SLR - September 2016 - Elena Manning
Reference: Yang JS, Dobbs MB. Treatment of Congenital Vertical Talus: Comparison of Minimally Invasive and Extensive Soft-Tissue Release Procedures at Minimum Five-Year Follow-up. J Bone Joint Surg Am. 2015 Aug 19;97(16): 1354–65.Scientific Literature Review
Reviewed By: Elena Manning, DPM
Residency Program: Mount Auburn Hospital
Podiatric Relevance: Congenital vertical talus is a rare flatfoot deformity characterized by a fixed dorsal dislocation of the navicular on the talus with associated Achilles tendon and dorsolateral soft-tissue contractures. Although this is a rare condition with an estimated prevalence of one in 10,000, without adequate treatment, the condition results in pain and long-term disability. The goal in treating congenital vertical talus is to achieve a plantigrade, mobile and functional foot. The goal of the study was to assess the long-term outcomes of patients with congenital vertical talus managed with the minimally invasive technique versus those within a cohort treated with extensive soft-tissue release surgery.
Methods: This is a retrospective cohort of 27 patients (42 feet) who were treated for congenital vertical talus at a single institution consecutively between 1998 and 2007. Inclusion criteria included diagnosis of vertical talus via lateral radiographs of the foot in maximum plantar flexion with a talar axis-first metatarsal base angle >35 degrees and radiographs pre and post treatment with a mean follow-up of seven years (five to 11.3 years). The treatment choice method utilized was based on surgeon preference for the severity of the deformity. Sixteen patients (24 feet) were treated using the minimally invasive technique consisting of serial manipulation and casting followed by percutaneous talonavicular joint pinning and percutaneous Achilles tenotomy, followed by shoe-and-bar bracing once casting was complete. Eleven patients (18 feet) were treated with extensive soft-tissue release surgery, performed as a single-stage surgery, including a posterior capsulotomy of the ankle and STJ, sectioning of the calcaneofibular ligament and capsulotomies of the calcaneocuboid and talonavicular joints. Outcomes included patient demographics, ankle ROM, PODCI (Pediatric Outcomes Data Collection Instrument) questionnaire and radiographic measurements.
Results: The mean ankle ROM at the latest follow-up was greater in patients treated with the minimally invasive method compared to those treated with extensive soft-tissue release surgery (42.4 degrees versus 12.7 degrees, p<0.0001). Only 15 patients in the minimally invasive group and 8 in the extensive soft tissue group provided PODCI data. Of those who provided PODCI scores, those who were treated in the minimally invasive group had better scores for pain. Radiographic values were similar for both groups, except the correction of hindfoot valgus (anteroposterior talar axis-first metatarsal base angle) was greater in the minimally invasive group (40.1 degrees versus 27.9 degrees, p= 0.03). Two patients (three feet) in the minimally invasive group had recurrence of deformity within one year compared to three patients (6 feet) within the extensive soft-tissue release group. Within the extensive soft-tissue release group one foot was complicated with skin necrosis that needed debridement.
Conclusions: The authors concluded that the minimally invasive treatment for congenital vertical talus resulted in better long-term foot flexibility and pain scores compared with extensive soft-tissue release surgery. The goal of treatment for congenital vertical talus is to provide correction to a mobile, plantigrade, functional foot with the least invasive method possible. The minimally invasive treatment method shows promise in achieving this goal. Longer-term studies are necessary to determine if these outcomes are maintained into adulthood.