ClubfootClubfoot deformation of the shape deformation of the shape

of the foot and impairment of the foot and impairment of functionof function

ClubfootClubfootEtiologyEtiology UnknownUnknown Most likely a Most likely a

combination of combination of genetic and genetic and environmental environmental factorsfactors

IncidenceIncidence

0,4-0,4-1:1000 live births1:1000 live births Male : Female 2:1Male : Female 2:1 50% Bilatera50% Bilaterall

Location of deformityLocation of deformity

Forefoot-phalanges Forefoot-phalanges and metatarsaland metatarsal

Midfoot-cuboid Midfoot-cuboid navicular navicular cuneiformscuneiforms

Hindfoot-talus Hindfoot-talus calcaneuscalcaneus

Plane of deformityPlane of deformity In the hindfoot, In the hindfoot,

coronalrotation coronalrotation produces heel varus produces heel varus (medial) or valgus (medial) or valgus (lateral)(lateral)

Sagital plane rotation Sagital plane rotation of the the hindfoot of the the hindfoot produced equinus produced equinus (plantarflexion) or (plantarflexion) or calcaneus (dorsiflexion) calcaneus (dorsiflexion)

Plane of deformityPlane of deformity

Coronal rotation of Coronal rotation of the midfoot and the midfoot and forefoot is forefoot is discribed as discribed as adduction or adduction or abduction as it abduction as it relates to medial relates to medial or laterl deviation or laterl deviation of the footof the foot

Plane of deformityPlane of deformity

Pronation and Pronation and supination are supination are axial rotations axial rotations through the through the midfoot and the midfoot and the midfoot-forefoot midfoot-forefoot articulationarticulation

Equinus deformity Equinus deformity

Supination & heel varusSupination & heel varus

Forefoot adductionForefoot adduction

Pathology – bonesPathology – bones

Talus abnormal relationships including:Talus abnormal relationships including: anterior extrusion of the body of the anterior extrusion of the body of the

talustalus external rotation of the body in the external rotation of the body in the

ankle mortise, equinusankle mortise, equinus medial and plantar deviation of the medial and plantar deviation of the

neck of the talusneck of the talus

Pathology – bonesPathology – bones

Calcaneus - Equinus, varus, medial Calcaneus - Equinus, varus, medial rotationrotation

Navicular, cuboid – medial subluxationNavicular, cuboid – medial subluxation Forefoot - adducted and supinated, Forefoot - adducted and supinated,

cavus in severe casescavus in severe cases Femur, tibia and fibula - the entire Femur, tibia and fibula - the entire

lower limb can be shorterlower limb can be shorter

Pathology – bonesPathology – bones

Pathology – musclesPathology – muscles

Imbalance of type I and II, fibrosis Imbalance of type I and II, fibrosis caused by infiltration of fibroblastcaused by infiltration of fibroblast

Atrophy of the leg especially in Atrophy of the leg especially in peroneal group, triceps surae, peroneal group, triceps surae, ttibibialisialis post posteriorerior, FDL,FHL are , FDL,FHL are contracted contracted

Pathology - soft tissuesPathology - soft tissues

Abnoraml colagen structureAbnoraml colagen structure Tendon sheaths - o frequently thickenedTendon sheaths - o frequently thickened Joint capsules – severe cases: Joint capsules – severe cases:

contractures of ankle, subtalar, contractures of ankle, subtalar, talonavicular, calcaneocuboid talonavicular, calcaneocuboid

Ligaments - severe cases: contractures of Ligaments - severe cases: contractures of calcaneofibular + talofibular ligs, deltoid calcaneofibular + talofibular ligs, deltoid lig, long and short plantar ligs, spring lig, lig, long and short plantar ligs, spring lig, long plantar lig. (bifurcate lig)long plantar lig. (bifurcate lig)

Fascia - contracture of fascial planes and Fascia - contracture of fascial planes and of plantar fasciaof plantar fascia

ClassificationClassification

Postural - postural or positional Postural - postural or positional talipes can be passively fully talipes can be passively fully corrected or even overcorrected corrected or even overcorrected

FixedFixed

1. Flexible1. Flexible

2. Resistant2. Resistant

Classification – DimeglioClassification – Dimeglio

soft-soft – postural (20%)soft-soft – postural (20%) soft-stiff – correction in saggital and soft-stiff – correction in saggital and

horizontal planes over 50%, hindfoot horizontal planes over 50%, hindfoot varus 20varus 20 (33%) (33%)

stiff-soft - correction in saggital and stiff-soft - correction in saggital and horizontal planes below 50% (35%)horizontal planes below 50% (35%)

stiff-stiff – correction of equinus and stiff-stiff – correction of equinus and varus less than 20%, hindfoot varus varus less than 20%, hindfoot varus 4545 (12%) (12%)

TreatmentTreatment

Treatment and outcomes depends on Treatment and outcomes depends on degree of deformationdegree of deformation

Non-operative Non-operative OperativeOperative

Non-operativeNon-operative

Series of redression casts applied Series of redression casts applied as early as first 7-10 of lifeas early as first 7-10 of life

Casts changed every 7-14 daysCasts changed every 7-14 days Post treatment options: lower leg Post treatment options: lower leg

splinters, Dennis-Brown orthosis, splinters, Dennis-Brown orthosis, footwear, physiotherapyfootwear, physiotherapy

Ponseti method – Achilles tenotomyPonseti method – Achilles tenotomy After 6-12 weeks x-ray controlAfter 6-12 weeks x-ray control

OperativeOperative treatment treatment

Time of surgery – 6-12 monthsTime of surgery – 6-12 months Type IV – no conservative treatmentType IV – no conservative treatment Restoration of correct position of Restoration of correct position of

bonesbones

Operative treatmentOperative treatment

Posterior releasePosterior release Posteromedial releasePosteromedial release Posteromedial and lateral releasePosteromedial and lateral release Complete peritalar releaseComplete peritalar release

Residual deformitiesResidual deformities

Forfoot adductus – opening wedge Forfoot adductus – opening wedge osteotomy of cuboid, closing wedge osteotomy of cuboid, closing wedge osteotomy of calcaneus, partial resection osteotomy of calcaneus, partial resection of calcaneus Lichtblau, calcaneo-cuboid of calcaneus Lichtblau, calcaneo-cuboid arthrodesis Evans, arthrodesis Evans,

Foot cavus – osteotomy of cvalcaneus Foot cavus – osteotomy of cvalcaneus Dwyer and Dwyer IIDwyer and Dwyer II

Over 12 years – triple arthrodesisOver 12 years – triple arthrodesis Ilizarov method – secondary correctionIlizarov method – secondary correction

Metatarsus adductusMetatarsus adductus

MA is medial MA is medial deviation of the deviation of the forefoot at the level forefoot at the level of the midtarsal jointsof the midtarsal joints

Etiology not Etiology not completely completely understood-packing understood-packing abnormalities abnormalities (abnormal (abnormal mechanical mechanical intrauterine forces)intrauterine forces)

Metatarsus adductusMetatarsus adductustreatmenttreatment

Spontaneus resolution-only Spontaneus resolution-only observationobservation

Home stretching programHome stretching program Serial castsSerial casts SurgerySurgery

CONGENITAL FLATFOOT (Planovalgus)CONGENITAL FLATFOOT (Planovalgus)

Deformity Deformity consisting:consisting: Hindfoot valgusHindfoot valgus Midfoot supination Midfoot supination

and abductionand abduction Deviation of plantar Deviation of plantar

arch arch Treatment- surgeryTreatment- surgery

Calcaneovalgus footCalcaneovalgus foot

The foot is in The foot is in extreme extreme dorsiflexiondorsiflexion

Treatment:Treatment: Home stretching Home stretching

programprogram Serial castsSerial casts SurgerySurgery