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Updated: Dec 24 2023

Congenital Vertical Talus

Images photo - courtesy Miller_moved.png lateral xray - courtesy Miller_moved.png flexion lateral xray - courtesy Miller_moved.png 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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