INVESTIGATING CLUBFOOT AND
ITS POSSIBLE TREATMENTS
By Russel Connery
11-19-09
Advisor – Dr. Andrew Mazz Marry
Outline of presentation
 Introduction
 1st Article “Clubfoot”
 2nd Article “Clinical assessment and gait
parameters”
 3rd Article “Physiotherapy versus Ponseti
casting”
 4th Article “Ossific nuclei and cartilaginous
anlagen in CF by 3-D MRI”
 Conclusion
What is Clubfoot?
 A.K.A Congenital Talipes Equinovarus (TEV)
 Congenital – present at birth
 Very common
 50/50 unilateral or bilateral
 More frequent in males 3:1
 Untreated makes people appear to be
walking on the sides of their feet
What it looks like
Yahoo! Images - Clubfoot
Two main classes
 Structural TEV and Postural TEV
 Both appear same, but have different causes
 Structural TEV- genetics
 Postural TEV- external influenced
Structural TEV
 Genetic factors such as Edwards Syndrome
 Edwards syndrome- 3 copies of Chromosome
18
 Compartment syndrome- injury, repetitive
/extensive muscle use, overall impairs blood
supply
 Family history – single dominant gene = 33%
chance
Edwards Syndrome
 Part or all of extra 18th chromosome
 2nd most common trisomy after down
syndrome
 1/3000 births, causes 5-10% CF
 Most infants die due to organ abnormalities
 Chances increase by old aged mothers
Postural TEV
 External factors
 Intrauterine compression from
oligohydraminos- amniotic fluid
(nourishment) deficiency
 Amniotic band syndrome- entrapment of
fetal parts in amniotic bands while in the
uterus.
Postural TEV continued
 Breech presentation – possible cause
 CF sometimes associated with Spina Bifida
 Ecstasy and smoking
http://www.abc.net.au/science/news/img/health/sbifida111103.jpg
Why this topic
 Born with unilateral Postural CF, and CF only
 Use my major to gain some knowledge about
myself.
Outline of presentation
 Introduction
 1st Article “Clubfoot”
 2nd Article “Clinical assessment and gait
parameters”
 3rd Article “Physiotherapy versus Ponseti
casting”
 4th Article “Ossific nuclei and cartilaginous
anlagen in CF by 3-D MRI”
 Conclusion
“Clubfoot”
 Stephan James Cooke, Birender Balain,
Cronan Christopher Kerin, Nigel Terrence
Kiely.
Foot development
 3 phases:
 Initial- 5-6 weeks, foot develops in line with
the leg
 Embryonic- 6-7 weeks, a lot of fibular growth,
foot elongates, CF posture is in this stage
 Foetal- 8-9 weeks, tibia development with
foot, corrects CF posture from embryonic
stage. Interruption of Foetal causes CF
Tissue development
 Abnormalities are seen in:
 Muscle
 Tendons
 Ligaments
 Nerves and blood vessels
 All abnormalities are linked, unknown which
if any are causes of CF
Tissue development continued
 Common finding is an absent or small
anterior tibial artery and dorsalis pedes
 May represent growth arrest during
embryonic phase (6-7wks)
Tissues
small
anterior
tibial artery
Dorsalis Pedes
http://www.wheelessonline.com/image4/foot48.jpg
Muscle
 Below the knee:
 Smaller in girth
 Shorter in length
 TEV- muscles develop a higher proportion of
type I to II (aerobic to long-term anaerobic)
Assessment
 4 categories to assess CF
 Antenatal diagnosis
 Examination
 Assessment of severity
 Investigations
Assessment #1 Antenatal
diagnosis
 -Assessment is mostly seen post-natally
 Ultrasound is possible
 Over 80% accuracy
 Can measure severity of CF
 Helps check for more than CF as mentioned
earlier
 Can be seen as early as 12 weeks
Ultrasound
http://drjoea.googlepages.com/clubfoot1.JPG/clubfoot1-full.jpg
Assessment #2 Examination
 Takes place after birth
 Examines for abnormalities
 Spine
 joints and muscle stiffness
 Flexibility of foot
 Severe metatarsus adductus commonly
confused with CF
Severe metatarsus adductus
http://rothbartsfoot.info/myPictures/69-A4.jpg
#3 assessment of severity
 Severity of CF determines if surgery is needed
 Pirani score rates severity
 6 parts
 0, .5, 1 , total score is to 6
 Higher score, more severe
Pirani Score
 Examines:
 Look
 Feel
 Movement
 Of the hind-foot and mid-foot
 0-3 in hind-foot, 0-3 in mid-foot = 0-6 total
Assessment #4 investigation
 No formal investigations are required
 Newborns bones are mainly cartilage
 Assessment and angular relationships hard to
examine
 X-ray, ultrasound and MRI (magnetic
resonance imaging) used to assess CF and
monitor response to treatment
 radiological abnormalities
Methods to manage CF
 2 main methods
 Ponseti and the French technique
 Goal is pain free, functional foot for life
 Look normal
 Good mobility
 No special footwear
 Never will be entirely normal
Ponseti
 78% good or excellent function
 Begins as early as possible
 Manipulation and serial plaster casts (2wks)
 Each cast change foot is examined (Pirani)
Ponseti Casting
 1st- alignment of the forefoot – actually
makes the foot appear worse
 Next forefoot is brought to greater degree of
abduction with counter pressure against talar
head (Talus, connects leg to foot)
 Calcaneus corrects to neutral then valgus
(outward angle) without any manipulation of
the heel itself
Ponseti casting
Alignment
of forefoot
Forefoot
abduction,
counter
pressure
talar head
Calcaneus
to neutral
And finally
Valgus
Ponseti surgery
 Majority of patients require Percutaneous





Achilles tenotomy.
Anesthesia is used
Blade passed anterior to Achilles (in front)
Turned posteriorly ( towards backside)
Divided from deep to superficial (inside to
surface)
Casted for 3 more weeks
Ponseti
 4-10 casts total
 Pirani score decreases at each new cast
 Failed if no improvement after 10 castings
http://www.chw.edu.au/prof/services/clubfoot
/what_is_ponseti_method.gif
French Technique
 Similar to Ponseti except no cast
 Manipulated 30 minutes every day for 2
weeks
 Then twice weekly until corrected
 Can take up to 6-8 weeks
 93% good or excellent
 23% need surgery
 Common in less severe cases
Complex CF
 ~5% don’t respond to Ponseti or French




Technique
Seen in 5.5-6 Pirani score
Best results are after age 2
Achilles Tenotomy is required
Long run results unknown
Reoccurring CF





1/3 of patients will have a relapse
80% occurs in first 2 years
15% 2-6 years
5% 6+ years
May be related Charcot-Marie-Tooth disease,
A.K.A. Myotonic dystrophy- wasting of
muscles, tendons act like rubber bands
 Splintage also used to prevent
(internal/external)
Neglected CF
 Uncommon
 Treatment can start around 6 months
 Ponseti success 9 years old, plastering 4
months longer
 Long term unknown
http://ponseti.info/philippines/images/stories/olde
rchild.jpg
Future Directions
 Still researching its causes
 It can be treated
 Possible to prevent it entirely
 Custom-fit dynamic orthosis (brace) has been
shown to give better Ponseti results
https://cp20.heritagewebdesign.com/
Outline of Presentation
 Introduction
 1st Article “Clubfoot”
 2nd Article “Clinical assessment and gait
parameters”
 3rd Article “Physiotherapy versus Ponseti
casting”
 4th Article “Ossific nuclei and cartilaginous
anlagen in CF by 3-D MRI”
 Conclusion
“Association between Clinical Assessment
and Gait Parameters in Surgically Treated
Idiopathic Clubfoot”
 E. Aksahin, G. Yavuzer, H.Y. Yuksel, L. Celebi,
H.H. Muratli, A. Bicimoglu. Department of
PMR Ankara University Faculty of Medicine,
Ankara Turkey.
Summary
 Designed to investigate assessment by the
International Clubfoot Study Group (ICFSG)
 Obtain quantitative and gait data (study of
human walking) of children with surgically
treated CF
 Foot is examined by mobility, muscle,
characteristics, morphological evaluation and
radiographic evaluation.
Methods
 19 patients
 30 surgically treated Clubfeet
 Bilateral-11, unilateral-8
 Age between 6-14 years average 9
Methods
 Evaluated by the ICFSG scale
 Rates morphologic evaluation, functional
evaluation and radiological evaluation
 Max score is 60 total
 12-morphologic
 36-functional
 12-radiological
ICFSG Scoring
Total Score out of 60
Rating
0-5
Excellent
6-15
Good
16-30
Fair
30+
Poor
Methods





Tested all time/distance in:
walking velocity
Step time
Step length
Joint rotation angles of pelvis, hips, knees
and ankles
 Kinetic ground reaction forces
 Movements and powers of hip, knee and
ankle
Methods
 Data were collected using Vicon Clinical
Manager Software
http://www.utc.edu/Academic/PhysicalTherapy/images
Results
 Mean = 8.63/60
 Excellent in 16, 0-5
 Good in 8, 6-15
 Fair in 6, 16-30
 Significant correlation between ICFSG score
and walking velocity
Results
 Of all tested, only foot progression angle
showed a significant difference of over 3%
http://images.search.yahoo.com/images/view?back=http%3A%
2F%2Fimages.search
Discussion
 ICFSG score is a successful method in people
with CF
 Ankle kinetic, kinematic parameters and
sagittal plane joint rotation angles of all joints
are in correlation with CF treatment results
 Foot progression angle is most important
predictor of clinical outcome
Outline of presentation
 Introduction
 1st Article “Clubfoot”
 2nd Article “Clinical assessment and gait
parameters”
 3rd Article “Physiotherapy versus Ponseti
casting”
 4th Article “Ossific nuclei and cartilaginous
anlagen in CF by 3-D MRI”
 Conclusion
“Gait analysis in children treated
nonoperatively for Clubfoot:
Physiotherapy versus Ponseti Casting”
 Lori Karol, Ron El-Hawary, Kelly Jeans, Texas
Scottish Rite Hospital, Dallas, Texas, United
States. Isaac Walton Killam Health Center,
Halifax, Nova Scotia, Canada. 2006
Introduction
 French Technique- daily manipulation
 Ponseti- casts changed every couple weeks
 Purpose of study to compare gait analysis in 2
year olds after successful Ponseti or French
Technique
Methods
 41 children with 56 CF by Ponseti
 47 Children with 71 CF by French Technique
 Used Dimeglio score on all subjects
 0 = normal, 20 = rigid foot
 All subjects were between 10-17 score –
pretty rigid
 Average age 2.3 yrs (1.9-3.3)
Methods
 Kinematics were collected using Vicon
motion analysis system
 Data were compared to 15 normal 2yr olds
Results
 No significant differences in cadence
(rhythm), walking speed or stride time
French technique
Ponseti
15% more walked in equinus
(ball of foot is always on the
ground)
0% walked in equinus
18% foot drop (ankle/toes up)
5% foot drop
Ankle sagittal plane kinematics
normal in 62%
Ankle sagittal plane kinematics
normal in 52%
Normal gait in 13%
Normal gait in 13%
Results
Discussion
 Study shows that the French Technique is
superior to operated CF
 Can anticipate better angle motion in future
patients
 Internal rotation was better in French
technique, likely because Ponseti uses splints,
internal or external (brace)
 It remains unknown if ankle range of motion
will deteriorate over time in both
Outline of presentation
 Introduction
 1st Article “Clubfoot”
 2nd Article “Clinical assessment and gait
parameters”
 3rd Article “Physiotherapy versus Ponseti
casting”
 4th Article “Ossific nuclei and cartilaginous
anlagen in CF by 3-D MRI”
 Conclusion
“Assessment of three-dimensional
relationship of the ossific nuclei and
cartilaginous anlagen in congenital
Clubfoot by 3-D MRI”
 Tomonobu Itohara, Kazuomi Sugamoto,
Nobuyiki Shimizu, Ikko Ohno, Hisashi Tanaka,
Yoshikazu Nakajima, Yoshinobu Sato, Hideki
Yoshikawa. 2005
Introduction
 Radiographic measurement is the usual




method to determine the extent of CF
MRI made it possible to assess relationship
between ossific nuclei and cartilaginous
anlagen in the hindfoot of the tarsus
Ossific nuclei- origin of bone cells
Cartilaginous anlagen- origin of cartilage cells
3-D MRI- helps estimate size and
relationships
Methods



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5 patients unilateral
2 boys, 3 girls – unusual
All Ponseti method and Achilles Tenotomy
MRI at 5.4 months (4-10 months)
Created their own software to image
cartilaginous plane and ossific center of
tarsus
 Constructed their own 3-d surface bone
model
Methods
 Bones in tarsus being examined
Results
Total volume of the Talus and Calcaneus
Talus
Calcaneous
Normal (mm^3)
Clubfoot (mm^3)
Cartilage
2975+/- 608
2345+/- 587
Ossific Nucleus
612+/- 210
352+/- 155
Cartilage
3810+/- 870
3213+/- 877
Ossific Nucleus
1187+/- 493
1043+/- 469
Results
 20.7% reduction in Talus cartilage in CF vs
normal
 42.6% reduction in Talus ossific nucleus in CF
vs normal
 15.7% reduction in Calcaneus cartilage in CF
vs normal
 12.1% reduction in Calcaneus ossific nucleus
in CF vs normal
Results
The length of the Talus and Calcaneus and the position of
the entire gravity of the ossific nucleus
Talus
Calcaneus
Normal
Clubfoot
Length (mm)
25.8+/- 1.7
23.7+/- 1.9
The position of
the center of
gravity of the
ossific nuclei (%)
43.8+/- 1.8
39.3+/- 3.3
Length (mm)
29.3+/- 2.2
27.8+/- 2.4
The position of
the center of
gravity of the
ossific nuclei (%)
46.5+/- 2.3
43.8+/- 2.7
Discussion
 Study was able to analyze the relationship
between cartilaginous anlagen and ossific
nuclei by 3-D MRI
 Volumes of cartilage and ossific nuclei were
found to be reduced in CF vs Normal
 Possibility that casting can limit growth
 Found that the location of the ossific nucleus
is more anterior in CF than Normal
Outline of presentation
 Introduction
 1st Article “Clubfoot”
 2nd Article “Clinical assessment and gait
parameters”
 3rd Article “Physiotherapy versus Ponseti
casting”
 4th Article “Ossific nuclei and cartilaginous
anlagen in CF by 3-D MRI”
 Conclusion
Conclusion
 Clubfoot/Congenital Talipes Equinovarus is:
 Common
 Has multiple causes
 Variety of treatments
 Treatment can begin early with ultrasound
 The overall purpose of treatment is to
function as normally as possible
My personal experience
 Unilateral
 Ponseti Treatment at nine months, casting,
Achilles lengthening and internal splint
 I rarely notice a difference, balance is most
recognizable
 Right foot becomes sore at a faster rate,
standing 4 hours+ on hard floor
References

Aksahin, E.; Yavuzer, G.; Yuksel, H.Y.; Celebi, L; Muratli, H.H.; Bicimoglu, A. “Association between
clinical assessment and gait parameters in surgically treated idiopathic clubfoot.” Abstracts of the
17th Annual Meeting of ESMAC Poster Presentations/Gait & Posture 28S (2008) S49-S118.

Itohara, Tomonobu; Sugamoto, Kazuomi; Shimizu, Nobuyiki; ohno, Ikko; Tanaka, Hisashi;
Nakajima, Yoshikazu; Sato, Yoshinobu; Yoshikawa, Hideki. “Assessment of the three-dimensional
relationship of the ossific nuclei and cartilaginous anlagen in congenital clubfoot by 3-D MRI.”
Journal of Orthopaedic Research 23 (2005) 1160-1164. Published by Elsevier Ltd.

James Cooke, Stephen; Balain, Birender; Christopher-Kerin, Cronan; Terrence Kiely, Nigel.
“Clubfoot.” Current Orthopaedics 22 (2008) 139-149.

Karol, Lori; El-Hawary, Ron; Jeans, Kelly. “Gait analysis in children treated nonoperatively for
clubfoot: Physiotherapy Versus Ponseti Casting.” Oral Presentations/Gait & Posture 24S (2006)
S7-S97.

Wicart, Ph.; Richardson, J.; Maton, B. “Adaption of gait initiation in children with unilateral
idiopathic clubfoot following conservative treatment.” Journal of Electromyography and
Kinesiology 16 (2006) pages 650-660.
 Any Questions??