Pediatric Clubfoot Deformity
Darren Groberg PGY 1
03/31/10
Congenital vs. Aquired
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Congenital:
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1/1000 births, 50% bilateral.
Subdivided into Intrinsic (rigid).
Extrinsic (supple)
Unknown origin
Many theories – most common
being…
Theory of primary osseous
deformity
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Aquired:
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Neuromuscular conditions
Meningitis
Poliomyelitis
Postcerebral vascular accident
Cerebral palsy (Little's syndrome)
Spinal deformity or spinal tumor
Diastematomyelia
Posttraumatic effects
Spinal cord trauma
Peripheral nerve trauma
Tendon laceration or avulsion
Fracture malunion or nonunion
Volkmann's contracture
Postburn contracture
McGlamry 945, table 1
Primary osseous deformity
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First described by Adams in 1866 as an
intrinsic Talar deformity.
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Specifically malformation of the head and
neck.
Normal is 15-20 degrees adduction in
transverse plane from Talar body.
Increased to 45-65 degrees in clubfoot.
Yields extreme medial rotation often with no
articulation.
Pathologic Anatomy
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Components
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Equinus
Varus
Adduction
Osseous
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Talus:
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Calcaneus:
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Diminished in size (two-thirds of normal size)Severe medial positioning
Articulates with tibia
Remaining lesser tarsus:
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Diminished in size; hypoplastic
Varus, equinus, and supinatory displacement beneath talus
Navicular:
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Diminished in size (three-fourths of normal size); positioned in severe equinus
Medial and plantarward deviation of the head, neck, and articular facets
Lateral positioning and anterior positioning in the ankle mortise
Normal morphology; adaptive changes corresponding to deformity of peritalar
complex
Forefoot:
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Metatarsals and phalanges adducted and varus rotated First ray extremely
plantarflexed in intrinsic deformity
McGlamry 946 table 2./Coughlan & Mann 1729-1730
Soft Tissue
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Tendons:
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Ligaments:
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Contracted triceps surae, posterior tibial, flexor hallucis longus, and flexor digitorum longus
Anterior tibial and long extensors medially displaced Peroneals elongated and often
posteriorly displaced
Plantar intrinsics, plantar fascia, long and short plantar ligaments contracted
Tendons histologically normal; changes secondary and adaptive
Abductor hallucis contracted, bowstrung
Posterior ankle, subtalar ligaments contracted Calcaneofibular and posterior talofibular,
tibionavicular ligaments contracted
Deltoid and calcaneonavicular (spring) ligaments contracted
Tarsometatarsal ligaments medially contracted
Ligaments histologically normal; changes secondary and adaptive
Other:
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Blood vessels, skin and nerves adaptively shortened along the medial and plantar aspects
Calf circumference and girth, as well as overall foot size, diminished
McGlamry 946 table 2./Coughlan & Mann 1729-1730
Radiologic assessment
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Standard radiographs should include AP and dorsiflexion
lateral stress views.
Important angles include
 Talocalcaneal AP (normal 30-55)
 Talocalcaneal (25-50), Tibiocalcaneal (10-40), lateral
 Talometatarsal (5-15) AP
"The most common cause of recurrent clubfoot is
unrecognized, uncorrected clubfoot."
Treatment
Each day the foot remains deformed is a
day of golden opportunity lost forever
Lenoir-
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Conservative
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Staged manipulation and
casting
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Stretching
Cast maintains
repositioned foot
Earlier the better.
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Surgical
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Soft tissue
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Posterior release
Posterior medial release
Lateral circumferential
release
Osseous procedures
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Lateral column shortening
(preserve growth plates in
children)
Medial column lengthening
Ponseti
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Poor outcomes to aggressive surgical
correction.
Histology: abundant young wavy collagen,
easily stretched
Navicular, cuboid and calcaneus could be
abducted back under talus without
surgery.
Ponseti Technique
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All deformities will be
addressed simultaneously
except for equinus.
Reduce the Cavus
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Cavus foot secondary to
pronation of forefoot vs
hindfoot.
Requires only supination to
achieve normal longitudinal
arch.
Manipulation
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Locate lateral head of the talus
Stabilize head of talus with thumb
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This will be pivot point for abduction of
forefoot.
Abduct forefoot in supination as far as
possible without causing discomfort
Hold for a short period of time and repeat
Cast Application
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2.
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***Maintain corrected position of foot while
casting***
Apply thin layer of cast padding.
Using plaster cast begin at the toes and wrap
proximally to just below the knee.
Mold cast to conform to corrected foot without
creating pressure points, calcaneus is not
manipulated.
Extend padding and cast beyond flexed knee
for stability.
Series of casts
Equinus and tenotomy
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When is the right time to address it?
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When anterior calcaneus can be abducted from
underneath the talus.
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Will allow dorsiflexion without crushing talus.
Tenotomy performed in clinic, percutaneously, 1.5 cm
above calcaneal insertion.
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Release will provide additional 20-25 degrees dorsiflexion.
Apply 5th (post tenotomy) cast.
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Can palpate anterior process
60 degrees abduction possible
Remove after 3 weeks.
Maintain correction with shoes etc.
Management of Congenital Talipes
Equinovarus by Ponseti Technique:
A Clinical Study
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Evaluate early ponseti intervention vs. other manipulation and
surgery.
Study:
 Included 100 patients, 156 feet.
 Avg. age 4.5 months.
 Primary assessment with Pirani score and photographs.
Results:
 Initial Pirani 4.26, mean FPA (foot print angle) 14.2 degrees
 Post Pirani 1.3, mean FPA 10.1 degrees
 96 % required Percutaneous TA tenotomy.
Conclusion: early, accurate Ponseti technique decreases
need for significant surgical intervention.
Mazhar A, Et Al, “Management of Congenital…”, JFAS 47(6):541/545, 2008
References
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Mazhar A, Et Al, “ Management of Congenital Talipes Equinovarus by
Ponseti Technique: A clinical study”, JFAS 47(6):541-545, 2008
Banks A, “Foot and Ankle Surgery”, McGlamry’s comprehensive
testbook, volume 1, edition 3, Ch 29 pg 943-974
Coughlin M, Et Al, “Surgery of the foot and ankle” Ch 29, Congenital
foot deformities.
Ponseti IV, “Clubfoot: Ponseti management”, Second edition, Global
health organization, 2003
Laaveg SJ, Ponseti IV, “Long-term results of treatment of congenital
club foot:, J Bone Joint Surg Am. 1980; 62: 23-31
Bradford EH, “Treatment of Club-Foot”, J Bone Joint Surg Am. 1889;
s1-1: 89-115
Colburn M, “Evaluation of the treatment of idiopathic clubfoot by
using the Ponseti technique”, JFAS 42(5):259-267, 2003