Updated: 6/14/2021

Congenital Vertical Talus

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https://upload.orthobullets.com/topic/4066/images/clinical photo - courtesy Miller_moved.png
https://upload.orthobullets.com/topic/4066/images/Neutral lateral xray - courtesy Miller_moved.png
https://upload.orthobullets.com/topic/4066/images/plantar flexion lateral xray - courtesy Miller_moved.png
https://upload.orthobullets.com/topic/4066/images/37B_moved.JPG
https://upload.orthobullets.com/topic/4066/images/meary and talocal labeled.jpg
  • summary
    • Congenital Vertical Talus is a rare congenital condition caused by neuromuscular or chromosomal abnormalities in neonates that typically presents with a rigid flatfoot deformity.
    • Diagnosis is made with forced plantar flexion lateral radiographs that show persistent dorsal dislocation of the talonavicular joint.
    • Treatment is usually serial manipulation and casting followed by surgical release and talonavicular reduction and pinning at age 6-12 months.
  • Epidemiology:
    • Incidence
      • rare, 1:150,000 births
    • Demographics 
      • M:F ratio of 2:1
    • Anatomic location
      • 50% bilateral
  • Etiology
    • Pathoanatomy
      • rigid foot deformity
        • irreducible dorsolateral navicular dislocation
        • vertically oriented talus
        • calcaneal eversion with attenuated spring ligament
      • soft tissue contractures
        • displacement of peroneal longus and posterior tibilais tendon so they function as dorsiflexors rather than plantar flexors
        • contracture of the Achilles tendon
      • Genetics
        • a positive family history is present in up to 20% of patients
        • HOXD10 gene mutation (transcription factor)
    • Associated conditions
      • 50% associated with neuromuscular disease or chromosomal aberrations
        • Myelomeningocele
        • Arthrogryposis
        • Diastematomyelia
        • congenital dislocation of the hip
        • cerebral palsy
        • spinal muscular atrophy
  • Presentation
    • Physical exam
      • rigid rockerbottom deformity
        • fixed hindfoot equinovalgus
          • due to contracture of the Achilles and peroneal tendons
        • rigid midfoot dorsiflexion
          • secondary to the dislocated navicular
        • forefoot abducted and dorsiflexed
          • due to contractures of the EDL, EHL and tibialis anterior tendons
      • prominent talar head
        • can be palpated in medial plantar arch on exam
          • produces a convex plantar surface
      • gait abnormality
        • patient may demonstrate a "peg-leg" or a calcaneal gait due to poor push-off power
        • limited forefoot contact, excessive heel contact
      • neurologic deficits
        • a careful neurologic exam needs to be performed due to frequent association with neuromuscular disorders
  • Imaging
    • Radiographs
      • recommended views
        • AP, oblique and lateral foot
      • findings
        • lateral
          • vertically positioned talus & dorsal dislocation of navicular
            • line along long axis of talus passes below the first metatarsal-cuneiform axis
              • before ossification of navicular at age 3, the first metatarsal is used as a proxy for the navicular on radiographic evaluation
        • AP
          • talocalcaneal angle > 40° (20-40° is normal)
      • alternative views
        • forced plantar flexion lateral radiograph is diagnostic
          • shows persistent dorsal dislocation of the talonavicular joint
            • oblique talus reduces on this view
            • Meary's angle > 20° (between line of longitudinal axis of talus and longitudinal axis of 1st metatarsal)
        • forced dorsiflexion lateral
          • reveals fixed equinus
    • MRI
      • neuraxial imaging should be performed to rule out neurologic disorder
  • Differential 
    • Oblique talus
      • anatomic variant
        • talonavicular subluxation that reduces with forced plantarflexion of the foot
      • treatment is generally observation, shoe inserts vs casting
        • some require surgical pinning of the talonavicular joint and achilles lengthening for persistent subluxation
    • Calcaneovalgus foot deformity
    • Posteromedial tibial bowing
    • Tarsal coalition
    • Paralytic pes valgus
    • Pes planovalgus
  • Treatment
    • Nonoperative
      • serial manipulation and casting
        • indications
          • indicated preoperatively to stretch the dorsolateral soft-tissue structures
          • foot is manipulated into inversion and plantarflexion
        • typically still requires closed vs open pinning of the talonavicular joint with percutaneous achilles tenotomy
    • Operative
      • surgical release and talonavicular reduction and pinning
        • indications
          • indicated in most cases
          • performed at 6-12 months of age
        • technique
          • involves pantalar release with concomitant lengthening of peroneals, Achilles, and toe extensors
          • talonavicular joint is reduced and pinned while reconstruction of the plantar calcaneonavicular (spring) ligament is performed
          • concomitant tibialis anterior transfer to talar neck
      • minimally invasive correction
        • indications
          • new technique performed in some centers to avoid complications associated with extensive surgical releases
        • technique
          • principles for casting are similar to the Ponseti technique used clubfoot
          • serial casting utilized to stretch contracted dorsal and lateral soft tissue structures and gradually reduced talonavicular joint
          • once reduction is achieved with cast, closed or open reduction is performed and secured with pin fixation
          • percutaneous achilles tenotomy is required to correct the equinus deformity
      • talectomy
        • indicated in resistant case
      • triple arthrodesis
        • as salvage procedure
  • Complications
    • Missed vertical talus
      • reconstructive options are less predictable after age 3, and patients may require triple arthrodesis as salvage procedure
  • Prognosis
    • Poor in untreated cases and associated with significant disability
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Questions (11)
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(SBQ13PE.84) A 9-month-old boy is referred for evaluation of bilateral 'rocker bottom' feet. Figure A exhibits a lateral foot radiograph. This diagnosis has a high association with which of the following congenital anomalies?

QID: 5243
FIGURES:

Cleft lip/palate

11%

(409/3662)

Neuromuscular disease

60%

(2186/3662)

Congenital heart disease

14%

(528/3662)

Deletion on chromosome 22q11

9%

(342/3662)

Duplication on chromosome 12

5%

(166/3662)

L 2 B

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(OBQ09.29) What is the preferred treatment for newly diagnosed irreducible congenital vertical talus in a toddler?

QID: 2842

Casting followed by open reduction and Achillies lengthening

83%

(2130/2570)

Serial Ponseti method casting

8%

(205/2570)

Percutaneous achillies lengthening

2%

(49/2570)

Talectomy with tendon interposition

4%

(105/2570)

Subtalar fusion with soft tissue release

3%

(68/2570)

L 1 B

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(OBQ07.97) All of the following are known to be associated with the deformity shown in Figure A EXCEPT:

QID: 758
FIGURES:

Chromosomal deletions

7%

(187/2802)

Arthrogryposis

5%

(154/2802)

Amniotic band syndrome

61%

(1696/2802)

Hip dysplasia

12%

(347/2802)

Spinal muscular atrophy

14%

(380/2802)

L 3 C

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(SAE07PE.18) Figures 8a and 8b show the clinical photograph and radiograph of a 4-month-old infant who has a left foot deformity. Examination reveals that the foot deformity is an isolated entity, and the infant has no known neuromuscular conditions or genetic syndromes. Which of the following studies will best confirm the diagnosis?

QID: 6078
FIGURES:

MRI of the foot

3%

(15/454)

Static ultrasound examination of the foot in dorsiflexion

5%

(24/454)

Lateral radiograph of the foot in maximum plantar flexion

68%

(308/454)

Lateral radiograph of the foot in maximum dorsiflexion

20%

(93/454)

CT of the foot

3%

(12/454)

L 3 E

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(OBQ07.154) Which of the following is not characteristic of the pathologic process displayed in Figure A.

QID: 815
FIGURES:

Dislocation of the talonavicular joint

6%

(206/3679)

Associated with posteromedial tibia bowing

58%

(2124/3679)

Associated with neural tube defects

15%

(538/3679)

Associated with arthrogryposis

9%

(343/3679)

Rigid rocker bottom deformity

12%

(441/3679)

L 1 C

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(OBQ06.127) 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?

QID: 313
FIGURES:

Talipes equinovarus

4%

(83/2110)

Congenital vertical talus

55%

(1167/2110)

Congenital oblique talus

36%

(758/2110)

Skewfoot

1%

(30/2110)

Normal radiographic findings

3%

(60/2110)

L 5 C

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(OBQ04.115) 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?

QID: 1220
FIGURES:

to help stretch the dorsolateral soft-tissue before surgery

69%

(1025/1484)

the deformity usually corrects with non-operative treatment

24%

(349/1484)

surgery is usually deferred until 5 years of age

5%

(80/1484)

surgery is usually deferred until 10 years of age

0%

(5/1484)

surgery does not help this condition

1%

(14/1484)

L 2 C

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