Club Foot, introduction, etiological factors, presentation, management.

1. Dr Muhammad Shoaib
KRL Hospital, Islamabad

2.  The term Clubfoot refers to a foot deformity characterized by
equinus of the hindfoot and adduction of the midfoot and
forefoot with varus through the subtalar joint complex.

3. HISTORY OF CLUB FOOT

7. Dr Ontonio Scarpa, an Italian surgeon
has great contributions in the
conservative management of Club Foot
and devised a First Club Foot
Correction Clamp

8. In 1831, surgeon Stromyer first time
gave the idea of per cutaneous
tenotomy of Tendo Achilles in the out
patient clinics as a safe procedure for
the correction of Equines of the foot

11.  Congenital:
◦ Present since birth.
◦ Associated with spina bifida.
◦ Bilateral.
◦ Skin, subcutaneous tissue &
muscles normal.
◦ Transverse crease present.
◦ Bones normal.

12.  Acquired:
◦ Not present since birth.
◦ Due to polio, cerebral palsy etc.
◦ Unilateral.
◦ Tropic changes in skin, muscle flaccid or spastic.
◦ No transverse crease.
◦ Bones are thinner.

13.  Commonest congenital foot
deformity in children.
 Incidence 1.2/1000 live births.
 2-3 times more common in
boys than girls.
 50 % bilateral.
 10 % family history of
clubfoot (CTEV).

14.  Osseous Type: Associated with absence of tibia &
fibula.
 Muscular Type: Arthrogryposis.
 Neuropathic Type: Due to spina bifida.
 Idiopathic Type: No apparent cause. Various theories
proposed.

15.  Turco’s: Medial displacement of navicular & calcaneum around
talus.
 Brockman’s: Congenital atresia of talonavicular joint.
 Mc-Kay’s: Three-dimensional bony deformity of subtalar complex.
 Intrauterine: Compression by malposition of fetus in utero.
 Genetic.
 Germ Plasm Theory: Primary germ plasm defect in talus with
subsequent soft tissue changes.

16.  Soft Tissue Theory: Primary soft tissue defect with secondary
bony changes.
 Prenatal Muscle Imbalance Theory: Weak pronators and
overacting extensors and invertors.
 Herzenberg: Talar neck is internally rotated and talar body is
externally rotated relative to ankle mortise.

18. 1. Talocalcaneus joint
2. Talocalcaneonaviculer
joint
3. Calcanocuboid joint

22. 1. Calf is smaller
 - Shorter and smaller
muscle tendon unit of
Triceps surae (=
Gastrocnemius, Soleus,
Plantaris), Tibialis posterior
and toe flexor

23. 2. Hind foot Equinus
 - Severe Plantar flexion in
the ankle joint.
 - High Calcaneus (not in the
heel pad).
 - Talus in severe Flexion

24. 3. Heel in Varus
 - Supination and Adduction
of the Calcaneus.
 - Calcaneus is locked under
the Talus.

25. 4. Inversion of the Mid foot
 (Inversion = Plantar flexion
+Add + Sup)
 - Navicular is medially
displaced, adducted and
supinated in relation to the
Talus.
 - Navicular articulates only
with the medial part of the
head of the Talus.

26. 5. Cavus
 Increase in the height
of the medial arch of
the foot

27. 6. Metatarsal I is
more in Plantar
flexion
 than the rest of the
Metatarsals

28.  7. Clubfoot is smaller
than a normal foot.

29.  Structures contracted on medial side:
◦ 3 muscles
 AHL
 TP
 FHL
◦ 3 ligaments
 Deltoid
 Spring
 Plantar
◦ 3 capsules
 Subtalar
 Tarsal
 Tarsometatarsal

30.  Structures contracted on
posterior side:
◦ 2 muscles
 Tibialis posterior
 Tendo-Achilles
◦ 2 ligaments
 Talofibular
 Calcaneofibular
◦ 2 capsules
 Ankle joint
 Subtalar joint

31.  Structures
contracted on
anterior side:
◦ 1 muscle
 Tibialis anterior if
inserted abnormally
◦ 1 ligament
 Superior peroneal
retinacula
◦ 1 capsule
 Calcaneocuboid joint

33.  Equinus of heel
 Hindfoot varus
 Midfoot cavus
 Forefoot adduction
 Internal tibial torsion

34.  Foot size is decreased to 50%.
 Medial border is concave, lateral border is convex.
 Froefoot is plantarflexed upon hindfoot.
 Skin is stretched over the dorsum of the foot.

35.  Callosities over dorsum of the foot.
 Stumbling gait.
 Hypotrophic anterior tibial atrery.
 Atrophy of muscles in anterior or posterior
compartments of leg.

36.  Degeneration of joints.
 Fusion of joints.

38.  Detects internal tibial torsion.
 Child is made to sit on a table with both lower
limbshanging from the edge.

39.  A line drawn from centre of patella to tibial tubercle
when extended down should cut the foot at 1st or 2nd
intermetatarsal space.
 In CTEV with medial rotation of tibia it cuts 4th or 5th
space.

40.  Detects muscle imbalance in an infant who can not obey
commands.
 Medial Scratch Test: when medial sole is scratched, foot
everts. This tests peroneals.
 Latearl Scratch Test: when lateral sole is scratched, foot
inverts. This tests invertors.

42. Four parameters are assessed on the basis of their
reducibility with gentle manipulation as measured
with a handheld goniometer

43. 1. Equinus deviation in the sagittal plane
2. Varus deviation in the frontal plane
3. Derotation of the calcaneopedal block in the horizontal plane
4. Adduction of the forefoot relative to the hindfoot in the
horizontal plane
Dimeglio A, Bensahel H, Souchet P, et al. Classification of
clubfoot. J Pediatr Orthop B 1995;4:129–136.

45. Classificati
on Grade
Type Score Reducibility
I Benign <5 > 90% soft-soft, resolving
II Moderate 5 - <10 > 50% soft-stiff, reducible, partly
resistant
III Severe 10 - <15 < 50% stiff-soft, resistant, partly
reducible
IV Very
Severe
15 - <20 < 10% stiff-stiff, resistant
Dimeglio A, Bensahel H, Souchet P, et al. Classification of clubfoot. J Pediatr Orthop B
1995;4:129–136.

46.  Composed of 10 different physical examination findings
 Each scored 0 for no abnormality, 0.5 for moderate
abnormality, or 1 for severe abnormality.
 Each foot is assigned a total score, the maximum being 10
points, with a higher score indicating a more severe deformity

47. Pirani S. A reliable and valid method of assessing the amount
of deformity in the congenital clubfoot. St. Louis, MO:
Pediatric Orthopaedic Society of North America, 2004.

48. 1. Curvature of lateral border of foot
2. Severity of medial crease (foot held in maximal correction)
3. Severity of posterior crease (foot held in maximal correction)
4. Medial malleolar–navicular interval (foot held in maximal
correction)

49. 1. Palpation of lateral part of head of talus (forefoot fully
abducted)
2. Emptiness of heel (foot and ankle in maximal correction)
3. Fibula-Achilles interval (hip flexed, knee extended, foot and
ankle maximally corrected)

50. 1. Rigidity of equinus (knee extended, ankle maximally
corrected)
2. Rigidity of adductus (forefoot is fully abducted)
3. Long flexor contracture (foot and ankle held in maximal
correction)

52.  AP View:
◦ Talocalcaneal angle is
reduced (normal 30-35°).
It measures degree of
varus.
◦ Talometatarsal angle is 0°
to negative (normal 5-
15°). Indicates extent of
forefoot adduction.

53.  Lateral View:
◦ Talocalcaneal angle is
reduced (normal 25-50°).
It measures degree of
varus.
◦ Tibiocalcaneal angle is
negative in CTEV
(normal 5-15°). Indicates
extent of equinus.

54.  Talocalcaneal Index:
◦ TC angle AP view + TC angle Lat view should be atleast 40°.
It is reduced in CTEV.

55. • Conservative management
• Surgical management
• Management by external fixator

56.  Soft tissue procedures are advocated for children <4years of
age.
 For mild CTEV with no severe internal rotation deformity of
calcaneus, a one-stage posteromedial release of TURCO is
preferred.

57.  For severe deformities a one-stage modified Mc-Kay
procedure of both posteromedial and posterolateral release is
preferred.
 Bony procedures are added to soft tissue procedures after
4years of age.

58.  Done between 6-12months of age.
 Cincinnati’s incision is used.
 Structures released are:
 Medial:
◦ TP/AHL/FHL/FDL
◦ Capsules of ST/Tarsal/TM joints
◦ Ligaments-Deltoid/Plantar/Spring ligaments

59.  Posterior:
◦ TA lengthening by z-plasty.
◦ Capsulotomy of ankle and subtalar joints.
◦ Calcaneofibular ligaments.
 Subtalar ligaments:
◦ Talocalcaneal ligaments
◦ Interosseous ligaments
◦ Bifurcated Y-ligaments.

60.  Postoperative Regimen:
◦ Change cast at 2weeks.
◦ Long leg cast untill 3 months.
◦ Orthoses for 6-9 months.

61.  Cincinnati’s incision.
 All structures on posteromedial side are released as in
Turco.
 In addition, lateral structures released are:
◦ Suprior peroneal retinaculum
◦ Inferior external reticanulum
◦ Dorsal calcaneocuboid ligament
◦ Origin of extensor digitorum brevis.

62.  Metatarsal osteotomy for metatarsus adductus.
 Dwyer’s lateral closing wedge osteotomy of calcaneus.
 Dillwyn Evan’s procedure: wedge resection from
midtarsal area.
 Triple Arthrodesis.

63.  Triple Arthrodesis:
◦ For children >10years.
◦ Functionally & cosmetically superior.Lateral closing
wedge osteotomy through subtalar and midtarsal joints
is done to fuse all three joints namely subtalar,
talonavicular and calcaneocuboid.
 Talectomy:
◦ Used as a salvage procedure.

64.  Garceaus Method:
◦ Transfer of tibialis anterior to middle cuneiform
bone.
 Modified Garceaus Method:
◦ Transfer of tibialis anterior to base of 5th metatarsal.

65.  Two types of frames:
◦ Ilizarov
◦ Joshi’s External Stabilization System (JESS)
 Semi-invasive, bloodless surgery and can be done without
touraiquet.
 Technically demanding but avoids complications of surgery
and scar.
 Corrects both bony and soft tissue component.
 If failure does occur, options of surgery are always open.