Pathology and

Non-surgical Treatment of
Congenital Clubfoot
Dr. Irfan Ali Shujah
B.Victoria Hospital
Bwpr, Pak
OVERVIEW
Definition
Epedemiology
Types of Clubfoot
Etiology
Components
Pathology
Diagnosis
Classification
Non-Surgical Treatment
Management of Recurrence
Normal Foot
Complex organ that is required to be:


Stable
Resilient
Mobile
Cosmetic

Club Foot
( Congenital Talipes EquinoVarus )
A condition in which one or both
feet are twisted into an abnormal
position at birth.
Definitions
Talipes :
Talus = Ankle
Pes = Foot

Equinus : Horse
Foot that is in a position of
planter flexion at the ankle,
Looks like that of the Horses foot
Planus : Flat Foot

Cavus : Highly Arched Foot

Varus : Heel going towards midline

Valgus : Heel going away from midline

Adduction : Forefoot going towards midline

Abduction : Forefoot going away from midline

Epidemiology
Incidence 1 : 1,000 live births

Sporadic

Bilateral in 50%

Males 65%

Types of Clubfoot
Flexible (Postural)



Rigid (Structural)
Etiology
Primary Germ Plasm defect in Talus

Primary Soft tissue abnormalities

Arrested fetal development

Abnormal Intra-uterine forces
( Oligohydramnios, Amniotic Band Syndrome )
Components of ClubFoot
Cavus

Adduction

Varus

Equinus
Pathology
Osseous Changes


Soft Tissue Anomalies/Changes
Osseous Changes
TALUS
- Diminished in size
- Medial & Plantarward deviation of
the head, neck and articular facet
- Neck internally rotated, Body ext. rotated
CALCANEUS
- Hypoplastic, Inverted under the Talus
- Post. End Upward and Laterally
- Ant. End Downward and Medially
- Tuberosity towards Lat. Mal. posteriorly
NAVICULAR
- Severe Medial Positioning
- Articulates with Tibia

CUBOID
- Displaced medially on Calcaneus

FOREFOOT
- Metatarsals and Phalanges Adducted
Soft Tissue Changes
TENDONS
- Tibialis Post, Flexor Hallucis Longus &
Flexor Digitorum Longus contracted
- Abductor Hallucis contracted
- Histologically normal
LIGAMENTS
- Deltoid, TMT & Spring Ligaments contracted
- Long and Short planter ligaments
- Histologically normal

OTHERS
- Blood vessels, nerves and skin
adaptively shortened along the
medial and plantar aspects

- Calf circumference, girth and
overall foot size diminished



Diagnosis
PHYSICAL EXAMINATION

Short Achilles Tendon
High and Small heel
No creases behind Heel
Abnormal crease in middle of
the foot
Foot is smaller in unilateral
cases
Callosities at abnormal
pressure areas
Calf muscles wasting

Radiologic Evaluation
Antero-Posterior view


Stress Dorsiflexion Lateral view
Talo-Calcaneal Angle (AP)

(Normal 30-55)



Talo-Calcaneal Angle (LAT.)

(Normal 25-50)

Talus-1
st
Metatarsal Angle

Radiographic measurement of forefoot
adduction

Useful in Rx. of Metatarsus Adductus &
Clubfoot

Normal 5-15

Negative in Clubfoot
Classification
Piranis Classification



Dimeglio et al. Classification
Pirani Classification of Clubfoot


Pirani system composed of 10 different Physical
Examination Findings

0 for No Abnormality
0.5 for Moderate Abnormality
1 for Severe Abnormality



Dimeglio et. al Classification

In Dimeglio et. al system, 4 parameters are
assessed on the basis of their Reducibility with
gentle manipulation measured with goniometer.







Equinus Deviation Adduction Deviation
Treatment
Each day the foot remains deformed
is a day of golden opportunity lost forever.

- Lenoir



NON-SURGICAL / CONSERVATIVE

SURGICAL

Non-Surgical Treatment
Manipulation and Casting

Splints to Maintain Correction
- Ankle-Foot Arthrosis (AFO)
- Denis Brown Splint
Ponseti Casting
Abundant young wavy collagen - easily
stretched
Navicular, Cuboid & Calcaneus can be
abducted back under Talus without surgery
Most widely accepted technique
Success rate >90% of children 2yrs & younger
Recurrence rate 10-30%
Ideally is used in New borns
Success rates are lower in Older children

Treatment Phase of Ponseti Casting
o Should begin ASAP .. Within 1
st
week of life
o Gentle manipulation and casting weekly

Order of Correction
1. Correction of forefoot Cavus & Adduction
2. Correction of Heel Varus
3. Correction of hindfoot Equinus

Generally 5-6 casts are required

First apply short leg cast
below knee
Then extend above knee
when plaster sets.

Long Leg Casts are essential

1
st
cast removed after 1 week

1 minute of gentle
manipulation and re-casting
focusing on Abducting the
foot around head of Talus
maintaining Supinated
position
Never pronate

Never manipulate the heel directly

Casting in gradual abduction for 2-3
weeks

Percutaneous Tendo-Achilles
Tenotomy under local anesthesia,
followed by final cast

Final Cast is applied in maximally
Abducted position (70 degrees) and
Dorsiflexion in 15 degrees for 3 weeks
Percutaneous TA Tenotomy

Series of Castings

Maintenace Phase of Ponsati Casting
Final Cast is removed after 3 weeks
AFO
Abduction 70 degrees
Dorsiflexion 15 degrees
Distance btw the shoes is 1 inch wider than
the width of infants shoulders
Brace is worn 23hrs/day (3 months)
then while sleeping (2-3 years)
Brace compliance is very important
Management of Recurrence
Infrequent if Bracing protocol is followed closely

Repeated manipulation and casting

1
st
cast with dorsiflexion of 1
st
ray if Cavus

Subsequent castings with Abduction and
ultimately ankle dorsiflexion

Achilles Tendon Lengthening and Ant. Tibial
Tendon transfer may be required
Summary
4 Components of Clubfoot deformity CAVE
Bony and Soft tissue adaptive Changes
Pirani and Dimeglio Classification systems
Non-Surgical treatment should start ideally
within 1
st
week
Ponsati Casting is worldwide accepted
technique
Brace wear Compliance is important
Recurrence is treated with Re-manipulation
and casting