HOXD10geneencoding,ahomeobox transcription factor Gene expressed early in limb development GDF5-CARTILAGE DERIVED MORPHOGENIC PROTEIN-1 Avarietyof syndromeshavealsobeendescribedinwhichverticaltalus isaclinicalmanifestation.
To such degree dorsal surface of foot touching ant surface of lower leg.
The incision is transverse and extends from the anteromedial to the anterolateral aspect of the foot over the back of the ankle at the level of the tibiotaler joint. The incision is a modified Cincinnati incision that passes beneath the medial malleolus just past the Achilles tendon posteriorly and proceeds dorsally over the navicular just past the extensor tendons
The first is concave downward over the medial talonavicular joint; the second is oblique over the sinus tarsi to expose the calcaneocuboid joint and peroneal and extensor tendons; the third is along the lateral border of the Achilles tendon to allow posterior release.
Congenital vertical talus
Dr. Joydeep Mandal
Term-1st used by : Henken in
Congenital convex pes valgus (CCPV)
Reverse club foot
congenital rigid flatfoot
Must be distinguished from flexible pes planus
commonly found in infants and children.
Incidence 1 in 10,000
The exact etiology of vertical talus in most
cases is not known.
Theories include increased intrauterine
pressure and resultant tendon contractures, or
an arrest in fetal development occurring
between the 7th and 12th week of gestation
Approximately one-half of all cases of vertical
talus occur in association with neurologic
abnormalities or genetic syndromes
A/W -Neurological abnormalities-
Arthrogryposis, myelomeningocoele, spinal
muscular atrophy, neurofibromatosis, cerebral palsy
-Genetic syndrome:trisomy 13,15 and 18
A thorough neurological and genetic work up
AD inheritance 12-20%
Mutation in HOXD10
Mutation in GDF5
Syndromes-1.De barsy syndrome
2.Prune Belly syndrome
Ogata and schoenecker –
2-A/W other abnormality but no neurological
3.A/W neurological deficit
3.Hamanishi: five groups-
1.NTD or spinal anomalies
Irreducible dorsal & lateral
dislocation of navicular
Posteriorly, Contracture of
equinus of calcaneus
subluxation over malleolus.
Tibialis Posterior acting as
Coleman divided CVT into 2 types:
type 1 was associated with a calcaneocuboid
dislocation, and type 2 was not.
This distinction is important clinically because
the type 1 deformity is stiffer and particular
attention must be paid to releasing the
Forefoot - abduction ; dorsiflexion
Hindfoot - equinus and valgus
CVT can be usually detected at birth by the presence of a rounded
prominence of the medial and plantar surfaces of foot.
Plantar surface is convex-Rocker bottom appearance. Heel does
not touch the ground.
After weight bearing begins, callosities develop beneath the
anterior end of calcaneus and along the medial border of the foot
superficial to the head of talus.
Deep creases on anterolateral aspect of foot
Foot is everted into valgus and externally rotated position
Head of talus, plantar & medial aspect of
Calcaneus is in equinus
The forefoot is dorsiﬂexed at the midtarsal
joints creating a palpable gap dorsally between
the navicular and where the talar neck should
normally be located. This gap can be helpful in
distinguishing congenital vertical talus from
the more common calcaneovalgus foot
Heel does not touches the ground, have poor
Wt bearing on talar head resulting in painful
Ambulation is usually not delayed but gait is
awkward with difficult in balancing
Forefoot become severely abducted
Talus become like “hourglass”
Abnormal shape of foot result in difficult shoe
The lack of ossiﬁcation of many of the bones in the
foot at birth can make the diagnosis of congenital
vertical talus challenging on plain radiographs
The talus, tibia, calcaneus, and metatarsals are
ossiﬁed at birth.
The cuboid ossiﬁes in the ﬁrst month of life while
the cuneiforms and navicular usually ossify
around the ages of 2 and 3 years, respectively.
Since most children with vertical talus are seen in
the newborn period, the radio- graphic evaluation
is focused on the relationships of the ossiﬁed talus
and calcaneus to the tibia as well as the
relationship of the metatarsals to the hindfoot.
Forced plantar ﬂexion and forced dorsiﬂexion lateral radiographs are necessary
to conﬁrm the diagnosis of vertical talus and rule out the oblique talus and
calcaneovalgus foot as diagnoses.
The forced plantar ﬂexion lateral radiograph in a vertical talus foot shows
persistent malalignment of the long axis of the talus and the ﬁrst metatarsal.it
show persistent dorsal translation of the forefoot on the hindfoot.
the forced dorsiﬂexion lateral radiograph demonstrates a persistently
decreased tibiocalcaneal angle indicating ﬁxed hindfoot equinus .
In contrast, a forced plantar ﬂexion lateral radiograph of an oblique talus will
demonstrate restoration of a normal relationship between the long axis of the
talus and the ﬁrst metatarsal
Measurements that can be obtained on the radiograph
the talocalcaneal – Increased in both AP & lateral
tibiocalcaneal – Increased in lateral view.
tibiotalar – Increased in lateral view.
talar axis- ﬁrst metatarsal base angles – Disrupted in
both AP and lateral views.
Radiographs of an infant's foot particularly less
than 6 months can be difficult to interpret. The
use of dynamic ultrasound has been reported
to be helpful in the evaluation of infants with
vertical or oblique talus.
Calcaneovalgus foot deformity:
-foot is dorsiflexed
-no equinus contracture of calcaneus
-forced plantar flexion lateral x-ray-normal
Posteromedial bow of the tibia : calcaneovalgus
foot,a shortened and bowed tibia
The goals of treatment are to restore the normal
anatomic relationships between the talus, the
navicular, and the calcaneus, in order to
provide a normal weight distribution through
In the OPD settings
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
Supine on the clinic
table with feet at the
end of the table
Crucial-to palpate the
head of talus:Plantar
medial aspect of
The foot is stretched
into plantar flexion
and inversion while
counter pressure is
applied to the medial
aspect of the head of
After a few minutes of manipulation,A/K
cast applied in two sections,with knee in 90’
1st section-short leg cast extending from
toes to just distal to knee with foot in plantar
flexion and inversion.
2nd stage-cast extended to A/K level.
4-6 plaster cast is usually enough to achieve
reduction of the talonavicular joint.
Carefully mold the malleoli, head of the talus,
above the calcaneum and arch.
Avoid constant pressure at single point.
Cast changed on weekly basis.
Never do pronation of the foot.
Final cast –Maximum plantar flexion, inversion.
Foot simulates –clubfoot.
Lateral radigraph in PF;TAMBA<30’.
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 but it
reduces extension and complexity of the surgery.
The type of procedure used for an individual
patient is based on
the age of the patient,
severity of the deformity,
and the preference of the surgeon.
Children up to the age of 1 to 4 years are usually
offered an open reduction of the talonavicular
joint, which can be performed through either a
one-stage or two-stage operation.
Occasionally, in children of 3yrs or old with
severe deformity require excision of navicular
during open reduction.
Children of 4 to 8 yrs require open reduction
and soft tissue procedures combined with
extra-articular subtalar arthrodesis.
Children of 12 yrs or older require triple
Several authors, beginning with Osmond-Clarke,
Herndon and Heyman, and Coleman and associates,
described staged, 2-incision reconstructive surgery.
The first stage of the Coleman procedure consisted of
lengthening the extensor digitorum longus (EDL),
extensor hallucis longus (EHL), and tibialis anterior, with
capsulotomies of the talonavicular and calcaneocuboid
joints and release of the talocalcaneal interosseous
The second stage consisted of tendo-Achilles lengthening
and a posterior capsulotomy of the ankle and subtalar
After noting a high incidence of complications
with the 2-stage technique, Ogata and
colleagues recommended a single-stage
procedure with a medial approach
Kodros and Dias published results they
derived using a single-stage approach with a
Seimon described a single-stage dorsal
The ﬁrst step is the reduction of the talonavicular joint which is
aided by release of the anterior tibialis tendon and the
tibionavicular and talonavicular ligaments. The reduction is held
by a Kirschner wire placed across the talonavicular joint .
The second step is lengthening of the toe extensors and
peroneals which aids in improving ankle plantar ﬂexion and
forefoot adduction. The calcaneocuboid joint is also reduced if
The third step is correction of the ankle equinus contracture
which is done by lengthening the Achilles tendon and releasing
the ankle and subtalar joint capsules.
Some authors have recommended the addition of a tibialis
anterior tendon transfer to the head or neck of the talus at the
time of open reduction to add a dynamic corrective force
The Cincinnati incision provided excellent
exposure to the pathoanatomy to allow
complete correction of the plantar flexed
vertical talus, reduction of the talonavicular
dislocation, and realignment of the
equinovalgus deformity of the calcaneus.
Three incisions- Described by Kumar ,
Cowell and Ramsey.
1st – Oblique incision
over sinus tarsi.
2nd – Concave incision
medial head of talus.
3rd – 2 inches long
incision over medial
side of TA.
Through DL approach - calcaneocuboid joint
inspected and reduced.
Medially – Tibialis anterior tendon exposed, if
contracted, lengthening done with Z plasty or
transpose it into the planter aspect of the repaired
dorsal talonavicular ligament (deltoid) released.
Planter calcaneonavicular ligament is released.
capsulotomy of talonavicular joint done
reduced and transfixed with k-wire.
Posteriorly - Z-lengthening of Achilles tendon
with distal transverse cut directed laterally.
Check lateral x-ray:
1st metatarsal axis should line up exactly with
long axis of talus
Described by Coleman et al. for older children
with severe or recurrent deformities.
It combines open reduction and realignment of
talonavicular joint (by Kumar et al.) with
Grice-Green fusion of talo-calcaneal joint
performed 6 to 8 weeks later.
Modification done by Dennyson and Fulford
using screws for talo-calcaneal fusion.
Apply long leg cast with knee flexed and ankle,
foot in neutral position for 8 weeks.
Steinmann pin or k wire removed and new
long leg cast applied for next 4 weeks.
Below knee cast for another 4 weeks.
Foot supported in ankle-foot orthosis for
another 3 to 6 months.
Correction of vertical talus through an open
reduction can be associated with signiﬁcant short-
term complications, including
undercorrection of the deformity ,
stiffness of the ankle and subtalar joint ,
The eventual need for multiple operative
procedures such as subtalar and triple arthrodesis .
Long-term outcomes are likely to be complicated
by a signiﬁcant amount of degenerative arthritis as
is seen in many patients with clubfoot treated with
extensive soft-tissue releases
Described by Dobbs et al.
Between 2000 to 2003, at St. Louis Children’s
Hospital & University of Iowa Hospitals and
Clinics ;Dobbs et al treated 11 cases (19 feet) of
idiopathic CVT by:
-serial manipulation and casting(reverse
-percutaneous fixation of talonavicular joint
- percutaneous Achilles tenotomy.
Both clinical and radiological parameter.
Clinical-1.ankle and subtalar movement
3.loss of the medial arch
4.medial prominence of the talar head
5.hind foot valgus
6 .abnormal shoe wear
As by Adellar et al-
Comprises 10 point scale :6 clinical appearance
Maximum 10 points –Excellent
Bone Joint J 2014;96-B:274–8
Excellent results, in terms of the clinical
appearance of the foot, foot function, and
deformity correction as measured
radiographically , in patients with idiopathic
and those associated with other genetic or
neuromuscular disorder ;congenital vertical
Early detection and methodical treatment in a
more comprehensive manner is the key to