Non operative
Ponseti casting
Aims of treatment
1. Correct the deformity early
2. Correct it fully
3. Hold the corrected position until foot stops growing
- AFO
- Denis Browne Boots
Timing
Start 1 - 3 weeks
- let parents settle and get used to diagnosis
- explain method and length of treatment required
Casting
5 - 6 casts applied weekly
- apply SL, then convert to LL
- minimal wool
- someone holds the foot corrected
- tight about foot and ankle, loose calf
- mould about LM /MM / TA
- covert to LL as high up as possible with soft cast
- use soft cast for this
Correction
Thumb on navicular, underhand, IF on heel
1. Correct cavus
- increase supination / elevate first ray
- matching forefoot to midfoot / hindfoot
- pronating foot worsens cavus
2. Increase abduction serially
- concept is rotation of calcaneus under the talus
- aiming to correct the STJ
- abduction / ER corrects the varus
- use talar head as fulcrum (Kite's mistake - cuboid)
- maintain elevation of first ray - avoid pronation
3. No attempt to correct equinus til varus / adduction completely corrected
- usually by week 5
Note
- forceful manipulation to correct equinus prior to correction of hindfoot varus
- will result in either a rockerbottom deformity or a flat top talus
Percutaneous tenotomy
Timing
- week 5 / 6
Indication
- abduction / ER 60o and DF < 10 - 20o
- 85% need tenotomy
Technique
- usually performed in OPD
- LA, beaver blade medially
- can go directly posterior
Post op
- ponsetti cast further 3/52 in abduction and DF
AFO
Once cast removed
- 23/24 hours
- 3/12
DB Boots
Denis-Browne / Mitchell boots
- worn at night until 4 years
- shoulder width apart
- clubfoot 70o, normal foot 40o
- also corrects tibial torsion
- critical to success is compliance
- lack of compliance with DB boots strongly linked to recurrence
Results
Successful 90 - 95%
- 5% require PMR / Ilizarov correction
- 7 - 15% need T anterior transfer
Follow up
- until 8
Recurrence
- metatarsus adductus
- dynamic supination
Operative Management
Open clubfoot release
Timing
- aged 9/12 to one year
- usually sufficient for child up to three
Going out of favour
- joint violating surgery
- may increase recurrence
- increase late stiffness
Approach Options
Cincinatti
Incomplete circumferential incision
- perform prone
- good exposure and access, especially lateral
- disadvantage heel pad necrosis
Turco
Posteromedial incision
- curved from base of 1st MT above posterior tubercle of calcaneus to the T achilles
- difficult to explore the posterolateral corner
- may need a seperate lateral incision especially in older child
Norris-Carroll
Two incisions
- curved incision from centre of os calcis to talonavicular joint
- second incision halfway between T achilles & lateral malleolus
Clubfoot Releases
Medial
Identify and protect NV bundle
- first thing
- put vessiloop about them
Tendons behind medial malleolus
- T achilles z lengthened
- T posterior z lengthened
- single suture placed
Capsulotomy AKJ / STJ
Identify Knot of Henry above Abductor Hallucis
- reflect Abductor Hallucis downwards
- may be easiest to follow down from ankle
- release plantar fascia
- section / Z lengthen FDL / FHL
Open and reduce TNJ - K wire
K wire up through STJ
Lateral
Divide CFL
Open and reduce CCJ
- stabilise with K wire
Post op
- plaster for 6/52, then AFO 3/12
Results