Everything about clubfoot... A complete review of the concepts, pathoanatomy, physiopathology, and treatment of clubfoot.

1. In the name of GOD
Foot Deformities : Clubfoot
Mohammadreza Razzaghof, MD MPH
Resident of Orthopedics Surgery
Tehran University of Medical Sciences

3. Metatarsus Adductus
 Pigeon toe
 Adduction of
forefoot
– at tarsometatarsal
joint
 Normal hindfoot
alignment

5. Vertical Talus
 Rocker Bottom foot
 Irreducible dorsal
dislocation of the
navicular on the talus
 producing a rigid
flatfoot deformity

6. Talipes Calcaneo-valgus
Vs.
Talipes Equino-varus

7. Talipes
Talus (ankle) + Pes (foot)
Hindfoot

8. Talipes Equinus vs. Calcaneus
Sagittal plane

9. Talipes Varus vs. Valgus
Coronal plane

11. Talipes Calcaneo-valgus
 Hindfoot eversion and
dorsiflexion
 Flexible deformity
– passively correctable
 dorsal surface of foot
can rest on anterior
tibia

13. Talipes Equino-varus
 Clubfoot
 most common musculoskeletal
birth defect (1-2 / 1000 live births)
 M / F = 2
 50% Bilateral

14. Nature
 Congenital dysplasia of all musculoskeletal tissues:
– Musculotendinous
– Ligamentous
– Osteoarticular
– neurovascular structures
distal to the knee.

15. Nature

16. Etiology
 Multifactorial
 maternal smoking during pregnancy
 Predisposing genes: NAT1, NAT2,
CYP1A, HOXA, …

17. Etiology
 Theories:
 Arrest in embryonic development (6-8w):
– Equinus, supination, forefoot adduction, and medial deviation of
the talar neck
 Dysmorphic talar head and the medial dislocation of the navicular  Not
seen in fetus
 Primary germ plasm defect in the cartilaginous talar
anlage produces:
– dysmorphic neck
– navicular subluxation

18. Etiology
 Theories:
 Increased myofibroblastic retractile tissue in the
medial ligaments
 Neuromyogenic imbalance, especially in peroneals
 Congenital fiber type disproportion with an imbalance
between types I and type II muscle fibers

19. PathoAnatomy
Deformity :
CAVE

20. PathoAnatomy
 Muscle
– Contractures
– Function imbalance
 Bone
– Intra-osseous
 Deformity within a bone
– Inter-osseous deformity
 Deformity in the relationship of bones
 Periarticular soft tissue
– Contractures

21. PathoAnatomy
 Muscle
– Tendon sheaths  thickening and contracture
– Muscuoltendinous units  shortened (all stages)
– Denervation and neuromyogenic changes :
 tibialis posterior, peroneals, triceps surae, and long toe flexors
 Due to the condition itself (not a complication of treatment)

22. PathoAnatomy
 Muscular Imbalance
, FDL, FHL
, Adductus

24. Intra-osseous def.
 Talus
– Body  dysmorphic, small, poorly placed within Mortise
– Neck  Short (No true neck), projecting medially
– Ant. End  medial and plantar deviation
– Neck-body declination angle  decreased to 90° (Nl=150-
160 °)
– Subtalar anterior and medial facets  absent, fused, or
misshapen

26. Intra-osseous def.
 Calcaneus
– Normal contour
– Small size
– sustentaculum tali  underdeveloped
– Ant. End  medially deviated and deformed

27. Intra-osseous def.
 Navicular
– Misshapen in talo-navicular
joint surface
– Medial tuberosity 
hypertrophied
 Thick tibio-navicular and
calcaneo-navicular lig.
 Cuboid
– Misshapen in calcaneo-
cuboid joint surface

28. Inter-osseous def.
 Transverse Plane, within the
Ankle mortise:
– Talus  internally rotated (45°)
and supinated
– Calcaneus  internally rotated
(22°) and supinated
 Both 20° > Normal

30. Inter-osseous def.
 Coronal Plane, within the
Ankle mortise:
– Talus  intorsion (pronation)
– Calcaneus  intorsion
(pronation)
– Talus > Calcaneus

31. Inter-osseous def.
 Navicular
– Displaced medially and plantarward on
talar head
– false articular relationship to the medial
malleolus
– articular cartilage of the talar head may
be uncovered laterally
 Cuboid
– displaced medially on the anterior end of the
calcaneus

32. PathoAnatomy
 Periarticular soft tissue
– Fibrosis of tissues:
 plantar fascia
 Calcaneonavicular
(“spring”) ligament
 tibionavicular ligament
 master knot of Henry

34. PathoAnatomy
 Periarticular soft tissue
 Moblizing possible if:
– Navicular
 Stretching T. Post and Master Knot of
Henry
– Talus / Calcaneus (of equinus)
 Achilles tendon lengthening
– Calcaneo-navicular divergence (NL=
25-40°):
 Subtalar capsule stretching

36. PathoAnatomy
 Flexor digitorum accessorius
longus
– 7% of clubfeet requiring surgery
– 7 times more in those with first-
degree relatives having clubfoot

37. PathoAnatomy
 Rare associateion:
 Congenital deficiencies of
– Dorsalis pedis artery
– Posterior tibial artery
 More common in clubfeet with
greater deformity
 Risk of partial ischemic necrosis of
foot following surgery!

38. REVIEW OF LAST SESSION

39. Talipes
Talus (ankle) + Pes (foot)
Hindfoot

40. Talipes Equinus vs. Calcaneus
Sagittal plane

41. Talipes Varus vs. Valgus
Coronal plane

43. PathoAnatomy
Deformity :
CAVE

44. PathoAnatomy
 Muscle
– Contractures
– Function imbalance
 Bone
– Intra-osseous
 Deformity within a bone
– Inter-osseous deformity
 Deformity in the relationship of bones
 Periarticular soft tissue
– Contractures

46. PathoAnatomy
 Muscular Imbalance
, FDL, FHL
, Adductus

47. Intra-osseous def.
 Talus
– Body  dysmorphic, small, poorly placed within Mortise
– Neck  Short (No true neck), projecting medially
– Ant. End  medial and plantar deviation
– Neck-body declination angle  decreased to 90° (Nl=150-
160 °)
– Subtalar anterior and medial facets  absent, fused, or
misshapen

49. Intra-osseous def.
 Calcaneus
– Normal contour
– Small size
– sustentaculum tali  underdeveloped
– Ant. Process  medially deviated and deformed

50. Inter-osseous def.
 Transverse Plane, within the
Ankle mortise:
– Talus  internally rotated (45°)
and supinated
– Calcaneus  internally rotated
(22°) and supinated
 Both 20° > Normal

52. Inter-osseous def.
 Coronal Plane, within the
Ankle mortise:
– Talus  intorsion (pronation)
– Calcaneus  intorsion
(pronation)
– Talus > Calcaneus

53. Inter-osseous def.
 Navicular
– Displaced medially and plantarward on
talar head
 Cuboid
– displaced medially on the anterior end of
the calcaneus

55. Diagnostic features
 It is rarely difficult to identify a
true clubfoot in a newborn!!

57. Diagnostic features
 True Vs. Postural???
 Postural
– Fully correctable by passive
maneuver
 by several minutes of gentle
stretching
– Absence of
 significant contractures
 Deep skin creases

58. Diagnostic features
 Idiopathic
 Non-idiopathic
– Associated anomalies and neuromuscular conditions
– Severe Recurrence
– Worse prognosis (response to treatment) except in:
 Down Syn.
 Larsen Syn.
– Due to significant ligamentous laxity

59. Diagnostic features
 Non-idiopathic clubfoot
– Arthrogryposis
– Diastrophic dysplasia
– Möbius Syn.
– Freeman-Sheldon syndrome
– Spina bifida
– Spinal dysraphism
– Fetal alcohol syndrome

61. Classification
 Determine Severity Index
– for each component of CLUBFOOT
1. Monitor treatment progress
– Need for surgical release or heel cord tenotomy
2. Prognostic value
– Outcome at 2 years old
Why?

62. Dimeglio Classification
 4 - 20 points
 Four major components (Reducibility)
 Four Parameters

63. Dimeglio Classification
 Four Parameters
 Posterior crease (=1)
 Medial crease (=1)
 Cavus (=1)
 Poor muscle condition (=1)

64. Dimeglio Classification
 Four Parameters
 Posterior crease (=1)
 Medial crease (=1)
 Cavus (=1)
 Poor muscle condition (=1)

65. Dimeglio Classification
 Four Parameters
 Posterior crease (=1)
 Medial crease (=1)
 Cavus (=1)
 Poor muscle condition (=1)

66. Dimeglio Classification
 Four Parameters
 Posterior crease (=1)
 Medial crease (=1)
 Cavus (=1)
 Poor muscle condition (=1)

67. Dimeglio Classification
 Four Parameters
 Posterior crease (=1)
 Medial crease (=1)
 Cavus (=1)
 Poor muscle condition (=1)

68. Dimeglio Classification
 4 - 20 points
 Four major components (Reducibility)
 Four Parameters

69. Dimeglio Classification
 Four major components
(reducibility)
 Equinus (=1-4)
 Heel Varus (=1-4)
 Medial Rotation of Calcaneopedal block
(=1-4)
 Forefoot adductus (=1-4)

71. Ankle Joint
 Tibiotalar joint
 Subtalar joint
 Distal Tibiofibular joint

72. Tibiotalar joint
 Sagittal Plane
 Medio-Lateral Axis
– Plantar flexion
– Dorsi-flexion

73. Dorsiflexion: Plantar flexion:

74. Subtalar joint
 Inversion
 Eversion

75. Functional Ankle Anatomy

76. Subtalar joint
 Axis of Henke
– Inversion
 Internal rotation
+ Plantar flexion
+ Supination
– Eversion
 External rotation
+ Dorsiflexion
+ Pronation
Lateral Medial

77. Eversion: Inversion:

79. Dimeglio Classification
 Four major components
(reducibility)
 Equinus (=1-4)
 Heel Varus (=1-4)
 Medial Rotation of Calcaneopedal block (=1-4)
 Forefoot adductus (=1-4)

80. 20 to 45°

81. 0 to 20°

82. Dimeglio Classification
 Four major components
(reducibility)
 Equinus (=1-4)
 Heel Varus (=1-4)
 Medial Rotation of Calcaneopedal block (=1-4)
 Forefoot adductus (=1-4)

83. 0 to 20°

84. Dimeglio Classification
 Four major components
(reducibility)
 Equinus (=1-4)
 Heel Varus (=1-4)
 Medial Rotation of Calcaneopedal block (=1-4)
 Forefoot adductus (=1-4)

85. -20 to 0 °

86. Dimeglio Classification
 Four major components
(reducibility)
 Equinus (=1-4)
 Heel Varus (=1-4)
 Medial Rotation of Calcaneopedal block (=1-4)
 Forefoot adductus (=1-4)

87. 0 to 20°

88. Dimeglio Classification
Most common

89. Dimeglio Classification
 Grade I
– All can be healed by conservative treatment, easily restored to
normal
 Grade II
– Reducibility > Resistance
 Grade III
– Resistance > Reducibility
 Grade IV
– Almost irreducible
– Pseudo-arthrogryposic

90. II. Moderate
95-100%
III. Severe
70-95%
IV. Very severe
<70%

91. Treatment
1. Non-operative
– Ponseti Method
– French Physiotherapy
2. Operative

92. Non-operative Tx

93. Ponseti Method
 Ignachio Ponseti (1914-
2009)
 Non-operative Tx of
Clubfoot
– Weekly manipulation +
cast application
World Clubfoot Day
2 June

94. Ponseti Method

95. Ponseti Method

96. Ponseti Method

97. Ponseti Method : Principles

98. Ponseti Method : Principles

99. Ponseti Method : Principles

100. Ponseti Method : Technique

103. Ponseti Method : Technique

105. Key Ponseti Maneuver
Distal Unit Proximal Unit Reference Joint
Forefoot midfoot Lisfranc
Forefoot +
midfoot
hindfoot Chopart
Forefoot +
midfoot +
hindfoot
Distal tibia and
fibula
Ankle mortis

106. Calcaneopedal Unit

107. Key Ponseti Maneuver
Distal Unit Proximal Unit Reference Joint
Forefoot midfoot Lisfranc
Forefoot +
midfoot
hindfoot Chopart
Forefoot +
midfoot +
hindfoot
Distal tibia and
fibula
Ankle mortis
Forefoot +
midfoot +
calcaneus (CPU)
Talus Subtalar joint

110. Key Ponseti Maneuver

111. Key Ponseti Maneuver

112. Why?

113. Right Clubfoot
132

115. Ponseti Method : Technique

116. Ponseti Method : Technique

117. Ponseti Method : Technique

118. Ponseti Method : Technique

119. Palpable pop Further foot dorsiflexion (15-20°)…

120. Ponseti Method : Technique

121. How should we follow up the
patient???

122. Ponseti Method: Follow-up

123. Ponseti Method: Follow-up

124. Ponseti Method: Follow-up

125. Ponseti Method: Outcome

126. Ponseti Method: Follow-up

127. Ponseti Method: Follow-up

128. Functional (French) method

129. Functional (French) method

131. Functional (French) method

134. THANKS FOR YOUR ATTENTION…