4) Clubfoot Flashcards
Clubfoot (talipes equinovarus) primary bone deformity
- Talar neck and head
Clubfoot (talipes equinovarus) secondary bone deformity
- Metatarsus adductus
Clubfoot (talipes equinovarus) primary joint deformity
- Talonavicular
Clubfoot (talipes equinovarus) secondary joint contractures
- STJ
- Ankle joint
- Midfoot and metatarsophalangeal joints
Talipes equinovarus demographics
- Rate 1 in 1,000 births.
- Male : Female is 2:1
- Increased 20 times for siblings.
- Only 33% of identical twins.
- 80% success with Ponseti Casting
- Then remaining 80% success with surgery
3 clubfoot ocmponents
- Ankle equinus
- Rearfoot varus
- Forefoot varus
Congenital clubfoot
- Intrinsic (Rigid) structural
- Extrinsic (Supple) positional
Intrinsic (rigid) structural clubfoot (congenital)
- Lower leg atrophy
- Decreased heel size
- Deep skin lines
- Poorly defined med mall
- Navicular abutting to ankle
Extrinsic (supple) positional clubfoot (congenital)
- More responsive to casting
- If untreated will become rigid
Acquired clubfoot etiologies
- Cerebral palsy
- Spina bifida
- Arthrogryphosis
- Trauma
Neuromuscular acquired talipes equinovarus
- Meningitis
- Polio
- Spinal deformities
- Cerebral palsy
- Diastematomyelia
Post-traumatic acquired talipes equinovarus
- Spinal of sciatic nerve damage
- Lower leg trauma or laceration
- Volkman’s contracture
- Distal tibial epiphyseal damage
Primary deformity in the talus
- Diminished in size, head and neck med/plantar deviated
- Calcaneus, and navicular can be diminished in size also
Shortening of all soft tissue
- Post tibiofibular ligament
- Calcaneofibular ligament
- Bifurcate ligament
- Flexor tendon contracture
- Abductor hallucis contracture
- Deltoid Ligament fused with talo-navicular capsule
Pathological anatomy
- Defect of the talar head and neck
- Anterior and middle facets abnormally directed medially
- Posterior facet is normal
- All muscle insertions are normal
- Abnormal innervation of the extrinsic musculature
- Secondary skin, nerve, tendon, vascular, and ligament contractures
“Windswept”
- CV/VT + MA/CF
Clubfoot radiographic evaluation
- Sustentaculum sign negative: Not visible due to superimpostion
- Talo-Calcaneal angle < 15 (normal 20-40)
- MA angle >30 ( normal 30 at birth, 20 at 1y/o and 15 after 4 y/o)
- Talar head and neck relative to the body is adducted and plantarflexed
Normal talocalcaneal angle
- 20 – 40 degrees
Clubfoot talocalcaneal angle
- Less than 15 degrees
Conservative casting
- Begin as soon as possible
- Stretching and manipulation first
- Reduction Sequence: transverse, frontal, sagittal (Adduction Varus Equinus)
- Do not evert or over pronate the foot
- Most effective in first 9 months of age
Weekly cast changes and manipulation for 6 weeks, then maintained for 3 months with abduction brace and night splints - Reserve equinus correction for last = surgery
Casting complications
- Navicular subluxation lateral and dorsal =
Vertical Talus or Rocker bottom - Avascular necrosis Talus or stretching the arteries too fast (same as surgery)
- Damage to growing cartilage
Turco incision
- Medial hockey stick over tarsal tunnel
Cincinnati incision
- Posterior medial to lateral malleolus
Posterior / medial soft tissue release
- Posterior = tendo achilles
- Medial = Z plasty of the TP, FDL, FHL tendon
- Release of the medial ankle and STJ capsule, deltoid, talonavicular joint, Spring ligament, interosseous talocalcaneal ligament
- Plantar Fascia
- Soft tissue is usually all that is needed
Surgery sequence
- Forefoot
- Rearfoot
- Ankle
Osseous procedures
- Older children with severe deformities
- Lateral Column shortening
- Lichtblau, Evans, Ganley
Fowler procedure
- Closing base wedge osteotomy on the lateral column then takes that autogenous piece of bone and inserts it into the medial cuneiform osteotomy
- Indicated for older children with persisted varus in the FF and Midfoot
Other osseous procedures
- Dywer = evert the calcaneus body
- Naviculectomy
- Talectomy
- TN, TC, CC individual arthodesis
- Triple arthrodesis
- Ankle arthrodesis
- Pantalar arthrodesis
