clubfoot

Question 1

Simons rule of 15

Answer 1

on AP: talo-1st met angle is greater than 15, and kites angle less than 15

Question 2

Reduction of clubfoot timeline

Answer 2

Start casting as soon as possible.

Ponseti tecnique serial casting weekly.
percutaneous tendoachilles tenotomy for hindfoot stall

Once corrected abduction foot orthosis worn full time for 12 weeks and then at night and naps until age 4.

if there are no signs of improvement after 12 weeks, consider surgical intervention

Question 3

Posterior release of clubfoot

what certain structures are severed? and what structures are kept?

Answer 3

reflection of abductor hallucis and plantar fascia at its origin

Z plasty of achilles tendnon

-Posterior capsulotomy of the ankle joint and the sub talar joint
Release of the posterior inferior tibiofibular ligament, posterior tibiofibular ligament, release of posterior medial and lateral STJ: the posterior talofibular and CFL severed

Question 4

Soft tissue medial release for club foot: when releasing TN joint, what else is severed?
what structure should NOT be severed for medial release?

Answer 4

• z-lengthening of the posterior tibial tendon, the flexor digitorum longus, and the flexor hallucis longus
• Perform a medial capsulotomy of the subtalar joint, talonavicular joint-release TNJ: spring ligament and knot of henry severed
• Insert a K-wire through the talus into the navicular in order to maintain a corrected alignment of the talonavicular joint

release of entire medial STJ including superficial deltoid ligament, NOT deep deltoid ligament

Question 5

Lateral release (performed through the STJ in the medial incision approach) for clubfoot

Answer 5

release of interosseous talocalcaneal ligament

release of bifurcate ligament

release of lateral STJ

Question 6

Reduction should be performed in what following order for clubfoot

Answer 6

adduction
varus
equinus

Question 7

what is the “horizontal breech” position of the talus for club foot

Answer 7

talar head and neck are medially deviated, and the talar body and trochlear talar surface is slightly externally rotated within the mortise leading to an external torsional deformity of tibia/fibula –> decrease in bimalleolar axis.

Question 8

what are the most popular incisions for soft tissue release for clubfoot

Answer 8

1. cincinnati incision

2. “ medial hockey stick incision” (turco)

Question 9

complications of cast tx for club foot

Answer 9

• met adductus
• heel varus
• Pes planovalgus (overcorrection)
• rocker bottom foot due to aggressive DF of midtarsal joint
• Midtarsal subluxation due to overzealous Equinus correction
• AVN or talar head flattening bc connective tissue is stronger than bone and cartilage
• Navicular subluxation

Question 10

Lichtblau osteotomy

Answer 10

anterior calcaneal closing base wedge osteotomy for club foot

Question 11

What happens to calcaneal inclination in clubfoot?

Answer 11

decrease -17

Question 12

what is a critical position during ponsenti technique

Answer 12

Abduct forefoot with forefoot supination. Key to keep forefoot supinated

Question 13

complication with sx tx for clubfoot

Answer 13

residual cavus
pes planus
In toeing 
dorsal bunion
osteonecrosis of talus