Congenital Vertical Talus
Congenital Vertical Talus
Congenital Vertical Talus (CVT), also known as "rocker-bottom foot," is a rare rigid flatfoot deformity characterized by fixed dorsal dislocation of the navicular on the talus, resulting in a rigid and irreducible hindfoot valgus and forefoot dorsiflexion.
Key Characteristics:
- Fixed dorsal navicular dislocation
- Rigid equinus of the hindfoot
- Forefoot dorsiflexion and abduction
- Convex plantar surface
- Rigidity of deformity
Epidemiology
- Incidence: 1 in 10,000 live births
- Bilateral in 50% of cases
- Male:Female ratio = 1:1
- Associated conditions in 50-90% of cases
- Strong genetic component
Pathoanatomy
- Key Deformities:
- Vertically oriented talus
- Dorsal dislocation of navicular
- Contracture of anterior tibialis
- Contracted dorsal capsule
- Posterior tibialis dysfunction
- Anatomical Changes:
- Hindfoot equinus
- Talonavicular dissociation
- Forefoot dorsiflexion
- Altered muscle balance
Clinical Presentation
- Physical Findings:
- Rigid rocker-bottom deformity
- Prominent talar head plantarly
- Deep crease on dorsum of foot
- Fixed hindfoot equinus
- Inability to reduce deformity
- Key Signs:
- Rigid deformity from birth
- Convex plantar arch
- Dorsal bunion appearance
- Tight anterior tendons
- Poor passive motion
Diagnostic Imaging
- Radiographic Features:
- Lateral view:
- Vertical orientation of talus
- Dorsal displacement of navicular
- Parallel axes of talus and 1st metatarsal
- AP view:
- Forefoot abduction
- Talar head uncoverage
- Hindfoot valgus
- Lateral view:
- Advanced Imaging:
- MRI: For complex cases
- CT: Surgical planning
- Stress radiographs
Associated Syndromes and Conditions
- Neuromuscular Disorders:
- Arthrogryposis
- Myelomeningocele
- Sacral agenesis
- Spinal muscular atrophy
- Chromosomal Abnormalities:
- Trisomy 13, 15, 18
- De Lange syndrome
- Down syndrome
- Other Associations:
- HOXD10 gene mutations
- DiGeorge syndrome
- Prune belly syndrome
- Neurofibromatosis
Systemic Evaluation
- Required Assessments:
- Neurological examination
- Genetic consultation
- Spine evaluation
- Hip screening
- Cardiac assessment
Treatment Approach
- Initial Management:
- Early intervention crucial
- Serial manipulation and casting
- Dobbs method preferred
- Weekly cast changes
- Dobbs Method:
- Reverse Ponseti technique:
- Sequential hindfoot and forefoot correction
- Pin fixation of talonavicular joint
- Percutaneous Achilles tenotomy
- Reverse Ponseti technique:
Surgical Management
- Limited Surgery:
- Percutaneous talonavicular pinning
- Achilles tenotomy
- Anterior tibial tendon transfer
- Extensive Surgery:
- Single-stage correction:
- Extensive soft tissue release
- Talonavicular reduction
- Pin fixation
- Tendon balancing
- Single-stage correction:
Post-Treatment Care
- Bracing Protocol:
- Full-time bracing initially
- Gradual weaning
- Night bracing until age 4-5
- Monitoring:
- Regular radiographic assessment
- Growth monitoring
- Functional evaluation
- Long-term follow-up
Complications and Outcomes
- Potential Complications:
- Recurrence (10-50%)
- Overcorrection
- Stiffness
- Avascular necrosis
- Wound problems
- Long-term Outcomes:
- Better with early treatment
- Variable with associated conditions
- Regular monitoring needed
- Possible arthritis in adulthood
