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http://upload.orthobullets.com/topic/4062/images/Hindfoot Paralellism - courtesy Miller_moved.png
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Introduction
  • Idiopathic deformity of the foot of unclear etiology
  • Epidemiology
    • demographics
      • most common birth defect
      • 1:250 to 1:1000 depending on population
      • highest prevalence in Hawaiians and Maoris
      • more common in males
    • location
      • half of cases are bilateral
  • Genetics
    • genetic etiology is strongly suggested
    • unaffected parents with affected child have 2.5% - 6.5% chance of having another child with a clubfoot
    • familial occurrence in 25%
    • recent link to PITX1, transcription factor critical for limb development
    • common genetic pathway may exist with congenital vertical talus  
  • Associated conditions
    • hand anomalies (Streeter dysplasia) 
    • diastrophic dysplasia  
    • arthrogryposis  
    • tibial hemimelia 
    • myelodysplasia  
    • amniotic band syndrome
    • Pierre Robin syndrome
    • Opitz syndrome
    • Larsen syndrome
    • prune-belly syndrome
    • absent anterior tibial artery
Anatomy
  • Muscles contractures lead to the characteristic deformity that includes (CAVE)     
    • midfoot Cavus (tight intrinsics, FHL, FDL)
    • forefoot Adductus (tight tibialis posterior)
    • hindfoot Varus (tight tendoachilles, tibialis posterior, tibialis anterior)
    • hindfoot Equinus (tight tendoachilles)
  • Bony deformity consists of
    • talar neck is medially and plantarly deviated
    • calcaneus is in varus and rotated medially around talus
    • navicular and cuboid are displaced medially
  • Table of foot deformity muscle imbalances 
Presentation
  • Physical exam
    • inspection
      • small foot and calf 
      • shortened tibia
      • medial and posterior foot skin creases
      • foot deformities
        • hindfoot in equinus and varus
          • differentiated from more common positional foot deformities by rigid equinus and resistance to passive correction
        • midfoot in cavus
        • forefoot in adduction
Imaging
  • Radiographs
    • recommended views
      • dorsiflexion lateral (Turco view)
        • shows hindfoot parallelism between the talus and calcaneus 
        • will see talocalcaneal angle < 35° and flat talar head (normal is talocalcaneal angle >35°)
      • AP
        • talocalcaneal (Kite) angle is < 20° (normal is 20-40°) 
        • talus-first metatarsal angle is negative (normal is 0-20°)
        • also shows hindfoot parallelism
  • Ultrasound 
    • helpful in prenatal diagnosis (high false positive rate)
    • can be diagnosed as early as 12 weeks of gestational age 
Treatment
  • Nonoperative
    • serial manipulation and casting (Ponseti method)    
      • indications
        • there has been a trend away from surgery and towards the nonoperative Ponseti method due to improved long term results
      • outcomes
        • Ponseti method has 90% success rate
        • with appropriate treatment, children can be expected to walk and run 
  • Operative 
    • posteromedial soft tissue release and tendon lengthening
      • indications
        • resistant feet in young children
        • "rocker bottom" feet that develop as a result of serial casting 
        • syndrome-associated clubfoot
        • delayed presentation >1-2 years of age
        • performed at 9-10 months of age so the child can be ambulatory at one year of age
      • outcomes
        • requires postoperative casting for optimal results
        • extent of soft-tissue release correlates inversely with long-term function of the foot and patient 
    • medial column lenthening or lateral column-shortening osteotomy, or cuboid decancellation
      • indications
        • older children from 3 to 10 years
    • triple arthrodesis
      • indications
        • in refractory clubfoot at 8-10 years of age
        • contraindicated in insensate feet due to rigidity and resultant ulceration
    • talectomy
      • indications
        •  salvage procedure in older children (8-10 yrs) with an insensate foot
    • multiplanar supramalleolar osteotomy  
      • indications
        • salvage procedure in older children with complex, rigid, multiplanar clubfoot deformities that have failed conventional operative management
    • gradual correction by means of ring fixator (Taylor Spatial Frame) application
      • complex deformity resistant to standard methods of treatment
Techniques
  • Serial manipulation and casting (long leg cast)  
    • goal is to rotate foot laterally around a fixed talus
    • order of correction (CAVE)
      1. midfoot cavus
      2. forefoot adductus
      3. hindfoot varus
      4. hindfoot equinus
Ponseti Method
Month 1-4 Weekly serial casting (with knee in 90° of flexion ) with forefoot supination, then forefoot abduction

• First correct cavus with forefoot SUPINATED (NOT pronation) by aligning the plantar-flexed 1st MT with the remaining metatarsals (forcible pronation would increase cavus deformity as the 1st MT is plantar-flexed further) 
• Secondly correct adduction and heel varus by rotating calcaneus and forefoot around talus (head of talus acts as a fulcrum) into forefoot ABDUCTION

Tendoachilles lengthening (TAL) at week 8 required in 80%

• Equinus correction last with tendinoachilles lengthening (TAL)
• Perform when foot is 70° abducted and heel is in valgus   
• Ponseti method uses a complete transverse cut of achilles
• Cast in maximal dorsiflexion after TAL

Month 4-8 Foot abduction orthosis (FAO) 
• 23 hours a day for 3 months after correction 
• night time/nap time only until age 4 years

• With Denis-Brown bar in external rotation (70° in clubfoot and 40° in normal foot) 
• Fit FAO on day of TAL

2-4 years Tibialis anterior tendon transfer (TA transfer) q at 2 yrs of age (10-20% will require)

• 10-20% will need TA transfer with or without repeat TAL for recurrent supination, varus, and/or equinus
• Indicated if the patient demonstrates supination of the foot during dorsiflexion (a dynamic intoeing gait)

 

French Method
Correction Phase

• Daily corrective manipulations of the clubfoot are performed by an experienced physical therapist and the correction is held with elastic taping  and splints until the next day's session. 

• Family participation is integral to the success of this treatment program as the family must be able to bring the infant to therapy during the week for 1-3 months

• Each session lasts approximately 30 mins per foot and manipulations are performed in a progressive gentle pattern

• Begin with derotation of the calcaneopedal block and correction of forefoot adduction through massage of the Achilles tendon and gastrocnemius muscle 

• Next, medial soft tissues are stretched to allow the navicular to move away from the medial malleolus and its medial position on the head of the talus Distraction of the forefoot and midfoot helps to loosen the tightened structures, and derotation of the foot facilitates reduction of the talus  

• To maintain the gain achieved in passive range of motion, the toe extensors and peroneals are recruited by stimulating (tickling) the lateral border of the foot and leg and the tops of the toes

• Once the talonavicular joint has been reduced, attention is directed toward the correction of varus and equinus. With the valgus maneuver, the calcaneus gradually moves to a neutral and eventually valgus position . The ankle is externally rotated at the same time that the calcaneus is being mobilized into valgus. The knee should be kept at 90° during these maneuvers

• Equinus is corrected with gradual dorsiflexion of the foot. Correction of equinus can be augmented with a percutaneous heel cord tenotomy

Maintenance Phase

• Fewer visits to the therapist are needed as the parents assume the daily treatment exercises and taping

• Periodic follow-up is needed to monitor the range of motion of the foot and the development of the infant and to fabricate new splints

• Once the patient is walking, taping is discontinued and a resting ankle-foot orthosis is used during nighttime and naps until the age of two years.

• Throughout this treatment program, the patient visits the physician every two to three months for evaluation of the foot

 

Complications
  • Complications with nonoperative treatment
    • deformity relapse
      • relapse in child < 2 years
        • early relapse usually the result of noncompliance with FAO
        • treat with repeat casting
      • relapse in child > 2 years
        • treat initially with casting
        • consider tibialis anterior tendon transfer to lateral cuneiform (can only perform if lateral cuneiform is ossified)
        • consider repeat Achilles tendon lengthening
    • dynamic supination
      • treat with whole anterior tibial tendon transfer (preferred in OITE question over split anterior tibial tendon transfer)    
  • Complications with surgical treatment 
    • residual cavus
      • result of placement of navicular in dorsally subluxed position q
    • pes planus
      • results from overcorrection
    • undercorrection
    • intoeing gait
    • osteonecrosis of talus
      • results from vascular insult to talus resulting in osteonecrosis and collapse
    • dorsal bunion    
      • caused by dorsiflexed first metatarsal (FHB and abductor hallucis overpull secondary to weak plantar flexion) and overactivity of anterior tibialis
      • treat with capsulotomy, FHL lengthening, and FHB flexor to extensor transfer at MTP joint
 

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