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New casting technique with minimal surgical releases effective for congenital vertical talus
The treatment approach follows the similar principles to the Ponseti method for clubfoot correction, but applies forces in the opposite direction.
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A treatment approach that involves serial manipulation and cast immobilization, combined with minimal surgery, can effectively manage infants with idiopathic congenital vertical talus, according to a study by surgeons in Missouri.
"Much of the correction is achieved with casting alone," Matthew B. Dobbs, MD, a pediatric orthopedic surgeon at Washington University School of Medicine, St. Louis, and lead author of the study, said in a press release from the university.
"In the cases where we are not able to reach full correction with casting, we reach the rest of the correction with a minimally invasive surgery. This type of surgery is very small compared to the extensive release surgery that has been done in the past," he said.
Dobbs and colleagues at university reviewed outcomes for 19 feet of 11 children treated for congenital vertical talus (CVT) with the new approach and who had at least 2 years follow-up. They reported their experience in a supplement to the American edition of the Journal of Bone and Joint Surgery.
The treatment approach involves repeatedly manipulating the foot and applying long leg casts weekly for 4 to 6 weeks to gradually correct the deformity. "The principles of manipulation and application of the plaster casts were similar to those used by Ponseti to correct a clubfoot deformity, but the forces were applied in the opposite direction," the study authors wrote.
After the casting period, surgeons performed limited surgery, which involved percutaneous Achilles tenotomy in all 19 feet. They also performed fractional anterior tibial tendon lengthening in two feet, fractional peroneal brevis tendon lengthening in one foot, and percutaneous pin fixation of the talonavicular joint in 12 feet, according to the study.
Pin fixation was maintained for about 2 months. After casting or pin removal, children wore a brace at night for several years to prevent CVT recurrence, according to the press release.
Children required an average of five casts to achieve the desired correction, and all 19 feet achieved initial correction both clinically and radiographically, the study authors reported. No children required extensive surgical releases, they noted.
"At the time of the latest follow-up, there was a significant improvement in all of the measured radiographic parameters compared with the pretreatment values, and all of the measured angles were within normal values for the patient's age," they wrote.
At final follow-up, ankle dorsiflexion averaged 25° and plantar flexion averaged 33°, according to the study.
Dorsal subluxation of the navicular recurred in three patients who did not receive pin fixation of the talonavicular joint, the authors noted.
"Our ultimate goal is that our new minimally invasive treatment for CVT will result in better long-term outcomes for patients just as the Ponseti method has done for clubfoot," Dobbs said in the release.