Management

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