new trends in congenital vertical talus management.

1. B Y :
D R . G I R I S H M O T W A N I
O R T H O P A E D I C S
B . J W A D I A H O S P I T A L F O R C H I L D R E N S .
CONGENITAL VERTICAL TALUS

2. CVT-
 Rare defomity
 Term-1st used by:Henken in 1914.
 Several Synonyms-
Congenital convex pes valgus(CCPV)
Reverse club foot
congenital valgus flatfoot
Rocker buttom foot
Talipes convex pes valgus

3.  “teratologic dorsolateral dislocation of the
talocalcaneonavicular joint.”
 resulting in a rigid flatfoot deformity.
 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

4. Etiology
 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 develop- ment occurring between
the 7th and 12th week of gestation
 50% idiopathic
 . Approximately one-half of all cases of vertical talus
occur in association with neurologic abnormalities
or genetic syndromes

5.  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

6.  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

8. 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

9. 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

10.  Irreducible dorsal & lateral
dislocation of navicular over
talus
 Posteriorly, Contracture of
tendoachillis creates equinus
of calcaneus
 Anteriorly,contracture of
EDL(EHL,TIB ANT)
 Laterally PL,PB
,calcaneofibular ligament
contracted
 Posterior tendons subluxation
over malleolus
Pathoanatomy:

11.  Navicular – hypoplastic
wedge shaped
 Talar head- flattened,
extreme planter
flexion,medially deviated
 Calacaneum-plantar
flexion ,ext rotated
 Angle between axis of talus
& calcaneum is increased
 Cuboid in very severe case
pathoanatomy

12. Coleman classification
 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 calcaneocuboid joint

13. Clinical presentation-
Forefoot-abduction ;dorsiflexion
Hindfoot-equinus and valgus

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

15.  Head of talus plantar medial aspect of midfoot
 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

16. What happen if untreated?
 Heel doesnot touches the ground, have poor push off
 Wt bearing on talar head resulting in painful
callosities
 Ambulation is usually not delayed but gait is
awkward with difficult in balancing
 Forefoot become severly abducted
 Talus become like “hourglass”
 Abnormal shape of foot result in difficult
shoewearing.

17. Radiological evaluation.
 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.

18. 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.
PLANTARFLEXED FILM:
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.
DORSIFLEXED FILM:
the forced dorsiflexion lateral radiograph demonstrates a persistently decreased
tibiocalcaneal angle indicating fixed hindfoot equinus .
OBLIQUE TALUS:
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

19. Measurements that can be obtained on the lateral
radiograph include
the talocalcaneal,
 tibiocalcaneal,
 tibiotalar, and
talar axis- first metatarsal base angles.

20.  Hamanishi described 2 radiographic angles:
 the talar axis–first metatarsal base angle (TAMBA)
and
 the calcaneal axis–first metatarsal base angle
(CAMBA).

21.  Congenital vertical talus: classification with 69 cases and new measurement
system.
 Hamanishi C.
 Abstract
 Sixty-nine cases of congenital vertical talus (CVT) were classified into five groups in association
with (1) neural tube defects or spinal anomalies, (2) neuromuscular disorders, (3) malformation
syndromes, (4) chromosomal aberrations, and (5) idiopathic CVT unassociated with any of the
systemic conditions described above. Forty-four cases of idiopathic CVT were subclassified into
four groups: (5A) intrauterine molded or deformed cases, (5B) cases of digitotalar
dysmorphism associated with contractile finger abnormalities and genetic inheritance, (5C)
patients whose close relatives had CVT or oblique talus (OT) deformity, and (5D) cases
unassociated with any skeletal deformity or genetic inheritance.
 “The talar and Calcaneal axis--first metatarsal base angles (TAMBA and CAMBA) are
introduced, which enable us to describe not only the obliquity of the talus and calcaneus but
also the severity of the dislocation of the talonavicular joint and the contracture of the tendo
Achilli.”
 The changing point from flexible OT to rigid CVT is TAMBA of about 60 degrees and CAMBA
of 20 degrees, and there are many borderline cases of CVT that could be treated conservatively.
For the typical CVT, open reduction should be carried out as promptly as possible if 3 months of
corrective casting in extreme equinovarus fails to reduce the TAMBA to 50 degrees.
Hamanishi C. Congenital vertical talus:
classification with 69 cases and new
measurement system. J Pediatr Orthop.
1984 May. 4(3):318-26

23. Role of USG
Pediatr Radiol. 2013 Mar;43(3):376-80. doi: 10.1007/s00247-012-2529-5. Epub 2012
Nov 27.
Dynamic US study in the evaluation of infants with vertical or oblique talus
deformities.
Supakul N1, Loder RT, Karmazyn
 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.

24. 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

25. Treatment .
 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 the foot.

26. There are multiple surgeries described for the
treatment of vertical talus.
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 3 years are usually offered an
open reduction of the talonavicular joint, which can
be performed through either a one-stage or two-
stage operation

27. Traditional procedures.
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 ligament.
 The second stage consisted of tendo-Achilles lengthening (TAL) and a posterior
capsulotomy of the ankle and subtalar joints.
Coleman SS, Stelling FH 3rd, Jarrett J. Pathomechanics and treatment of congenital vertical talus. Clin Orthop Relat Res. 1970 May-Jun. 70:62-72.
 Herndon CH, Heyman CH. Problems in the recognition and treatment of congenital pes valgus. J Bone Joint Surg Am. 1963. 45:413-29.

28. Then trend changed to single stage technique.
 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 Cincinnati incision.
 Seimon described a single-stage dorsal approach

30. Three basic components
 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 pero- neals
which aids in improving ankle plantar flexion and forefoot
adduction. The calcaneocuboid joint is also reduced if necessary.
 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

31. Modified cincinnati incision-

33.  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

34. Single stage repair-
 Three incisions-

35.  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.

36.  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

37. COMPLICATIONS.
Correction of vertical talus through an open reduction can
be associated with significant short-term complications,
including
 wound necrosis
 undercorrection of the deformity ,
 stiffness of the ankle and subtalar joint ,
 and 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

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

39.  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.

40. REVERSE PONSETI CASTING
 The foot is stretched into plantar flexion and
inversion while counter pressure is applied to the
medial aspect of the head of the talus
4-6 plaster cast is usually enough to achieve reduction of the talonavicular
joint

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

42. 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

43. 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.

44. 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.

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

46. AFTER TA TENOTOMY …….
 An assessment is made of the ankle plantar flexion and
forefoot passive adduction at this point. If plantar flexion
is limited to <25, a fractional lengthening of the extensor
digitorum communis is done at the level of the
musculotendinous junction.
 If passive forefoot adduc- tion is <10, fractional
lengthening of the peroneal brevis tendon is performed
at the musculotendinous junction.
 Lengthening of the peroneal brevis and extensor
digitorum communis is not often needed since the
preoperative casting usually stretches these structures
enough

47. 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

48.  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

49. 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

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

51. 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

52.  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.

53.  J Bone Joint Surg Am. 2006 Jun;88(6):1192-200.
 Early results of a new method of treatment for idiopathic congenital vertical talus.
 Dobbs MB1, Purcell DB, Nunley R, Morcuende JA.
 Abstract
 BACKGROUND:
 The treatment of idiopathic congenital vertical talus has traditionally consisted of manipulation and application of casts followed by
extensive soft-tissue releases. However, this treatment is often followed by severe stiffness of the foot and other complications. The
purpose of this study was to evaluate a new method of manipulation and cast immobilization, based on principles used by Ponseti
for the treatment of clubfoot deformity, followed by pinning of the talonavicular joint and percutaneous tenotomy of the Achilles
tendon in patients with idiopathic congenital vertical talus.
 METHODS:
 The cases of eleven consecutive patients who had a total of nineteen feet with an idiopathic congenital vertical talus deformity were
retrospectively reviewed at a minimum of two years following treatment with serial manipulations and casts followed by limited
surgery consisting of percutaneous Achilles tenotomy (all nineteen feet), fractional lengthening of the anterior tibial tendon (two) or
the peroneal brevis tendon (one), and percutaneous pin fixation of the talonavicular joint (twelve). The principles of manipulation
and application of the plaster casts were similar to those used by Ponseti to correct a clubfoot deformity, but the forces were applied
in the opposite direction. Patients were evaluated clinically and radiographically at the time of presentation, immediately
postoperatively, and at the time of the latest follow-up. Radiographic measurements obtained at these times were compared. In
addition, the radiographic data at the final evaluation were compared with normal values for an individual of the same age as the
patient.
 RESULTS:
 Initial correction was obtained both clinically and radiographically in all nineteen feet. A mean of five casts was required for
correction. No patient underwent extensive surgical releases. At the final evaluation, the mean ankle dorsiflexion was 25 degrees
and the mean plantar flexion was 33 degrees . Dorsal subluxation of the navicular recurred in three patients, none of whom had had
pin fixation of the talonavicular joint. At the time of the latest follow-up, there was a significant improvement (p < 0.0001) in all of
the measured radiographic parameters compared with the pretreatment values, and all of the measured angles were within normal
values for the patient's age.
 CONCLUSIONS:
 Serial manipulation and cast immobilization followed by talonavicular pin fixation and percutaneous tenotomy of the Achilles
tendon provides excellent results, in terms of the clinical appearance of the foot, foot function, and deformity correction as
measured radiographically at a minimum two years, in patients with idiopathic congenital vertical talus.

54.  J Bone Joint Surg Am. 2012 Jun 6;94(11):e73. doi: 10.2106/JBJS.K.00164.
 Minimally invasive approach for the treatment of non-isolated congenital
vertical talus.
 Chalayon O1, Adams A, Dobbs MB.
1Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA.
 Abstract
 BACKGROUND:
 Traditional extensive soft-tissue release for the treatment of congenital vertical talus is associated with a myriad of complications. A
minimally invasive approach has recently been introduced with good short-term results in patients with isolated vertical talus. The
purpose of the present study was to evaluate the effectiveness of this approach for the treatment of rigid vertical talus associated with
neuromuscular and/or genetic syndromes.
 METHODS:
 Fifteen consecutive patients (twenty-five feet) with non-isolated congenital vertical talus were retrospectively reviewed at
a minimum of two years following treatment with serial casting followed by limited surgery. The surgery consisted of
percutaneous Achilles tenotomy in all feet and either pin fixation of the talonavicular joint through a small medial incision to ensure
joint reduction and accurate pin placement (five feet) or selective capsulotomies of the talonavicular joint and the anterior aspect of
the subtalar joint (twenty feet). Patients were evaluated clinically and radiographically at the time of presentation, immediately
postoperatively, and at the time of the latest follow-up. Radiographic data at the time of the latest follow-up were compared with age-
matched normative values.
 RESULTS:
 Initial correction was obtained in all cases. The mean number of casts required was five. Mean ankle dorsiflexion was 22° and mean
plantar flexion was 25° at the time of the latest follow-up. Recurrence was noted in three patients (five feet), all of whom had had
initial subluxation of the calcaneocuboid joint. All radiographic parameters measured at the time of the latest follow-up had
improved significantly (p < 0.0001) compared with the values before treatment, and the mean values of the measured angles did not
differ significantly from age-matched normal values.
 CONCLUSIONS:
 Serial manipulation and casting followed by limited surgery, consisting of percutaneous tenotomy of the Achilles tendon
and a small medial incision to either palpate the talonavicular joint or perform capsulotomies of the talonavicular joint
and the anterior aspect of the subtalar joint to ensure accurate reduction and pin fixation, result in excellent short-term
correction of the deformity while preserving subtalar and ankle motion in patients with rigid congenital vertical talus
associated with neuromuscular and/or genetic syndromes

55.  Indian J Orthop. 2008 Jul-Sep; 42(3): 347–350.
 doi: 10.4103/0019-5413.41860
 PMCID: PMC2739479
 Congenital vertical talus: Treatment by reverse ponseti technique
 Atul Bhaskar
.
 Abstract
 Background:
 The surgery for idiopathic congenital vertical talus (CVT) can lead to stiffness, wound complications and under or over correction.
There are sporadic literature on costing with mixed results. We describe our early experience of reverse ponseti technique.
 Materials and methods:
 Four cases (four feet) of idiopathic congenital vertical talus (CVT) which presented one month after
birth were treated by serial manipulation and casting, tendoachilles tenotomy and percutaneous
pinning of talonavicular joint. An average of 5.2 (range - four to six) plaster cast applications were required to correct the
forefoot deformity. Once the talus and navicular were aligned based on the radiographic talus-first metatarsal axis, percutaneous
fixation of the talo-navicular joint with a Kirschner wire, and percutaneous tendoachilles tenotomy under anesthesia was
performed following which a cast was applied with the foot in slight dorsiflexion.
 Results:
 The mean follow-up period for the four cases was 8.5 months (6-12 months). At the end of the treatment all feet were supple and
plantigrade but still using ankle foot orthosis (AFO). The mean talocalcaneal angle was 70 degrees before treatment and this
reduced to 31 degrees after casting. The mean talar axis first metatasal base angle (TAMBA) angle was 60° before casting and this
improved to 10.5°.
 Conclusion:
 Although our follow-up period is small, we would recommend early casting for idiopathic CVT along
the same lines as the Ponseti technique for clubfoot except that the forces applied are in reverse
direction. This early casting method can prevent extensive surgery in the future, however, a close vigil
is required to detect any early relapse.

56. WHAT ABOUT OLDER CVT?
• Some children after the age of 3 years require excision of
the navicular at the time of open reduction.
• Children between the ages of 4 and 8 years with either a
primary or a recurrent deformity can be treated with
open reduction combined with extraarticular arthrodesis
(GRICE GREEN )
• Those patients that are older than 8 years often require
a triple arthrodesis . However, arthrodesis does result in
painful degenerative arthritis of the ankle and midtarsal
joints when the patients are followed long-term