ATYPICAL CLUBFOOT

MANAGEMENT.

A UNIT SEMINAR PAEDITRIC

PRESENTATION.

PRESENTER: OKOLI, CHUKWUEMEKA C.

 WHAT IS CLUBFOOT

• Also known as Talipes

EquinoVarus is a common foot
abnormality in which the foot
points downward and
inwards, caused by
shorthening of achilles
tendon.
 INTRODUCTION

Ponseti et al, reported for the

first time in 2006 , on what they
termed ‘complex ‘ clubfoot.
One that the forefoot was :
•in severe equinus
• in supination
• shortenened
• stubby in appearance ,
The forefoot is midly
adducted but in significant
equinus relative to the
midfoot,
 Big toe held in
Hammertoe position.
• appears shorter,
• characteristic dorsal
crease at the base of the
toe.
A
 Turco-1994– 1 st
to
describe this deformity as
ATYPICAL IDIOPATHIC
CLUBFOOT.
Atypical Clubfoot
•subtype of CF
•Created over time
•By specific factors
•Its rx require changes
Relevant Anatomy.
•Bones
•Joints
•Ligaments
•Muscles
•Tendons
•Nerves
( https://orthopaedia.com/page/Anatomy-of-the-Foot-Ankle, 2022 )
The Regions of the Foot.
THE FOOT
•2
•5
•5,14,2
HINDFOOT
•Begins-Ankle jnt and
• stops-Transverse Tarsal jnt (a
combination of Talonavicular &
calcaneal-cuboid jnts)
•Talus +calcaneus=bones of HF

( https://orthopaedia.com/page/Anatomy-of-the-Foot-Ankle, 2022 )
MIDFOOT.
•Begins-TTJ, endsTMTJ
•Its jts have limited mobility
•Consists of 5 bones

( https://orthopaedia.com/page/Anatomy-of-the-Foot-Ankle, 2022 )
FOREFOOT.

•Composed 21 bones from 3

group of bones ie
metatarsals, phalanges, and
sesmoids
( https://orthopaedia.com/page/Anatomy-of-the-Foot-Ankle, 2022 )
COLUMNS OF THE FOOT.

The foot has 2 columns:

•Medial column
•Lateral column

( https://orthopaedia.com/page/Anatomy-of-the-Foot-Ankle, 2022 )
COLUMNS OF THE FOOT.
Medial column:
•Is more mobile
•Consists of talus, navicular,
medial cuneiform, 1 st

metartasal & great toe.

( https://orthopaedia.com/page/Anatomy-of-the-Foot-Ankle, 2022 )
COLUMNS OF THE FOOT.
Lateral column:
•Is stiffer
• Includes Calcaneus , Cuboid
,and the 4 th
and 5 th

Metatarsals.
( https://orthopaedia.com/page/Anatomy-of-the-Foot-Ankle, 2022 )
COLUMNS OF THE FOOT.
Bones & Joints of the Foot.
•28 bones
• 2 types of joint ( based on
level of mobility)

( https://orthopaedia.com/page/Anatomy-of-the-Foot-Ankle, 2022 )
Bones & Joints of the Foot.
3 types of joint ( based on
level of mobility) ie
•Essential joints (mobile jnts)
•Moderately mobile joints
•Non-essential joints
( minimal movement)
( https://orthopaedia.com/page/Anatomy-of-the-Foot-Ankle, 2022 )
Bones & Joints of the Foot.
Essential joints
•Ankle joint(tibiotalar jnt)

( https://orthopaedia.com/page/Anatomy-of-the-Foot-Ankle, 2022 )
Bones & Joints of the Foot.
Essential joints
•Ankle joint(tibiotalar jnt)
•Subtalar joint

( https://orthopaedia.com/page/Anatomy-of-the-Foot-Ankle, 2022 )
Bones & Joints of the Foot.
Essential joints
•Ankle joint(tibiotalar jnt)
•Subtalar joint
•Talonavicular joint

( https://orthopaedia.com/page/Anatomy-of-the-Foot-Ankle, 2022 )
Bones & Joints of the Foot.
Essential joints
•Ankle joint(tibiotalar jnt)
•Subtalar joint
•Talonavicular joint
•Metatarsophalangeal joints
( https://orthopaedia.com/page/Anatomy-of-the-Foot-Ankle, 2022 )
Bones & Joints of the Foot.
Essential joints
•Ankle joint(tibiotalar jnt)
•Subtalar joint
•Talonavicular joint
•Metatarsophalangeal joints
( https://orthopaedia.com/page/Anatomy-of-the-Foot-Ankle, 2022 )
Bones & Joints of the Foot.
Moderately mobile joints
•Calcaneal-Cuboid joint
•Cuboid-Metatarsal joint for
the 4 & 5 metatarsal.
th th

•Proximal Interphalangeal jt
•Distal interphalangeal joint
( https://orthopaedia.com/page/Anatomy-of-the-Foot-Ankle, 2022 )
Non-essential joints.
•Navicular-cuneiform joints
•Intercuneiform joints
•Tarsometatarsals joint
(“Lisfranc” jt a.k.a Midfoot
jt.
( https://orthopaedia.com/page/Anatomy-of-the-Foot-Ankle, 2022 )
 PREVALENCE: Atypical
clubfoot is rather a rare
condition – it affects less
than 5% of children, which
is a small percentage among
other types of feet.

(ignatio Ponceti foundation, 2022)

 ETIOLOGY:
•Not fully understood
•Idiopathic atypical clubfoot
•Acquired atypical clubfoot
(iatrogenic)

(https://www.physio-pedia.com/Atypical_Clubfoot, 2022)
 Acquired atypical clubfoot
(iatrogenic)
•Poor treatment (cast slips)
•Usually btw 2nd & 4th casting
•Foot pushed into
1. Equinus
2. Plantaris
3. Midfoot flexes midway
4. Can cause swelling
&irritation
EQUINUS
Cast slipping:
• Heavy padding
• Poor moulding
(feet/heel)
• Not enough knee flexion
• Below knee casts

( Africal Clubfoot Training Project Manual, 2017)

Clinical Features:
• Rigid equinus
• Severe plantar flexion of all
metatarsals
• Deep posterior crease (heel)
• Transverse crease (sole of
foot)
( ponseti, 2006)
Clinical Features contd:
• Short hyperextended first
toe
• Resistant to correction and
standard manipulation and
casting

( ignatio ponseti foundation, 2022)

Clinical Features contd:
• Adduction is moderate
• Plantar fascia is
shortened
• All metatarsals flexed
• Transverse crease

( ignatio ponseti foundation, 2022)

Management/Treatment:
• The modified Ponseti
method is an effective
first line treatment for
atypical clubfoot
(matar,2017)
 Modified Ponseti Method :
• The subtalar joint and
head of the talus must be
precisely identified,
which may be difficult
due to the prominent
anterior process of the
calcaneus.
 Modified Ponseti Method :
• Once identified, place the
thumb over the talar
head and index finger on
the posterior aspect of
the lateral malleolus and
then gently abduct the
foot with the other hand.
Modified Ponseti Method :
Caution 1:
Care should be
taken not to over
abduct the forefoot
Modified Ponseti Method :
• Once the forefoot
abduction is corrected, the
plantarflexion of all
metatarsals is addressed by
grasping the ankle with both
hands and dorsiflexing the
foot with both thumbs while
an assistant supports the
knee in flexion
Modified Ponseti Method :
• The knee should be
casted in at least 110
degrees of flexion to
prevent cast
slippage
Modified Ponseti Method :
Tenotomy:
Percutaneous Achilles
tenotomy is performed
after
• Plantarflexion of the
metatarsals has been
corrected.
 Modified Ponseti Method :
Tenotomy contd:
• Head of talus is covered
• Heel is neutral

(advanced non-surgical clubfoot treatment provider course)

Modified Ponseti Method :
Tenotomy contd:
The site chosen is 1.5cm above
the posterior skin crease as
opposed to the traditional 1cm
to avoid injury to the
proximally positioned
posterior tuberosity of the
calcaneus.
Modified Ponseti Method :
Tenotomy contd:
A second Achilles tenotomy
may be required for some
patients with serial casting
following until five degrees
of dorsiflexion and no more
than 40 degrees of
abduction are obtained.
Modified Ponseti Method :
Bracing:
•At this point abduction
bracing is initiated with a
soft 3-strap sandal attached
to the bar at 40 degrees of
external rotation
(Ponseti, 2006).
BRACING
 Complications:
• Atypical clubfeet do not
correct with the standard
Ponseti method.
• Frequent cast slipping
may cause foot edema,
bruising, and skin
breakdown.
Complications contd:
Ponseti reported a
22% complication rate
with his modified
method including:
Complications contd:
• Erythema,
• Swelling of the forefoot and
toes,
• Mild rocker-bottom deformity,
• Midfoot hyperabduction, and
• Repeated downward cast
slippage.
 Complications contd:
• Relapse rate at 2 years
was 14%, and most
frequently attributed to
difficulty with ill-fitting
shoes during abduction
bracing (Ponseti, 2006).
 Complications contd:
• Using the modified
Ponseti method, Matar
found 53% relapse at 7
years average follow up
(range 3-11 years).

(POSNA,2022)
The Atypical Clubfoot:
Foot AbductionBrace (FAB)

• 30-40 abduction
• Increased abduction and dorsiflexion
of brace as foot range increase
• Watch for recurrence of lateral crease
in FAB.

(advanced non-surgical clubfoot treatment provider course)

 REFERENCES:
1. Ponseti , Zhivkov, M , Davis, N , . Treatment of the complex idiopathic
clubfoot. Clin Orthop Relat Res 2006; 451: 171– 176.
2. Turco, VJ . Recognition and management of the atypical idiopathic clubfoot.
In: Simons, GW , ed. The clubfoot: the present and a view of the
future. New York, NY: Springer-Verlag, 1994: 76– 77.
3. Africa Clubfoot Training Project. Chapter 12 Africa Clubfoot Training Basic
& Advanced Clubfoot Treatment Provider Courses - Participant Manual.
University of Oxford: Africa Clubfoot Training Project, 2017.
4. https://ponseti.pl/atypical-and-complex-clubfoot/?lang=en (Ignacio
Ponsenti Foundation)
5. Sangiorgio S, Ebramzadeh E, Morgan R, Zionts L. The timing and relevance
of relapsed deformity in patients with idiopathic clubfoot. J Am Acad
Orthop Surg. 2017; 25: 536-545.
6. Matar HE, Beirne P, Bruce CE, Garg NK. Treatment of complex idiopathic
clubfoot using the modified Ponseti method: up to 11 years follow-up. JPO
B 2017 26:137-142.
7. https://posna.org/Physician-Education/Study-Guide/Atypical-Club-
Foot,2022