Congenital Vertical Talus Treatment & Management
- Author: Jeffrey D Thomson, MD; Chief Editor: Murali Poduval, MBBS, MS, DNB more...
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.
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.
Serial casting should be the initial treatment, though before the article by Dobbs et al, 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. 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.
In the Dobbs technique, 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 ; however, the author also prefers the Ollier-type incision. (See the image below.)
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.
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.
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. 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, Seimon, Stricker and Rosen, and Mazzocca et al 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.
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