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 login to view 1 more bullet rigid midfoot dorsiflexion login to view 1 more bullet forefoot abducted and dorsiflexed login to view 1 more bullet prominent talar head can be palpated in medial plantar arch on exam login to view 1 more bullet 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 login to view 3 more bullets AP login to view 1 more bullet alternative views forced plantar flexion lateral radiograph is diagnostic login to view 3 more bullets forced dorsiflexion lateral login to view 1 more bullet 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 login to view 2 more bullets typically still requires closed vs open pinning of the talonavicular joint with percutaneous achilles tenotomy Operative surgical release and talonavicular reduction and pinning indications login to view 2 more bullets technique login to view 3 more bullets minimally invasive correction indications login to view 1 more bullet technique login to view 4 more bullets 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