Clubfoot

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Introduction

  • Clubfoot is predominantly a hindfoot deformity caused by malalignment of the calcaneo-talo-navicular complex
  • The components of deformity are
    • Plantar flexion of the 1st ray
    • Adduction of the forefoot / midfoot on the hindfoot
    • Varus and equinus of the hindfoot
    • The mnemonic CAVE (cavus, adductus, varus, equinus) is useful in remembering the components of this deformity

Pathogenesis

  • Although numerous theories have been proposed, the aetiology is multifactorial and likely involves the effects of environmental factors in a genetically susceptible host
  • There is abnormal tarsal morphology
    • Plantar and medial deviation of the head and neck of the talus
    • Abnormal relationships between the tarsal bones in all three planes
    • Contracture of the soft tissues on the plantar and medial aspects of the foot

Natural History

  • Congenital clubfoot is seen in approximately 1/1,000 births
  • The risk is approximately 1 in 4, when both a parent and one sibling have clubfeet
  • It occurs more commonly in males (2 : 1)
  • Bilateral in 50% of cases

Clinical Presentation

  • Infant demonstrates
    • Forefoot cavus and adductus
    • Hindfoot varus and equines
  • There is a range in the degree of flexibility
  • All patients will exhibit calf atrophy
  • Some cases have both internal tibial torsion and shortening of the ipsilateral extremity
  • A complete physical examination should be performed to rule out coexisting musculoskeletal and neuromuscular problems
  • The spine should be inspected for signs of occult dysraphism

Imaging and Diagnostic Studies

  • Many clinicians reserve radiographs for older children with persistent or recurrent deformities
  • AP and lateral radiographs are most commonly used to obtain radiographic measurements to describe the malalignment between the tarsal bones
  • Most clinicians will hold the foot in the maximally corrected position
  • A common radiographic finding is "parallelism" between lines drawn through the axis of the talus and the calcaneus on the lateral radiograph, indicating hindfoot varus

Treatment

  • Immediate non operative treatment is recommended for all infants following birth
  • These include techniques such as manipulation and casting (Ponseti method) or functional treatment (French method)

Ponseti method

  • The Ponseti method involves a specific technique for manipulation and serial casting
  • May be best described as minimally invasive rather than non operative
  • The order of correction follows the mnemonic CAVE (described above)
  • Weekly cast changes are performed
  • Overall, 5-10 casts are typically required
  • The most difficult deformity to correct is the hindfoot equinus
    • 90% of patients will require an outpatient percutaneous tenotomy of the heel cord 
    • A long leg cast with the foot in maximal abduction (70 degrees) and dorsi-flexion is worn for 3 weeks following tenotomy
  • Then a bracing program begins
    • Full time brace for 3 months
    • Night-time brace for 3-5 years
  • A subset of patients will require transfer of the tibialis anterior tendon to the middle cuneiform for recurrence
  • Compliance with the splinting program is essential, as recurrence is common if the brace is not worn as recommended

French method

  • Functional treatment or the "French method" is performed while the baby sleeps and involves
    • Daily manipulations
    • Splinting with elastic tape
    • Continuous passive motion (machine required)
  • While the early results are promising, the method is labor intensive
  • It remains unclear whether the technique will achieve greater popularity in the United States

Surgery

  • Surgical realignment has a definite role in the management of clubfeet, especially in
    • Congenital clubfeet that have failed non operative or minimally invasive methods
    • Neuromuscular and syndromic clubfeet that are characteristically rigid
  • In resistant cases, non operative methods such as the Ponseti technique may potentially be of value in decreasing the magnitude of surgery required
  • Common surgical approaches include
    • Release of the involved joints (realign the tarsal bones)
    • Lengthening of the shortened posteromedial musculotendinous units
    • Pinning of the foot in the corrected position
  • The specific procedure is tailored to the unique characteristics of each deformity
  • Bony procedures (osteotomies), in addition to soft-tissue surgery, may be required for
    • Older children with untreated clubfeet
    • Recurrence
    • Residual deformity
  • Triple arthrodesis is reserved as salvage for painful, deformed feet in adolescents and adults

Outcome

  • The results of the Ponseti method are excellent at up to 40 year of follow-up
  • The early results of functional method are promising
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