This document discusses congenital vertical talus (CVT), a rare foot deformity. It begins by defining CVT and providing background information. It then describes the anatomy and pathoanatomy of CVT. Key points include that CVT results in an almost vertical talus bone and rigid flatfoot deformity. Treatment involves serial casting and manipulation to prepare for surgery, with the goal of restoring normal anatomical relationships in the foot. Surgical techniques described include open reduction and percutaneous fixation of the talonavicular joint with K-wires. Complications of surgery can include wound issues and stiffness.

1. B Y :
D R . N A V E E N R A T H O R
D E P T . O F O R T H O P A E D I C S
R . N . T . M E D I C A L C O L L E G E
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 bottom foot
Talipes convex pes valgus

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.  Talus is so distorted planterwaed and medially as to be almost
vertical.
 “ 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

6. 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

7.  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

8.  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

9. 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

10. 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

11.  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:

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. 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. 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.

17. 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

18. Measurements that can be obtained on the lateral
radiograph include
Increase talocalcaneal,(normal-20-40 degree)
decreased tibiocalcaneal,(normal 60-90 degree)
 talar axis- first metatarsal base angle(normally<30)

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

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

21. Role of USG
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.

22. 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

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

24. 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.

25. 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

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

27.  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

28.  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.

29. 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

30. Traditional procedures.
Several authors, beginning with Osmond-Clarke, Herndon
and Heyman, and Coleman and associates, described two
staged,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.

31. 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

32. 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

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. Modified cincinnati incision-

36. Single stage repair-
 Three incisions-

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. 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

41. 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.

42. 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.

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

44. 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

45. 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

46.  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

47. 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

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

49.  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 .

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

51. 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