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.