There are no studies looking at the natural history of untreated CVT but some authors have discussed the consequences of untreated or conservatively treated but uncorrected CVT. It has been claimed that if left untreated the child with CVT will have a painful and rigid flatfoot with weak push-off power and a rocker bottom deformity [8, 12, 13]. They have difficulty with footwear and have painful callosities due to limited weight bearing area [14, 15]. It is likely that such a deformity would result in significant functional deficit. Natural history of untreated CVT is also confounded by the fact that approximately 50 % of the patients will have major musculoskeletal or neurologic abnormality that may also significantly affect their walking ability. Published papers do not discuss the natural history of isolated CVT separately from the teratologic type. Authors appear to agree that untreated CVT does not affect walking and assert that in some patients the deformity may not be noted until patients start walking [15, 16].

A number of treatments have been attempted for correction of CVT and treatment has evolved over the years taking into account the complications and results thereof. The goal of treatment in CVT has been to restore the anatomical relationship of the hindfoot bones and to recreate a plantigrade foot to allow pain-free weight bearing. Initial reports attested to failure of conservative treatment with manipulation followed by serial casting, boots and bars, shoe wedges, corrective night splint etc. [16] As a result surgical reduction with extensive soft tissue release became the treatment of choice. A number of reports were published attesting to the results of surgery. The cornerstone of surgery was to perform soft tissue release to restore hindfoot relationship to normal. A number of techniques were then used to keep the hindfoot joints reduced. This included re-routing of the tibialis anterior, transposition of the peroneus brevis, k wire fixation, partial or complete naviculectomy [19]. Subsequently a two stage procedure became popular. The forefoot and midfoot was initially reduced to the fixed plantar-flexed hindfoot by reducing the TNJ and maintaining the reduction with k wire through the TNJ. Six weeks later a second procedure was performed to release the tendoachilles and the posterior ankle and the sub-talar joints [20]. Coleman et al. [3] advocated that the dorsal extensors should be lengthened as part of the first procedure and the tibialis posterior tendon should be advanced to the plantar surface of the navicular as part of the second procedure. Later Ogata and Shoenecker [21] recommended a single stage correction in view of their observed complications of two stage surgery. Seimon [22] published a small series with good results from single stage surgery. Single stage correction became the standard performed procedure. However, there was considerable variation in practice among the proponents of single stage release. In addition to TNJ capsulotomy and tendoachilles lengthening surgeons variably performed dorsal extensor lengthening, peroneal lengthening, tibialis anterior tendon transfer to the neck of talus, or more extensive postero-medial and/or lateral release with or without additional bony surgery. Single stage release is the standard surgical procedure at present and results are still being published. The proponents of single stage correction can be divided into two camps: those who perform peri-talar release and those who perform mid-tarsal release. Surgery can be performed either through a Cincinnati incision or a modification thereof, multiple separate incisions or a dorsal incision. Mazzocca et al. [18] and Saini et al. [12] have claimed better results for single stage correction using the dorsal approach instead of the traditional Cincinnati approach. However, while Mazzocca essentially performed mid-tarsal release Saini appears to have performed peri-talar release with the addition of a posterior incision to approach the ankle and the sub-talar joint. Stricker-Rosen [23] and Seimon [22] also had good results using a longitudinal dorsal incision although they only performed TNJ release and Stricker-Rosen only had teratogenic CVT in their series. It appears from the limited evidence that dorsal approach might give better outcome than the Cincinnati approach especially for mid-tarsal or isolated TNJ release. Results of single stage surgical correction are presented in Table 17.3.