Club Foot PDF

CLUB FOOT
Nattawat angkavanich, MD
OUTLINE
• Introduction • Differential Diagnosis

• Epidemiology • Radiographic
• Etiology • Classification
• Pathology • Treatment
INTRODUCTION
• Congenital Talipes Equinovarus or Club Foot

• CAVE
• Cavus: Plantarflexion of forefoot on the hindfoot [B]
• Adductus: Adductus of the forefoot on the midfoot [D]
• Varus:Varus of the subtalar joint [C]
• Equinus Equinus of the ankle [E]
CLINICAL FEATURE
1. Cavus
2. Forefoot Adduction
3. Heel Varus
4. Equinus of ankle
CLINICAL FEATURE
Deep transverse skin crease
WWumoints
Whinfu nun's
Posterior ankle skin crease
Head of Talus
00
smaller foot and calf
LLD~ 0.5cm
INTRODUCTION
• Involve soft tissue and bony parts
• 80% isolated deformity

• 20% associated with syndrome, developmental disorder or
neurological abnormality
EPIDEMIOLOGY
• Incidence: 1:1000 live births

• Males: females 2:1
• Bilateral 50%
• Occurrence rate 17 times higher than normal in First degree
relative
1000
Males: females 2:1
Bilateral 50%
mu wir mu
unit
unio mo BA
ETIOLOGY UNKNOWN
• Genetic > dominant genes • Nerve lesion

• Proposed theory e.g. • Abnormal tendon insertion
• primary muscle lesion • Retracting fibrosis
• bone deformity • Abnormal histology
• vascular lesion • Environmental e.g smoking mother
• Intrauterine enteroviral infection • Hyperlaxity
• Development arrest
PATHOLOGY
• Abnormal bones and ligament: Talus, Calcaneus, Navicular

• Abnormal vascular
• Abnormal muscle
ABNORMAL BONES
• Talus • Calcaneus
• Shortened • Medial rotation
• Head - Medial deviation • Equinus
• Body External rotate. Extruded • Adduction
anterolateral
• Navicular
• Neck medial deviated , plantar flexed
• Medial subluxation
ABNORMAL LIGAMENTS
• Posterior tibial tendon shealth thickening

• Calcaneonavicular ligament contracture
• Calcaneofibular ligament contracture
ABNORMAL MUSCLE
• Abnormal in anatomical insertion and intrinsic structure

( smaller intracellular connective tissue)
'
as og
ABNORMAL VESSELS
• 20 54% Absent dorsalis pedis artery

DIFFERENTIAL DIAGNOSIS
• Calcaneovalgus
• Congenital vertical talus
• Congenital posteromedial tibial bowing
no CAVE
VoneinUnrin calcareous outlines
self -
limited www.OI
nocans
no adenitis
ankle Unni Angulation tibia Nguni
O
CLASSIFICATION NU
66011
4 UrghAN
• Postural clubfoot onto stretching turn to normal I si
• Congenital idiopathic clubfoot

• Syndromic clubfoot e.g. Arthrogryposis
• Neurogenic clubfoot e.g Myelomeningocele
• Very rigid and difficulty to treatment
Arthrogryposis
• Congenital joint contractures in two or more
areas of the body
• 84% all limbs are involved

• 11% only the legs
• 4% only the arms
• Caused by genetic and environmental factors

• any factor that curtails fetal movement
• decreased intrauterine movement
• oligohydramnios
• The exact causes of arthrogryposis are

unknown yet
9106091 of
POSTURAL CLUBFOOT
• Structurally normal, Abnormal resting position

• Develops during 3rd trimester
• Almost full passive range of motion at birth
• Able to manipulate at least 10 degrees ankle dorsiflexion
O treatment is required
• No
• Resolution within first week 1 month uh cast a -
2 on Is
RADIOGRAPHIC FEATURES
Jai Jarod d on n film
I a
,
N deformity
preoperative
CLASSIFICATION OF CLUB FOOT
(ASSESSMENT)
• Important clinical features

• Rigid and degree of the deformity
• Depth of skin crease
• Tightness and contractility of muscles
CLASSIFICATION OF CLUB
FOOT (ASSESSMENT)
Clinical classification
• Carroll 98 clinical diagnosis
• Goldner
• Catteral
Base on physical exam

• Dimeglio
• Pirani
DIMEGLIO S CLASSIFICATION
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DIMEGLIO S CLASSIFICATION
TREATMENT
• Non operative treatment *
• Surgical treatment
GOALS
• Form: plantigrade foot, supple, look normal
• Function: painless weight bearing
NON OPERATIVE TREATMENT
• Weekly serial manipulation and casting at the first 6th wk of life

• Casting program
• Kite
• Lovel
* • Ponseti *Standard*
IGNASIO V. PONSETI
Standard of conservative
2 phases
• Treatment phase
• Maintenance phase
Success rate more than
90% in children with
younger than 2 years
CONCEPT 1
O
• The whole foot moves under the Talus.
• Calcaneo - Pedis block
CONCEPT 2
• Forefoot and hindfoot are corrected simultaneousl b

abduction
0
CONCEPT 3
pressure point at
• Pressure point at the Head of Talus Heda of Talus
• Elevation & Abduction

CASTING TECHNIQUE
• Before each cast is applied, the foot is manipulated

• Never ever touch the heel
ONE HAND TECHNIQUE
TWO HANDS TECHNIQUE
PONSETI TECHNIQUE
• Start soon after birth

• All deformities are corrected spontaneously except equinus
• Cavus is corrected by elevating the first metatarsal
• The entire foot is abducted under the talus
SEQUENCE OF MANIPULATION
(PONSETI TECHNIQUE)
unwished du
1. Corrected cavus deformity (1st-2nd wk)
• Elevate/Supination first metatarsal + Head of talus -> fulcrum
2. Corrected forefoot adductus and hindfoot varus (2nd-6th/8th wk)
Serial cast • Forefoot Abduction
• Hindfoot Evert/external rotate around the talus, while maintain
supination of forefoot
• Head of talus : fulcrum
• Avoid pronation,dorsiflexion a c a
calcaneus
GOAL : Abduction 70 , Dorsifle ion <15
SEQUENCE OF MANIPULATION
(PONSETI TECHNIQUE)
3. Corrected equinus deformity (7th/9th wk)

• Achilles tenotomy
• 1 cm above achilles tendon insertion
• 10-20 degrees dorsiflexion
• Final LLC 3 weeks
CASTING long Leg cast
hold position
goinmy
Tenotomy
• For corrected equinus

• Indication
– Talar head is covered
– Heel is in slight valgus
– Foot is maximally abducted 60 – 70˚
– < 15 degrees dorsiflexion
Tenotomy
• Position
• 1 cm above Achilles tendon
insertion
• Incision
• Insert blade medial side of heel
and parallel to tendon
• Turned the blade ˚ and resect
tendon
• Avoid post.tibial a.and nerve injury
www.nio.n
PONSETI Method for Clubfoot No MT woo
Denis browne bar
TREATMENT PHASE MAINTENANCE Incomplice

PHASE Twin
Serial Casting Achilles Tenotomy
1
6-8 wk everton LLCO
3 wk Until 4 years old
elevate recurrent't
1st Mt supination abduct
1st-2nd 2nd-6th/8th 7th/9th-9th/11th 3mo 6mo-4y
C A &V E 23hr/d Nighttime
Denis Browne bar

Long Leg Cast (Toe to groin cast) 70ºER, 15ºDorsiflexion
40ºER in Normal foot
Goal Goal
No Cavus, Abduction70º, Dorsiflexion15º Prevent Recurrent
DENIS BROWNE BAR
• Fulltime 23 hrs/d
for 3 months
• Nighttime
until 4 years old
Keep ext.rotation 70 , dorsifle 15 in clubfoot and 40-45 in normal foot

Biggest risk factor of recurrent deformity : Noncompliance
PITFALL IN MANIPULATION
• Pronation of foot
• Increase cavus and locking
calcaneus under talus
IN pronate w :
• Correct adduction by external rotation of the foot while

calcaneus is in varus
• Posterior displacement of lateral malleolus
• Correct equinus before other deformities
• Rocker bottom deformity
-
• Forceful dorsiflexion
• Flat-top talus
• Abducting the foot at the midtarsal joints with the thumb pressing
on the lateral side of the foot near the calcaneocuboid joint
• Abduction of the calcaneus is blocked -> interfering with correction of
the heel varus
OPERATIVE TREATMENT
• Indication
• Failed non-operative treatment
• Controversy in timing of surgery
• Different techniques
• Turco, Mckay, Simons, Corroll
• Goal
• Restore or create, as normal a foot as possible
• 3P : Painless, Pliable, Plantigrade
OPERATIVE TREATMENT
• Deformities that do not respond to conservative treatment by

serial manipulation and casting.
• Posteromedial release (PMR)
• Dynamic supination
• TA transfer to 3rd cuneiform

Figure 25-24 Turco procedure for posteromedial clubfoot release.
TAKE HOME MESSAGE
TREATMENT PHASE
MAINTENANCE
PHASE
Serial Casting Achilles Tenotomy Until 4 years old
6-8 wk LLC 3 wk
1st-2nd 2nd-6th/8th 7th/9th-9th/11th 3mo 6mo-4y

C A &V E 23hr/d Nighttime
Denis Browne bar

Long Leg Cast (Toe to groin cast) 70ºER, 15ºDorsiflexion
40ºER in Normal foot
Goal Goal
No Cavus, Abduction70º, Dorsiflexion15º Prevent Recurrent
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CLUB FOOT

• Introduction • Differential Diagnosis

• Congenital Talipes Equinovarus or Club Foot

Deep transverse skin crease

Posterior ankle skin crease

• Involve soft tissue and bony parts

• 80% isolated deformity

• Incidence: 1:1000 live births

• Genetic > dominant genes • Nerve lesion

• Abnormal bones and ligament: Talus, Calcaneus, Navicular

• Posterior tibial tendon shealth thickening

• Abnormal in anatomical insertion and intrinsic structure

• 20 54% Absent dorsalis pedis artery

VoneinUnrin calcareous outlines

• Postural clubfoot onto stretching turn to normal I si

• Congenital idiopathic clubfoot

• 84% all limbs are involved

• Caused by genetic and environmental factors

• The exact causes of arthrogryposis are

• Structurally normal, Abnormal resting position

• Important clinical features

Base on physical exam

• Non operative treatment *

• Weekly serial manipulation and casting at the first 6th wk of life

• Forefoot and hindfoot are corrected simultaneousl b

• Pressure point at the Head of Talus Heda of Talus

• Elevation & Abduction

• Before each cast is applied, the foot is manipulated

• Start soon after birth

3. Corrected equinus deformity (7th/9th wk)

• For corrected equinus

Denis browne bar

TREATMENT PHASE MAINTENANCE Incomplice

Denis Browne bar

Keep ext.rotation 70 , dorsifle 15 in clubfoot and 40-45 in normal foot

• Correct adduction by external rotation of the foot while

• Deformities that do not respond to conservative treatment by

• Posteromedial release (PMR)

• TA transfer to 3rd cuneiform

1st-2nd 2nd-6th/8th 7th/9th-9th/11th 3mo 6mo-4y

Denis Browne bar

dorsal bunnion gastroc imbalance

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