Detailed viva on Club Foot
Findings
Small foot , stretched skin on dorsolateral region and thrown into creases along medial aspect
scars and callosities
head of talus palpable
lateral convex border and medial concavity with furrows
heel rotated medially and drawn up
ancilliary
genu valgum ,
extrinsic / intrinsic type
gait - stumbling
ROM -
ankle , knee , inversion , eversion at subtalar joint
other examination
hip for DDH
Spine for Dysrahism
Cerebral Palsy
Polio - tight iliotibial band
cleft lip , palate , exomphalos and congenital hernia
correctible or not
Impression -
Primary or Idiopathic Secondary Clubfoot
Recurrent Club Foot
Deformities in club Foot
equinus at ankle
varus and internal rotation
forefoot adduction and supination
midfoot cavus
others -
internal rotation of tibia
atrophy of claves and smaller circumference than others
small foot
How do you look for equinus , varus , adduction ?
Heel varus from behind the patients
Supination
behind - 2 concave curves above and below lateral malleolus are normal #
if curve below lateral mallolus is convex outwoards suggest supinated foot
Equinus oberved from side
Adduction of forefoot - observed from behind . Great toe prominently seen .
Cavus - - medial longitudinal arch , prominent on tip toeing
Supination - combination of the deformities
abduction of forefoot
internal rotation and plantar flexion at ankle
inversion at subtalar joint
medial arch elevation
Pronation
forefoot abduction
hindfoot eversion
DF at ankle
depression at ankle
Silfverskiold test
Improved Dorsiflexion on flexing knee which suggests Gastrosoleus tightness .
Etilogy of CTEV
1.Intrauterine packaging defet - Primi , Oligohydraminous
2.Neuromuscular defect - Spina Bifida , AMC
3.Fetal Developmental arrest in fibular stage
4.Defective Cartilage enlage of talus
5.Retracting fibrosis
6.Anomalous tendon insertion
7. Germ plasm Defect
8.Myoblast in medial fascia
9.Hereditary ; polygenic multifactorial trait ; 1:35 chances if sibling affected ; 1 : 3 if twin affected
deletion of chromosme 2 (2q3, : 33 ) related to CASP gene ( Heck et al. , Edwards Syndrome )
10.Electromagnetic radiation and toxins ( paternal smoking , drugs )
11.Vascular thoery ; Absent anterior tibial artery or posterior tibial artery in parents.
12.Infective Pathogens ; enteroviruses , conflicting evidence
Syndromes associated with CTEV
AMC
Streeter's Dysplasia
Tibial Hemimilia
Down's syndrome
Larsen Syndrome
Fetal Alcohol Syndrome
Pierre - Robin Syndrome
Opitz Syndrome
Prunnel Belly Syndrome
Freeman - Sheldon Syndrome (whistling fac )
Club Foot types
Kawashima classification
Type 1
Extrinsic / Non - rigid
foot normal sized , mild varus
heel can be brought down with ease , minimal varus
creases normal
telescopy absent
Type II
Intrinsic / Rigid
foot small , marked varus
heel cant be brought down with ease , marked varus
deep medial , posterior and plantar creases
telescopy present
Aims of treatment
supple plantigrade foot with good function
Objectives of correction
to correct deformity early , fully and develop muscle power of limb sufficiently to maintain correction
Manipulation Techniques
Kite and Lovells
calcaneocuboid junction- fulcrum which prevented abduction of calcaneum and whole foot
remains in adduction and forefoot relatively more .
Ponseti's method of straping and taping for premature babies , babies with multiple anomalies and
baibes under treatment in ICU requiring multiple blood samples .
Montepiller and Dimglio method of CPM
Botox injection into Tendoachillies
Sequence of correctio of Club Foot
C- lifting Ist MT and more supination
A- Abduction
V- it corrects itself
E - heel cord release , last cast applied for 3 weeks
Ponseti Method of treatment .
manipulative casting technique to simultaneously correct deformity from pronation to equinus in end.
concept - relaxation of collagen and atraumatic remodelling of joint surfaces - Talonavicular ,
Calcaneocuboid , Talocalcaneal.
What defines the end of treatment ?
1. no adduction / inversion deformity
2. hollow on dorusm of foot previously occupied by talar head
3. passive movement to full calcaneovalgus
4. child able to evert and dorsiflex foot voluntarily to about right angle
5. squat test
What is Spurious correction ?
apparent correction without actual correction or development of new unrelated deformities due to faulty manipulation
Rocker bottom deformities
Bean shaped foot
Skewed foot
fractures
flat top talus
How do you manage ?
Take AP and lateral radiogarphs
Scoring of foot - Dimeligo scoring and classification
AP - talocalcaneal - 25 - 50 degrees normal
less than 25 degrees - CTEV
Lateral - Talocalcaneal angle 25- 50 degrees
less than 25 degrees in CTEV.
Correction depends on Age and Rigidity of the deformity .
choices ; Ponseti Method , Ilizarov , Triple Arthrodesis , Posteromedial release
Early presentation ,Pirani scoring is useful.
0- normal , 0- 5 moderately abnormal , 1 - severly abnormal
Midfoot score
0- 3
1. curved latereal border
2. medial crease
3. talar head coverage
Hindfoot score
0 - 3
1. posterior crease
2. rigid equinus
3. empty heel
Tenotomy done when hindfoot score > 1 AND midfoot score < 1 and head of talus fully covered.
treat as above and plot score on graph.
Soft tissue releases on clubfoot
Indications ; neglected clubfoot ( < 4 years ) ,
resistant clubfoot or deformity
relapsed/residua deformity
Ponseti applied to decrease magnitude of surgery ; various releases desribed
1.Posterior releases
2. Posteromedial release
3. Extensile Posteromedial release
4.Combined posteromedial and posterolateral release
5. complete subtalar release
timing is an issue
French - within few weeks to months capitalizing on remodelling potential of growing foot .
Turco - considers 1-2 years adequate timing as anatomic details become clearer , under/over
correction wont be magnified as foot grows if delayed.
Simon's - considers 8 cm foot size as approprite timing for release and not the age.
Different techniques for release are
Turco
one stage Posteromedial release
Carol
emphazied PMR + plantar fascia release + calcaneocuboid joint osteotomy as forefoot
adduction and supination not addressed by Turco
Goldner
Emphasized on correction of talar rotation by tibiotalar joint release leaving subtalr joint to
prevent valgus overcorrection .
McKay and Simons - complete subtalar release which is actually a peritalar release with release of
interosseous ligament and talonavicular joint and calcaneocuboid joint
Posterior release only for persistent equinus , fully PM plantar and lateral
release if all defomities persistent.
What structures are released in posteromedial soft tissue release of McKay ?
Incisions
Turco - Hockeystick posteromedial release
Cincinnati - Circumferential
Caroll's and incision technique - posteromedial and a sall lateral
Medial release
1. posterior and medial subtalar joint capsule ( preserve interosseous ligament )
2. talonavicular joint capsule
3. spring ligament
4.Y - ligament
5. Medial calcanecuboid capsule
6. knot of henry
7.abductor hallucis
8.lengthening of posterior tibial tendon , FHL , FDL
9 . Plantar fascia , quadratus plantae
Posterior Release
1. Ankle joint capsule
2. subtalar joint capsule
3.achillies tendon lengthening
4. posterior talofibular ligament
Lateral Release
1. Lateral subtalar joint capsule
2. Peroneal tendon sheath
3. calcaneofibular ligament
4. lateral talocalcaneal ligament
5. ED Brevis, Calcaneocuboid ligament, Inferior Extensor Retinaculum , Calcaneonavicular ligament
in resistant cases .
Structures preserved
dorsal strucutres , medial neurovascular bundle , deltoid ligament , interosseous ligament
talonavicular joint subtalar joint often fixed with smooth K - wires.
Complications of surgery
1.Neurovascular damage , physeal/ bony damage
2.Undercorrection - inadequate postoperative maintenance (CAVE )
3. Overcorrection
valgus , abduction , calcaneous deformity , Pes Planus
4. Talar AVN
5. Sinus Tarsai syndrome
6. Dorsal Navicular subluxation leading to cavovarus foot
Treatment - repeated plantar release + Tendoachillies lengthening
7. Skew foot
8. Dorsal bunion
weak peroneus longus + strong DF and PF
Treatment - Ist ray realignment + drosal FHB transfer with MTP release
Some terms
Neglected Clubfoot
Patient not getting any treatment upto 9 months of age .
Recurrent Clubfoot
1 or more deformity recurring during the course of treatment
Relapsed - 1 or more defromity which recur after sucessful treatment.
Resistant Clubfoot
better termed persistent clubfoot
correction not obtained by manipulation / surgical methods (conservative /surgery )
in any or all of deformities
Role of tendon transfer in clubfoot
Evertor insufficiency - leads to Dynamic supination /inversion , weight borne on
lateral aspect of foot
Tr. - Anterior Tibialis Tendon transfer
min. age 5 years
SPLATT (Split Anterior Tibialis Tendon Trasfer )
tendon rerouted under retinaculum to cuboid /lateral cuneiforom
Triceps Surae insufficiency - Calcaneous gait
Prevention - overlengthening of Tendoachillies
Option - Peronei , TP or long toe flexor
Peroneus Brevis split and rerouted into calcaneal tuberosity with tenodesis of distal stump to longus to prevent evertor insufficiency
Bony Surgery in Clubfoot
Deformity
Metatarsus Adductus
age > 5 years
Metatarsal osteotomy
Hindfoot Varus
< 2-3 years
Modified Mc Kay
3-10 years
Dwyer Osteotomy (Heel Varus, lateral closing wedge osteotomy)
Dilwin Evans (Calcaneocuboid fuse, for long lat. column)
Lichtblau - Pseudoarthrosis (long lat. column)
10-12 years
Triple Arthrodesis
Equinus
Posterior release (mild moderate deformity )
Lamrudini (severe )
Excision of portion of talar head /navicle
Distal tibial DF osteotomy (salvage )
Cavus
> 6 Years
Japas V -Osteotomy
Akron mid-tarsal osteotomy (dome )
transmid tarsal
All deformities
> 10 Years
triple arthrodesis
Persistent Intoeing gait
> 2 years following correction
a. tibial intorsion
b. medial spin of hindfoot in ankle mortise
supramalleoloar derotation osteotomy proximal to
distal tibia physis correcting 35 degree ER .
Medial deviation of forefoot due to talar neck deviation
Evans/ Lichtblau
Neglected Clubfoot or secondary clubfoot
adults Cuneiform tarsectomy
myelomeningocele talectomy
severe resistant clubfoot
Neglected clubfoot wedge tarsectomy
8-11 yers , hardly ever done
Methods of Surgery
Soft tissue release
Bony procedures
Ilizarov method
simultanous 3 d multilevel correction
correction without shortening of foot
Characteristics of club foot shoes (Robert Jones shoes )
1. straight inner border
2. outer shoe raise
3. no heel
maintain correction prevent relapse
also correct mild residual deformity in flexible foot.
DB Splint (Dennis Browne )
aka Abduction bar
consists of metal or Polypropylene Bar
shoes attached to ends over foot plate (Aluminium) rotated outwards at midline
shoes
open toe high top with straight medial border
velcro straps
problems
wight , pressure sore , injury to infants and parents.
Classification ; Demeglio
Gr Type Score
I Benign <5
II Moderate 5- <10
III Severe 10- <15
IV Very severe 15- < 20
Points ; 0-4
Deformity Points
Supination < 20- 0 1
Adduction 0- 20 2
Varus 20-45 3
Equinus 45-90 4
other parameters
poor muscle condition 1
cavus 1
Posterior crease 1
Medial Crease 1
Bracing Protocol
Abducted to 60 - 70 degrees (thigh foot axis )
unilateral ; 60- 70 degrees external rotation on clubfoot side , 30-40 degrees on normal side
B/L - 70 degrees ER on each side ,
Bar width equal to baby's shoulder width.
narrow bar - cause of lack of compliance
convexity 5- 10 degrees away from baby to hold foot in Dorsiflexion
Timing
full time for first 3 months
16 hours for 3-4 years
(12 hours night , day 4 hours )
During brace
not child may develop eternal tibial torsion + heel valgus
then decrease External rotation on shoe bar from 70 to 40 degrees.
Pirani score importance
assesss severity of club foot ,
monitor patients progress
predicts treatment outcomes
higher score - increases number of relapse in bracing phase
Ideal foot after triple arthrodesis
looks natural in shoes
no external rotation on foot - standing / walking
no need for brace
appears natural when bare
weight evenly distributes over plantar surface of foot
axis of ankle perpendicular to foot
no pain
pateint can even control ankle joint motion
Derofmity in Clubfoot
1.medial displacement of navicle and calcaneum around talus
2.talus forced into equinus by calcaneum and navicle wherease head and neck deviated medially .
3.calcaneus -inverted under talus with posterior end displaced upward and laterally and anterior end displaced downward and medially
3. 3D - it appears varus .
4.soft tissue contractures or anomalies
a.Talocalcaneal joint - opposed by 1.Calcaneofibular ligament 2. superior peroneal retinaculum
3.posterior talocalcaneal ligament 4. superior peroneal
retinaculum
b. Talonavicular joint
opposed by 1. Posterior Tibia ligament , 2. Deltoid ligament, 3.Spring ligament
4.Y-ligament 5.Talonavicular capsule
c. Calcaneocuboid ligament
opposed by 1. long plantar ligament 2. plantar calcaneocuboid
If deformity persists late adaptive changes on bone and some joints spontaneously fuse or go degenerative changes.
some terms at last
Deltoid ligament
tibial navicular
Spring ligament
calcaneonavicular ligament
Bifurcated Y ligament
calcaneonavicular oblique ligament.
Small foot , stretched skin on dorsolateral region and thrown into creases along medial aspect
scars and callosities
head of talus palpable
lateral convex border and medial concavity with furrows
heel rotated medially and drawn up
ancilliary
genu valgum ,
extrinsic / intrinsic type
gait - stumbling
ROM -
ankle , knee , inversion , eversion at subtalar joint
other examination
hip for DDH
Spine for Dysrahism
Cerebral Palsy
Polio - tight iliotibial band
cleft lip , palate , exomphalos and congenital hernia
correctible or not
Impression -
Primary or Idiopathic Secondary Clubfoot
Recurrent Club Foot
Deformities in club Foot
equinus at ankle
varus and internal rotation
forefoot adduction and supination
midfoot cavus
others -
internal rotation of tibia
atrophy of claves and smaller circumference than others
small foot
How do you look for equinus , varus , adduction ?
Heel varus from behind the patients
Supination
behind - 2 concave curves above and below lateral malleolus are normal #
if curve below lateral mallolus is convex outwoards suggest supinated foot
Equinus oberved from side
Adduction of forefoot - observed from behind . Great toe prominently seen .
Cavus - - medial longitudinal arch , prominent on tip toeing
Supination - combination of the deformities
abduction of forefoot
internal rotation and plantar flexion at ankle
inversion at subtalar joint
medial arch elevation
Pronation
forefoot abduction
hindfoot eversion
DF at ankle
depression at ankle
Silfverskiold test
Improved Dorsiflexion on flexing knee which suggests Gastrosoleus tightness .
Etilogy of CTEV
1.Intrauterine packaging defet - Primi , Oligohydraminous
2.Neuromuscular defect - Spina Bifida , AMC
3.Fetal Developmental arrest in fibular stage
4.Defective Cartilage enlage of talus
5.Retracting fibrosis
6.Anomalous tendon insertion
7. Germ plasm Defect
8.Myoblast in medial fascia
9.Hereditary ; polygenic multifactorial trait ; 1:35 chances if sibling affected ; 1 : 3 if twin affected
deletion of chromosme 2 (2q3, : 33 ) related to CASP gene ( Heck et al. , Edwards Syndrome )
10.Electromagnetic radiation and toxins ( paternal smoking , drugs )
11.Vascular thoery ; Absent anterior tibial artery or posterior tibial artery in parents.
12.Infective Pathogens ; enteroviruses , conflicting evidence
Syndromes associated with CTEV
AMC
Streeter's Dysplasia
Tibial Hemimilia
Down's syndrome
Larsen Syndrome
Fetal Alcohol Syndrome
Pierre - Robin Syndrome
Opitz Syndrome
Prunnel Belly Syndrome
Freeman - Sheldon Syndrome (whistling fac )
Club Foot types
Kawashima classification
Type 1
Extrinsic / Non - rigid
foot normal sized , mild varus
heel can be brought down with ease , minimal varus
creases normal
telescopy absent
Type II
Intrinsic / Rigid
foot small , marked varus
heel cant be brought down with ease , marked varus
deep medial , posterior and plantar creases
telescopy present
Aims of treatment
supple plantigrade foot with good function
Objectives of correction
to correct deformity early , fully and develop muscle power of limb sufficiently to maintain correction
Manipulation Techniques
Kite and Lovells
calcaneocuboid junction- fulcrum which prevented abduction of calcaneum and whole foot
remains in adduction and forefoot relatively more .
Ponseti's method of straping and taping for premature babies , babies with multiple anomalies and
baibes under treatment in ICU requiring multiple blood samples .
Montepiller and Dimglio method of CPM
Botox injection into Tendoachillies
Sequence of correctio of Club Foot
C- lifting Ist MT and more supination
A- Abduction
V- it corrects itself
E - heel cord release , last cast applied for 3 weeks
Ponseti Method of treatment .
manipulative casting technique to simultaneously correct deformity from pronation to equinus in end.
concept - relaxation of collagen and atraumatic remodelling of joint surfaces - Talonavicular ,
Calcaneocuboid , Talocalcaneal.
What defines the end of treatment ?
1. no adduction / inversion deformity
2. hollow on dorusm of foot previously occupied by talar head
3. passive movement to full calcaneovalgus
4. child able to evert and dorsiflex foot voluntarily to about right angle
5. squat test
What is Spurious correction ?
apparent correction without actual correction or development of new unrelated deformities due to faulty manipulation
Rocker bottom deformities
Bean shaped foot
Skewed foot
fractures
flat top talus
How do you manage ?
Take AP and lateral radiogarphs
Scoring of foot - Dimeligo scoring and classification
AP - talocalcaneal - 25 - 50 degrees normal
less than 25 degrees - CTEV
Lateral - Talocalcaneal angle 25- 50 degrees
less than 25 degrees in CTEV.
Correction depends on Age and Rigidity of the deformity .
choices ; Ponseti Method , Ilizarov , Triple Arthrodesis , Posteromedial release
Early presentation ,Pirani scoring is useful.
0- normal , 0- 5 moderately abnormal , 1 - severly abnormal
Midfoot score
0- 3
1. curved latereal border
2. medial crease
3. talar head coverage
Hindfoot score
0 - 3
1. posterior crease
2. rigid equinus
3. empty heel
Tenotomy done when hindfoot score > 1 AND midfoot score < 1 and head of talus fully covered.
treat as above and plot score on graph.
Soft tissue releases on clubfoot
Indications ; neglected clubfoot ( < 4 years ) ,
resistant clubfoot or deformity
relapsed/residua deformity
Ponseti applied to decrease magnitude of surgery ; various releases desribed
1.Posterior releases
2. Posteromedial release
3. Extensile Posteromedial release
4.Combined posteromedial and posterolateral release
5. complete subtalar release
timing is an issue
French - within few weeks to months capitalizing on remodelling potential of growing foot .
Turco - considers 1-2 years adequate timing as anatomic details become clearer , under/over
correction wont be magnified as foot grows if delayed.
Simon's - considers 8 cm foot size as approprite timing for release and not the age.
Different techniques for release are
Turco
one stage Posteromedial release
Carol
emphazied PMR + plantar fascia release + calcaneocuboid joint osteotomy as forefoot
adduction and supination not addressed by Turco
Goldner
Emphasized on correction of talar rotation by tibiotalar joint release leaving subtalr joint to
prevent valgus overcorrection .
McKay and Simons - complete subtalar release which is actually a peritalar release with release of
interosseous ligament and talonavicular joint and calcaneocuboid joint
Posterior release only for persistent equinus , fully PM plantar and lateral
release if all defomities persistent.
What structures are released in posteromedial soft tissue release of McKay ?
Incisions
Turco - Hockeystick posteromedial release
Cincinnati - Circumferential
Caroll's and incision technique - posteromedial and a sall lateral
Medial release
1. posterior and medial subtalar joint capsule ( preserve interosseous ligament )
2. talonavicular joint capsule
3. spring ligament
4.Y - ligament
5. Medial calcanecuboid capsule
6. knot of henry
7.abductor hallucis
8.lengthening of posterior tibial tendon , FHL , FDL
9 . Plantar fascia , quadratus plantae
Posterior Release
1. Ankle joint capsule
2. subtalar joint capsule
3.achillies tendon lengthening
4. posterior talofibular ligament
Lateral Release
1. Lateral subtalar joint capsule
2. Peroneal tendon sheath
3. calcaneofibular ligament
4. lateral talocalcaneal ligament
5. ED Brevis, Calcaneocuboid ligament, Inferior Extensor Retinaculum , Calcaneonavicular ligament
in resistant cases .
Structures preserved
dorsal strucutres , medial neurovascular bundle , deltoid ligament , interosseous ligament
talonavicular joint subtalar joint often fixed with smooth K - wires.
Complications of surgery
1.Neurovascular damage , physeal/ bony damage
2.Undercorrection - inadequate postoperative maintenance (CAVE )
3. Overcorrection
valgus , abduction , calcaneous deformity , Pes Planus
4. Talar AVN
5. Sinus Tarsai syndrome
6. Dorsal Navicular subluxation leading to cavovarus foot
Treatment - repeated plantar release + Tendoachillies lengthening
7. Skew foot
8. Dorsal bunion
weak peroneus longus + strong DF and PF
Treatment - Ist ray realignment + drosal FHB transfer with MTP release
Some terms
Neglected Clubfoot
Patient not getting any treatment upto 9 months of age .
Recurrent Clubfoot
1 or more deformity recurring during the course of treatment
Relapsed - 1 or more defromity which recur after sucessful treatment.
Resistant Clubfoot
better termed persistent clubfoot
correction not obtained by manipulation / surgical methods (conservative /surgery )
in any or all of deformities
Role of tendon transfer in clubfoot
Evertor insufficiency - leads to Dynamic supination /inversion , weight borne on
lateral aspect of foot
Tr. - Anterior Tibialis Tendon transfer
min. age 5 years
SPLATT (Split Anterior Tibialis Tendon Trasfer )
tendon rerouted under retinaculum to cuboid /lateral cuneiforom
Triceps Surae insufficiency - Calcaneous gait
Prevention - overlengthening of Tendoachillies
Option - Peronei , TP or long toe flexor
Peroneus Brevis split and rerouted into calcaneal tuberosity with tenodesis of distal stump to longus to prevent evertor insufficiency
Bony Surgery in Clubfoot
Deformity
Metatarsus Adductus
age > 5 years
Metatarsal osteotomy
Hindfoot Varus
< 2-3 years
Modified Mc Kay
3-10 years
Dwyer Osteotomy (Heel Varus, lateral closing wedge osteotomy)
Dilwin Evans (Calcaneocuboid fuse, for long lat. column)
Lichtblau - Pseudoarthrosis (long lat. column)
10-12 years
Triple Arthrodesis
Equinus
Posterior release (mild moderate deformity )
Lamrudini (severe )
Excision of portion of talar head /navicle
Distal tibial DF osteotomy (salvage )
Cavus
> 6 Years
Japas V -Osteotomy
Akron mid-tarsal osteotomy (dome )
transmid tarsal
All deformities
> 10 Years
triple arthrodesis
Persistent Intoeing gait
> 2 years following correction
a. tibial intorsion
b. medial spin of hindfoot in ankle mortise
supramalleoloar derotation osteotomy proximal to
distal tibia physis correcting 35 degree ER .
Medial deviation of forefoot due to talar neck deviation
Evans/ Lichtblau
Neglected Clubfoot or secondary clubfoot
adults Cuneiform tarsectomy
myelomeningocele talectomy
severe resistant clubfoot
Neglected clubfoot wedge tarsectomy
8-11 yers , hardly ever done
Methods of Surgery
Soft tissue release
Bony procedures
Ilizarov method
simultanous 3 d multilevel correction
correction without shortening of foot
Characteristics of club foot shoes (Robert Jones shoes )
1. straight inner border
2. outer shoe raise
3. no heel
maintain correction prevent relapse
also correct mild residual deformity in flexible foot.
DB Splint (Dennis Browne )
aka Abduction bar
consists of metal or Polypropylene Bar
shoes attached to ends over foot plate (Aluminium) rotated outwards at midline
shoes
open toe high top with straight medial border
velcro straps
problems
wight , pressure sore , injury to infants and parents.
Classification ; Demeglio
Gr Type Score
I Benign <5
II Moderate 5- <10
III Severe 10- <15
IV Very severe 15- < 20
Points ; 0-4
Deformity Points
Supination < 20- 0 1
Adduction 0- 20 2
Varus 20-45 3
Equinus 45-90 4
other parameters
poor muscle condition 1
cavus 1
Posterior crease 1
Medial Crease 1
Bracing Protocol
Abducted to 60 - 70 degrees (thigh foot axis )
unilateral ; 60- 70 degrees external rotation on clubfoot side , 30-40 degrees on normal side
B/L - 70 degrees ER on each side ,
Bar width equal to baby's shoulder width.
narrow bar - cause of lack of compliance
convexity 5- 10 degrees away from baby to hold foot in Dorsiflexion
Timing
full time for first 3 months
16 hours for 3-4 years
(12 hours night , day 4 hours )
During brace
not child may develop eternal tibial torsion + heel valgus
then decrease External rotation on shoe bar from 70 to 40 degrees.
Pirani score importance
assesss severity of club foot ,
monitor patients progress
predicts treatment outcomes
higher score - increases number of relapse in bracing phase
Ideal foot after triple arthrodesis
looks natural in shoes
no external rotation on foot - standing / walking
no need for brace
appears natural when bare
weight evenly distributes over plantar surface of foot
axis of ankle perpendicular to foot
no pain
pateint can even control ankle joint motion
Derofmity in Clubfoot
1.medial displacement of navicle and calcaneum around talus
2.talus forced into equinus by calcaneum and navicle wherease head and neck deviated medially .
3.calcaneus -inverted under talus with posterior end displaced upward and laterally and anterior end displaced downward and medially
3. 3D - it appears varus .
4.soft tissue contractures or anomalies
a.Talocalcaneal joint - opposed by 1.Calcaneofibular ligament 2. superior peroneal retinaculum
3.posterior talocalcaneal ligament 4. superior peroneal
retinaculum
b. Talonavicular joint
opposed by 1. Posterior Tibia ligament , 2. Deltoid ligament, 3.Spring ligament
4.Y-ligament 5.Talonavicular capsule
c. Calcaneocuboid ligament
opposed by 1. long plantar ligament 2. plantar calcaneocuboid
If deformity persists late adaptive changes on bone and some joints spontaneously fuse or go degenerative changes.
some terms at last
Deltoid ligament
tibial navicular
Spring ligament
calcaneonavicular ligament
Bifurcated Y ligament
calcaneonavicular oblique ligament.
