Verticaltalus is a heterogeneous birth defect Resulting from many diverse etiologies Neurolo-distal arthrogyposis,myelomeningocoele,sacral agenesis,-muscle imbalance, Neuromuscular-arthgryposis,sma,neurofibromatosis Gen syn-trisomy 13 n trisomy 18
HOXD10geneencoding,ahomeobox transcription factor Gene expressed early in limb development GDF5-CARTILAGE DERIVED MORPHOGENIC PROTEIN-1 Avarietyof syndromeshavealsobeendescribedinwhichverticaltalus isaclinicalmanifestation.
dorsolateral subluxation or dislocation of the calcaneocuboid joint. All dese deformities leads to elongation of the medial column and shortening of the lateral column
Ligamentous abnormalities mirror the bony deformity
Vascular supply at risk-extensive ant dissection and foot in plantar flexed
There has been several classification schemes proposed for vertical talus based either on anatomical abnormalities or associated diagnoses. In contrasttocongenitalclubfoot,thereiscurrentlynoclini- calclassiﬁcationforCVTwhichassessestheseverityof thedeformity;currentclassiﬁcationsaremorefocusedon associateddisorders
Less severe variant of vertical talus,
Since most children with vertical talus are seen in the newborn period, the radiographic 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.
To such degree dorsal surface of foot touching ant surface of lower leg.
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
With each successive cast, the foot is brought into more equi- nus, hindfoot varus, and fore- maximum plantar flexion and inversion to ensure adequate stretching of the contracted dorsolateral ten- dons, joint capsules, and skin
In literature different type of recon.sx ve been described.
However all of these techniques have been associated with substantial complications
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.
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
to hold the talonavicular joint in the reduced position
A Beaver eye blade (Becton Dickinson, Franklin Lakes, New Jersey) is introduced through the skin onto the medial edge of the Achilles tendon about 1 cm above its calcaneal in- sertion with the cutting surface of the blade pointed proxi- mally. The undersurface of the tendon is palpated with the tip of the blade, which is then rotated 45° to allow the tendon to be severed from ventral to dorsal.
range of ankle motion and foot inversion, to be performed two or three times a day at home.
congenital vertical talus BY Dr Nk singh
Presenter-Dr Navin Singh
Co-Moderator- Dr Gajanand
Moderator-Dr.Shah Alam Khan
All India Institute of Medical Sciences ,
Congenital + vertical + talus
Term-1st used by:Henken in 1914.
Congenital convex pes valgus(CCPV)
Reverse club foot
congenital valgus flat foot
Rocker buttom foot
Talipes convex pes valgus
Tachdjian describes as the “teratologic dorsolateral
dislocation of the talocalcaneonavicular joint.”
Incidence 1 in 10,000
Tachdjian M: Pediatric Orthopedics, vol 4. 2nd ed. Philadelphia, WB Saunders, 1990.
Jacob sen ST,Crawford AH(1983)Congenital vertical talus.
J Pediatr Orthop 3:306–310
CVT-fixed dorsal dislocation of the navicular on the
talar head and neck and fixed equinus contracture of
the hindfoot resulting in rigid flatfoot deformity.
Idiopathic /or associated with other neuromuscular or
Lamy L,Weissman L(1939)Congenital convex pes valgus. J Bone Joint Surg Am21:79
Left untreared –causes significant 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 .
Exact etiology :unknown.
Possible causes-Muscle imbalance;
Arrest in fetal development betn 7th -12th wk
A/W -Neurological abnormalities-
-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
Talus-head and neck flattened
and medially deviated
- plantar flexed position
Calcaneum-plantar flexed and
Navicular- Displaced dorsally
Cuboid- in severe deformity
Talocalcaneal angle is increased
Middle and anterior subtalar facet-hypoplastic
The medial tendons,the calcaneo navicular ligament
and the anterior ﬁbres of the delta ligament are
Contractures are on the dorsolateral side and
include the peroneal tendons,the extensor
tendons,the calcaneoﬁbular ligament,the talo-
navicular ligaments and the capsule of the ankle and
the subtalar joint.
Drennan JC(1995)Congenital vertical talus.J Bone Joint Surg Am77:1916–1923
Contracture of the TA,EHB,PL,PT,and AT
Posterior tibial tendon and PB,PL-act as dorsiflexors
rather than plantiflexors.
Vascuar supply-dominated by DPA and ATA ;deficient
Characterized by: 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
Head of talus plantar medial aspect of midfoot
Calcaneus is in equinus
Palpable gap dorsally between navicular and talar
Left untreated –more rigid deformity and adaptive
changes in tarsal bones
Callosities around the head of talus
Heel doesn’t touch the ground ;shoewear becomes
difficult and pain is inevitable.
1.Coleman-1st:isolated talonavicular dislocation
2nd-both talonavicular and calcaneocuboid
Coleman SS,Stelling FH 3rd,Jarrett J(1970)Pathomechanics and treatment of congenital vertical talus .Clin Ortho
2.Ogata and schoenecker -Three group-
2-A/W other abnormality but no neurological defecit
3.A/W neurological defecit
Clinical Orthopaedics (1979 )139:128–132
less rigid,navicular will reduce on plantiflexion
observation and /or casting
Ossification –cuboid 1st month
AP and lateral radiographs of foot in neutral position
Lateral x-ray in forced dorsi and planti flexion of foot
Measurements:-on lateral x-ray –
talocalcaneal; tibiocalcaneal, tibiotalar,talar axis 1st
metatarsal base angle(TAMBA)
In CVT-talar axis vertical,calcaneus in equinus and
increased talocalcaneal angle
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
Goal:restore and maintain normal anatomic
As with the ponseti method of treatment of clubfoot
Serial manipulations and casting-all deformities corrected
simultaneously except heel equinus
In the OPD settings
One parent beside the baby to offer a pacifier or bottle of
One assistant to either hold the corrected foot or apply
If breastfeed-nursed before manipulation
More relaxed the baby-better the cast that can be applied
Supine on the clinic table with feet at the end of the
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
After a few minutes of manipulation,A/K cast applied
in two sections,with knee in 90’ of flexion
1st section-short leg cast extending from toes to just
distal to knee with foot in plantar flexion and
2nd stage-cast extended to A/K cast
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
Final cast –Maximum plantar flexion,inversion
Foot simulates –clubfoot
Lateral radigraph in PF;TAMBA<30’
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
However, unlike clubfoot, essentially 100% of reported
vertical talus deformities have not been fully corrected
with cast immobilization alone and have required major
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
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.
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
Major reconsructive surgeries-
-single stage releases
-two stage releases
-soft tissue releases with navicular excision
-Grice –green subtalar fusion after release
-stiffness of the ankle and subtalar
- undercorrection of the deformity
-needs of multiple surgeries
J Pediatr Orthop B. 2002;11:60-7
J Pediatr Orthop. 2001;21:212-7.
J Bone Joint Surg Am. 1952;34:927-40.
Type of procedure-age of child
-severity of the deformity and
Upto age three open reduction of talonavicular joint.
-one stage /or two stage operation
Two stage operation-
1st stage-lengthening of extensor tendons and tibialis
anterior tendon and reduction of talo navicular joint
2nd stage -correcting equinus contracture by
lengthening Achilles tendon,peroneal tendon and
posterior ankle and subtalar release
Complication –AVN of talus
The extensor digitorum longus and peroneus tertius
tendons are lengthened
The dorsal and lateral talonavicular joint capsule are
divided and talonavicular joint reduced and fixed
Achilles tendon lengthened percutaneously
After hind foot correction,second k-wire from plantar
surface of heel through the calcaneus and talus into
Long leg above knee cast for 6 weeks
After 6 weeks ,remove 2 k-wires and B/K cast for
further 6 weeks
Through DL approach-calcaneocuboid joint inspected
Medially,dorsal talonavicular ligament
(deltoid)divided and capsulotomy of talonavicular
joint done; reduced and transfixed with k-wire.
Postriorly,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
Origin of Anterior tibial tendon released and transfer
it to the mid talar neck using a drill hole and sewing it
Similarly posterior tibial tendon, is sewed beneath the
talar head and neck to assist in support.
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
In literature various surgical techniques have been
described: 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)
1)Wedge from navicular (WN),
3)Naviculectomy,extensive release and tendon transfer
4)Subtalar / triple arthrodesis (STA).
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
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.
Matthew B Dobbs, MD
Recognized for his skill at treating all
paediatric foot disorders.
Minimally invasive approach toward the treatment
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 ponseti
-percutaneous fixation of talonavicular joint using k-
- percutaneous Achilles tenotomy.
Dobbs minimally invasive
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
Dobbs minimally invasive
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
If this is successful, the talonavicular joint is held with
Dobbs minimally invasive
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.
Once talonavicular joint reduced and fixed with k-wire
percutaneous tenotomy was done.
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
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
Routine follow up assessment
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
4 radiological parameter
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 talus.
J Child Orthop 2007;1:165–174
J Bone Joint Surg [Am] 2012;94-A:73.
J Bone Joint Surg [Am] 2006;88-
Kinematics and pathoanatomy of deformity
Failure to obtain maximum hindfoot varus,forefoot
adduction in the last cast
b/k cast application- a toe to groin cast :to prevent ankle
and talus from rotating
Failure to have perfect talonavicular reduction(role of x-
Achilles tenotomy before first securing talonavicular
Failure of parents to do stretching exercises