Rocker bottom foot, Rigid Pes Planus, Congenital convex pes valgusCongenital Vertical Talus is a condition in which there is dorsal subluxation/dislocation of navicular with equinus of the talus/ankle
Isolated idiopathic CVT < 50% cases
Bilateral cases: 50 %
Associated Syndromes:
- Neuromuscular disorders
- Sacral agenesis
- Diastematomyelia
- Myelodysplasia
- Arthrogryposis
Trisomy:- 13, 15 and 18
Pathoanatomy
Hallmark: Dorsal subluxation/dislocation of navicular with equinus of the talus/ ankle (an essential component of deformity) and Equinus and Valgus of calcaneus and foot
Skin in the vertical talus (undersurface) is callosed due to weight-bearing by the talar head.
Oblique talus
Condition where all deformities are present but navicular can be reduced over talar head in plantar flexion
Tendon and capsule are contracted on the dorsal and lateral surface
Tendoachilllis, long toe extensors, peronei, talonavicular, and posterior ankle capsule are contracted
Tibialis anterior is shortened
Peronei , tibialis posterior, subluxated anteriorly
The orientation of the talus is vertical
So, articular cartilage is present over dorsum of talar head, Lateral translation and valgus of calcaneum, Misshaped calcaneal facet
Coleman classification:
Type I: Joint relation is normal
Type II: Subluxed/ displaced calcaneo-cuboidal joint
Lichtblau types:
- Teratogenic
- Neurogenic
- Acquired
Clinical Features
- Forefoot – Valgus
- Heel – Valgus + Equinus
Rigid: Ankle plantarflexion restricted
The medial border is convex: Prominence of the talar head
Convexity persists during weight-bearing ( Unlike flexible flat foot)
Dimple at anterolateral aspects
Deep skin crease is present at the anterior aspect of the ankle
Long-standing cases: callosities is present on weight bearing head of the talus
Shoe wear: uncomfortable: long cases secondary Osteoarthritis sets in Foot become painful
Radiological Investigation:
Taken in [Supine position for infants], [Weight bearing film for older children]
Normal talocalcaneal angle (Kites) angle: 25-50 degree in AP
Talo-calcaneal angle: 30-55 degree in lateral
In CVT:
AP: talocalcaneal angle is INCREASED . (Subtalar valgus deformity)
Meary’s angle: (Talo-1st metatarsal angle): NEGATIVE (Normal: 0-20 degrees)
Talus is almost verticle and aligns parallel to the tibia
Normally long axis of the talus passes the lower 1/3rd of cuboid
In CVT: the long axis of the talus passes behind cuboid
Treatment
Aim: To obtain plantigrade foot, pain-free and normal-appearing foot
Reverse Ponseti
- Pressure is applied to the medial part of the talus while the forefoot is abducted and plantigrade
- This reduces joint
- This position held by plantar cast
- Combined with soft tissue lengthening
- Tendoachillis
- Peronei
- EDL
- Tibialis anterior
- Sometimes, capsulotomy is needed
- Archived position held for 5-6 weeks with joining transfixing K-wires with 5 degrees than 15 degrees dorsiflexion of the ankle in long leg cast
- Then, Ankle foot orthosis for 2 years
15° of plantar flexion
15° adduction and midtarsal joint
At night, clubfoot-like brace with feet fixed at 6° for 12-14 hours
Surgical Treatment
Done at the earliest possible time (Before 6 months)
Indicated for:
- Rigid, syndromic, and relapsed
- Stiff
Aim:
- Lengthening tight soft tissue structure and
- Reduce dislocated joint (talonavicular joint reduction)
Approach:
- Medial
- Lateral
- Cincinnati
Release of soft tissue done on order:
Lateral – Posterior – Anterior
Peronei – tendoachilis – EDL – Tibialis anterior with Z- Plasty
After Z- Plasty, the talonavicular joint is opened
In children over 2 years, transfer of one 1/2 of tibialis anterior to neck of talus done to maintain in a dorsiflexion position
Older children may require excision of the navicular to achieve the reduction
Salvage Surgery
- Coleman subtalar arthrodesis
- Triple arthrodesis
Post-operatively, solid AFO- 2 years, medial wedge in regular footwear
Complications
- Relapse
- Surgical complication
- Skin necrosis
- AVN of navicular and talus
- OA of foot
- Calcaneum deformity (Due to the excessive lengthening of tendon-Achilles and tight transferred tibialis anterior)
Summary of treatment of CVT depending upon age
1-4 years:
- Open reduction and realignment of talonavicular, calcaneocuboid, and subtalar joints
- navicular excision, partial talectomy, and decancellation of tarsal bones may be required for > 3 years of child
- Lateral Column Lengthening
4-8 years:
- Open reduction, soft tissue release, and extraarticular ( Grice-green) subtalar arthrodesis, sometimes intraarticular arthrodesis
- A gap of 6-8 weeks is usually given between release and arthrodesis
>8 years:
- Triple arthrodesis
See also: Developmental dysplasia of the hip (DDH)
See also: Congenital Talipus Equinovarus (CTEV)
See also: Legg-calve-Perthes disease (LCPD)
