CONGENITAL VERTICAL TALUS

ARTHUR L. EYRE-BROOK, BRISTOL, ENGLAND

The term congenital vertical talus is applied to a severe congenital deformity of the foot,
which resembles club foot (talipes equino-cavo-varus) in that the heel is elevated, there is
dislocation of the talo-navicular joint and the foot is stiff. The displacement of the talo-
navicular joint is, however, opposite in the two conditions: in club foot it is downwards and
medially, whereas in congenital vertical talus the navicular bone moves upwards and laterally
to lie on the dorsum of the head or neck of the talus. A further difference is that the elevated
heel in vertical talus is not fixed. Rigidity of the foot is so formidable in congenital vertical
talus that most authorities agree that the condition is amenable only to operative treatment.
Lloyd-Roberts and Spence (1958) discussed the differential diagnosis between congenital
vertical talus (Figs. l to 8) and idiopathic club foot, paralytic flat foot, the flat foot of cerebral
palsy, the spuriously corrected club foot (Fig. 9) and the mobile talipes-calcaneo-valgus with the
hindfoot in calcaneus. Among the diagnostic features they emphasised the elevated heel, the

Fto. 1
Case 1-Photograph of the feet from behind, at age of 9 months. Bilateral severe
congenital vertical talus.

fixed foot deformity from birth and the characteristic shape of the foot. Radiographs
(Figs. 2 to 4) show the vertical talus and the convex contour of the sole of the foot, and also the
marked angulation between the axis of the talus and first metatarsal bone in antero-posterior
views of the foot. Judging from the cases reported here there is no fixed equinus of the heel;
lateral radiographs of the dorsiflexed foot show the calcaneus almost normally related to the
tibia.
The purpose of this paper is to illustrate the condition as seen in the infant, to direct
attention to the importance in the differential diagnosis of a lateral radiograph taken in
fullest plantar-flexion, and to describe a method of operative treatment that has been successful;
three patients were followed up for five, six and ten years.

DIAGNOSIS
It is important to note that a diagnosis of vertical talus is established only by a radiograph
in which dorsal dislocation of the navicular bone on to the head or neck of the talus is shown
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 CONGENITAL VERTICAL TALUS 619

flGS. 2 TO 4
a 1-The left fo t. figure 2 - T h e calcaneu is noi in equinu.
Figur 3-There i a convex outline of 1he ole even in full plantar-
fle ion. Figurc Thcre i valgu of Odcgrees al 1he mid-wrsal j in
in the antero-posterior view. FIG. 4

FIG. 5 FIG. 6
Case 1-Right foot before operation.

FIG. 7 F10. 8
Case 1-Right foot four weeks after operation. There may be slight varus at the
talo-navicular joint, a tendency to overcorrection.

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620 A. L. EYRE-BROOK

to be maintained în the position of greatest plantar-flexion. Admittedly, a child's foot below

three years of age may not show an ossified navicular bone, but its situation can easily be
identified because it lies between the ossified medial cuneiform and the head of the talus. ln
all cases of true congenital vertical talus, în full plantar-flexion the navicular will lie on the
dorsum of the head of the talus, and it is this persistence of the deformity when the foot is
plantar-flexed as far as it will go that is essential for diagnosis.
Figures 10 and 11 show a child of two years and nine months, the lateral radiograph of
whose foot în the right-angled position appeared to show a vertical talus; but when

FIG. 9
Spurious correction of severe club foot, the resuit of open reduction at
age of 3 years without elongation of calcaneal tendon. (Radiograph at
7 years old.) There is fixed equinus of the calcaneus. Compare with
Figures 5 and 6.

FIG. 10 FIG. l i
This child of 2 years and 9 months has not gol a congenital vertical talus: there is excellent alignment when the
foot is plantar-flexed. The navicular bone is not ossified but must lie in the correct relationship to the talus
between that bone and the ossified medial cuneiform bone.

radiographs were taken in full plantar-flexion they showed a normal relationship of the talus
with the medial cuneiform and therefore with the intervening navicular bone. Such a case
can be readily treated by plaster fixation and possibly later by elongation of the tendo calcaneus
as advocated by Wainwright (1963). True congenital vertical talus will not respond in this way
(Osmond-Clarke 1956, Stone and Lloyd-Roberts 1963).
Of the four patients reported in this paper, three had other congenital abnormalities.
Two were mentally retarded, with abnorma] facies and various skeletal abnormalities, one
being thought to have arthrogryposis. A third had severe scoliosis with two hemivertebrae
and a "tuning-fork rib." 1n only one case was the foot deformity bilateral.
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 CONGENITAL VERTICAL TALUS 621

FIG. 12 FIG. 13
Case I. Figure 12-Photograph taken of the right foot during operation on Case I (Figs. 2 to 8). The navicular
bone lies on dorsum of head of vertical talus above the distal end of the cut tibialis posterior. The tight tibialis
anterior tendon is seen anteriorly. Figure 13-The talo-navicular dislocation has been reduced but the talus
is still lying almost vertically. (The lateral exposure is not seen in this photograph.) The navicular bone is
identified by the tibialis posterior tendon; its proxima! surface is still unsatisfactorily opposed to the head of talus
with foot in full plantar flexion. A wedge of navicular bone has yet to be removed.

.I

,,/
/ / '-
()
\ Jf .;

// OF
HEAD

TALUS
AN TERIOR '-_

V --
//

N,''-
-; r
/

/
,,
PRESSED AGAINST ,
UPPER SURFACE OF TIBIALIS TIBIALIS ,,, '
HEAD OF TALUS POSTERIOR ANTERIOR

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B
622 A. L. EYRE-BROOK

TECHNIQUE OF OPERATION
Tbe operation consists in exposing tbe talo-navicular joint on tbe medial side tbrougb a
curved incision witb a brancb towards tbe beel. Tbe bead of tbe talus lies in a deep poucb
formed by a greatly elongated spring ligament and is exposed by cutting tbe tibialis posterior
tendon and tben opening tbis poucb (Fig. 12). Tbe navicular bas always been found lying on
tbe dorsum of tbe bead or neck of tbe talus, witb its proximal articular surface directed
downwards and posteriorly. After tbe dorsal ligament of tbis dislocated joint bas been cut
it is still found impossible to reduce tbe dislocation until tHe tigbt extensor tendons are
elongated. (ln Case 2 division of tbe dorsal retinaculum witb elongation of tbe peroneal
tendons did suffice, but in tbe otbers elongation of all tbe tendons was necessary.) Tbe tibialis
anterior and extensor ballucis longus tendon can be elongated from tbe medial side, but a

FIG. 14
Diagrammatic representation of the operation. On the left is seen
the state before operation and on the right the change accomplished
by the operation with the navicular wedge excised and placed under
the elevated head of talus. The spring ligament is reefed and the
tibialis posticus bas been shortened while all the extensor tendons
have been lengthened.
separate lateral incision is needed for elongation of tbe tendons of extensor digitorum longus,
peroneus tertius and peronei longus and brevis, wbicb last bave often become dislocated in
front of tbe lateral malleolus, taking a straigbt course to tbe mid-foot. Tbrougb tbis lateral
incision tbe subtalar and calcaneo-cuboid joints are opened and tbe ligaments in tbe sinus
tarsi are severed, to assist tarsal mobilisation. Wben tbe tendons bave been lengtbened tbe
navicular bone can be placed opposite tbe bead of tbe talus, but it is still unstable because its
proximal surface is inclined downwards and posteriorly (Fig. 13). Tberefore a wedge, based
dorsally, is taken from tbe proxima! part of tbe navicular bone, so tbat tbe inclination of tbe
proxima! surface is cbanged to face posteriorly and sligbtly upwards. A stable reduction is
now possible and is supplemented by placing tbe excised wedge of navicular below tbe bead
of tbe talus; it is secured by suturing tbe poucb-consisting of tbe spring ligament-witb
considerable overlap (Fig. 14).
Removal of tbe dorsal wedge from tbe navicular bone not only alters tbe direction of tbe
proxima! surface but also sbortens tbe total lengtb of tbe skeletal constituents of tbe medial
pillar. Tbe importance of tbe latter is sbown by tbe radiograpb several years later wben tbe
bead of tbe talus will be found to be articulating largely witb tbe bases of tbe cuneiform bones
(Figs. 20 to 22 and 26 to 28). Tbe tibialis posterior is sbortened before tbe skin closure wbicb
may be difficult because of tbe altered sbape of tbe foot. A well padded plaster is applied
witb tbe foot in full plantar-flexion and sligbt inversion and is kept on for four to eigbt weeks,
depending on tbe age of tbe cbild. Tbereafter mobilisation is allowed. No furtber treatment
bas been called for in tbe tbree patients followed up for ten, six and five years.

FOUR CASE REPORTS

Case 1-This mentally retarded infant failed to thrive; he had fusion of the second and third cervical
vertebrae and a large sacral defect-rather more than a complete spina bifida. He had coarse features,
thick lips, a broad nose, widely separated eyes and a left convergent squint. There were large scrotal
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 CONGENITAL VERTICAL TALUS 623
hemiae. Gargoylism was excluded by the appropriate chemical tests on the urine. He was first seen
at nine months of age with typically stiff and deformed feet (Figs. I to 6). Although the child was
nine months old when operated upon, he was small for his age in general and had particularly
small feet. Much mobilisation was necessary (Figs. 12 and 13) before a reasonable position was
obtained (Figs. 7 and 8). Complete subtalar mobilisation was necessary before the reduction was
satisfactory. Swelling after operation was considerable but this settled in a few days and healing of the
wounds was uneventful. The right foot appears to have been overcorrected and some equinovarus and
stiffness gave trouble later. The right calcaneal tendon was elongated four months later, the only one
to be so treated în this series. One month later the left foot was dealt with in the same way except
that the navicular bone was excised and the position of the talus and the cuneiform bones was
maintained by a transfixing wire. The child îs still too young to stand on his feet, particularly as he îs
somewhat retarded mentally, and these have been the most difficult feet to treat in the series. The
final resuit will have to be awaited many years hence.
Case 2-This child was bom with a left congenital vertical talus, a diastematomyelia and congenital
scoliosis; she was otherwise quite normal. First seen when two weeks old, she was treated by stretching
and plaster immobilisation until she was six months old. There was no improvement and operation
was done when she was nine months. The condition before operation is shown in Figure 15. Although
there was no ossification of the cuneiform or navicular bones, the proximal projection of the axes of
the metatarsal bones points to the dorsum of the talus at its head when the foot was plantar-flexed;
the navicular bone was found in this position at operation a few days later. After operation the left
foot was in plaster for only three weeks and it has had no other treatment since the operation ten
years ago. The appearance of the foot is good (Fig. 17) and the radiographs (Fig. 16) show good
alignment. The talus îs in contact with the medial cuneiform above and the remains of the navicular
bone are displaced downward and fused with the head of the talus. The range of plantar-flexion and
dorsiflexion is limited to 30 degrees entirely in the ankle joint, and tarsal movement is very restricted.

FIG. 15 FIG. 16
Case 2. Figure 15-Radiograph of the left foot at age of 9 months, after six months treatment by stretching
and plaster immobilisation and before operation. Figure 16---Radiograph of the left foot ten years after
operation. The navicular bone appears fused to head of talus and îs în correct relationship although the
superior portion of the bone îs clearly defective.

FIG. 17
Case 2-Photographs of the feet JO years after operation. The scar of the incision can be seen on the left foot.

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624 A. L. EYRE-BROOK

FIG. 18 FIG. 19
Case 3-Radiographs of the right foot in full dorsiflexion (Fig. 18) and în full
plantar-flexion to show the congenital vertical talus at the age of 11 months.

FIG . 20 TO 22
Casc 3-Radiographs of right f ot i and a half years after operation. The
na icular bonei repre ented only by a mall o iele belo\ the head of the talu ,
which articulate direct wiih the cuneiform bones.
FIG. 22

FIG. 23
Case 3-Photograph six and a half years after operation. The right foot is now the better looking of the two
because the left foot shows some cavus with claw toes.

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FIG. 24 FIG. 25
Case 4-Pre-operative radiographs of right foot after eight months of stretching and plaster immobilisation.
The navicular is not ossified but must lie on the dorsum of the head of the talus between that bone and the
ossified cuneiform bone, even in full plantar-ftexion.

FIG . 26 TO 28
ae Radiographs of righL foOl i years after operation. There i
light varus in the antero-posterior view.
FIG. 28

FIG. 29
Case 4-Appearance of the right foot six years after operation. There is slight varus in all views and the scars
of both incisions can be seen.

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626 A. L. EYRE-BROOK

Case 3-This boy had abnorma! wrists and fingers with very limited movement; the wrists had ulnar
deviation and the fingers were atavistic in their distal parts; he also had a mild scoliosis. He was
subnormal mentally, with small pinched features, and was considered to be suffering from arthrogryposis.
The right foot had a typical congenital vertical talus, which remained completely unreduced in full
plantar-ftexion which was just below the right angle. The normal left foot was considerably larger
(Figs. 18 and 19). Operation was performed at eleven months, when he was first seen; no conservative
treatment was given. The operation resembled that described but reduction was only effected when
much of the dorsal part of the navicular bone had been excised, so that some of the proxima! surface
of the cuneiform bones was in contact with the head of the talus at the end of the operation. The
resuit over six years later is shown in Figures 20 to 22. The antero-posterior radiograph shows
excellent alignment of the foot but the only evidence of the navicular bone is a bony fragment lying
beneath the head of the talus. The lateral radiograph also shows that only a small fragment of
the navicular bone remains beneath the head of the talus. This no doubt represents the displaced
portion, which was placed between the front of the calcaneus and the under-surface of the talus,
to assist in keeping the latter elevated. The appearance and function were equally satisfactory
(Fig. 23); there was no treatment except a period of seven weeks în plaster immediately after
operation.
Case 4-This otherwise normal boy was first seen at the age of three weeks. The right foot showed
the typical deformity, while the left was normal. Some time was spent in conservative treatment but
eight months later there was no fundamental improvement (Figs. 24 and 25), and even in full plantar-
ftexion the navicular bone lay on the dorsum of the head of the talus between it and the ossified
cuneiform bone. Operation was performed; the resuit over five years later îs shown in Figures 26 to 28.
The alignment antero-posteriorly is not as good as in Case 3, because there is some varus which is
also evident clinically (Fig. 29). The part of the navicular bone that remains is larger than in Case 3
and seems to be the factor preserving the varus. Were the remains of the navicular bone smaller, or
absent, a better alignment of the bones în the medial pillar would occur, and the varus or overcorrection
would disappear. The child bas had no treatment since the operation and the subsequent eight weeks
plaster immobilisation, apart from a half-inch outside fiare to the heel of his shoe during the Iast year.
He is now a very active schoolboy nearly seven years of age.

DISCUSSION
Three of these children (Cases 2 to 4) were submitted to operation at the ages o f nine,
eleven and nine months, were retained in plaster for periods o f three to eight weeks only and
received no other treatment whatsoever. They were followed up for periods o f ten, six and
five years. The other, Case 1, is recent and was the only bilateral condition. The essential
feature of the operation is the removal o f a wedge-often almost h a l f - o f the navicular bone,
which is then placed beneath the head o f the talus to help keep it elevated. The late results
show that the remainder o f the navicular bone plays little part in the medial pillar o f the foot
in the better aligned cases and supports the contention that, in the more severely deformed feet,
it could be completely removed, but with a part ofit used to elevate the talus; this wedge must
fit neatly between the forepart o f the calcaneus and the head o f the talus and is held in position
by reefing the spring ligament.
There is much to be said for the contention that an important factor in the difficulty o f
reducing and retaining reduction in the club foot results from the bony constituents o f the
medial pillar of the foot being too long to lie comfortably in the available interval; the resuit
is that, after effective treatment, the dislocation at the talo-navicular joint will often recur to
relax the medial pillar of the foot, between the talus and the big toe. This idea bas been
championed by Batchelor (1945) who advocated, for children o f four to six years of age, an
operation to shorten the bony pillar by removing a section from the neck of the talus. I have
found this operation very satisfactory. The corrected club foot can, on the other hand,
accommodate by reversing the mid-foot displacement, as shown in Figure 9, producing a
deformity very similar to a congenital vertical talus.
In the congenital vertical talus there is a similar difficulty in that the bony constituents
o f the inner pillar are relatively too long. This is supported by the success of the operation
described in this paper, in which the depth o f the navicular is much reduced; on occasions
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 CONGENITAL VERTICAL TALUS 627
the bone has been almost completely removed (Figs. 20 to 22). Recurrence of the vertical
talus deformity has not occurred so far but there has been a tendency to reversal in two
children (Cases 2 and 4) who have developed slight varus both clinically and radiologically.

SUMMARY
l. Four cases of true congenital vertical talus are described; in three of the four cases there
were other major deformities of the skeleton. Ali were treated by open operation; the operation
sacrificed part of the substance of the navicular bone, which was placed between the forepart
of the calcaneus and the head of the talus.
2. The results five to ten years after operation show that stable reduction was maintained
without any further treatment. They suggest, however, that more of the navicular bone could
have been removed or that the whole navicular might be excised, at least in the more severe
deformities.
3. Congenital vertical talus resembles club foot (equino-cavo-varus) in that difficulty in
reduction and in maintenance of the reduction results from the tension in the medial pillar
of the foot. Easing of the tension can resuit in recurrence of the dislocation or, alternatively,
a reversal of the deformity.

My thanks are due to Dr T. Jaykumar for the drawings.

REFERENCES
BATCHELOR, J. S. (1945): The Treatment of the Uncorrected Clubfoot in Childhood. Proceedings of the Roya/
Society of Medicine, 39, 713.
LLOYD-ROBERTS, G. C., and SPENCE, A. J. (1958): Congenital Vertical Talus. Journal of Bone and Joint Surgery,
40-B, 33.
0sMOND-CLARKE, H. (1956): Congenital Vertical Talus. Journal of Bone and Joint Surgery, 33--B, 334.
SroNE, H. K., and LLOYD-ROBERTS, G. C. (1963): Congenital Vertical Talus. Proceedings of the Roya/ Society
of Medicine, 56, 12.
WAINWRIGHT, D. (1963): The Recognition and Cure of Congenital Fiat Foot. Journal of Bone and Joint Surgery,
45-B, 210.

VOL. 49 B, NO. 4, NOVEMBER 1967