Pathology and Non-surgical Treatment of Congenital Clubfoot

Dr. Irfan Ali Shujah B.Victoria Hospital Bwpr, Pak

OVERVIEW
Definition Epedemiology Types of Clubfoot Etiology Components Pathology Diagnosis Classification Non-Surgical Treatment Management of Recurrence

Normal Foot
Complex organ that is required to be:

Stable Resilient Mobile Cosmetic

Club Foot ( Congenital Talipes EquinoVarus )

A condition in which one or both feet are twisted into an abnormal position at birth.

Definitions
Talipes : Talus = Ankle Pes = Foot

Equinus : Horse Foot that is in a position of planter flexion at the ankle, Looks like that of the Horses foot

Planus :
Cavus : Varus :

Flat Foot
Highly Arched Foot Heel going towards midline

Valgus :

Heel going away from midline

Adduction : Forefoot going towards midline Abduction : Forefoot going away from midline

Epidemiology
Incidence 1 : 1,000 live births Sporadic Bilateral in 50% Males 65%

Types of Clubfoot
Flexible (Postural)

Rigid (Structural)

Etiology
Primary Germ Plasm defect in Talus Primary Soft tissue abnormalities

Arrested fetal development

Abnormal Intra-uterine forces ( Oligohydramnios, Amniotic Band Syndrome )

Components of ClubFoot
Cavus
Adduction Varus Equinus

Pathology
Osseous Changes

Soft Tissue Anomalies/Changes

Osseous Changes
TALUS - Diminished in size - Medial & Plantarward deviation of the head, neck and articular facet - Neck internally rotated, Body ext. rotated CALCANEUS - Hypoplastic, Inverted under the Talus - Post. End Upward and Laterally - Ant. End Downward and Medially - Tuberosity towards Lat. Mal. posteriorly

NAVICULAR - Severe Medial Positioning - Articulates with Tibia CUBOID - Displaced medially on Calcaneus

FOREFOOT - Metatarsals and Phalanges Adducted

Soft Tissue Changes

TENDONS - Tibialis Post, Flexor Hallucis Longus & Flexor Digitorum Longus contracted - Abductor Hallucis contracted - Histologically normal LIGAMENTS - Deltoid, TMT & Spring Ligaments contracted - Long and Short planter ligaments - Histologically normal

OTHERS - Blood vessels, nerves and skin adaptively shortened along the medial and plantar aspects - Calf circumference, girth and overall foot size diminished

Diagnosis
PHYSICAL EXAMINATION Short Achilles Tendon High and Small heel No creases behind Heel Abnormal crease in middle of the foot Foot is smaller in unilateral cases Callosities at abnormal pressure areas Calf muscles wasting

Radiologic Evaluation
Antero-Posterior view

Stress Dorsiflexion Lateral view

Talo-Calcaneal Angle (AP)

(Normal 30-55)

Talo-Calcaneal Angle (LAT.)

(Normal 25-50)

Talus-1st Metatarsal Angle

Radiographic measurement of forefoot adduction Useful in Rx. of Metatarsus Adductus & Clubfoot

Normal 5-15
Negative in Clubfoot

Classification
Piranis Classification

Dimeglio et al. Classification

Pirani Classification of Clubfoot

Pirani system composed of 10 different Physical Examination Findings 0 for No Abnormality 0.5 for Moderate Abnormality 1 for Severe Abnormality

Dimeglio et. al Classification

In Dimeglio et. al system, 4 parameters are assessed on the basis of their Reducibility with gentle manipulation measured with goniometer.

Equinus Deviation

Adduction Deviation

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

NON-SURGICAL / CONSERVATIVE SURGICAL

Non-Surgical Treatment
Manipulation and Casting

Splints to Maintain Correction - Ankle-Foot Arthrosis (AFO) - Denis Brown Splint

Ponseti Casting
Abundant young wavy collagen - easily stretched Navicular, Cuboid & Calcaneus can be abducted back under Talus without surgery Most widely accepted technique Success rate >90% of children 2yrs & younger Recurrence rate 10-30% Ideally is used in New borns Success rates are lower in Older children

Treatment Phase of Ponseti Casting

o Should begin ASAP .. Within 1st week of life o Gentle manipulation and casting weekly Order of Correction 1. Correction of forefoot Cavus & Adduction 2. Correction of Heel Varus 3. Correction of hindfoot Equinus Generally 5-6 casts are required

 First apply short leg cast below knee Then extend above knee when plaster sets. Long Leg Casts are essential 1st cast removed after 1 week 1 minute of gentle manipulation and re-casting focusing on Abducting the foot around head of Talus maintaining Supinated position

 Never pronate
Never manipulate the heel directly Casting in gradual abduction for 2-3 weeks

Percutaneous Tendo-Achilles Tenotomy under local anesthesia, followed by final cast

Final Cast is applied in maximally Abducted position (70 degrees) and Dorsiflexion in 15 degrees for 3 weeks

Percutaneous TA Tenotomy

Series of Castings

Maintenace Phase of Ponsati Casting

Final Cast is removed after 3 weeks AFO Abduction 70 degrees Dorsiflexion 15 degrees Distance btw the shoes is 1 inch wider than the width of infants shoulders Brace is worn 23hrs/day (3 months) then while sleeping (2-3 years) Brace compliance is very important

Management of Recurrence
Infrequent if Bracing protocol is followed closely

Repeated manipulation and casting

1st cast with dorsiflexion of 1st ray if Cavus Subsequent castings with Abduction and ultimately ankle dorsiflexion Achilles Tendon Lengthening and Ant. Tibial Tendon transfer may be required

Summary
4 Components of Clubfoot deformity CAVE Bony and Soft tissue adaptive Changes Pirani and Dimeglio Classification systems Non-Surgical treatment should start ideally within 1st week Ponsati Casting is worldwide accepted technique Brace wear Compliance is important Recurrence is treated with Re-manipulation and casting