Club Foot -Viva Station

Turco attributed the deformity to medial displacement
of the navicular and calcaneus around the talus. The talus is
forced into equinus by the underlying calcaneus and navicular,
whereas the head and neck of the talus are deviated medially.
The calcaneus is inverted under the talus, with the
posterior end displaced upward and laterally and the anterior
end displaced downward and medially.

three-dimensional perspective, The heel appears to be in varus because the calcaneus rotates
through the talocalcaneal joint in a coronal plane and horizontally.
The talonavicular joint is in an extreme position of
inversion as the navicular moves around the head of the talus.
The cuboid is displaced medially on the calcaneus.


CAUSES

Contractures or anomalies of the soft tissues

Talocalcaneal joint realignment is opposed by the calcaneofibular ligament, the
superior peroneal retinaculum (calcaneal fibular retinaculum),
the peroneal tendon sheaths, and the posterior talocalcaneal
ligament.
Resisting realignment of the talonavicular joint by

the posterior tibial, the deltoid ligament (tibial navicular),
the calcaneonavicular ligament (spring ligament),
the entire talonavicular capsule, the dorsal talonavicular ligament,
the bifurcated (Y) ligament, the inferior extensor retinaculum, and occasionally the cubonavicular oblique
ligament.

Internal rotation of the calcaneocuboid joint 
causes
contracture of the bifurcated (Y) ligament, the long plantar
ligament, the plantar calcaneocuboid ligament, the navicular
cuboid ligament, the inferior extensor retinaculum (cruciate
ligament), the dorsal calcaneocuboid ligament, and, occasionally,
the cubonavicular ligament.

If the clubfoot is allowed to remain deformed, many
other late adaptive changes occur in the bones

some joints may spontaneously
fuse or they may develop degenerative changes
secondary to the contractures.

Ponseti - Generally five to six casts are required to correct the alignment of the
foot and ankle fully. Before application of the final cast,
 most infants require percutaneous Achilles tenotomy
to gain adequate lengthening of the Achilles tendon and prevent a
 rocker-bottom deformity.
first, correction of forefoot cavus and adduction; next, correction
of heel varus; and, finally, correction of hindfoot equinus

The first cast application corrects the cavus deformity
by aligning the forefoot with the hindfoot, supinating the forefoot
to bring it in line with the heel, and elevating
(dorsiflexing) the first metatarsal. The casts
should be applied in two stages: first, a short-leg cast to just
below the knee, and then extension above the knee when
the plaster sets. Long-leg casts are essential to maintain a
strong external rotation force of the foot beneath the talus, to
allow adequate stretching of the medial structures, and to
prevent cast slippage.One week after application, the first
cast is removed, and after about 1 minute of manipulation,
the next toe-to-groin cast is applied. Manipulation
and casting at this stage are focused on abducting the
foot around the head of the talus, with care to maintain the
supinated position of the forefoot and avoid any pronation.


MAINTENANCE PHASE
When the final cast is removed, the infant is placed in a brace
that maintains the foot in its corrected position (abducted
and dorsiflexed). The brace (foot abduction orthosis) consists
of shoes mounted to a bar in a position of 70 degrees of
external rotation and 15 degrees of dorsiflexion. The distance
between the shoes is set at about 1 inch wider than the width
of the infant’s shoulders. This brace is worn 23 hours each day
for the first 3 months after casting and then while sleeping
for 2 to 3 years.





MANAGEMENT OF RECURRENCE
Recurrence of the deformity is infrequent if the bracing protocol
is followed closely. Early recurrences (usually mild equinus
and heel varus) are best treated with repeat manipulation and
casting. The first cast may require some dorsiflexion of the first
ray if cavus deformity is present. Subsequent casts abduct the
foot around the talar head, correcting the varus and ultimately
allowing ankle dorsiflexion. Achilles tendon lengthening
 may be necessary if dorsiflexion is insufficient;
transfer of the anterior tibial tendon may be
necessary to help maintain correction.




Treatment of Resistant Clubfoot

 TREATMENT IS ACCORDING TO THE DEFORMITY

TREATMENT

Metatarsus adductus
>5 yr: metatarsal osteotomy

Hindfoot varus
   <2-3 yr: modified McKay procedure

   3-10 yr:
   Dwyer osteotomy (isolated heel varus)- lateral closing wedge osteotomy of the calcaneus in a modified way.otherwise a medial opening wedge osteotomy


   Dillwyn-Evans procedure (short medial column)-

   Lichtblau procedure (long lateral column)- corrects the long lateral column of the foot by a
closing wedge osteotomy of the lateral aspect of the
calcaneus or by cuboid enucleation

   10-12 yr: triple arthrodesis

Equinus
Achilles tendon lengthening plus posterior capsulotomy of subtalar joint, ankle joint (mild-to-moderate deformity)

Lambrinudi procedure (severe deformity, skeletal immaturity)

All three deformities

>10 yr: triple arthrodesis









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