Congenital Vertical Talus 

  • Author: Jeffrey D Thomson, MD; Chief Editor: Dennis P Grogan, MD   more...
 
Updated: May 15, 2012
 

Background

Congenital vertical talus (CVT) is an uncommon disorder of the foot, manifested as a rigid rocker-bottom flatfoot. Its characteristic radiographic feature is a dorsal dislocation of the navicular on the talus. If left untreated, CVT results in a painful and rigid flatfoot with weak push-off power. CVT has been referred to in the literature by several synonyms, including congenital convex pes valgus.[1]

Recent studies

Thometz et al reported on the MRI pathoanatomy of CVT. They found significant pathology at the level of the subtalar joint. Based on this, they recommended that methods to ensure realignment of the calcaneus under the talus may be a crucial component of deformity correction and to prevent recurrence of deformity.[2]

Merrill et al published an investigation on skeletal muscle abnormalities and genetic factors related to vertical talus. They found that abnormal skeletal muscle biopsies from the abductor hallucis muscle were common but it was unclear whether this was primary or secondary to the joint deformity.[3]

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History of the Procedure

Closed treatment, consisting of manipulation and casting, was the earliest form of treatment. Limited surgery was sometimes additionally employed.

Lamy and Weissman recommended excision of the talus, while Eyre-Brook advocated excising the navicular.[4, 5] Today, neither of these techniques is accepted as a definitive treatment.

Several authors, beginning with Osmond-Clarke, Herndon and Heyman, and Coleman and associates, described staged, 2-incision reconstructive surgery.[6, 7, 8] 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.

After noting a high incidence of complications with the 2-stage technique, Ogata and colleagues recommended a single-stage procedure with a medial approach.[9] Kodros and Dias published results they derived using a single-stage approach with a Cincinnati incision.[10]

Seimon described a single-stage dorsal approach in which the EHL and peroneus tertius were tenotomized and the talonavicular joint was opened.[11] The talonavicular joint was reduced and held with a Kirschner (K) wire. The Achilles tendon was lengthened percutaneously. Stricker and Rosen published their experience with this technique, as did Mazzocca and associates; both groups noted excellent results with few complications.[12, 13]

The trend toward less surgery for CVT continued with Dobbs and colleagues, who published their technique of casting; percutaneous K-wire pinning of the talonavicular joint; and percutaneous heel-cord tenotomy.[14] No patients had extensive soft-tissue releases, although some required lengthening of the anterior tibialis or the peroneus brevis tendon. Casting without pinning of the talonavicular joint was associated with recurrence of deformity.

Saini et al reported on their surgical experience with 20 cases of CVT using a dorsal approach. According to the authors, talonavicular reduction was achieved in all 20 feet, and postoperative talocalcaneal and talo-first metatarsal angles were significantly improved. The results were retained at 4-year follow-up.[15]

Bhaskar described a surgical technique used for idiopathic CVT in 4 feet, similar to the Ponseti technique for clubfoot except that the forces applied were in reverse direction. In the author's experience, the 4 feet were treated by serial manipulation and casting, tendoachilles tenotomy, and percutaneous pinning of the talonavicular joint. To correct the forefoot deformity, according to the author, 4 to 6 plaster cast applications were required. Once the talus and navicular were aligned, percutaneous fixation of the talo-navicular joint with a Kirschner wire and percutaneous tendoachilles tenotomy under anesthesia were performed, followed by application of a cast with the foot in slight dorsiflexion. Following treatment, the mean talocalcaneal angle decreased from 70º to 31º, and the mean talar axis first metatarsal base angle (TAMBA) decreased from 60º to 10.5º.[16]

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Problem

Congenital vertical talus (CVT) is defined by an irreducible and rigid dorsal dislocation of the navicular on the talus. If the navicular is reducible on the lateral maximum plantarflexion radiograph, it is deemed an oblique talus, which is better treated with tendo-Achilles lengthening (TAL) and orthotics.

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Epidemiology

Frequency

Congenital vertical talus (CVT) is an uncommon disorder. Jacobsen and Crawford reported only 273 cases.[17] Some have estimated the incidence of CVT to be one tenth that of congenital clubfoot.

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Etiology

The etiology is unknown, but congenital vertical talus (CVT) frequently is associated with a wide variety of neuromuscular disorders. Ogata and associates proposed a CVT classification system that divides patients into 3 groups: idiopathic, genetic/syndromic, and neuromuscular.[9]

Vertical talus is a heterogeneous birth defect resulting from many diverse etiologies. Based on skeletal muscle biopsies, the most common findings in patients with idiopathic vertical talus were abnormal variations in muscle fiber size and type I muscle fiber smallness. These findings were not specific, but they are common in congenital myopathies and distal arthrogryposis. It is unclear whether the biospy findings are primary or secondary to the joint deformity.[3]

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Pathophysiology

The hallmark of the deformity is an irreducible and rigid dorsal dislocation of the navicular on the talus. Seimon hypothesized that a contracture of the tendo-Achilles posteriorly creates equinus of the calcaneus, with increased verticality of the talus, while contracture of the extensor digitorum longus (EDL) (and sometimes the extensor hallucis longus [EHL] and tibialis anterior) pulls the navicular onto the dorsum of the navicular.[11]

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Presentation

Clinically, congenital vertical talus (CVT) presents as a rigid flatfoot with a rocker-bottom appearance of the foot. The calcaneus is in fixed equinus, and the Achilles tendon is very tight. The hindfoot is in valgus, while the head of the talus is found medially in the sole, creating the rocker-bottom appearance. The forefoot is abducted and dorsiflexed.

The foot is stiff. In ambulatory children, calluses can develop under the head of the talus, which is very prominent along the plantar-medial foot.

Associated genetic syndromes must be excluded; therefore, a consultation with a pediatric geneticist may be indicated.

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Indications

Surgery is indicated when the talonavicular joint is found, after a trial of serial casting, to be unreducible. Although most patients require surgical intervention, serial casting with the foot in plantarflexion may occasionally be successful. More importantly, serial casting helps to stretch out the contracted dorsal skin, tendons, and joint capsules, which should be helpful at the time of surgery. Lateral radiographs of the foot in maximal plantarflexion can reveal if the navicular is reducible.

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Relevant Anatomy

A rigid, irreducible talonavicular dislocation is the hallmark of congenital vertical talus. Contractures of the tendo-Achilles posteriorly and the extensor digitorum longus (EDL) and dorsal talonavicular capsule anteriorly are common. In feet with greater involvement or in older children, more contractures and deformity are present (eg, contractures of the tibialis anterior and extensor hallucis longus (EHL) anteriorly, peroneus tertius and inferior retinaculum of the ankle anterolaterally, peroneus brevis and longus laterally with the calcaneofibular ligament, and the tibiotalar joint posteriorly).

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.[6]

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Contraindications

If the talonavicular joint is reducible on the lateral maximum plantarflexion view radiograph, surgery is probably not needed. In these cases, TAL and orthotics, such as a University of California Berkeley Laboratory (UCBL) orthosis, may be effective.

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Contributor Information and Disclosures
Author

Jeffrey D Thomson, MD  Associate Professor, Department of Orthopedic Surgery, University of Connecticut School of Medicine; Director of Orthopedic Surgery, Department of Pediatric Orthopedic Surgery, Associate Director of Clinical Affairs for the Department of Surgical Subspecialties, Connecticut Children's Medical Center

Jeffrey D Thomson, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Mininder S Kocher, MD, MPH  Associate Professor of Orthopedic Surgery, Harvard Medical School/Harvard School of Public Health; Associate Director, Division of Sports Medicine, Department of Orthopedic Surgery, Children's Hospital Boston

Mininder S Kocher, MD, MPH is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for the History of Medicine, American College of Sports Medicine, American Orthopaedic Society for Sports Medicine, Massachusetts Medical Society, and Pediatric Orthopaedic Society of North America

Disclosure: Smith & Nephew Endoscopy Consulting fee Consulting; EBI Biomet Consulting fee Consulting; OrthoPediatrics Consulting fee Consulting; Pivot Medical Stock Consulting; pediped Consulting fee Consulting; WB Saunders Royalty None; Fixes-4-Kids Consulting

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

George H Thompson, MD  Director of Pediatric Orthopedic Surgery, Rainbow Babies and Children's Hospital, University Hospitals Case Medical Center, and MetroHealth Medical Center; Professor of Orthopedic Surgery and Pediatrics, Case Western Reserve University School of Medicine

George H Thompson, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Pediatric Orthopaedic Society of North America, and Scoliosis Research Society

Disclosure: OrthoPediatrics None Consulting; Journal of Pediatric Orthopaedics Salary Management position; SpineForm None Consulting; SICOT None Board membership

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Dennis P Grogan, MD  Clinical Professor, Department of Orthopedic Surgery, University of South Florida College of Medicine; Chief of Staff, Department of Orthopedic Surgery, Shriners Hospital for Children of Tampa

Dennis P Grogan, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Eastern Orthopaedic Association, Irish American Orthopaedic Society, Pediatric Orthopaedic Society of North America, and Scoliosis Research Society

Disclosure: Nothing to disclose.

References
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  2. Thometz JG, Zhu H, Liu XC, Tassone C, Gabriel SR. MRI pathoanatomy study of congenital vertical talus. J Pediatr Orthop. Jul-Aug 2010;30(5):460-4. [Medline].

  3. Merrill LJ, Gurnett CA, Connolly AM, Pestronk A, Dobbs MB. Skeletal muscle abnormalities and genetic factors related to vertical talus. Clin Orthop Relat Res. Apr 2011;469(4):1167-74. [Medline]. [Full Text].

  4. Eyre-Brook AL. Congenital vertical talus. J Bone Joint Surg Br. Nov 1967;49(4):618-27. [Medline]. [Full Text].

  5. Lamy L, Weissman L. Congenital convex pes planus. J Bone Joint Surg. 1939;21:79-91.

  6. Coleman SS, Stelling FH 3rd, Jarrett J. Pathomechanics and treatment of congenital vertical talus. Clin Orthop Relat Res. May-Jun 1970;70:62-72. [Medline].

  7. Herndon CH, Heyman CH. Problems in the recognition and treatment of congenital pes valgus. J Bone Joint Surg Am. 1963;45:413-29.

  8. Osmond-Clarke H. Congenital vertical talus. J Bone Joint Surg Br. Feb 1956;38-B(1):334-41. [Medline].

  9. Ogata K, Schoenecker PL, Sheridan J. Congenital vertical talus and its familial occurrence: an analysis of 36 patients. Clin Orthop Relat Res. Mar-Apr 1979;(139):128-32. [Medline].

  10. Kodros SA, Dias LS. Single-stage surgical correction of congenital vertical talus. J Pediatr Orthop. Jan-Feb 1999;19(1):42-8. [Medline].

  11. Seimon LP. Surgical correction of congenital vertical talus under the age of 2 years. J Pediatr Orthop. Jul-Aug 1987;7(4):405-11. [Medline].

  12. Mazzocca AD, Thomson JD, Deluca PA. Comparison of the posterior approach versus the dorsal approach in the treatment of congenital vertical talus. J Pediatr Orthop. Mar-Apr 2001;21(2):212-7. [Medline].

  13. Stricker SJ, Rosen E. Early one-stage reconstruction of congenital vertical talus. Foot Ankle Int. Sep 1997;18(9):535-43. [Medline].

  14. Dobbs MB, Purcell DB, Nunley R, et al. Early results of a new method of treatment for idiopathic congenital vertical talus. J Bone Joint Surg Am. Jun 2006;88(6):1192-200. [Medline].

  15. Saini R, Gill SS, Dhillon MS, Goyal T, Wardak E, Prasad P. Results of dorsal approach in surgical correction of congenital vertical talus: an Indian experience. J Pediatr Orthop B. Mar 2009;18(2):63-8. [Medline].

  16. Bhaskar A. Congenital vertical talus: Treatment by reverse ponseti technique. Indian J Orthop. Jul 2008;42(3):347-50. [Medline].

  17. Jacobsen ST, Crawford AH. Congenital vertical talus. J Pediatr Orthop. Jul 1983;3(3):306-10. [Medline].

  18. Hamanishi C. Congenital vertical talus: classification with 69 cases and new measurement system. J Pediatr Orthop. May 1984;4(3):318-26. [Medline].

  19. Kruse L, Gurnett CA, Hootnick D, Dobbs MB. Magnetic resonance angiography in clubfoot and vertical talus: a feasibility study. Clin Orthop Relat Res. May 2009;467(5):1250-5. [Medline].

  20. Mathew PG, Sponer P, Karpas K, Shaikh HH. Mid-term results of one-stage surgical correction of congenital vertical talus. Bratisl Lek Listy. 2009;110(7):390-3. [Medline].

  21. Jochymek J, Skvaril J. [Surgical treatment in congenital vertical talus]. Rozhl Chir. Jan 2009;88(1):32-4. [Medline].

  22. Clark MW, D'Ambrosia RD, Ferguson AB. Congenital vertical talus: treatment by open reduction and navicular excision. J Bone Joint Surg Am. Sep 1977;59(6):816-24. [Medline].

  23. Dodge LD, Ashley RK, Gilbert RJ. Treatment of the congenital vertical talus: a retrospective review of 36 feet with long-term follow-up. Foot Ankle. Jun 1987;7(6):326-32. [Medline].

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  25. Duncan RD, Fixsen JA. Congenital convex pes valgus. J Bone Joint Surg Br. Mar 1999;81(2):250-4. [Medline].

  26. Sullivan JA. Pediatric flatfoot: evaluation and management. J Am Acad Orthop Surg. Jan 1999;7(1):44-53. [Medline].

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