

10. Clinical presentation-
• Forefoot-abduction ;dorsiflexion
• Hindfoot-equinus and valgus
• Plantar surface is convex-Rocker
bottom appearance
• Deep creases on anterolateral aspect
of foot
• Foot is everted into valgus and
externally rotated position

11. Clinical presentation-
• Oblique Talus: Head of talus palpable on plantar medial aspect
of midfoot
• Left Untreared –more rigid deformity and adaptive changes in
tarsal bones, Callosities around the head of talus, causes
significant disability.
• Disability: Heel doesn’t touch the ground-pt forced to bear wt
on talar head; later on develop painful callosities and have
awkward gait with difficulty balancing .

12. Diagnosis :confirmed by-

13. Pes Plano Flexus /Rigidus
• Pes plano flexus: navicular will reduce on
plantiflexion
R/: observation and /or casting
Pes Plano Rigidus: Navicular never reduce on
planti flexion:
R/ : +/_ Casting, Mostly Surgery

14. Xray to confirm Differentials-
• Calcaneovalgus foot deformity:
-foot is dorsiflexed
-no equinus contracture of calcaneus
-flexible foot
-forced plantar flexion lateral x-ray-
normal
• Posteromedial bow of the tibia:
calcaneovalgus foot,a shortened and bowed
tibia
• Oblique talus : pes plano Flexus

15. Treatment-
• Goal:
Restore and maintain normal anatomic relationship.
Methods:
o Non-Operative : Manipulation & Casting
o Manipulation Casting & Minimal Invasive
Reduction
o Open reduction
o Fusion/ Osteotomies

16. Manipulation & Casting
Reverse Ponseti Method
• Methodoly similar as with the ponseti method of treatment of
clubfoot deformity: Reverse Ponseti
• Stretching the foot into plantar flexion and inversion with one hand
while counter pressure is applied with the thumb of the opposite
hand to the medial aspect of the head of the talus
• Serial manipulations and casting-all deformities corrected
simultaneously except heel equinus.

17. Manipulation-Reverse ponseti
technique
• In the OPD settings
• One parent beside the baby to offer a pacifier or bottle of milk
• One assistant to either hold the corrected foot or apply cast.
• If breastfeed-nursed before manipulation
• More relaxed the baby-better the cast that can be applied

18. Reverse Ponseti Method
• Crucial-to palpate the
head of talus:Plantar
medial aspect of
midfoot
• The foot is stretched
into plantar flexion
and inversion while
counter pressure is
applied to the medial
aspect of the head of
the talus

19. Reverse Ponseti Manipulation
Casting & Molding
• Manipulation for 2 minutes,
• Hold knee in 90’ of flexion, foot in plantar flexion and
inversion
• Cast A/K in two stages:
1st B/k, mold and Dry
• Carefully mold the malleoli, head of the talus, above the
calcaneum and arch
• Avoid constant pressure at single point
• Extend A/K

20. Reverse Ponseti: Molding
• Cast changed on weekly basis
• 4-6 plaster cast is usually enough to achieve reduction of the
talonavicular joint
• Final cast –Maximum plantar flexion, inversion
• Foot simulates –clubfoot
• Lateral radigraph in PF;TAMBA<30’

21. With each successive cast, the foot is brought into more equinus, hindfoot varus, and
fore- maximum plantar flexion and inversion to ensure adequate stretching of the
contracted dorsolateral ten-dons, joint capsules, and skin
Right foot Left foot

22. Caring for casts-instruction for parents
• Don’t get the cast wet
• Don’t let the cast get damaged
• Look out for potential problems-
The cast slips down –cant see babies toes
The cast fall off
Bad smell coming from cast
Toes are red white or black
Baby appears very distressed

23. Matthew B Dobbs, MI Technique
• Minimally invasive approach toward the treatment of
Idiopathic CVT.
• Serial manipulation and casting(reverse ponseti technique),
• Percutaneous fixation of talonavicular joint using k- wire.
• Percutaneous Achilles tenotomy.

24. Dobbs minimally invasive
technique-
• After the talonavicular joint has been reduced(after 5-6 casts),
fixed percutaneously with k-wire.
• Wire passed retrogade from the navicular into the talus with
foot in maximum plantiflexion
• Wire bent and cut outside skin

25. Dobbs minimally invasive
technique
• Even after 6 cast talonavicular joint is not seen to be reduced
(TAMBA>30) then an attempt is made in the operating room
to lever the talus into position percutaneously with a k-wire
placed into the talus in a retrograde manner.
• If this is successful, the talonavicular joint is held with k-wire.

26. Dobbs minimally invasive
technique
• If the talonavicular joint not reduced closed, a small medial
incision is made and dorsal capsulectomy of talonavicular
joint was done to reduce the joint.
• Fractional lengthening of tibialis anterior and peroneus brevis
tendon.

27. • Once talonavicular joint reduced and fixed with k-wire
percutaneous tenotomy was done.

28. Dobbs Post op protocol
• After tenotomy,a long leg cast :foot –neutral
Ankle 5’ DF
• Cast changed at 2 weeks (Mold is made for solid AFO
with 15’ of PF at midtarsal joint)
• A long leg cast –ankle in 10-15’DF x 3 weeks
• After 5 wks;cast removed and k-wire pulled

29. • The solid orthoses is applied and parents are instructed regarding
exercise and ankle ROM.
• Orthoses is worn for 23 hrs a day until walking age.
• Then 12-14 hrs a day until the age of 2 years.
• After bracing every 3 monthly until age of 2 yrs
• Then every 6 month-1 yr until age of 7 yrs
• After 7,once every 2 yr until skeletal maturity is reached

30. Literature Review
• However, unlike clubfoot, essentially 100% of reported vertical talus
deformities have not been fully corrected with cast immobilization
alone and have required major reconstructive surgery.
Dodge et al .Foot ankle .1987;7:326-32
Coleman et al clin orthop Relat Res 1970;70:62-72
J Bone Joint surg Br.1967;49:618-27

31. Literature Review
• Serial cast treatment of the foot is viewed as beneficial for
stretching the soft tissues and neurovascular structures on
the dorsum of the foot and ankle,thereby decreasing the
complexity of the operation.
J Pediatr Orthop. 1987;7:405-11
J Pediatr Orthop. 1983;3:306-10.

32. Literature Review
• However, unlike casting for clubfoot,serial casting for congenital
vertical talus has not been used until recently as a method of
achieving definitive correction.
J Bone Joint Surg Am(2006)88:1192–1200

33. Open Reduction
• Type of procedure:
-Age of child
-Severity of the deformity (Complex / Associated disordes))
-Surgeon preference: Single / two stage releases
• Prodedures:
• Soft tissue releases
• Soft tissue releases with navicular excision
• Grice –green subtalar fusion after release

34. Age & procedure
• Most authors agree that the disorder should be recognised at
birth and treated before the age of 2.
• If treatment is delayed beyond 2 years of age,more aggressive
procedures must be employed.
J Foot Ankle Surg 2001; 40:166-171.

35. Single stage reconstruction:
Three incisions
• 1ST: concave downward
over the medial
talonavicular joint;
• 2nd oblique over the
sinus tarsi to expose
the calcaneocuboid
joint and peroneal and
extensor tendons;
• 3rd along the lateral
border of the Achilles
tendon to allow
posterior release.

36. Single stage reconstruction:
Three incisions
• Medial side Reduction , dorsal talonavicular ligament
(deltoid)divided and capsulotomy of talonavicular joint done;
reduced and transfixed with k-wire.
• Dorso lateral elongation: calcaneocuboid joint inspected and
reduced
• Postrior Lengthenig: Achilles Z-Plasty Lengthening

37. Single stage
reconstruction:
Three incisions

38. Single stage reconstruction:
Relese & Tibialis Ant Transfer
• Origin of Anterior tibial
tendon released and
transfer it to the mid
talar neck using a drill
hole and sewing it to
itself.
• Similarly posterior
tibial tendon, is sewed
beneath the talar head
and neck to assist in
support.

39. Single stage reconstruction:
Modified cincinnati incision-

40. Single stage reconstruction:
Modified cincinnati incision-

41. Single stage
reconstruction
Check lateral x-ray:
TMT1- 1st metatarsal
axis should line up
exactly with long axis
of talus
(TAMBA<30)

42. Two stage operation-
• 1st stage-lengthening of extensor tendons and
tibialis anterior tendon, Peronius Tertius and
Dorsolateral capsulotomy / reduction of talo
navicular joint
• 2nd stage -correcting equinus contracture by
lengthening Achilles tendon, peroneal tendon
and posterior ankle and subtalar release

43. Maintain Reduction
• After hind foot correction,second k-wire from plantar surface
of heel through the calcaneus and talus into tibia
• Long leg above knee cast for 6 weeks
• After 6 weeks ,remove 2 k-wires and B/K cast for further 6
weeks

44. Reconstructive Surgery in
Older age
• The technique of choice in a child younger than 2 years of age is -
extensive release with lengthening of tendons and fixation
procedures.
• In a child over 2 years of age, extensive release with
tendon transfer is the preferred procedure.
• When this procedure has failed, naviculectomy with extensive release
and tendon transfer,or subtalar / triple arthrodesis must be
considered

45. Literature Review
• The single-stage surgical correction resulted in good results
with a low rate of complications.
• The Cincinnati incision provided excellent exposure to the
pathoanatomy to allow complete correction of the
plantarflexed vertical talus, reduction of the talonavicular
dislocation, and realignment of the equinovalgus deformity of
the calcaneus.
• Kodros, Steven A. M.D.*; Dias, Luciano S. M.D. Single-Stage Surgical Correction of Congenital
Vertical Talus. Journal of Pediatric Orthopaedics; 19(1), January/February 1999, pp 42-48

46. Reconstructive Surgery in
Older age
• Two soft tissue and four bony procedures.
• Soft tissue procedures-
1)extensive release with lengthening of tendons and fixation
procedures (ETLF),
2)extensive release with tendon transfer procedures (ETT)

47. Reconstructive Surgery in
Older age
Bony procedures-
1. Wedge from navicular (WN),
2)Naviculectomy (NE),
3)Naviculectomy,extensive release and tendon transfer
procedures (NERTT),
4)Subtalar / triple arthrodesis (STA).

49. Acta Orthopædica Belgica, Vol.73 - 3 - 2007

50. Thank you!!!!!!!!

51. Coleman divided CVT into 2 types
• Type 1 was associated with a calcaneocuboid dislocation
• Type 2 was not associated with a calcaneocuboid dislocation.
• This distinction is important clinically because the type 1 deformity
is stiffer and particular attention must be paid to releasing the
calcaneocuboid joint.

52. assesment
• key feature of fixed dorsal dislocation of naviclar on neck of
talus, equinus position of talus and calcaneus, dorsiflexion of
forefoot,
and abduction contracture of the foot;
• In CVT line through talus is plantar to navicular (cuboid) in
both resting lateral and plantar flexed views;

53. AP radiogrph
• Kite angle(TaloCalcaneal angle)
>40 (20_40 is Normal)
• Valgus of midfoot

54. Lateral radiograph
• Vertical position of Talus
• Mearry,s angle( angle between long axis of talus and first
Metatarsal) is >20
• Shows Navicular dislocation

55. In normal foot
long axis of first metatarsal
passes plantarward to long axis
of talus.
In congenital vertical talus, long axis
of first metatarsal remains
dorsal to long axis of talus, indicating
dorsal dislocation of
midfoot and forefoot.

56. plantar flexion view
• diagnosis is confirmed by lateral x-ray in maximum
plantarflexion, which demonstrates the
irreducible talonavicular joint,
- navicular cannot be reduced on the talus;
- plantar flexion fails to realign talus & first metatarsal,
confirming diagnosis of a fixed talonavicular dislocation
("vertical talus");
- line drawn thru axis of talus passes plantar to metatarsal
axis;

57. IMAGING STUDIES
• AP: increased talocalcaneal angle
• Plantarflexed lateral: fixed forefoot dorsal
dislocation
• Dorsiflexed lateral: fixed equinus of hindfoot
• Lateral radiographs of the foot in maximal
plantarflexion can reveal if the navicular is
reducible; CONGENITAL OBLIQUE TALUS

58. • Because the navicular may not be ossified, the alignment of the
first metatarsal to the talus must be evaluated.
• Hamanishi described 2 radiographic angles: the talar axis–first
metatarsal base angle (TAMBA) and the calcaneal metatarsal base
angle (CAMBA). The changing point from a flexible oblique talus to
rigid CVT is a TAMBA of approximately 60° and a CAMBA of 20