Treatment of Clubfoot deformities

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Treatment of Clubfoot deformities

• Prof. Dr. Greta Dereymaeker, MD, PhD
• Catholic University of Leuven Department of
  Biomechanics
• University Hospital of Antwerp
• Member of Artsen zonder Vakantie - MSV
• Belgium

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CLUBFOOT

• Treatment algoritm
• Primary
• Neglected Clubfoot

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Talipes equinovarus

• 0.5 - 1 of all babies born alive
• Genetic factor?? - unknown origin
• 70 boys
• 50 bilateral cases
• Often associated with other orthopaedic
  deformities hipdysplasia and spine!
• Intra-uterine malposition or intra-uterine growth
  disturbance
• Neurological defects

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Pathology

• Abnormal positioning of hindfoot bones
• Talus quite often deformed
• Calcaneum
• Navicular
• Soft tissue retraction and stifness especially
  posterior and medial side
• Stifness of the postero-medial capsule of
• Tibio-talar and subtalar joint
• Talo-navicular joint
• Achilles tendon
• Tibialis posterior
• Flexor hallucis longus
• Flexor digitorum longus
• Leg and Foot dystrofia is often present

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Classification

• Ponsetti
• Supple
• Rigid
• Teratologic
• Dimeglio
• Soft-soft benign supple (intra-uterine
  malposition)
• Soft-Stiff semi-rigid form ( but reducable)
• Stiff-Soft more rigid and resistant to reduction
• Stiff-Stiff Not reducable (arthrogryposis,
  teratologic)

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Treatment (1)

• At Birth as soon as possible
• Make a classification
• Look for other orthopaedic deformities
• Hip
• Spine
• Start manipulations or
• Corrective casting
• First correction of adductus of midfoot
• Folowed by correction of heel varus
• Finally correction of the equinus

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How do we do corrective serial casting?
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Casting technique video
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Treatment (2)

• At 6 to 8 weeks
• Corrective serial casting weekly to 2 weekly
• Continue progressive correction of the equinus of
  the hindfoot
• Keeping foot in pronation correction of adductus
  of midfoot
• ?Cave Rocker Bottom !!!!
• If no correction of equinus can be obtained of
  the hindfoot
• ?Consider subcutaneous Achilles tendon
  lengthening
• Continue corrective serial casting up to 3months

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Treatment (3)

• At 3 months upto 1 year
• Dennis Brown splint or abduction boot with spring
  when sleeping during day and night
• Continue careful observation for recurrence of
  deformity
• When starting making efforts to walk wear
  straigth shrank or abducted shrank shoe
• When full correction is obtained at 1 year or
  walking
• Continue with normal shoewear
• Discontinue nightsplints
• Observe for leg length discrepancy

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Treatment (4)

• At 8 months to 1 year
• In case of recurrence of deformity specially
• varus of heel and/or
• adduction of midfoot
• Consider surgical correction
• Continue corrective casting 2 to 3 weekly for at
  least 12 weeks
• Until walkingwhen sleeping during day and night
• Dennis Brown splints or
• Abduction boot with spring

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Treatment (4)

• Consider surgical correction
• at 8 months to 1 year
• Open Achilles tendon lengthening
• Lengthening of tendons
• Tibialis posterior
• Flexor Hallucis longus
• Flexor digitorum longus
• Posteromedial release
• tibio-talar joint and subtalar joint
• Reduction of talus in the ankle mortise
• Release of talo-navicular /- Nav-cuneiform joint
• Fixation of Talo-navicular-cuneiform joints by
  K-wire

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Postero-medial Release

• Differentiate, dissect and free
• Flexor Hallucis Longus
• Neurovascular Bundle mark with vessel loop
• Tibialis posterior
• Flexor Digitorum Longus
• Open tibiotalar joint and remove part of the
  capsule
• Retact Neurovascular Bundle anterior/ FHL medial
• Open subtalar capsule
• Following the FHL at his lateral site

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Posterior Capsulectomy

• Tibio talar joint and subtalar joint
• Retract Neurovascular bundle anterior
• Retract FHL medial and follow distal part
• Move the foot up and down
• Section capsule with eletric bistouri
• Remove part of the capsule if necessary
• Go up to fibula posterior border

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Treatment (5)

• Up to 12 years- Adolescence
• In case of recurrence of deformity
• varus of heel
• And/or adduction of midfoot
• Still consider surgical correction
• Soft tissue
• Bony procedures
• Osteotomies
• Arthrodesis
• Corrective casting until consolidation of bony
  procedures

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Treatment (5)

• In Adolescence surgical correction à la
  carte
• Open Achilles tendon lengthening
• Posteromedial release of tibio-talar joint and
  subtalar joint
• Eventually lengthening of
• the tibialis posterior tendon
• flexor tendons
• Release of soft tissues around talo-navicular-cune
  iform joint
• Osteotomy of calcaneus Dwyer procedure to
  correct varus of heel
• Osteotomy of Cuboid of
• Osteotomies of the midfoot at base of
  metatarsals to abduct and pronate forefoot
• Reduction of
• The talus in the ankle mortise
• Subtalar and chopart joint
• If necessary Triple arthrodesis
• Rotational skinflap over dorsum of the foot

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Treatment (6)

• In the adult foot Surgery ? à la carte?
• Treatment adapted to major deformity location
• Open Achilles tendon lengthening
• Posteromedial release of tibio-talar joint and
  subtalar joint
• Release of talo-navicular joint cut
  springligament
• Triple arthrodesis
• Talectomy in severe cases
• /-Lengthening of the tibialis posterior tendon-
  FHL and FDL
• Rotation of skinflap over dorsal of foot

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Treatment (6)

• In adolescence and the adult foot
• Surgery ? à la carte?
• Treatment adapted to major deformity location
• Post operative follow-up important
• Serial casting until consolidation of the bony
  procedures
• Keep foot aligned with orthosis during at least
  1year
• Dynamic splints during the day if neccessary

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Untreated congenital clubfeet 14year old boy
February 2005
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Bilateral congenital untreated clubfeet
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14 months after surgery

• Posteromedial capsulectomy
• Tendon lengthening A/TP/FDL/DHL
• Triple arthrodesis

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17 year old boy congenital untreated clubfeet

• February 2005

View from anterior
View from posterior
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17 year old boy congenital clubfeet

• February 2005

View from anterior
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17year old boy congenital clubfoot
14 months after Bilateral talectomy and
posteromedial release
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14 months after bilateral talectomie