FACULTY OF MEDICINE UNIVERSITY OF INDONESIA Jakarta

CLUB FOOT :
Tibiotalar plantar flexion Medial displacement of navicular Wedge-shaped head of talus

Wedge-shaped Navicular
Adducted and inverted calcaneus Medially displaced cuboid

New Concept of Treating Congenital Club Foot

CLUB FOOT :
Many Controversies A Comparative Deformity Still poorly understood Relapses Do Occur

New Concept of Treating Congenital Clubfoot

CONTROVERSIES
1. Causes 2. Pathology Anatomy 3. Evaluation dx. Technique (Grading of Severity) 4. Treatment Assessment a. Type of non operative treatment b. When to do surgery 5. Evaluation of result

New Concept of Treating Congenital Clubfoot

ETIOLOGY
Genetic gene mutation Enterovirus 8 weeks gestation Abnormal intra uterine force Arrested fetal development Abnormal muscle and tendon insertion Abnormal rotation talus Germ plasma defects (primary bone dysplasia of the talus

New Concept of Treating Congenital Clubfoot

PATHOLOGY
Histology : Abnormality in almost tissue Ultra structural Type I : Type II musclefiber ratio : 1 : 2 7 : 1

MRI : * Medial angulation of the neck talus * Medial tilting and rotation of body talus

Varus deformity of hind foot Supination of the fore foot

Ponsetti : Retraction and fibrosis of distal muscle

New Concept of Treating Congenital Clubfoot

PATHOLOGY

Electron Microscopic (Zinny) Myobifroblast contracture and deformity

Immuno histochemical + Electro Microscope (Sano) Contractile protein gradation - Deformity in clubfoot cell from fibroblast to myofribrolast
- Common recurrence

Vascular anomalies Hypoplasia / absence of A. tibialis anterior Dysplasia of A. tibialis arterior

Deformity

Classification :

Grading of Severity : Dimeglio Classification

20 points
Equinus : 4 points Internal Rotation : 4 points

Sagittal plane evaluation of equinus

Horizontal plane evaluation of derotation of the calcaneopedal block

Varus : 4 points

Adduction : 4 points

Frontal plane evaluation of varus

Horizontal plane evaluation of forefoot Relative to hindfoot

DIMEGLIO CLASSIFICATION

New Concept of Treating Congenital Clubfoot

GRADING OF SEVERITY
Grade 1 Grade 2 Grade 3 Grade 4 Postural Not requiring surgery Considerable reducibility Resistant and partially reducible

New Concept of Treating Congenital Clubfoot

GRADING OF SEVERITY
Classification Ucok

: 16 points
:0 :1 :3 :0 :1 :2 :2 :2 :1 :2 :2

Age : - less than 9 months - more than 9 months - more than 18 months Passive fore foot abduction to - beyond midline - only to midline - no abduction Cavus No active dorsoflexi Leg Atrhophy No dorsasl MP joint creases No increased ligamentum laxity

Severity Score :
1. Mild 2. Moderate 3. Severe 12 35 6 - 16

New Concept of Treating Congenital Clubfoot

Grading of Severity

M. Kamegaya Chiba MRI study Talar neck angle (TNA) Medial / lateral shift of navicular TNA > 35 Severe

Medial shift navicular

Surgery

TREATMENT
NON SURGICAL :

New Concept of Treating Congenital Clubfoot

- Shortly after birth - Gentle manipulation (should not injure cartilage) - Retention cast Controversies - Weekly cast changes

SURGICAL :
- When no further correction by manipulation - Posterior release alone only after complete correction of fore foot adduction and hind foot varus / non operative treatment ATL

Non surgical treatment :

a. Ponsetti method >>minimal invasive surgery b. Kites and Lovell <<minimal invasive surgery c. French method
Newer Non Operative Treatment Physiologic motion Dennis Brown 1937 Shoes and Bar : Progressive external rotation Physical therapy Bensehal / French Stretching + Continoues passive motion Dimeglio

Botox to grastrocnemeus + Soleus and tibialis posterior Reduce tone Lengthening by stretching

New Concept of Treating Congenital Clubfoot

PONSETTI
1. Cavus Correction 2. Mid foot Alignment

3. Hind Foot Correction equinus and varus ATL Local Anaesthesia 4. External Rotation

FRENCH METHOD
A B
C

Correction of the forefoot adduction and heel varus

Reduction of talonavicular displacement

Derotation of calcaneopedal block

Manipulation of heel varus, Calcaneusmedially, Forefoot ext rot

Manipulation of equinus

Source : Herring JA(ed): Tachdjians Pediatric Orthopaedics, ed3. Philadelphia. PA: WB Saunders. 2001. pp 933 -934

Kites Method
Abduction of fore foot in pronation the cavus becomes more severe Calcaneus locked (jammed) under the head of talus; mid foot and forefoot are twisted eversion

Calcaneo-cuboid is used as fulcrum which is pressed medial ward while fore foot is moved lateral ward (abduction);

Calcaneus will not move lateral ward (no abduction) the varus will not be corrected ; only naviculare and fore foot will move lateral ward.

NEW BORN

MANIPULATION CASTING
NO FURTHER CORRECTION DEFINITIVE SURGERY

EQUINUS (complete correction of fore foot Adduction & hind foot varus

NEUTRAL

Heel cord release percutaneus 3 months Local anasthesia MANIPULATION & CASTING

MANIPULATION AND CASTING

DENNIS BROWN SPLINT (3 months)

RELAPS

MANIPULATION CASTING

SURGERY :

New Concept of Treating Congenital Clubfoot

Good correction a la carte approach Incision : 1. Hockey stick / posteromedial Turco 2. Circumferential Cincinnati 3. Two incision Carroll Navicular Reduced : - Pin centrally in the head of talus - Pin in line with the first metatarsal

New Concept of Treating Congenital Clubfoot

Complication Surgery :
1. Recurrence
2. Over correction 3. Stiffness 4. Pain

Age of Patient at Time of Revision

Step Method of Treament 1 2 3 Revision soft-tissue clubfoot release If prominent plantar crease, add plantar release If forefoot adductus is not corrected, add capsulotomies (navicular-first cuneiform or first cuneifor-first metatarsal) as needed If forefoot adductus is not fully corrected after steps 1, 2, and 3, add excision of cartilage of calcaneocuboid joint or decancellation of cuboid If forefoot adductus is not fully corrected after steps 1 through 4, add one of the following steps Fusion of calcaneocuboid joint (Dillwyn Evans procedure) Excision of distal part of calcaneus (Lichtblau procedure) Cuboid decancellation Opening-wedge osteotomy of first cuneiform

6 mo to 2 yr

2 to 4 yr

4 to 8 yr

5
5A B 5C 5D

Age of Patient at Time of Revision Step Method of Treament

4 to 8 yr

5E 5F 6

Tarsometatarsal capsulotomies Metatarsal osteotomies (for patients > 5 yr old) If patient has overactive tibialis anterior tendon and weak peroneals, add tibialis anterior tendon transfer If varus angulation of heel remains uncorrected, add osteotomy of heel (Dwyer procedure) Midtarsal osteotomy for persistent cavus Distraction osteogenesis (Ilizarov) as only procedure Triple arthrodesis as only procedure

8 to 10 yr

8 9 10

> 10 yr

New Concept of Treating Congenital Clubfoot

Result Not Completely Normal Goal of Treatment Plantigrade foot Pain free Stable over time Near anatomically normal Normal shoes

No satisfactory standardized evaluation Radiology no correlation with the function

Celebrities/Athletes born with Clubfeet:

Kristi Yamaguchi: 1992 Olympic Figure Skating Gold Medalist: treated with serial manipulations/casting

Troy Aikman: Quarterback Dallas Cowboys: treated with serial manipulations/casting

Source : The American Academy of Orthopaedic Surgeons (AAOS) - Information on Clubfoot The American Orthopaedic Foot and Ankle Society