Children born with a foot deformity that causes them to have a rigid flatfoot once faced extensive surgery to fully correct the problem. A treatment developed by a pediatric orthopaedic surgeon at Washington University School of Medicine in St. Louis has shown early success in correcting congenital vertical talus with minimal surgery in most cases.
Congenital vertical talus (CVT), or "rocker-bottom flat foot," occurs in about 1 in 10,000 live births. Left untreated, the patient would walk on the inside of the ankle rather than the bottom of the foot, resulting in pain and disability. CVT afflicts both healthy children and those with genetic birth defects and neuromuscular disorders.
Matthew B. Dobbs, M.D., who performs surgeries at St. Louis Children's Hospital, developed a treatment for CVT that involves gently manipulating the foot and applying long leg casts weekly for four to six weeks to gradually correct the deformity. After the casting period, Dobbs and his colleagues take an X-ray to determine the success of the correction.
"Much of the correction is achieved with casting alone," says Dobbs, associate professor of orthopaedic surgery at the School of Medicine. "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."
In the minor surgical procedure, Dobbs inserts a small pin into a joint in the foot where it meets the ankle to hold the correct position for about two months. After the casting treatments or the surgical pinning, CVT patients wear a nighttime brace for several years to prevent recurrence.
Details about the treatment in 11 patients with CVT, or a total of 19 feet, are discussed in the March 2007 issue of The Journal of Bone and Joint Surgery.
His method has caught the attention of pediatric orthopaedic surgeons worldwide, and he is training other surgeons in the United States and internationally to use the method successfully.
The difference between Dobbs' method and casting techniques tried in the past is in the way forces are applied to the foot and the way the casts are molded, he says.
"What has previously been lacking in any cast treatments for CVT is a lack of understanding by orthopaedists as to how the joints in the foot move and work together," Dobbs says. "Now, thanks to the work of Ignacio Ponseti, we do have a better understanding of the mechanics of the foot and ankle which has made it possible to figure out how best to gradually correct the deformity in CVT."
The treatment is based on principles developed in the 1950s for clubfoot, another congenital foot deformity. Ignacio Ponseti, M.D., professor emeritus of orthopaedics and rehabilitation at the University of Iowa, pioneered a method that called for weekly casting and manipulation of the foot starting soon after birth. When done correctly, the Ponseti method has greatly reduced the need for extensive surgery, and as a result, has improved the long-term outcomes for clubfoot patients. Extensive surgical releases for clubfoot can result in feet that are painful and arthritic in adulthood, which is something that is not often seen in clubfoot patients treated successfully with the Ponseti method.
"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 says.
Dobbs M, Purcell D, Nunley R, Morcuende J. Early Results of a New Method of Treatment for Idiopathic Congenital Vertical Talus. The Journal of Bone and Joint Surgery March 2007, Vol. 89-A, Supplement 2, Part 1, pp. 111-121.
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