80/81: Congenital Clubfoot - Dayton

Question 1

when in fetal development does clubfoot occur?

Answer 1

• Embryonic defect
  
  • Occurring in first 12 weeks after fertilization
• Temporary arrest of normal fetal development
  
  • During 7-8th weeks –leads to RIGID clubfoot
  • During 9-12th weeks—leads to FLEXIBLE deformity

Question 2

associated congenital deformities

Answer 2

• Congenital hip dysplasia
• Metatarsus adductus of opposite foot
• Rigid flatfoot of opposite foot (vertical talus)
• Hand deformities
• Spina bifida
• Arthrogryphosis
• Myelomeningocele

Question 3

clinical features talipes equinovarus

Answer 3

• Adducted forefoot
• Varus rotated heel
• Equinus ankle
• Cavus forefoot
• Small foot
• Small calf
• Short calf (LL discrepancy)

Question 4

changes in the talus

Answer 4

• Talus remains within the ankle mortise
• navicular, cuboid, and calcaneus are medially rotated around talus but in normal relation to each other
• Head is prominent laterally due to movement of calcaneus cuboid & navicular around it

Question 5

diagram of clubfoot

Answer 5

Question 6

is metatarsus adductus a component of clubfoot?

Answer 6

no

can be associated, but not a required component

Question 7

ankle ROM clubfoot

Answer 7

rigid equinus

in baby you should be able to touch tibia and foot

Question 8

what is the lateral prominence on club foot?

Answer 8

talar head

Question 9

findings on AP radiograph

Answer 9

• Talus and calcaneus overlap due to the medial rotation under the talus
• Kite’s angle (talocalcaneal angle; long axis of the talus and calcaneus)
  
  • Normal: 20-40 degrees
  • Clubfoot: Decreased
• Talo-1st Metatarsal angle (long axis of the first met and talus)
  
  • Normal: 0 to -20 degrees
  • Clubfoot: Increased >15 degrees (+ = medial)

Question 10

simmons rule

Answer 10

• AP Kite’s angle less than 15 degrees
• Talar first metatarsal angle greater than 15 degrees
  
  • Normal is a negative angle
• Correlates with TN dislocation in >90% of surgical specimens

Question 11

lateral radiograph findings

Answer 11

• Talus and calcaneus are parallel
  
  • Normal lateral talocalcaneal angle is about 35-50 degrees
• Turco-Forced dorsiflexion lateral view
  
  • Talocalcaneal angle is typically increased but with clubfoot the angle is decreased

Question 12

kites vs. ponseti

Answer 12

• Kites method of individual deformity correction does not work
  
  • leads to surgical treatment when castings don’t work: posterior medial release, piecemeal release
• Ponseti casting method has been established as the standard

Question 13

kite’s treatment concepts

Answer 13

• Each component of clubfoot is distinct
• Each component is corrected separately in a stepwise approach
  
  • Adduction of FF
  • Varus of calcaneus
  • Equinus
• Cavus is corrected through pronation of the forefoot on the hindfoot

Question 14

ponseti method

Answer 14

• Perfected a system of manipulation and casting over 8 weeks to correct 95% of untreated clubfeet
• 5-6 casts progressively more abducted with the foot supinated
• Navicular, cuboid and calcaneus move as a unit
• Achilles tenotomy when foot is rectus followed by 3 weeks of casting
  
  • don’t worry babies heal quick
• Maintain with brace for up to 2 years

Question 15

ponseti’s functional concepts

Answer 15

• The 4 components of clubfoot are directly interrelated
• Failure to concurrently treat cavus adduction and varus results in failure due to locking
• The navicular, cuboid and calcaneous move as a unit under the fixed talus
• Supination of the forefoot is required to “unlock” the joints

Question 16

what should you do for equinus in clubfoot?

Answer 16

never cast out the equinus

tx: achilles tenotomy

Question 17

maintenance of correction

Answer 17

• Bar with feet abducted 70 degrees
• Full time for 3 months
• Nightly for 2-3 years
• Relapses can occur, usually between 2 and 5 years
• These are treated with manipulation and tib anterior transfer