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Pathology and
Non-surgical Treatment of
Congenital Clubfoot
Dr. Irfan Ali ShujahB.Victoria Hospital
Bwpr, Pak
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OVERVIEW Definition
Epedemiology Types of Clubfoot
Etiology
Components
Pathology
Diagnosis
Classification
Non-Surgical Treatment
Management of Recurrence
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Normal Foot
Complex organ that is required to be:
StableResilient
Mobile
Cosmetic
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Club Foot
( Congenital Talipes EquinoVarus )
A condition in which one or bothfeet are twisted into an abnormal
position at birth.
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Definitions
Talipes:Talus = Ankle
Pes = Foot
Equinus: Horse
Foot that is in a position of
planter flexion at the ankle,Looks like that of the Horses foot
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Planus: Flat Foot
Cavus: Highly Arched Foot
Varus: Heel going towards midline
Valgus: Heel going away from midline
Adduction: Forefoot going towards midline
Abduction: Forefoot going away from midline
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Epidemiology
Incidence 1 : 1,000 live births
Sporadic
Bilateral in 50%
Males 65%
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Types of Clubfoot
Flexible (Postural)
Rigid (Structural)
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Etiology
Primary Germ Plasm defect in Talus
Primary Soft tissue abnormalities
Arrested fetal development
Abnormal Intra-uterine forces
( Oligohydramnios, Amniotic Band Syndrome )
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Components of ClubFoot
Cavus
Adduction
Varus
Equinus
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Pathology
Osseous Changes
Soft Tissue Anomalies/Changes
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Osseous Changes
TALUS
- Diminished in size
- Medial & Plantarward deviation of
the head, neck and articular facet
- Neck internally rotated, Body ext. rotated
CALCANEUS
- Hypoplastic, Inverted under the Talus
- Post. EndUpward and Laterally
- Ant. End Downward and Medially
- Tuberosity towards Lat. Mal. posteriorly
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NAVICULAR
- Severe Medial Positioning- Articulates with Tibia
CUBOID
- Displaced medially on Calcaneus
FOREFOOT
- Metatarsals and Phalanges Adducted
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Soft Tissue Changes
TENDONS
- Tibialis Post, Flexor Hallucis Longus &
Flexor Digitorum Longus contracted
- Abductor Hallucis contracted
- Histologically normal
LIGAMENTS
- Deltoid, TMT & Spring Ligaments contracted- Long and Short planter ligaments
- Histologically normal
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OTHERS-Blood vessels, nerves and skin
adaptively shortened along the
medial and plantar aspects
- Calf circumference, girth and
overall foot size diminished
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Diagnosis
PHYSICAL EXAMINATION
Short Achilles Tendon High and Small heel No creases behind Heel Abnormal crease in middle of
the foot Foot is smaller in unilateral
cases Callosities at abnormal
pressure areas Calf muscles wasting
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Radiologic Evaluation
Antero-Posterior view
Stress Dorsiflexion Lateral view
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Talo-Calcaneal Angle (AP)
(Normal 30-55)
Talo-Calcaneal Angle (LAT.)
(Normal 25-50)
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Talus-1stMetatarsal Angle
Radiographic measurement of forefoot
adduction
Useful in Rx. of Metatarsus Adductus &
Clubfoot
Normal 5-15
Negative in Clubfoot
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Classification
PiranisClassification
Dimeglio et al. Classification
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Pirani Classification of Clubfoot
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Pirani system composed of 10 different Physical
Examination Findings
0 for No Abnormality
0.5 for Moderate Abnormality
1 for Severe Abnormality
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Dimeglio et. al Classification
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In Dimeglio et. al system, 4 parameters are
assessed on the basis of their Reducibility with
gentle manipulation measured with goniometer.
Equinus Deviation Adduction Deviation
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Treatment
Each day the foot remains deformed
is a day of golden opportunity lost forever.
- Lenoir
NON-SURGICAL / CONSERVATIVE
SURGICAL
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Non-Surgical Treatment
Manipulation and Casting
Splints to Maintain Correction
- Ankle-Foot Arthrosis (AFO)
- Denis Brown Splint
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Ponseti Casting
Abundant young wavy collagen - easilystretched
Navicular, Cuboid & Calcaneus can be
abducted back under Talus without surgeryMost widely accepted technique
Success rate >90% of children 2yrs & younger
Recurrence rate 10-30%
Ideally is used in New borns
Success rates are lower in Older children
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Treatment Phase of Ponseti Casting
o Should begin ASAP .. Within 1stweek of life
o Gentle manipulation and casting weekly
Order of Correction1. Correction of forefoot Cavus & Adduction
2. Correction of Heel Varus
3. Correction of hindfoot Equinus
Generally 5-6 casts are required
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First apply short leg castbelow kneeThen extend above knee
when plaster sets.
Long Leg Casts are essential
1stcast removed after 1 week
1 minute of gentlemanipulation and re-castingfocusing on Abducting thefoot around head of Talusmaintaining Supinatedposition
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Never pronate
Never manipulate the heel directly
Casting in gradual abduction for 2-3weeks
Percutaneous Tendo-AchillesTenotomy under local anesthesia,followed by final cast
Final Cast is applied in maximallyAbducted position (70 degrees) andDorsiflexion in 15 degrees for 3 weeks
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Percutaneous TA Tenotomy
S i f C i
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Series of Castings
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Maintenace Phase of Ponsati Casting
Final Cast is removed after 3 weeksAFO
Abduction 70 degrees
Dorsiflexion 15 degrees
Distance btw the shoes is 1 inch wider than
the width of infants shoulders
Brace is worn 23hrs/day (3 months)
then while sleeping (2-3 years)
Brace compliance is very important
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M f R
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Management of Recurrence
Infrequent if Bracing protocol is followed closely
Repeated manipulation and casting
1stcast with dorsiflexion of 1stray if Cavus
Subsequent castings with Abduction and
ultimately ankle dorsiflexion
Achilles Tendon Lengthening and Ant. Tibial
Tendon transfer may be required
S
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Summary
4 Components of Clubfoot deformity CAVE
Bony and Soft tissue adaptive Changes
Pirani and Dimeglio Classification systems
Non-Surgical treatment should start ideallywithin 1st week
Ponsati Casting is worldwide accepted
technique
Brace wear Compliance is important
Recurrence is treated with Re-manipulation
and casting
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