Damascus Hospital

Dr.MOHAMMAD BASHAR AL BOSHI

CONGENITAL TALIPES
)EQUINOVARUS(CLUBFOOT

:
hindfoot .


.

+ Adduction


,
.

.


T
.
N
Cu

Ca

 :
.
. 1-2 in 1000 live births
. 2/1
1/3 .
.

Etiology
Idiopathic .
:
:
.
: ,
.
:
.

 :

8 6
+
+ +
Talus

14 12


.

 :
.
.
: Talus

.
: , .


:Talus
. Mortise
/ 45 /
/ 25 /

.
- .
: subtalar
T
.

 :Calcaneus





.
Ca

 .Navicular:
Talus


Cuboid .

.
N
.
C

T
N

Ca
Cu

 :
.


.
.

 :
:
.
+ . . - . - Y Spring . - ( ) .

 :
% 85
.

:
.1 .2 .3 ( )

:

,
CREASE
6
.

 :
,
,
/ 40 /
/25/
Heel ,
Crease
.

 :
,
/ 50 / /20 /,
Heel ,



.


: Metatarsus varus
Hind-midfoot
forefoot .

Calcaneo varus :

. Nonidiopathic

 Non idiopathic idiopathic

: .

Diagnosis


.


.

 :


(
)


,
.

X- ray
: ,
.
:
.

 A-P
:
.
. .
. .
. 20 =A
40 .
15 -5= B .
:
:
.
20 < A .
( ) B

.


:
40 20 /
/ .
40 10 /
/ .
:
.
.

Abnormal




. Talocalcaneal index
/ 40 / .

Treatment
:
.
.

.

Conservative Treatment

:
.1
.2 ()
.3
(
).

6 .

/ 20 /

TALUS AS THE FULCRUM

TALUS FIXED,
NAVICULAR REDUCES

1ST
CAST

Residual Equinus

Percutaneous Tenotomy
( LA )

A, Tendo calcaneus lengthening. B, Clinical appearance after

lengthening in right foot.

Ankle Dorsiflexion

Final Cast 4 Weeks

W1

W3

W5

T
T

T
T
N

W1

W3

Cu
Cu

Ca

Ca

W5

Cu

Ca

W1

W3

W 5 post tenotomy

T
N

Week 1

T
Ca

Week 5

T
Ca

Surgical treatment
6
3
:
.1

.2
.3
4 /12 /





.
( turco :
.carroll;Cincinnati
:

), ,

Turco procedure: for posteromedial clubfoot release. A, Medial incision. B, Exposure and lengthening of posterior tibial, flexor
digitorum longus, and flexor hallucis longus tendons. Inset, Mobilization of neurovascular bundle
. C, Z-plasty lengthening of tendo calcaneus. D, Incision of posterior capsule of ankle joint. E, Release of
talonavicular joint and spring ligament, medial subtalar ligaments, and interosseous ligament.

TENDO
ACHILLES

TIB POST

FDL
POST TIB VS
& NERVE
FHL

Carroll two-incision technique. Carroll two-incision technique. A, Medial

incision; center of heel, front of medial malleolus, and base of first ray form a triangle.
Incision (dotted line) parallels base of triangle but curves plantarward proximally and
anteriorly distally. B, Posterolateral incision runs obliquely from midline of distal calf
posteriorly to point midway between tendo calcaneus and lateral malleolus. C and D,
Right clubfoot preoperatively. E and F, After surgical correction.

V-Y advancement flap for closure of Cincinnati incision. A, Typical incision. B, Wound gapping after full correction of 32clubfoot; potential flaps are outlined. C, Completed V-Y advancement flaps with foot in full correction
.



subtalar

 : Turco .
.

.
.
: Cincinnati

.
.

Complications
:
:

:

.
:

:

 :


: 3
.
+
Dorsal subluxation of the Navicular
Valgus overcorrection
Dorsal Bunion

Revision / secondary procedures

:
.
( >== )nonidiopathic
...........

.

physical examination:
assessment of the forefoot and hindfoot.
dynamic (a flexible forefoot) or rigid.
The amount of inversion and eversion of the calcaneus.
dorsiflexion and plantar flexion of the ankle.
surgical scarring about the foot or loss of motion should be noted.
Standing anteroposterior and lateral roentgenograms;
if the clubfoot deformity is unilateral, the opposite foot can be
used as a control for measurements.
All possible etiologies( neuropathy, abnormal growth of the
bones, or muscle imbalance).

Loss of correction
( ) ----
---------
.
+ (
) ====> + .

Dorsal subluxation of the

Navicular:
shortened Cavovarus foot (Turco procedure).

.
.
.
< 6 yrs :
midfoot release (calcaneocuboid,cubonavicular,lateral\ dorsal\medial
talonavicular ligaments)+planter release -\+ tibial anterior
lengthening+ fixation talonaviculocuneiform.
> 6 yrs:
more extensive surgery ( medial column lengthning, lateral column
shortening).

Valgus overcorrection
Excessive hindfoot valgus + forefoot abduction+
pronation
pain.
/
. +
)interosseous ligament) subtalar
.
medial column shortening
:
lateral column lengthning+
-\+ Triple arthrodesis(mid-hindfoot no corrected)and
medial translation of the calcaneus

Dorsal Bunion
Postoperative clubfoot +Weak triceps overact flexors
halluces.
.
:
.
( )


( )
:MCKAY +
===>

A, Dorsal bunion in 9-year-old boy after clubfoot release at 9 months of age. B, Lateral view of dorsal bunion at
metatarsophalangeal joint of left great toe. C, Postoperative appearance of left foot after plantar closing wedge
osteotomy of first metatarsal with transfer of flexor hallucis longus to first metatarsal neck.

 +
8-5



4-3

.

tendons transferring





=> ,
.


4 .

Anterior tibial tendon transfer

dynamic inversion/ supination of
(midfoot midfoot
).
plantigrade
.
.
===> .
===> (.

).

Transfer for insufficient triceps

)surae (calcaneus gait

.
( ) .
20
.
8-6 .
: , ,
.

Bony procedure(Lateral column

)shortening
(( ()
() )) .
( EVANS procedure 8-4 )
+ (
.(Fusion
< 4 ( .)Lichtblau
: LICHTBLAU procedure
.

< 6 yrs

4-8 yrs

Older children

Severe residual clubfoot deformity in 5-year-old child on anteroposterior (A) and lateral (C)
roentgenograms. B and D, After Lichtblau procedure.

: FOWLER procedure
> 6 .
( ) (
) .
.

Calcaneal osteotomy
heel
.
: .
: DWYER procedure
+ + + .
( , ) .
(:
, ==>
.

Supramalleolar osteotomy

Toe-in gait

( )
> 2 ==> +
.
> 35 .
.

Triple arthrodesis

10 .
,

10 -8 .

Arthrodesis for persistent or untreated clubfoot. Area between broken lines represents amount of bone removed from
midtarsal region and subtalar joint in moderate fixed deformity. In severe deformity, wedge may include large part of
talus and calcaneus and even part of cuneiforms.

Talectomy
should be reserved for severe, untreated clubfoot,
for previously treated clubfoot that is uncorrectable
by any other surgical procedures, and
for neuromuscular clubfoot.
The Steinmann pins are removed at 6 weeks. and a
below-the-knee, weight-bearing cast is applied(12
more weeks).

Talectomy. A, Anterolateral skin incision. B, Total talectomy

Correction using
the ilizarov technique
.
( 9-5) ==> .
.
+ ==> .

MoKazem.com

. . ,
.
This lecture is one of a series of lectures were prepared and
presented by residents in the department of orthopedics in
Damascus hospital, under the supervision of Dr. Bashar Mirali.
This site is not responsible of any mistake may exist in this
lecture.
Dr. Muayad Kadhim