The Treatment of Congenital Vertical Talus

Congenital vertical talus (CVT), also known as congenital convex pes valgus or rocker-bottom foot, is a rare orthopedic deformity present at birth, characterized by a rigid dislocation of the talonavicular joint where the talus bone is positioned vertically instead of horizontally. This results in a flattened arch, a heel that points downward, and a forefoot that is dorsiflexed and abducted, creating a distinctive "rocker-bottom" appearance. CVT affects approximately 1 in 10,000 live births and can occur unilaterally or bilaterally, often associated with neuromuscular disorders such as arthrogryposis, myelomeningocele, or genetic syndromes like trisomy 18. Early diagnosis and intervention are crucial to prevent long-term complications like pain, gait abnormalities, and arthritis. The treatment of CVT has evolved significantly over the decades, shifting from extensive surgical corrections to more conservative, minimally invasive approaches that prioritize serial manipulation and casting. This essay explores the multifaceted treatment strategies for CVT, including non-surgical methods, surgical interventions, outcomes, and emerging techniques, drawing on contemporary medical literature to provide a thorough analysis.

Diagnosis of CVT typically occurs shortly after birth through clinical examination and radiographic imaging. Clinically, the foot presents with a rigid equinus deformity at the hindfoot and dorsiflexion at the midfoot, resistant to passive correction. Radiographs, particularly lateral views in plantarflexion, confirm the vertical orientation of the talus and dorsal dislocation of the navicular bone. Ultrasound may be used in neonates for soft tissue assessment, while MRI can help identify associated anomalies in complex cases. Early detection is vital, as untreated CVT leads to severe functional impairments, including difficulty walking and chronic pain in adulthood. Once diagnosed, treatment is initiated promptly, ideally within the first few weeks of life, to capitalize on the malleability of infantile tissues.

The cornerstone of CVT treatment is non-surgical management, primarily through serial manipulation and casting, inspired by the Ponseti method used for clubfoot. This approach involves gentle stretching of the foot to gradually reduce the talonavicular dislocation, followed by application of long-leg casts changed weekly. The goal is to dorsiflex the forefoot while plantarflexing the hindfoot, reversing the deformity over 4-6 weeks. Studies have shown that this method achieves initial correction in up to 80-90% of cases, particularly when started early. For instance, a technique developed by Dobbs and colleagues emphasizes reverse Ponseti casting, where the foot is manipulated into plantarflexion and inversion, followed by percutaneous Achilles tenotomy if equinus persists. After casting, bracing with a Denis-Browne bar or ankle-foot orthosis (AFO) is essential for maintenance, worn full-time for several months and then nocturnally for years to prevent recurrence. Physical therapy complements this by improving muscle strength and joint mobility. Non-surgical treatment is preferred due to its lower risk of complications like wound infections or stiffness compared to surgery.

However, not all cases respond to conservative measures, especially rigid or syndromic forms of CVT. In such instances, surgical intervention becomes necessary, typically performed between 6-12 months of age to allow for initial casting attempts. Traditional surgical approaches involved extensive soft-tissue releases, including capsulotomies of the talonavicular and subtalar joints, tendon lengthenings (e.g., Achilles, tibialis anterior), and sometimes osteotomies. These procedures aim to realign the talus and navicular, often secured with Kirschner wires (K-wires) for stability during healing. A single-stage posteromedial release was once standard but has fallen out of favor due to high rates of overcorrection, avascular necrosis of the talus, and residual deformities. Modern minimally invasive surgeries have gained prominence, offering better outcomes with less morbidity. For example, the Dobbs method combines serial casting with a limited surgical release, involving only a talonavicular joint reduction and pinning, plus Achilles tenotomy. This approach has reported success rates exceeding 90% in achieving plantigrade feet with minimal scarring.

In more complex or recurrent cases, advanced surgical techniques may be employed. Naviculectomy, the excision of the navicular bone, is reserved for salvage procedures in older children or when primary corrections fail. It can be combined with posterolateral releases or tendon transfers to restore foot alignment. Another option is the use of gradual distraction with external fixators, like the Ilizarov apparatus, to correct severe deformities without extensive incisions. For associated conditions, such as in arthrogryposis, staged surgeries addressing multiple joint contractures are common. Surgical correction must consider the three-dimensional nature of the deformity—addressing sagittal, coronal, and axial planes—to ensure comprehensive realignment. Postoperative care includes casting for 6-8 weeks, followed by bracing and physical therapy to maintain correction and promote normal development.

Outcomes of CVT treatment vary based on the severity, associated syndromes, and timeliness of intervention. With early non-surgical management, many children achieve functional, pain-free feet, allowing normal ambulation by toddlerhood. Long-term studies indicate that minimally invasive approaches yield excellent radiographic and clinical scores, with low recurrence rates (around 10-20%). However, complications can occur, including talar avascular necrosis, wound issues, over- or under-correction, and the need for revision surgeries in up to 30% of cases. In syndromic CVT, outcomes are poorer due to underlying neuromuscular involvement, often requiring lifelong orthotic support. Patient and family education is key, emphasizing compliance with bracing to mitigate relapse. Functional assessments, such as the Pediatric Outcomes Data Collection Instrument (PODCI), help track progress, with most treated children reporting high satisfaction and activity levels.

Recent advances in congenital vertical talus treatment focus on refining minimally invasive techniques and incorporating technology. Algorithmic approaches provide structured guidelines, starting with serial casting and escalating to surgery only if needed, tailored to the deformity's rigidity. 3D printing for custom orthotics and intraoperative navigation enhance precision. Research into genetic factors may lead to prenatal interventions, while regenerative therapies like stem cell injections show promise in animal models for improving cartilage health. Multidisciplinary teams, including orthopedists, physical therapists, and geneticists, are increasingly involved to optimize care.

The treatment of congenital vertical talus has progressed from aggressive surgeries to a conservative paradigm emphasizing serial manipulation, casting, and targeted minimally invasive procedures. This shift has improved outcomes, reducing complications and enhancing quality of life for affected children. Early intervention remains paramount, with ongoing research poised to further refine protocols. By integrating evidence-based strategies, clinicians can effectively manage this challenging deformity, ensuring that children with CVT can lead active, unhindered lives. (Word count: 1023)

Craig Payne is a University lecturer, runner, cynic, researcher, skeptic, forum admin, woo basher, clinician, rabble-rouser, blogger and a dad.