Pediatric Clubfoot Deformity

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Pediatric Clubfoot Deformity

• Darren Groberg PGY 1
• 03/31/10

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Congenital vs. Aquired

• Congenital
• 1/1000 births, 50 bilateral.
• Subdivided into Intrinsic (rigid). Extrinsic
  (supple)
• Unknown origin
• Many theories most common being
• Theory of primary osseous deformity

• Aquired
• Neuromuscular conditions
• Meningitis
• Poliomyelitis
• Postcerebral vascular accident
• Cerebral palsy (Little's syndrome)
• Spinal deformity or spinal tumor
• Diastematomyelia
• Posttraumatic effects
• Spinal cord trauma
• Peripheral nerve trauma
• Tendon laceration or avulsion
• Fracture malunion or nonunion
• Volkmann's contracture
• Postburn contracture

McGlamry 945, table 1
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Primary osseous deformity

• First described by Adams in 1866 as an intrinsic
  Talar deformity.
• Specifically malformation of the head and neck.
• Normal is 15-20 degrees adduction in transverse
  plane from Talar body.
• Increased to 45-65 degrees in clubfoot.
• Yields extreme medial rotation often with no
  articulation.

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Pathologic Anatomy

• Components
• Equinus
• Varus
• Adduction

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Osseous

• Talus
• Diminished in size (three-fourths of normal
  size) positioned in severe equinus
• Medial and plantarward deviation of the head,
  neck, and articular facets
• Lateral positioning and anterior positioning in
  the ankle mortise
• Calcaneus
• Diminished in size hypoplastic
• Varus, equinus, and supinatory displacement
  beneath talus
• Navicular
• Diminished in size (two-thirds of normal
  size)Severe medial positioning
• Articulates with tibia
• Remaining lesser tarsus
• Normal morphology adaptive changes corresponding
  to deformity of peritalar complex
• Forefoot
• Metatarsals and phalanges adducted and varus
  rotated First ray extremely plantarflexed in
  intrinsic deformity

McGlamry 946 table 2./Coughlan
Mann 1729-1730
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Soft Tissue

• Tendons
• Contracted triceps surae, posterior tibial,
  flexor hallucis longus, and flexor digitorum
  longus
• Anterior tibial and long extensors medially
  displaced Peroneals elongated and often
  posteriorly displaced
• Plantar intrinsics, plantar fascia, long and
  short plantar ligaments contracted
• Tendons histologically normal changes secondary
  and adaptive
• Abductor hallucis contracted, bowstrung
• Ligaments
• Posterior ankle, subtalar ligaments contracted
  Calcaneofibular and posterior talofibular,
  tibionavicular ligaments contracted
• Deltoid and calcaneonavicular (spring) ligaments
  contracted
• Tarsometatarsal ligaments medially contracted
• Ligaments histologically normal changes
  secondary and adaptive
• Other
• Blood vessels, skin and nerves adaptively
  shortened along the medial and plantar aspects
• Calf circumference and girth, as well as overall
  foot size, diminished

McGlamry 946 table 2./Coughlan Mann
1729-1730
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Radiologic assessment

• Standard radiographs should include AP and
  dorsiflexion lateral stress views.
• Important angles include
• Talocalcaneal AP (normal 30-55)
• Talocalcaneal (25-50), Tibiocalcaneal (10-40),
  lateral
• Talometatarsal (5-15) AP
• "The most common cause of recurrent clubfoot is
  unrecognized, uncorrected clubfoot."

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Treatment

• Each day the foot remains deformed is a day of
  golden opportunity lost forever
• Lenoir-

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• Conservative
• Staged manipulation and casting
• Stretching
• Cast maintains repositioned foot
• Earlier the better.

• Surgical
• Soft tissue
• Posterior release
• Posterior medial release
• Lateral circumferential release
• Osseous procedures
• Lateral column shortening (preserve growth plates
  in children)
• Medial column lengthening

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Ponseti

• Poor outcomes to aggressive surgical correction.
• Histology abundant young wavy collagen, easily
  stretched
• Navicular, cuboid and calcaneus could be abducted
  back under talus without surgery.

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Ponseti Technique

• All deformities will be addressed simultaneously
  except for equinus.
• Reduce the Cavus
• Cavus foot secondary to pronation of forefoot vs
  hindfoot.
• Requires only supination to achieve normal
  longitudinal arch.

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Manipulation

• Locate lateral head of the talus
• Stabilize head of talus with thumb
• This will be pivot point for abduction of
  forefoot.
• Abduct forefoot in supination as far as possible
  without causing discomfort
• Hold for a short period of time and repeat

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Cast Application

• Maintain corrected position of foot while
  casting
• Apply thin layer of cast padding.
• Using plaster cast begin at the toes and wrap
  proximally to just below the knee.
• Mold cast to conform to corrected foot without
  creating pressure points, calcaneus is not
  manipulated.
• Extend padding and cast beyond flexed knee for
  stability.

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Series of casts
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Equinus and tenotomy

• When is the right time to address it?
• When anterior calcaneus can be abducted from
  underneath the talus.
• Can palpate anterior process
• 60 degrees abduction possible
• Will allow dorsiflexion without crushing talus.
• Tenotomy performed in clinic, percutaneously, 1.5
  cm above calcaneal insertion.
• Release will provide additional 20-25 degrees
  dorsiflexion.
• Apply 5th (post tenotomy) cast.
• Remove after 3 weeks.
• Maintain correction with shoes etc.

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Management of Congenital TalipesEquinovarus by
Ponseti TechniqueA Clinical Study

• Evaluate early ponseti intervention vs. other
  manipulation and surgery.
• Study
• Included 100 patients, 156 feet.
• Avg. age 4.5 months.
• Primary assessment with Pirani score and
  photographs.
• Results
• Initial Pirani 4.26, mean FPA (foot print angle)
  14.2 degrees
• Post Pirani 1.3, mean FPA 10.1 degrees
• 96 required Percutaneous TA tenotomy.
• Conclusion early, accurate Ponseti technique
  decreases need for significant surgical
  intervention.

Mazhar A, Et Al, Management of Congenital,
JFAS 47(6)541/545, 2008
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References

• Mazhar A, Et Al, Management of Congenital
  Talipes Equinovarus by Ponseti Technique A
  clinical study, JFAS 47(6)541-545, 2008
• Banks A, Foot and Ankle Surgery, McGlamrys
  comprehensive testbook, volume 1, edition 3, Ch
  29 pg 943-974
• Coughlin M, Et Al, Surgery of the foot and
  ankle Ch 29, Congenital foot deformities.
• Ponseti IV, Clubfoot Ponseti management,
  Second edition, Global health organization, 2003
• Laaveg SJ, Ponseti IV, Long-term results of
  treatment of congenital club foot, J Bone Joint
  Surg Am. 1980 62 23-31
• Bradford EH, Treatment of Club-Foot, J Bone
  Joint Surg Am. 1889 s1-1 89-115
• Colburn M, Evaluation of the treatment of
  idiopathic clubfoot by using the Ponseti
  technique, JFAS 42(5)259-267, 2003