Idiopathic club foot Taiz University,faculty of medicine and health sciences By Dr : Malika Hameed

1. Done by malika hameed
Group D

2. Talipes Equinovarus

3. TalipesEquinovarus
*Talipes: derived from talus ( L = ankle bone )
and pes ( L = foot ).
* Equinovarus: one of the several different
deformities of talipes and means that the
entire hindfoot is in varus and the mid &
forefoot are adducted and supinated.
* Others:Talipes calcaneus &Talipes valgus.

5. Incidence
* 1-2 every 1000 live births.
* Boys : Girls → 2 : 1 .
* Sporadic but may be autosomal
dominant trait.
* Bilateral in 50% of patients or in one
third of cases.

6. Causes/Mechanisms
1- Genetic defect : primary germ plasm defect in
the talus causes continued planter flexion and
inversion of this bone and soft tissue
changes.
2- Form of arrested development.
3- Neuromuscular disorder : primary soft tissue
abnormalities within neuromuscular units
cause secondary bony changes , e.g : neural
tube defect.

10. What part of the foot is
affected?
Clubfoot primarily affects three bones:
calcaneus, talus and navicular.
The deformity can affect the growth of the entire
foot to some degree so other bones may be
involved as well.

11. PathologicalAnatomy
①Talus :
- Neck : downwards , deviated medially.
- Body : rotated slightly outwards in relation to
calcaneus and ankle mortise.
② Calcaneus :
- Posterior part is held close to fibula by a tight
calcaneo-fibular ligament and tilted into
equinus and medially rotated beneath the
ankle.

12. ③ Navicular & the entire forefoot :
- Shifted medially and rotated into supination.
④ Metatarsals : adducted & deviated at
tarsometatarsal joints.

15. ClinicalPicture
1- Foot is turned & twisted inwards , so the sole
faces posteromedially with high medial arch (
cavus ) & smaller than the other normal foot.
2- Ankle is in equinus.
3- Forefoot is adducted & supinated.
4- Skin & soft tissues of the calf &medial side of
the foot are short & underdeveloped.
5-The heel is small & high.
6- Deep creases appear posteriorly & medially.

17. Examination
* In infants :
examine associated disorders as congenital hip
dislocation & spina bifida.
* 3 Basic components of club foot :
equinus , varus , adduction , & may be cavus.

19. RoentgenographicEvaluation
* Before , during & after treatment.
*To assess progress after treatment.
* 3 views:
- AP with foot 30° planter flexion & tube
angled 30°.
- Stress dorsiflexion lateral view of both heels.
- Lateral standing view : in older children.

20. * Important angels :
1-Talocalcaneal angle.
2-Talo-1st metatarsal angle.

21. APfilm
- Line is drawn through the long axis of talus
parallel to its medial border & through the
calcaneus parallel to its lateral border ,
normally cross at angle 20°- 40° “ Kite’s angle
“, in club foot , the two lines may be parallel.

23. LateralFilm
* Foot is forced dorsiflexion.
* Line is drawn through the mid-longitudinal
axis of talus & lower border of calcaneus ,
normally the angle is 40°.
* If the angle is less than 20° >>> club foot.
* Angles normally changes with age.
* Club foot can’t be dorsiflexed , but if so , it will
be broken at the midtarsal level producing
“Rocker – Bottom deformity”.

25. Treatment
- Aim : to produce & maintain a plantigrade ,
replase may occur in neuromuscular disorders
babies.
① Non-operative : the initial treatment.
- Repeated manipulation & adhesive strapping.
-Weekly serial manipulation & light plaster cast
during the first 6 weeks of life followed by
manipulation & casting every the other week
untill the foot clinically & roentgenohraphic
corrected.

26. *With experience , predict which feet will respond to non-
surgical treatment.
*The more the rigid the initial deformity , more likely surgical
treatment.
*The order of correction :
1- Correction of forefoot adduction : rotational alignment
with hindfoot , by ↑ supination deformity.
2- Correction of hindfoot & forefoot for varus & supination by
keeping fulcrum on the lateral side of head of talus.
3- Correction of hindfoot equinus by bringing the heel down
& dorsiflexing the ankle & percutaneous tendo Achillis
lengthening.

27. *The aim of the order is to prevent “Rocker Bottom Deformity”
by dorsiflexing the foot from the hindfoot rather than
midfoot , but if occurs, forefoot placed back in planter
flexion , casting & surgery is important here.
* Casting by Kite , modified by Lovell & Hancock.
* Manipulation & casting success rate is 15-80%.
* Resistant cases declare after 8-12 weeks of serial
manipulation & strapping , so early surgery or continued
conservative treatment is indicated.
* Delaying surgery untill child walking >>> surgery is easier &
maintenance of the correction. It is suitable for severe ,
rigid deformities.
* Less severe cases >>> operation at 6 months.

34. OperativeTreatment②

35. OperativeTreatment
* Indication :
1- No response to conservative treatment often
in children with significant rigid deformity.
2- Deformity has recurred.
3-The forefoot has been corrected by
conservative treatment but hindfoot remains
fixed in both varus & equinus.
* Surgical treatment is according to the age of
child & deformity to be corrected.

36. * Objectives :
1- Complete release of joint tethers.
2- Lengthening of tendons.

37. Incisions
1- Posteromedial incision >>> Turco.
2- Posterior curved transverse , extended
anteriorly on both sides medial & lateral >>>
Cincinatti – Crawford.
3- Posterolateral with separate curved medial
incision >>> Caroll.

40. *To correct equinus :
1- Achillis tendon & tibialis posterior tendon are
lengthened through Z-divisions.
2- Posterior capsules of ankle & subtalar joints are
divided.
*To correct cavus :
1- Release contractures around talonavicular &
calcanocuboid joints.
2- Origin of intrinsic muscles & planter fascia from
calcaneum are divided.

42. *The foot , in its corrected position , is
immobilized in a plaster cast.
* Kirshner wires >>> across talonavicular &
subtalar joint.
*Wires & cast are removed at 6-8 weeks.

43. * After immobilization , hobble boots “ Dennis
Browne “.
* Stretching exercises are continued.

44. Dennis Browne “

45. DAFOs for Clubfoot:
designed for soft, comfortable repositioning of
clubfoot or maintaining post-surgical positions

46. Lateorrelapsedclubfoot
* Late >>> comes with secondary bony changes.
* Relapsed >>> scarring of previous surgery.
*Youngs ( 4-7 ) years >>> calcaneo-cuboid fusion or
cuboid enucleation ( Dilwyn Evans ).
* Calcaneal osteotomies >>> for varus.
*Tendon transfer.
* Circular external fixator ( Ilizarov method ) >>>
gradual correction.

49. Metatarsusadductus

50. *Varies from slightly curved forefoot to mild club
foot.
* Management :
- 90% improve spontaneously.
- corrective casts followed by straight last shoes.
- Extensive capsulectomy of tarsometatarsal
joints. No splintage to avoid early degenerative
arthritis.
- Dilwyn Evans procedure + Basal metatarsal
osteotomy.

51. TalipesCalcaneovalgus