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Pediatric Clubfoot Deformity

Pediatric Clubfoot Deformity. Darren Groberg PGY 1 03/31/10. Congenital vs. Aquired. Congenital: 1/1000 births, 50% bilateral. Subdivided into Intrinsic (rigid). Extrinsic (supple) Unknown origin Many theories – most common being… Theory of primary osseous deformity. Aquired:

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Pediatric Clubfoot Deformity

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  1. Pediatric Clubfoot Deformity Darren Groberg PGY 1 03/31/10

  2. Congenital vs. Aquired Congenital: 1/1000 births, 50% bilateral. Subdivided into Intrinsic (rigid). Extrinsic (supple) Unknown origin Many theories – most common being… Theory of primary osseous deformity Aquired: Neuromuscular conditions Meningitis Poliomyelitis Postcerebral vascular accident Cerebral palsy (Little's syndrome) Spinal deformity or spinal tumor Diastematomyelia Posttraumatic effects Spinal cord trauma Peripheral nerve trauma Tendon laceration or avulsion Fracture malunion or nonunion Volkmann's contracture Postburn contracture McGlamry 945, table 1

  3. Primary osseous deformity First described by Adams in 1866 as an intrinsic Talar deformity. Specifically malformation of the head and neck. Normal is 15-20 degrees adduction in transverse plane from Talar body. Increased to 45-65 degrees in clubfoot. Yields extreme medial rotation often with no articulation.

  4. Pathologic Anatomy Components Equinus Varus Adduction

  5. Osseous Talus: Diminished in size (three-fourths of normal size); positioned in severe equinus Medial and plantarward deviation of the head, neck, and articular facets Lateral positioning and anterior positioning in the ankle mortise Calcaneus: Diminished in size; hypoplastic Varus, equinus, and supinatory displacement beneath talus Navicular: Diminished in size (two-thirds of normal size)Severe medial positioning Articulates with tibia Remaining lesser tarsus: Normal morphology; adaptive changes corresponding to deformity of peritalar complex Forefoot: Metatarsals and phalanges adducted and varus rotated First ray extremely plantarflexed in intrinsic deformity McGlamry 946 table 2./Coughlan & Mann 1729-1730

  6. Soft Tissue Tendons: Contracted triceps surae, posterior tibial, flexor hallucis longus, and flexor digitorum longus Anterior tibial and long extensors medially displaced Peroneals elongated and often posteriorly displaced Plantar intrinsics, plantar fascia, long and short plantar ligaments contracted Tendons histologically normal; changes secondary and adaptive Abductor hallucis contracted, bowstrung Ligaments: Posterior ankle, subtalar ligaments contracted Calcaneofibular and posterior talofibular, tibionavicular ligaments contracted Deltoid and calcaneonavicular (spring) ligaments contracted Tarsometatarsal ligaments medially contracted Ligaments histologically normal; changes secondary and adaptive Other: Blood vessels, skin and nerves adaptively shortened along the medial and plantar aspects Calf circumference and girth, as well as overall foot size, diminished McGlamry 946 table 2./Coughlan & Mann 1729-1730

  7. Radiologic assessment • Standard radiographs should include AP and dorsiflexion lateral stress views. • Important angles include • Talocalcaneal AP (normal 30-55) • Talocalcaneal (25-50), Tibiocalcaneal (10-40), lateral • Talometatarsal (5-15) AP • "The most common cause of recurrent clubfoot is unrecognized, uncorrected clubfoot."

  8. Treatment Each day the foot remains deformed is a day of golden opportunity lost forever Lenoir-

  9. Conservative Staged manipulation and casting Stretching Cast maintains repositioned foot Earlier the better. Surgical Soft tissue Posterior release Posterior medial release Lateral circumferential release Osseous procedures Lateral column shortening (preserve growth plates in children) Medial column lengthening

  10. Ponseti Poor outcomes to aggressive surgical correction. Histology: abundant young wavy collagen, easily stretched Navicular, cuboid and calcaneus could be abducted back under talus without surgery.

  11. Ponseti Technique All deformities will be addressed simultaneously except for equinus. Reduce the Cavus Cavus foot secondary to pronation of forefoot vs hindfoot. Requires only supination to achieve normal longitudinal arch.

  12. Manipulation Locate lateral head of the talus Stabilize head of talus with thumb This will be pivot point for abduction of forefoot. Abduct forefoot in supination as far as possible without causing discomfort Hold for a short period of time and repeat

  13. Cast Application ***Maintain corrected position of foot while casting*** Apply thin layer of cast padding. Using plaster cast begin at the toes and wrap proximally to just below the knee. Mold cast to conform to corrected foot without creating pressure points, calcaneus is not manipulated. Extend padding and cast beyond flexed knee for stability.

  14. Series of casts

  15. Equinus and tenotomy When is the right time to address it? When anterior calcaneus can be abducted from underneath the talus. Can palpate anterior process 60 degrees abduction possible Will allow dorsiflexion without crushing talus. Tenotomy performed in clinic, percutaneously, 1.5 cm above calcaneal insertion. Release will provide additional 20-25 degrees dorsiflexion. Apply 5th (post tenotomy) cast. Remove after 3 weeks. Maintain correction with shoes etc.

  16. Management of Congenital TalipesEquinovarus by Ponseti Technique:A Clinical Study • Evaluate early ponseti intervention vs. other manipulation and surgery. • Study: • Included 100 patients, 156 feet. • Avg. age 4.5 months. • Primary assessment with Pirani score and photographs. • Results: • Initial Pirani 4.26, mean FPA (foot print angle) 14.2 degrees • Post Pirani 1.3, mean FPA 10.1 degrees • 96 % required Percutaneous TA tenotomy. • Conclusion: early, accurate Ponseti technique decreases need for significant surgical intervention. Mazhar A, Et Al, “Management of Congenital…”, JFAS 47(6):541/545, 2008

  17. References Mazhar A, Et Al, “ Management of Congenital Talipes Equinovarus by Ponseti Technique: A clinical study”, JFAS 47(6):541-545, 2008 Banks A, “Foot and Ankle Surgery”, McGlamry’s comprehensive testbook, volume 1, edition 3, Ch 29 pg 943-974 Coughlin M, Et Al, “Surgery of the foot and ankle” Ch 29, Congenital foot deformities. Ponseti IV, “Clubfoot: Ponseti management”, Second edition, Global health organization, 2003 Laaveg SJ, Ponseti IV, “Long-term results of treatment of congenital club foot:, J Bone Joint Surg Am. 1980; 62: 23-31 Bradford EH, “Treatment of Club-Foot”, J Bone Joint Surg Am. 1889; s1-1: 89-115 Colburn M, “Evaluation of the treatment of idiopathic clubfoot by using the Ponseti technique”, JFAS 42(5):259-267, 2003

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