CLUBFOOT

(Congenital Talipes Equinovarus)

 Overview
• Clubfoot is a congenital foot deformity consisting of :
– midfoot cavus
– forefoot adduction
– hindfoot varus and equinus (ankle)
• It is more common in males.
• One-half of cases are bilateral.
• Unaffected parents with an affected child have a 2.5% to 6.5% chance of
having another child with clubfoot.
• Potential etiologies include
– abnormal fibrosis, neurologic abnormalities, and arrested embryologic
development.
 Pathoanatomy
• The four basic deformities are :
– Cavus ( tight intrinsic, FHL, FDL)
– Adductus (tight tibialis posterior)
– Varus (tight tendoachiles, tibialis posterior, and tibialis anterior)
– Equinus (tight tibialis anterior)
• The forefoot deformity results from medial and plantar subluxation of the
navicular bone on the talar head.
• The hindfoot is adducted and inverted under the talus.
• The entire foot appears supinated; however, the forefoot is pronated
relative to the hindfoot, leading to the cavus deformity.
• The muscles and tendons of the gastrocnemiussoleus complex, the
posterior tibialis, and the long toe flexors are shortened.
 Evaluation
• Common clinical findings are :
– A small foot
– A small calf
– A slightly shortened tibia
– Skin creases medially and posteriorly.
• Clubfeet associated with arthrogryposis,
myelomeningocele, diastrophic dysplasia, and amniotic
band syndrome are more challenging to treat and more
prone to relapse.
 Evaluation
• Radiographs are of limited use.
• On both the AP and lateral views of a
clubfoot, the talus and calcaneus are
less divergent and more parallel
(smaller talocalcaneal angle) than
normal.
• Recommended views dorsiflexion
lateral (Turco view)
– shows hindfoot parallelism between
the talus and calcaneus
– will see talocalcaneal angle < 35° and
flat talar head (normal is talocalcaneal
angle >35°)
• AP
– talocalcaneal (Kite) angle is < 20°
(normal is 20-40°)
– talus-first metatarsal angle is negative
(normal is 0-20°)
– also shows hindfoot parallelism
Evaluation
• The Dimeglio-Bensahel and
Catterall-Pirani classification
systems are based on the
severity of the clinical findings
and the correctability of the
deformity.
• Catterall / Pirani
Evaluation
• Di-meglio Bensahel
 Treatment
Ponseti method
• The outcome is much better
than with historic casting
techniques (80% to 90% success
rate versus 10% to 50%).
• The sequence of deformity
correction is
– cavus, adductus, varus, and
equinus.
• Long leg casts are changed
weekly.
Ponseti Method
• The initial cast places the forefoot in supination to correct
forefoot cavus  aligning the plantar-flexed 1st MT with the
remaining metatarsals
• Counter pressure is applied to the lateral aspect of the talar
head only (as fulcrum), not the calcaneus  forefoot in
abduction to correct adduction and heel varus
• Percutaneous Achilles tenotomy is frequently required before
final cast application to treat residual equinus (up to 90% of
feet). Perform when foot is 70° abducted and heel is in valgus
 cast in maximal dorsiflexion
Ponseti Method
• Foot abduction orthoses (FAO), such as the Denis-
Brown splint, are used to prevent recurrence.
• external rotation position (70° in clubfoot and 40° in
normal foot)
• The recommended use is
– 23 hours per day for 3 months after casting
– and then during naps and overnight for 2 to 3 years.
• Recurrences are typically managed with repeat
manipulation and casting followed by resumption of
bracing.
• Tibialis anterior tendon transfer may be required
(20%) in patients with dynamic swing phase supination
(patient demonstrates supination of the foot during
dorsiflexion)
 Treatment
French Method
• Daily manipulations are required for
clubfeet in newborns, typically performed
and directed by a physical therapist.
• The feet are taped, not casted, in position
following manipulations.
• Continuous passive motion devices are used
in the first 12 weeks of treatment.
• Therapy sessions are continued until the
child is walking or the deformity is stable.
 Surgical Management
• Surgery is reserved for feet that are refractory to
manipulations/casting, syndrome-associated clubfoot, and
delayed presentation (children older than 1 to 2 years).
• The surgical plan should be individualized for each patient.
Releases of the posteromedial structures are performed as
needed (the “a la carte” approach).
• Residual deformities may require surgical intervention (Table 1).
 Surgical Management
• Posteromedial soft tissue release and tendon lengthening
– indications
• resistant feet in young children
• "rocker bottom" feet that develop as a result of serial casting
• syndrome-associated clubfoot
• delayed presentation >1-2 years of age
• performed at 9-10 months of age so the child can be ambulatory at one year of age
– outcomes
• requires postoperative casting for optimal results
• extent of soft-tissue release correlates inversely with long-term function of the foot and patient
• Medial column lengthening or lateral column-shortening osteotomy, or cuboid
decancellation
– indications
• older children from 3 to 10 years
 Surgical Management
• Triple arthrodesis
– indications
• in refractory clubfoot at 8-10 years of age
• contraindicated in insensate feet due to rigidity and resultant ulceration
• Talectomy
– indications
• salvage procedure in older children (8-10 yrs) with an insensate foot
• Multiplanar supramalleolar osteotomy
– indications
• salvage procedure in older children with complex, rigid, multiplanar clubfoot deformities that have
failed conventional operative management
• Gradual correction by means of ring fixator (Taylor Spatial Frame) application
– complex deformity resistant to standard methods of treatment
TERIMA KASIH