congenital clubfoot
TRANSCRIPT
Introduction – definition
Developmental deformity of foot
described as:
◦ Equinus
◦ Inversion (HF varus)
◦ Cavus (FF pronation)
◦ Adduction
Epidemiology
1-2 in 1000
50% bilateral, Boys 2X
Associations (20%) - SP, CP, AG ? DDH (Paton RW, 2009)
Family studies:
◦ 30% in identical twins, one parent 3-4%
and two parents 30%
Etiology
Many theories:
◦ Mechanical, neuromuscular, vascular
deficiencies
◦ Polygenic multifactorial trait
◦ AD with incomplete penetrance
◦ Environmental – early amniocentesis,
maternal smoking
◦ Genetic – PITX1 gene
Soft tissue contractures
Cavus (tight intrinsics, FHL, FDL)
Adductus (tight tibialis posterior)
Varus (tight tendoachilles, tibialis
posterior)
Equinus (tight tendoachilles)
Clinically
Small foot
Small calf
Tibia - shortened
Medial and posterior foot skin creases
Foot deformities:
◦ Hindfoot - Equinus + Varus
◦ Midfoot - Cavus
◦ Forefoot - Adduction
Imaging
Antenatally – US
X-Rays – not routinely done
Views - AP and lateral in stress dorsiflexion. ◦ On AP view: Talocalcaneal angle (30-55˚) and the talo-first
metatarsal angle (5-15˚).
◦ Lateral view: Talocalcaneal angle (10-40˚) and the tibiocalcaneal
angle (10-20˚).
Hindfoot parallelism
All of these angles are decreased.
Treatment – Ponseti
technique Since 1950
POSNA members – 96.7% (2010)
Success rate – 90%
Timing – first weeks of life
Serial casting (average 4-5 casts)
Long leg cast
Dennis brown bar
Achilles tenotomy – 70%
Treatment - French technique
74% success rate
Daily manipulation by physiotherapist followed by immobilization with adhesive taping to maintain the correction achieved with stretching.
Daily for 2 months then 3/week till age 6 months.
If successful in achieving correction, parents continue both the home exercises and night splints until the child reaches walking age.
Treatment – surgical options
Posteromedial soft tissue release: Resistant cases
Delayed presentation
Syndrome-associated clubfoot
Medial opening or lateral column-
shortening osteotomy, or cuboidal
decancellation – older children 3-10
years
Tripe arthrodesis – refractory cases
Talectomy – salvage procedure