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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° and the mean plantar flexion was 33°. 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.
Here are my lecture notes on congenital vertical talus:
Quote:
Congenital vertical talus
Rare. Dorsal dislocation of navicular on talus (may be a form of clubfoot).
Cause unknown – but intrauterine position, genetic and neuromuscular conditions have been implicated. May be isolated deformity of part of another syndrome (eg arthrogryposis multiplex congenita; neurofibromatosis; nail-patella syndrome).
Rocker bottom appearance to foot; talus is prominent talus head in plantar medial side of foot; dorsal creasing in the MTJ region; rigid STJ; forefoot is abducted and dorsiflexed.
On x-ray, the dorsal dislocation of the navicular off the head of the talus onto the talar neck is seen
Posterior tibial tendon is more dorsally located --> acts as a dorsiflexor
Two types:
1. Dislocation of talonavicular joint, subluxation of subtalar joint, normal calcaneocuboid joint (more flexible)
2. Dislocation of talonavicular joint, subluxation of subtalar joint and calcaneocuboid joint, ankle joint equinus (more rigid)
Initially treatment at birth is manipulation and casting – later treatment is surgical. Prognosis is often not good without surgery.
__________________ Craig Payne
__________________________________________________ ___________________________________ Follow me on Twitter | Run Junkie God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
I have a 14 year old female patient who has bilateral anterior knee pain. Tip toe test shows no reformation of the medial arch and no calcaneal inversion. She is max pronated and supination resistance is hard. There is excessive medial buldging and she has previously not been able to tollerate neutral type casted orthoses. Her STJ ROM is normal and the forefoot in not plantarflexed on rearfoot (as you mention above).
Whilst I haven't yet taken x-ray, I am certain this is a structural type flat foot deformty abd have considered a vertical talus as a cause.
Have you any thoughts on this and on what orthoes may work?
__________________ Craig Payne
__________________________________________________ ___________________________________ Follow me on Twitter | Run Junkie God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The Following User Says Thank You to Craig Payne For This Useful Post:
With all the reseach with congenital foot deformities, casing is really only effective if commenced in really early stages (like first coupel of months of life). Past that, ossification of bones means taht surgery is required.. Robcox, if this was a congenital vertical talus, you'd see it without an X-ray, it's quite pronounced. Think those old rocker bottom feet in old people with abducted forefeet and huge lumps under the MLA.
Cheers!
__________________
Adrian Misseri
B.Pod.,M.Hlth.Sci.(Pod.)
You know.. we could just cut it off.....?
The Following User Says Thank You to Adrian Misseri For This Useful Post:
OBJECTIVE: Congenital vertical talus is a rare condition but a well-known cause of severe rigid flatfoot in children. The aim of this study was to evaluate the mid-term clinical and radiological results of one-stage surgical correction in children with congenital vertical talus.
METHODS: Five feet in three children diagnosed with congenital vertical talus who had undergone surgical correction were followed up for a mean period of seven and half years. During this period they were clinically evaluated for subjective complaints and objective findings focused on the range of movement at the ankle joint, position of the hindfoot, and weight-bearing ability of the treated extremity. They were also evaluated on the basis of radiographs of foot and ankle made in standard projections.
RESULTS: All the children had a good functional range of movement and normally shaped foot. The range of movement remains restricted and decreased during the follow-up period without causing any functional disability. All radiological measurements were within normal limits. There was no evidence of necrosis of talus.
CONCLUSION: We recommend operative treatment for congenital vertical talus by the end of first year of age. The range of movement remains restricted and seems to decrease during follow-up, which had a little effect on the functional outcome of the ankle joint
BACKGROUND: Prior reports regarding the pathologic anatomy for congenital vertical talus have noted some disagreement as to which elements of the pathologic anatomy are consistently present. The purpose of his study is to evaluate the 3-dimensional morphologic changes and pathoanatomy of the congenital vertical talus using magnetic resonance imaging.
METHODS: Nine patients with congenital vertical talus (ranging from 5 mo-11 y) underwent magnetic resonance imaging of both feet. A foot and ankle coil was used for the 1.5 T system. The protocol consisted of T1-weighted spin echo sequence image and T2-weighted fast spin echo sequence image in the sagittal, coronal, and axial planes. Slice thickness ranged from 3 to 4 mm with 0 to 1.0 mm interspace thickness. A descriptive analysis was performed based upon the T1-weighted image by physicians.
RESULTS: At the level of the talonavicular joint, the navicular was seen significantly subluxed dorsally with associated wedging of the navicular. At the level of the calcaneocuboid joint, often there was a significant dorsal subluxation of the cuboid in relation to the calcaneus. Lateral obliquity of the calcaneocuboid joint could be present to varying degrees. The anterior calcaneus was significantly laterally displaced in relation to the talar head with an element of lateral translation and eversion of the calcaneus at the subtalar joint. Distal cavus at the cuneiform-first metatarsal joint was observed in 5 patients.
CONCLUSIONS: This study suggests that there is significant pathology at the level of subtalar joint in congenital vertical talus. In addition to satisfactory reduction of the talonavicular joint, methods to ensure realignment of the calcaneus under the talus may be a crucial component of deformity correction and to prevent recurrence of deformity.
BACKGROUND/RATIONALE: Congenital vertical talus is a fixed dorsal dislocation of the talonavicular joint and fixed equinus contracture of the hindfoot, causing a rigid deformity recognizable at birth. The etiology and epidemiology of this condition are largely unknown, but some evidence suggests it relates to aberrations of skeletal muscle. Identifying the tissue abnormalities and genetic causes responsible for vertical talus has the potential to lead to improved treatment and preventive strategies.
QUESTIONS/PURPOSES: We therefore (1) determined whether skeletal muscle abnormalities are present in patients with vertical talus and (2) identified associated congenital anomalies and genetic abnormalities in these patients.
METHODS: We identified associated congenital anomalies and genetic abnormalities present in 61 patients affected with vertical talus. We obtained abductor hallucis muscle biopsy specimens from the affected limbs of 11 of the 61 patients and compared the histopathologic characteristics with those of age-matched control subjects.
RESULTS: All muscle biopsy specimens (n = 11) had abnormalities compared with those from control subjects including combinations of abnormal variation in muscle fiber size (n = 7), type I muscle fiber smallness (n = 6), and abnormal fiber type predominance (n = 5). Isolated vertical talus occurred in 23 of the 61 patients (38%), whereas the remaining 38 patients had associated nervous system, musculoskeletal system, and/or genetic and genomic abnormalities. Ten of the 61 patients (16%) had vertical talus in one foot and clubfoot in the other. Chromosomal abnormalities, all complete or partial trisomies, were identified in three patients with vertical talus who had additional congenital abnormalities.
CONCLUSIONS: Vertical talus is a heterogeneous birth defect resulting from many diverse etiologies. Abnormal skeletal muscle biopsies are common in patients with vertical talus although it is unclear whether this is primary or secondary to the joint deformity. Associated anomalies are present in 62% of all cases.
AIM:
The widely accepted treatment of vertical talus after casting is correction by extensive surgery. Dobbs described a new method for the treatment of vertical talus by casting and minimally invasive surgery. The purpose of the present study was to evaluate the efficacy of this new method.
MATERIAL AND METHOD:
Between 11/06 and 11/09 we treated 7 patients with 12 vertical tali. Treatment followed the protocol of Dobbs. The initiation of treatment, number of casts, surgery, as well as clinical and radiological results were documented. To evaluate the radiological result we used the Hamanishi score.
RESULTS:
From the beginning all feet could be treated successfully with the Dobbs method. According to the Hamanishi classification we have four excellent and five good results. Two feet had a relapse with subluxation or dislocation of the talonavicular joint.
CONCLUSION:
Treatment of vertical talus with the Dobbs method is successful. Extensive surgery could be reduced. We recommend the method as primary treatment for vertical talus
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.
The short-term effect of an anchor in treatment of congenital vertical talus in infants.
Zhu ZX, Lei W, Huang LY. Orthop Surg. 2010 Aug;2(3):218-22.
Quote:
OBJECTIVE:
To investigate the short-term effect of a mini anchor in treatment of congenital vertical talus (CVT) in infants.
METHODS:
From February 2006 to March 2008, seven patients (nine feet) with CVT were treated in the authors' hospital by the Kumar method combined with transferring and fixing the tendon of the anterior tibial muscle to the head of the talus with a mini anchor. There were five girls and two boys, aged from 10 to 42 months (mean, 18 months). All the feet had a rocker-bottom when the infants were taken to the hospital by their parents and none of them could walk independently. All cases were followed up in the outpatient department, and the Hamanishi and Adelaar standards were used to evaluate the radiograph and clinical results, respectively.
RESULTS:
All cases were followed up for 20 to 29 months (mean, 24 months). The parents of these infants were all satisfied with this operation, and five infants can now walk independently. At the most recent follow-up, seven feet were fine and two good according to the Adelaar standard, and six feet were good and three fine according to the Hamanishi standard.
CONCLUSION:
The short-term effect of an anchor in treatment of CVT in infants was satisfactory with no recurrence nor talus necrosis.
Bilateral congenital vertical talus with severe lower extremity external rotational deformity:
Treated by reverse Ponseti technique
Adem Aydın, Halil Atmacaemail, Ümit Sefa Müezzinoğlu The Foot Volume 22, Issue 3 , Pages 252-254, September 2012
Quote:
Congenital vertical talus, also known as congenital convex pes valgus, is a complex, rare, foot deformity that is resistant to conservative treatment. We report a case of bilateral congenital vertical talus with severe lower extremity external rotational deformity that was treated by means of a method of serial manipulations and casts. Although the initial manipulation and casting before surgical treatment is the current concept of idiopathic congenital vertical talus, a good result can be obtained by a well-organized conservative treatment with the help of patient compliance, so routine surgical release of the Achilles tendon may not be necessary in all cases.
The talar axis–first metatarsal base angle in CVT treatment: a comparison of idiopathic and non-idiopathic cases treated with the Dobbs method
Oliver Eberhardt, Francisco Fernandez Fernandez, Thomas Wirth Journal of Children's Orthopaedics; November 2012
Quote:
Purpose
Congenital vertical talus (CVT) appears as an idiopathic or non-idiopathic deformity. In this study, we analysed the talar axis–first metatarsal base angle (TAMBA) values of idiopathic and non-idiopathic CVT cases treated with the Dobbs method.
Materials and methods
Between January 2007 and July 2012, 20 cases of CVT were treated, starting with a manipulation, casting and a minimally invasive surgical approach. We analysed retrospectively the TAMBA values in idiopathic and non-idiopathic CVT. As a new indicator for the mobility in the talonavicular complex, we used the difference of the TAMBA in neutral position and the TAMBA in plantarflexion. TAMBA measurements of CVT successfully treated with the Dobbs method were compared to TAMBA values of CVT unsuccessfully treated using a minimally invasive approach.
Results
Out of 20 CVT, 14 were successfully treated with the Dobbs method. Of these 14, five feet were non-idiopathic and nine feet were idiopathic. Six feet did not have complete correction following the Dobbs protocol, and were associated with arthrogryposis or caudal regression syndrome. The initial TAMBA in idiopathic feet ranged from 70 to 110° (mean 88°). The TAMBA in non-idiopathic feet ranged from 75 to 128° (mean 105). Feet successfully treated with the Dobbs method had an initial TAMBA between 74 and 110° (mean 87°). Feet unsuccessfully treated with the Dobbs method had an initial TAMBA between 95 and 128° (mean 118°).The measurement difference between the TAMBA in neutral and plantarflexion positions in cases unsuccessfully treated with the Dobbs method were smaller compared to values of feet successfully treated with the Dobbs method. These differences were statistically significant (p < 0.0001).
Conclusion
In our series, the success of the Dobbs method in CVT treatment depended on the flexibility in the talonavicular complex. The TAMBA value and TAMBA difference (TAMBA neutral minus TAMBA plantarflexion) express the flexibility in the talonavicular joint and could be predictive for the success of a minimally invasive treatment. Only in a few cases is the success of the Dobbs method limited. These feet are associated with a TAMBA greater than 120° in neutral position and, particularly, a TAMBA difference smaller than 25°.
Dynamic US study in the evaluation of infants with vertical or oblique talus deformities.
Supakul N, Loder RT, Karmazyn B. Pediatr Radiol. 2012 Nov 27.
Quote:
BACKGROUND:
Congenital vertical talus (CVT) is a rare foot deformity that is sometimes difficult to differentiate from oblique talus (OT) by physical examination and foot radiography.
OBJECTIVE:
The purpose of this study was to summarize our experience with US in evaluation of CVT and OT deformities.
MATERIALS AND METHODS:
We identified all children (2005-2011) younger than 6 months who underwent dynamic focused US of the foot at our tertiary-care facility to evaluate clinically equivocal cases of CVT. Diagnostic criteria for CVT were persistent talonavicular dislocation on forced plantar flexion of the foot. OT was diagnosed based on reduction of the talonavicular dislocation on forced plantar flexion. Medical and imaging charts were reviewed for diagnosis on US and plain radiographs (when available) and for underlying neuromuscular disorders, treatment and outcome on follow-up.
RESULTS:
Ten patients (eight boys and two girls, mean age 33 days) were evaluated by US for CVT. Radiographs of the foot were obtained in only two children and were non-diagnostic. Thirteen feet were evaluated by US. Diagnosis of CVT was confirmed by surgery in seven children, three of whom had bilateral CVT. Diagnosis of OT in three children was supported by response to casting treatment.
CONCLUSION:
Dynamic US can reliably distinguish between CVT and OT deformities.
Narrowing the critical region for congenital vertical talus in patients with interstitial 18q deletions.
Mark PR, Radlinski BC, Core N, Fryer A, Kirk EP, Haldeman-Englert CR. Am J Med Genet A. 2013 Mar 13.
Quote:
Interstitial deletions of 18q lead to a number of phenotypic features, including multiple types of foot deformities. Many of these associated phenotypes have had their critical regions narrowly defined. Here we report on three patients with small overlapping deletions of chromosome 18q determined by microarray analysis (chr18:72493281-73512553 hg19 coordinates). All of the patients have congenital vertical talus (CVT). Based on these findings and previous reports in the literature and databases, we narrow the critical region for CVT to a minimum of five genes (ZNF407, ZADH2, TSHZ1, C18orf62, and ZNF516), and propose that TSHZ1 is the likely causative gene for CVT in 18q deletion syndrome
Vertical talus : Current diagnostic and therapy options
Arbab D, Rath B, Quack V, Lüring C, Tingart M. Orthopade. 2013 May 19.
Quote:
Congenital vertical talus is a rare condition which presents as an isolated deformity or in association with neuromuscular and/or genetic disorders. Pathoanatomically the deformity shows a dislocated talonavicular and subtalar joint. The etiology and pathogenesis are still not finally determined although in some cases a genetic basis has been identified. The clinical picture is that of a flat, convex longitudinal arch with abduction and dorsiflexion of the forefoot and an elevated heel. Clinical diagnosis is confirmed by plain radiographic imaging. Congenital vertical talus should not be confused with other deformities of the foot, such as congenital oblique talus, flexible flat feet or pes calcaneus. The object of treatment of congenital vertical talus is to restore a normal anatomical relationship between the talus, navicular and calcaneus to obtain a pain-free foot. Major reconstructive surgery has been reported to be effective but is associated with substantial complications. Good early results of a modified non-operative treatment using serial manipulation, cast treatment and minimally invasive surgery may change therapeutic concepts.
Congenital Vertical Talus
Linear Mode
