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What is the preferred treatment for newly diagnosed irreducible congenital vertical talus in a toddler?
Casting followed by open reduction and Achillies lengthening
Serial Ponseti method casting
Percutaneous achillies lengthening
Talectomy with tendon interposition
Subtalar fusion with soft tissue release
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The preferred treatment of congenital vertical talus (CVT) is surgical reduction of the navicular onto the reduced talus with soft-tissue releases in either a staged or one-step procedure. Casting prior to surgery is helpful in stretching the contracted dorsal soft-tissues but does not typically reduce the talonavicular joint. Manipulation and casting have been tried as definitive treatment, but most authors now agree that surgical treatment is required.
Surgical treatment requires lengthening of the Achilles tendon and sometimes the dorsiflexors, as well as sectioning of the midfoot capsules. A subtalar fusion is not performed initially, although it may be required if there is recurrence. Untreated, patients develop an awkward gait due to a rocker bottom type foot, a painful rigid foot as well as calluses under the midfoot.
The Sullivan article reviews causes of pediatric flat foot and cautions the need to rule out CVT.
The Drennan instructional course lecture reviews CVT etiology, diagnosis, and treatment.
J Am Acad Orthop Surg. 1999 Jan;7(1):44-53. PMID: 9916191 (Link to Abstract)
Instr Course Lect. 1996;45:315-22. PMID: 8727751 (Link to Abstract)
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Which of the following is not characteristic of the pathologic process displayed in Figure A.
Dislocation of the talonavicular joint
Associated with posteromedial tibia bowing
Associated with neural tube defects
Associated with arthrogryposis
Rigid rocker bottom deformity
Congenital vertical talus (CVT) is not associated with posteromedial bowing.
Congenital vertical talus (CVT) presents as a fixed rocker bottom foot. The hindfoot is in equinus and the forefoot is in dorsiflexion, producing a fixed midfoot dislocation through the talonavicular joint that does not correct with plantar flexion. CVT is a surgical problem that requires peritalar release to reduce the talonavicular and talocalcaneal articulations. Surgical treatment is required but preoperative casting can stretch the contracted tissues to facilitate surgery. Arthrodesis is not needed to correct deformity as soft tissue release and reduction have been shown to have acceptable results.
Drennan presents a Level 5 review article. In CVT, the talonavicular joint is irreducibly dislocated dorsally. CVT is usually associated with other congenital or neuromuscular abnormalities such as neural tube defects (myelomeningocele), neuromuscular disorders (arthrogryposis), malformation syndromes, and chromosomal aberrations.
Illustration A depicts the lateral radiograph demonstrating plantar flexion of an oblique (A) and vertical (B) talus. In the oblique talus, the navicular (unossified) and first metatarsus (and thus the talonavicular joint) line up in plantar flexion. In a true congenital vertical talus, the the navicular (unossified) and first MT remain dorsal to the talus in plantar flexion.
Calcaneovalgus foot is associated with posteromedial bowing of the tibia.
An 13-month-old boy is evaluated for a foot deformity and asymmetric gait. A clinical photo is shown in Figure A. A plantarflexion lateral radiograph is shown in Figure B. What is the most likely diagnosis?
Congenital vertical talus
Congenital oblique talus
Normal radiographic findings
The clinical presentation and radiographic findings are consistent with congenital oblique talus (COT), not congenital vertical talus (CVT). The plantarflexion lateral radiograph is key to differentiating between these two conditions. In congenital oblique talus, the talonavicular joint will reduce and the talus will parallel the first metatarsal on plantarflexion radiographs. However, the talus will not reduce in CVT, and with plantar flexion the long axis of the first metatarsal remains dorsal to the long axis of the talus. This is shown in Illustration A, which demonstrates plantarflexion radiographs of a congenital oblique talus (A) and congenital vertical talus (B). The distinction is important as congenital vertical talus is a true dislocation of the talonavicular joint which requires casting followed by surgery.
Mazzaocca et al retrospectively evaluated 33 feet with congenital vertical talus who were treated surgical release through either a traditional posterior approach or a single stage dorsal approach. The feet treated with the dorsal approach had shorter surgical times, better clinical outcomes, fewer complications (AVN was significant in posterior approach), and fewer revisions.
Kodros et al reviewed 55 patients treated with a single stage Cincinnati incision (a transverse posterior approach at the level of the tibiotalar joint). There were no cases of AVN. Ten feet required a secondary surgery. At final clinical and radiographic follow-up 75% were stratified as good results and 25% were fair.
Mazzocca AD, Thomson JD, Deluca PA, Romness MJ
J Pediatr Orthop. 2001 Mar-Apr;21(2):212-7. PMID: 11242252 (Link to Abstract)
Kodros SA, Dias LS.
J Pediatr Orthop. 1999 Jan-Feb;19(1):42-8. PMID: 9890285 (Link to Abstract)
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A 2-month old infant is born with a rocker-bottom foot deformity. A radiograph is shown in figure A. Why is the initial treatment manipulation and casting?
to help stretch the dorsolateral soft-tissue before surgery
the deformity usually corrects with non-operative treatment
surgery is usually deferred until 5 years of age
surgery is usually deferred until 10 years of age
surgery does not help this condition
The X-ray shows a plantar flexion lateral foot X-ray denoted by the plantar flexed position of the toes. This X-ray denotes a dorsally dislocated talonavicular joint consistent with congenital vertical talus resulting in a rocker bottom foot.
The etiology, inheritance, and incidence of this entity are unknown, though a family tendency has been reported. In congenital vertical talus, the hindfoot is fixed in an equinovalgus position and the forefoot is abducted and dorsiflexed in the midtarsal region. It is rigid and uncorrectable. The plantar surface of the foot has a rounded or convex appearance (“rocker-bottom feet”) and children can develop an awkward gait due to a painful rigid foot and calluses under the midfoot.
Lateral radiographs in a neutral and maximally plantarflexed position will confirm the diagnosis, showing that in the neutral position the calcaneus is in equinus, the forefoot is fixed in dorsiflexion, and there is a dorsal talonavicular dislocation. These findings do not correct in the maximally plantar flexed position. In the similar oblique talus, the dorsally positioned navicular will reduce in line with the talus.
Treatment for the condition should begin as early as possible. Most authors agree that surgical treatment is required for correction of the deformity. Casting before surgery is performed to stretch the soft tissues, improve final surgical correction and minimize surgical intervention. Historically, a single-stage procedure through an extensile incision was most commonly used. Dobbs et al describe the success with serial manipulation and cast immobilization followed by talonavicular pin fixation and percutaneous tenotomy of the Achilles tendon providing excellent results.
J Pediatr Orthop. 1987 Jul-Aug;7(4):405-11. PMID: 3611335 (Link to Abstract)
Dobbs MB, Purcell DB, Nunley R, Morcuende JA
J Bone Joint Surg Am. 2006 Jun;88(6):1192-200. PMID: 16757750 (Link to Abstract)
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HPI - non treated vertical talus
What is the best treatment?
Gait evaluation of a patient with bilateral neglected vertical tali deformities