congenital vertical talus

1. Presenter-Dr Navin Singh
Co-Moderator- Dr Gajanand
Moderator-Dr.Shah Alam Khan
All India Institute of Medical Sciences ,
New Delhi

2. Objectives-
Anatomy of foot
Introduction
Etiology
Pathoanatomy
Clinical presentation
Treatment modalities

3. Anatomy-
 Foot-bones:Tarsals-7
Metatarsals-5
Phalanges-14
Foot-hind foot
mid foot
fore foot
Joints-Ankle joint:15’DF,55’PF
-subtalar joint:inv 30’,ev-10’
-mid tarsal joint:Abd 10’;Add 15’

4. Talus-

5. CVT-
Congenital + vertical + talus
Term-1st used by:Henken in 1914.
Several Synonyms-
Congenital convex pes valgus(CCPV)
Reverse club foot
congenital valgus flat foot
Rocker buttom foot
Talipes convex pes valgus

6.  Tachdjian describes as the “teratologic dorsolateral
dislocation of the talocalcaneonavicular joint.”
 Incidence 1 in 10,000
 Male=female
 B/L -50%
 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

7.  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
genetic disorder.
 Lamy L,Weissman L(1939)Congenital convex pes valgus. J Bone Joint Surg Am21:79

8.  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 .

9. Etiology-
 Exact etiology :unknown.
 Possible causes-Muscle imbalance;
Intrauterine compression
Arrest in fetal development betn 7th -12th wk
of POG
 Idiopathic-50%

10.  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

11.  AD inheritance 12-20%
 Mutation in HOXD10
 Mutation in GDF5
 Syndromes-1.De barsy syndrome
2.Prune Belly syndrome
3.Costello syndrome
4.Rasmussen syndrome
 Iatrogenic

12. Patho-anatomy:
 “Kinematic coupling”
 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

13.  Talocalcaneal angle is increased
 Middle and anterior subtalar facet-hypoplastic

14.  The medial tendons,the calcaneo navicular ligament
and the anterior fibres of the delta ligament are
elongated.
 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

15.  Contracture of the TA,EHB,PL,PT,and AT
 Posterior tibial tendon and PB,PL-act as dorsiflexors
rather than plantiflexors.

16.  Vascuar supply-dominated by DPA and ATA ;deficient
PTA.

17. Clinical presentation-
 Characterized by: Forefoot-abduction ;dorsiflexion
Hindfoot-equinus and valgus

18.  Plantar surface is convex-Rocker bottom appearance
 Deep creases on anterolateral aspect of foot
 Foot is everted into valgus and externally rotated
position

19.  Head of talus plantar medial aspect of midfoot
 Calcaneus is in equinus
 Palpable gap dorsally between navicular and talar
neck
 Left untreated –more rigid deformity and adaptive
changes in tarsal bones

20.  Callosities around the head of talus
 Heel doesn’t touch the ground ;shoewear becomes
difficult and pain is inevitable.

21. Classification-
1.Coleman-1st:isolated talonavicular dislocation
2nd-both talonavicular and calcaneocuboid
dislocation
Coleman SS,Stelling FH 3rd,Jarrett J(1970)Pathomechanics and treatment of congenital vertical talus .Clin Ortho
p70:62–72

22. 2.Ogata and schoenecker -Three group-
1-Idiopathic
2-A/W other abnormality but no neurological defecit
3.A/W neurological defecit
Clinical Orthopaedics (1979 )139:128–132

23. 3.Hamanishi:five groups-
1.NTD or spinal anomalies
2.neuromuscular disorders
3.malformation syndromes
4.chromosomal aberrations
5.idiopathic
J Pediatric Orthopaedics (1984)4:318–326

24. Oblique talus-
 less rigid,navicular will reduce on plantiflexion
 observation and /or casting

25. Radiographic features-
 Ossification –cuboid 1st month
cuneiform-2nd year
navicular-3rd year
 AP and lateral radiographs of foot in neutral position
 Lateral x-ray in forced dorsi and planti flexion of foot

26.  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

28. Diagnosis :confirmed by-

29. 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

30. Treatment-
 Goal:restore and maintain normal anatomic
relationship.

31.  As with the ponseti method of treatment of clubfoot
deformity
 Serial manipulations and casting-all deformities corrected
simultaneously except heel equinus

32. 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

33.  Supine on the clinic table with feet at the end of the
table
 Crucial-to palpate the head of talus:Plantar medial
aspect of midfoot

34.  The foot is stretched into plantar flexion and
inversion while counter pressure is applied to the
medial aspect of the head of the talus

35.  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
inversion
2nd stage-cast extended to A/K cast
 4-6 plaster cast is usually enough to achieve reduction
of the talonavicular joint

36.  Carefully mold the malleoli,head of the talus,above
the calcaneum and arch
 Avoid constant pressure at single point
 Cast changed on weekly basis

37.  Final cast –Maximum plantar flexion,inversion
 Foot simulates –clubfoot
 Lateral radigraph in PF;TAMBA<30’

38. 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

39.  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

40.  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.

41.  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

42.  Major reconsructive surgeries-
-single stage releases
-two stage releases
-soft tissue releases with navicular excision
-Grice –green subtalar fusion after release

43.  Complications-talar necrosis
-wound necrosis
-stiffness of the ankle and subtalar
joint
- undercorrection of the deformity
-pseudoarthrosis
-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.

44.  Type of procedure-age of child
-severity of the deformity and
-surgeon preference
Upto age three open reduction of talonavicular joint.
-one stage /or two stage operation

45. 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

46. Dorsolateral approach-
 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
using k-wire

47.  Achilles tendon lengthened percutaneously
 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

48. Single stage repair-
 Three incisions-

49.  Through DL approach-calcaneocuboid joint inspected
and reduced
 Medially,dorsal talonavicular ligament
(deltoid)divided and capsulotomy of talonavicular
joint done; reduced and transfixed with k-wire.

50.  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
of talus

51.  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.

52. Modified cincinnati incision-

54.  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

55.  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)

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

57.  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

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

60.  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.

61. Matthew B Dobbs, MD
 Recognized for his skill at treating all
paediatric foot disorders.
 Minimally invasive approach toward the treatment
of CVT.

62.  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
technique),
-percutaneous fixation of talonavicular joint using k-
wire and
- percutaneous Achilles tenotomy.

63. 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

64. 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.

65. 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.

66.  Once talonavicular joint reduced and fixed with k-wire
percutaneous tenotomy was done.

67. 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

68.  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

69. Routine follow up assessment
 Both clinical and radiological parameter.
 Clinical-1.ankle and subtalar movement
2.cosmetic appearance
3.loss of the medial arch
4.medial prominence of the talar head
5.hind foot valgus
6 .abnormal shoe wear

70.  Radiological –anteroposterior:
1.talocalcaneal –hindfoot algus
2.TAMBA-forefoot abduction
lateral:
1.talocalcaneal
2.tibiocalcaneal
3.TAMBA

71. Outcome measures
 As by Adellar et al-
 Comprises 10 point scale :6 clinical appearance
4 radiological parameter
 Maximum 10 points –Excellent
7-9 -good
4-6 -fair
<3 -poor
Bone Joint J 2014;96-B:274–8

72.  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-
A:1192–1200.

73. Pitfalls
 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-
ray)
 Achilles tenotomy before first securing talonavicular
joint
 Failure of parents to do stretching exercises

74. Thank you!!!!!!!!