Complex Clubfoot
Journal Title: Journal of Bone and Joint Diseases - Year 2018, Vol 0, Issue 0
Abstract
Clubfoot is one of the most common foot deformities which can hamper with the development of child if not corrected properly. Congenital talipes equinovarus (CTEV) has an incidence of 1–2 per 1000 live births [1]. After various attempts of surgical as well as conservative management, the inability to achieve correction of deformity is very frustrating for the treating doctor as well as the parents. In recent past, if the deformity was not amenable to correction within 3–6 months, joint releases were recommended [2, 3, 4, 5]. Surgical correction is advantageous in terms of correcting the deformity in single attempt and has good early results. However, long-term outcomes of surgical correction were not favorable as it led to significant muscle weakness, insufficient ankle range of movement and avascular necrosis of tarsal bones, subluxation of weight-bearing joints of the foot, soft tissue contractures, and large surgical scar [6, 7, 8]. Furthermore, functional results were found to be better if extensive surgery was avoided [9, 10]. More than half of the surgically treated patients required reoperation and risk of the complication arising as a result of surgical correction was more difficult to treat [11, 12]. As per the latest published papers, Ponseti method gave a promising solution for CTEV management and achieved excellent corrections in the majority of patients [13, 14, 15]. Role of Ponseti’s technique in the understanding of clubfoot pathoanatomy Nonoperative techniques evolved through the past century. Kite followed the sequential correction of deformity first adduction then inversion and at last the equinus. This led to poor outcomes as the majority of patients’ required surgical release by the age of 9 months. The failure can be traced to the poorly understood pathoanatomy of clubfoot. It was Ponseti who recognized that the deformity of the forefoot was actually adductovarus and the inversion of the hindfoot was actually the supination of the whole talocalcaneonavicular complex. So for reducing the deformity, the entire complex has to be brought up and laterally on to the talar head. This simultaneously moves the calcaneus from a medial, plantar, and inverted position to a more dorsal and lateral position. Achilles tendon tenotomy was required at the end as tendons do not have the stretching capability as the ligaments and capsule. Limitations of Ponseti Technique Ponseti technique enabled physicians to treat CTEV successfully without an extensive surgical scar and deep tissue fibrosis of the foot and ankle complex and has been the internationally accepted method for the treatment of CTEV since the 1990s [16, 17, 18]. However, even after this success, there are certain therapeutic limitations of this method. Since CTEV being an anatomic entity, there can be several ways to classify it based on etiology and the underlying morbid anatomy. The idiopathic form being the major part of the cases, postural and positional, teratologic forms associated with arthrogryposis, myelomeningocele, and tethered cord syndrome, and at last those associated with syndromes like myotonic dystrophy form another chunk of the disease. Ponseti also recognized an atypical form of talipes equinovarus. The main features of atypical CTEV are plantar flexion of both medial and lateral columns, small foot, rigid equinus, a deep plantar and medial midfoot crease, and a deep crease above the posterior heel. He considered these to be resistant, some syndromic, others teratologic, some neurogenic, and occasionally iatrogenic. Hence, he modified the manipulation and casting protocol for these feet. Mater and colleagues in their study evaluated the Ponseti technique for the management of talipes equinovarus in myelomeningocele affected patients and concluded that it was an effective first-line therapy but more number of casts were required for correction, and there was a higher relapse rate [19] Similarly in patients of tethered cord syndrome more number of casts were required and the recurrence rate was found to be 42% [17]. Similarly, Ponseti technique has proved to be good first-line treatment for arthrogrypotic clubfoot [20, 21] and those with unsuccessful posteromedial soft tissue release [22, 23]. Complex clubfeet According to Turco, way back in 1994, some clubfeet were refractory to usual manipulation and responded in different manner to operative as well as a nonoperative treatment modality and these severe kind of clubfeet were labeled as atypical [24]. The main identifying features are severe supination of the forefoot with toes pointing to the ipsilateral thigh, long wide and tight tendons Achilles with the small calf muscle. All four metatarsals lie in severe plantar flexion with forefoot in adduction which causes deep crease traversing across the sole of the foot and severe cavus. The foot is short and stubby (1.5–2 cm shorter than normal foot, if unilateral case) and the skin is soft and subcutaneous tissue is fluffy. There is deep posterior crease above heel so that the heel is in severe rigid equinus and varus. The under the surface of the calcaneus is covered by thick fat pad. The navicular bone is so medially displaced that it may be in touch with the medial malleolus. The anterior tuberosity of the calcaneus is lying prominent in front of the lateral malleolus and can be confused with the head of talus which lies just above the tuberosity. The subtalar joint is so stiff that even after the application of 2–3 casts very minimal motion takes place at this joint during the initial manipulation. The first toe is short and hyperextended. Modification of the manipulation and casting technique [25] Modification of manipulation to correct the midfoot inversion and heel varus The thumb is put over the lateral aspect of the head of the talus, and the index finger of the same hand is put over the posterior aspect of the lateral malleolus. The forefoot is abducted with the other hand while counter-pressure on the lateral aspect of the head of the talus and posterior aspect of the lateral malleolus is maintained. It should be kept in mind never to abduct the forefoot beyond 40°. If one tries to gain more abduction, it will lead to further flexion of metatarsals and toes as well as hyperabduction of the metatarsals at the Lisfranc joint. This is due to short and tight deep plantar muscles, for example, severe fibrosis of quadratus plantae muscle. Modification to correct hyperflexion of metatarsals and the rigid equinus simultaneously Both the index fingers are placed on either side of the head of the talus, and both the thumbs are placed on the sole of the foot on the heads of 1st and 5th metatarsals. The foot is pushed in dorsiflexion simultaneously pressure being applied on both the metatarsal heads to produce the extension of all the four metatarsals while an assistant keeps the knee stabilized in flexion. The forefoot should be in mild abduction and heel in mild valgus. Care should be taken not to create a rocker bottom foot deformity. How to avoid plaster cast from slipping down? One should be sure that the hyperflexed metatarsals and the equinus are getting corrected. The plaster cast is put in 110⁰–120⁰ flexion at the knee joint. Too much of plaster is avoided in the popliteal and the anterior aspect of foot and ankle. The plaster should be well molded. When and how to perform the percutaneous tenotomy? Once mild abduction of 30⁰ have been achieved, and the hyperflexion at metatarsals has improved, but the equinus is still very severe, tenotomy can be performed in complex clubfeet. The tenotomy should be done 1.5 cm above the posterior crease of the heel to avoid damage to the posterior tuberosity of the Calcaneus which is usually in a very high position. If necessary, the post-operative cast is changed every 4–5 days so that at least 5⁰ of dorsiflexion and 40⁰ of abduction is achieved. Bracing The brace should only have an abduction of about 40°. The shoes must be well made to prevent slippage of the foot. Result expected from modified Ponseti technique in complex clubfeet Using the described modified Ponseti treatment, one can expect a successful correction of the feet without requiring extensive corrective surgery. By keeping the correct bracing protocol, the foot’s shape, length, motion of the subtalar joint, and dorsiflexion will usually continue to improve a few months after correction. The foot will appear more and more like a normal foot. Ponseti et al. in their study on 75 complex clubfeet observed that all feet were well corrected with mean ankle dorsiflexion of 15° (range: 10°–25°). There was a minimal cavus deformity in six patients, which was passively corrected [25]. Seven (14%) had relapse after initial treatment which were related mainly to problems with shoe fit with the standard foot abduction brace (most parents reported difficulties keeping the shoes on, with subsequent slippage of the foot, and development of skin lesions). A maximum of 4 cast was applied to correct the relapse at intervals of 2 weeks. In a Turkish series with a mean follow-up duration of 46 months, Göksan et al. reported a relapse rate of 38% on a subgroup of complex clubfeet (15 patients, 21 feet) [26].
Authors and Affiliations
Mazhar Abbas, Latif Zafar Jilani
Keywords
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