Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Congenital Vertical Talus Treatment & Management

  • Author: Jeffrey D Thomson, MD; Chief Editor: Murali Poduval, MBBS, MS, DNB  more...
 
Updated: May 09, 2016
 

Approach Considerations

Treatment is indicated when the talonavicular joint is found to be unreducible with maximum plantarflexion. Lateral radiographs of the foot in maximal plantarflexion can reveal if the navicular is reducible. However, radiographs of an infant's foot can be difficult to interpret. The use of dynamic ultrasonography has been reported to be helpful in the evaluation of infants with vertical or oblique talus.[26]

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

It is hoped that in the future, the amount of dissection can be minimized, reducing the incidence of avascular necrosis (AVN) and, in turn, improving the overall outcome. Early diagnosis to allow for surgical correction in infants younger than 2 years also should help to improve results.

Controversy exists over the choice of surgical approaches. However, the author believes that the choice of structures to be released is a more important factor in determining outcomes than is the choice of incisions to be used. Special attention must be paid to the dorsal and dorsolateral contracted tissues. Controversy also exists over the need for an anterior tibialis tendon transfer.

Next

Medical Therapy

Serial casting should be the initial treatment, though before the article by Dobbs et al,[17] it was usually thought to be unsuccessful.

Serial casting should be used to stretch the foot in plantarflexion and inversion while counterpressure is applied to the medial aspect of the talus.[18] Elongating and stretching the talonavicular joint in order to facilitate its reduction is important in avoiding compression of the dorsally displaced navicular into the talus. A long leg cast is then applied, with the knee flexed 90° to prevent the cast from slipping. The cast should be changed frequently (about every 1-2 weeks) in order to maximize its effectiveness.

Whereas preoperative casting may be useful for stretching out the dorsal structures, casting rarely is associated with permanent correction.

Previous
Next

Surgical Therapy

In the Dobbs technique,[17] if the navicular can be manipulated into the correct alignment relative to the talus, it can then be pinned with a Kirschner wire (K-wire) to maintain the reduction. A small incision can be made over the talonavicular joint, and the joint can be reduced via an open technique if there is any difficulty with the reduction. A percutaneous heel-cord tenotomy is always performed.

The K-wire is left in place for a total of 5 weeks, and the position is held with a long leg cast, which is changed 2 weeks after surgery. A postoperative brace is worn 23 hours per day until walking age, and it is then worn for walking until age 2 years.

A single-stage surgical correction is another option and can be accomplished via either the Cincinnati approach or the dorsal approach. The author generally prefers the dorsal approach, as described by Seimon[5] ; however, the author also prefers the Ollier-type incision. (See the image below.)

Schematic representation of posteromedial release. Schematic representation of posteromedial release.

Operative details

In the author's preferred technique, dissection is performed under tourniquet control, and the superficial peroneal and sural nerves are identified and protected. The author typically finds a contracted peroneus tertius, which is released, as well as an abnormal band of the inferior retinaculum causing a tether from the tibia to the calcaneus. The dorsalis pedis vein and artery and the deep branch of the peroneal nerve are protected, while the tibialis anterior, the extensor hallucis longus (EHL), and the extensor digitorum communis (EDC) are retracted.

The talonavicular joint is visualized and opened dorsally, medially, and laterally. The calcaneocuboid joint also is opened along its dorsal, medial, and lateral aspects. Occasionally, the peroneus longus and brevis must be lengthened. The EHL and EDC can be lengthened, but this is not always necessary. Some advocate transferring the tibialis anterior to the talus.

A percutaneous tendo Achillis tenotomy is performed. The author has not found it to be necessary to perform an open capsulotomy of the tibiotalar (ankle) joint.

A 0.062-in. K-wire is used to hold the talonavicular joint. A talocalcaneal wire typically is not used, nor is it necessary. The author finds it easier to drive the K-wire antegrade into the navicular, through the cuneiform, and out dorsally through the first metatarsal. The talonavicular joint is reduced, and the K-wire is then driven retrograde across the talonavicular joint. The K-wire is cut and buried, and the foot is splinted in a long leg splint for about 10-14 days to allow the swelling to decrease. At that point, the patient is put into a long leg cast, with the ankle in neutral position.

Previous
Next

Postoperative Care

The K-wire is removed 8 weeks after surgery, and a walking short leg cast then is used for about 2-4 weeks. The author does not generally use a postoperative brace or orthosis for idiopathic CVT. Postoperative bracing is advised for children with myelodysplasia, arthrogryposis, or other syndromes to maintain correction and prevent recurrence.

Previous
Next

Complications

Complications can occur around the time of surgery (perioperatively) or can manifest early or late in the postoperative period.

Common complications in the perioperative period include infection, wound-healing problems, and skin slough; however, these complications are not unique to CVT.

In the first 1-2 years after surgery, the deformity can recur, usually secondary to undercorrection. Undercorrection can occur because of incomplete talonavicular reduction, insufficient posterior ankle release, or residual forefoot abduction.[16] Recurrence of the deformity can also be attributable to neurologic causes, especially in patients with spina bifida. Kodros and Dias reported a high recurrence rate in patients with spina bifida and believed that in these cases the recurrences might be secondary to a tethered spinal cord or other neurologic abnormality.

AVN of the talus is a unique complication of CVT surgery. It was more often reported in the older literature and was associated with the two-stage release and extensive surgery. Subsequent articles by Kodros and Dias,[14] Seimon,[5] Stricker and Rosen,[16] and Mazzocca et al[15] did not report occurrences of AVN of the talus.

Late complications include restricted range of motion of the foot and ankle, which can contribute to calf muscle atrophy. This in turn can lead to easy fatigue of the affected limb.

Previous
 
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; President, Connecticut Children's Specialty Group

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

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 Orthopaedic Association, Scoliosis Research Society, Pediatric Orthopaedic Society of North America, American Academy of Orthopaedic Surgeons

Disclosure: Received none from OrthoPediatrics for consulting; Received salary from Journal of Pediatric Orthopaedics for management position; Received none from SpineForm for consulting; Received none from SICOT for board membership.

Chief Editor

Murali Poduval, MBBS, MS, DNB Associate Professor, Department of Orthopedic Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), India

Murali Poduval, MBBS, MS, DNB is a member of the following medical societies: Indian Orthopedic Association, Association of Medical Consultants of Mumbai, Bombay Orthopedic Society, Indian Society of Hip and Knee Surgeons

Disclosure: Nothing to disclose.

Additional Contributors

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 College of Sports Medicine, Pediatric Orthopaedic Society of North America, American Association for the History of Medicine, American Orthopaedic Society for Sports Medicine, Massachusetts Medical Society

Disclosure: Received consulting fee from Smith & Nephew Endoscopy for consulting; Received consulting fee from EBI Biomet for consulting; Received consulting fee from OrthoPediatrics for consulting; Received stock from Pivot Medical for consulting; Received consulting fee from pediped for consulting; Received royalty from WB Saunders for none; Received stock from Fixes-4-Kids for consulting.

References
  1. McKie J, Radomisli T. Congenital vertical talus: a review. Clin Podiatr Med Surg. 2010 Jan. 27(1):145-56. [Medline].

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

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

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

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

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

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

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

  9. 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. 2009 Mar. 18(2):63-8. [Medline].

  10. 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].

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

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

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

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

  15. 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. 2001 Mar-Apr. 21(2):212-7. [Medline].

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

  17. 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. 2006 Jun. 88(6):1192-200. [Medline].

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

  19. Wright J, Coggings D, Maizen C, Ramachandran M. Reverse Ponseti-type treatment for children with congenital vertical talus: comparison between idiopathic and teratological patients. Bone Joint J. 2014 Feb. 96-B(2):274-8. [Medline].

  20. Chalayon O, Adams A, Dobbs MB. Minimally invasive approach for the treatment of non-isolated congenital vertical talus. J Bone Joint Surg Am. 2012 Jun 6. 94(11):e73. [Medline].

  21. Yang JS, Dobbs MB. Treatment of Congenital Vertical Talus: Comparison of Minimally Invasive and Extensive Soft-Tissue Release Procedures at Minimum Five-Year Follow-up. J Bone Joint Surg Am. 2015 Aug 19. 97 (16):1354-65. [Medline].

  22. Chan Y, Selvaratnam V, Garg N. A comparison of the Dobbs method for correction of idiopathic and teratological congenital vertical talus. J Child Orthop. 2016 Apr. 10 (2):93-9. [Medline].

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

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

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

  26. Supakul N, Loder RT, Karmazyn B. Dynamic US study in the evaluation of infants with vertical or oblique talus deformities. Pediatr Radiol. 2013 Mar. 43(3):376-80. [Medline].

 
Previous
Next
 
Schematic representation of posteromedial release.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.