Congenital talipes equinovarus (the ‘club foot’)

Congenital talipes equinovarus (the ‘club foot’)

In true congenital talipes equinovarus (CTEV) the three- dimensional deformity is fixed ( Figure 44.29 ). Intrauterine moulding can cause an identical pattern that is postural and therefore correctable. Incidence and aetiology The incidence varies from 1 to 6 per 1000 live births, depending on ethnic di ff erences. It is more common in boys and is bilateral in 50% of cases. A family history is common but inheritance is multifactorial. The diagnosis may be made during an antenatal ultrasound: the sensitivity is higher in bilateral cases, which are more likely to have a syndromic association. In some countries, the detection of CTEV may be grounds for a termination of the pregnancy but the parents should be reassured that, with treatment, their child will function as well as his/her peers. Most cases are idiopathic but because the outcome varies with the aetiology it is important to consider the cause when planning treatment ( Table 44.10 ). Many idiopathic cases will have some weakness of the evertor muscles. Pathology The talonavicular joint is subluxed, with the navicular displaced medially with respect to the talar head. Ligaments, particularly the calcaneofibular ligament, and tendon sheaths, such as the posterior tibial tendon sheath, are shortened and thickened and contain contractile myofibroblasts. The gastrocsoleus and posterior tibial muscles are smaller than normal, with reduced myofibrils and increased connective tissue, possibly because of a local neuromuscular abnormality . The vascular supply via the dorsalis pedis may be diminished. It remains unclear which abnormalities are primary and which occur as the deformity develops. Clinical assessment The postural club foot may benefit from physiotherapy stretches but, by definition, it must be normal by 3 months of age. Shafique Pirani , contemporary , Clinical Professor, Department of Orthopaedic Surgery , University of British Columbia, V ancouver, Canada. Alain Diméglio , contemporary , orthopaedic surgeon, Montpellier, France. In contrast, the structural idiopathic club foot has fixed deformity with elements of hindfoot equinus and varus, midfoot adductus and pronation of the first ray , giving the appearance of forefoot cavus. The heel feels ‘empty’ as the calcaneus is pulled up by the shortened tendo-Achilles. There is a deep medial and a single posterior crease. All children with structural club-foot deformity will have a small calf and foot. Tibial shortening may become apparent with growth. Children should be examined carefully for signs of intraspinal pathology . Both the Pirani and Diméglio classification systems ar e based on the appearance of the foot in its position of max - imal correction. They predict tr eatment response and hence outcome.

TABLE 44.10 Several different types of club foot are recognised. Type Example Postural Idiopathic Neuromuscular Spina bi /f_i da; arthrogryposis Syndromic Trisomy 15 or Disastrophic Dysplasia or Amniotic Band Syndrome (b) Figure 44.29 (a) Anteroposterior photograph of a foot showing the classic deformities associated with a club foot. The hindfoot (not seen) is in equinus and varus, there is midfoot cavus and the forefoot lies adducted and apparently supinated, although it is actually pronated relative to the hindfoot. (b) Untreated congenital talipes equinovarus in a child aged 7 years. Shoe wear is dif /f_i cult although some indepen

dent mobility is possible.

Club foot /uni25CF /uni25CF /uni25CF /uni25CF Treatment Ponseti method The Ponseti method corrects foot deformity in 95% of idio pathic cases without the need for a formal surgical release and is the treatment of choice for all feet. Treatment commences within a few weeks of birth. A specific set of manoeuvres, followed by a series of well-moulded above-knee plaster casts, results in gradual correction of the deformity ( Figure 44.30 The head of the talus is the fulcrum around which the rest of the foot rotates. After the forefoot has been corrected, most feet lack 15° of dorsiflexion and require a percutaneous Achilles tenotomy (performed under local anaesthetic in the clinic setting). Once corrected the foot position is maintained by a foot abduction orthosis (FAO) that holds the foot in external rotation and slight dorsiflexion. The FAO is worn full time for 3 months and at ‘night and nap time’ f or up to 4 years. Poor compliance with the FAO is associated with a higher relapse rate. Recurrent deformity can be treated with further plasters, but a tibialis anterior tendon transfer (TATT) may be required around the age of 2.5–4 years for persisting dynamic supination. Feet treated with the Ponseti method are less sti ff , less likely to be painful and less subject to overcorrection than those treated surgically . The Ponseti method also works reasonably well in non-idiopathic feet but both the failure and relapse rates are higher. Surgical treatment If conservative treatment fails, surgical intervention is required, ideally before walking age; this is more likely in non-idiopathic deformities. Surgical release is generally performed ‘à la carte’, with sequential release of the pathologically tight structures via either Turco or Cincinnati incisions to reduce the subluxated joints. Stabilisation may include temporar y Kirschner wire fixation. Following correction, wound closure can be di ffi cult but the Cincinnati incision heals well by secondary intention during the postoperative casting period. Ignacio Ponseti , 1914–2009, faculty member of the University of Iowa, USA. Born in Menorca, fled Spain during the Civil War because of the political situation, worked as a general practitioner in Mexico and then went to Iowa to train in orthopaedics. The technique that bears his name only became popular years after he retired – but it brought him back to work for another 20 years. Vincent J Turco , 1916–1999, Chief of Orthopedic Surgery , St. Francis Hospital, Hartford, CT , and Assistant Clinical Professor, Yale University Medical School, New Haven, and the University of Connecticut Medical School, Farmington, CT , USA. Martin Kirschner , 1879–1942, Professor of Surgery , Heidelberg, Germany , introduced the use of skeletal traction wires in 1909. - Good or excellent results can be achieved but sti ff ness and over- or undercorrection are common complications. ). Surgery for recurrent deformity r equires a careful assess - ment of the forefoot, hindfoot and tibial torsion. The foot becomes progressively sti ff er with each surgical intervention. Summary box 44.13 Treatment of club foot /uni25CF /uni25CF /uni25CF

Multiplanar deformity: hindfoot equinus and varus, midfoot adductus and forefoot cavus Incidence is 1–6 per 1000 live births, more common in boys and with a familial tendency Most cases are idiopathic but neuromuscular causes include spina bi /f_i da and arthrogryposis Scoring systems (Pirani/Diméglio), are used to assess severity Corrected Uncorrected Figure 44.30 A series of casts documenting the stepwise correction of the foot deformity with the Ponseti method of serial manipulation and casting. The Ponseti method of serial casting is successful in 95% of feet when de /f_i ned as avoiding formal surgical release The standard sequence of manipulations is: C – correction of the apparent forefoot cavus by elevation of the /f_i rst ray A – gradual forefoot abduction to 60°, and simultaneous V – correction of the hindfoot varus E – correction of hindfoot equinus usually follows a percutaneous Achilles tenotomy, which is an integral part of treatment TATT is used to correct dynamic supination in older children If the Ponseti method fails: Surgical release addresses posterior, medial, plantar and lateral structures, and results in a stiffer foot than one treated conservatively

Congenital talipes equinovarus (the ‘club foot’)

In true congenital talipes equinovarus (CTEV) the three- dimensional deformity is fixed ( Figure 44.29 ). Intrauterine moulding can cause an identical pattern that is postural and therefore correctable. Incidence and aetiology The incidence varies from 1 to 6 per 1000 live births, depending on ethnic di ff erences. It is more common in boys and is bilateral in 50% of cases. A family history is common but inheritance is multifactorial. The diagnosis may be made during an antenatal ultrasound: the sensitivity is higher in bilateral cases, which are more likely to have a syndromic association. In some countries, the detection of CTEV may be grounds for a termination of the pregnancy but the parents should be reassured that, with treatment, their child will function as well as his/her peers. Most cases are idiopathic but because the outcome varies with the aetiology it is important to consider the cause when planning treatment ( Table 44.10 ). Many idiopathic cases will have some weakness of the evertor muscles. Pathology The talonavicular joint is subluxed, with the navicular displaced medially with respect to the talar head. Ligaments, particularly the calcaneofibular ligament, and tendon sheaths, such as the posterior tibial tendon sheath, are shortened and thickened and contain contractile myofibroblasts. The gastrocsoleus and posterior tibial muscles are smaller than normal, with reduced myofibrils and increased connective tissue, possibly because of a local neuromuscular abnormality . The vascular supply via the dorsalis pedis may be diminished. It remains unclear which abnormalities are primary and which occur as the deformity develops. Clinical assessment The postural club foot may benefit from physiotherapy stretches but, by definition, it must be normal by 3 months of age. Shafique Pirani , contemporary , Clinical Professor, Department of Orthopaedic Surgery , University of British Columbia, V ancouver, Canada. Alain Diméglio , contemporary , orthopaedic surgeon, Montpellier, France. In contrast, the structural idiopathic club foot has fixed deformity with elements of hindfoot equinus and varus, midfoot adductus and pronation of the first ray , giving the appearance of forefoot cavus. The heel feels ‘empty’ as the calcaneus is pulled up by the shortened tendo-Achilles. There is a deep medial and a single posterior crease. All children with structural club-foot deformity will have a small calf and foot. Tibial shortening may become apparent with growth. Children should be examined carefully for signs of intraspinal pathology . Both the Pirani and Diméglio classification systems ar e based on the appearance of the foot in its position of max - imal correction. They predict tr eatment response and hence outcome.

TABLE 44.10 Several different types of club foot are recognised. Type Example Postural Idiopathic Neuromuscular Spina bi /f_i da; arthrogryposis Syndromic Trisomy 15 or Disastrophic Dysplasia or Amniotic Band Syndrome (b) Figure 44.29 (a) Anteroposterior photograph of a foot showing the classic deformities associated with a club foot. The hindfoot (not seen) is in equinus and varus, there is midfoot cavus and the forefoot lies adducted and apparently supinated, although it is actually pronated relative to the hindfoot. (b) Untreated congenital talipes equinovarus in a child aged 7 years. Shoe wear is dif /f_i cult although some indepen

dent mobility is possible.

Club foot /uni25CF /uni25CF /uni25CF /uni25CF Treatment Ponseti method The Ponseti method corrects foot deformity in 95% of idio pathic cases without the need for a formal surgical release and is the treatment of choice for all feet. Treatment commences within a few weeks of birth. A specific set of manoeuvres, followed by a series of well-moulded above-knee plaster casts, results in gradual correction of the deformity ( Figure 44.30 The head of the talus is the fulcrum around which the rest of the foot rotates. After the forefoot has been corrected, most feet lack 15° of dorsiflexion and require a percutaneous Achilles tenotomy (performed under local anaesthetic in the clinic setting). Once corrected the foot position is maintained by a foot abduction orthosis (FAO) that holds the foot in external rotation and slight dorsiflexion. The FAO is worn full time for 3 months and at ‘night and nap time’ f or up to 4 years. Poor compliance with the FAO is associated with a higher relapse rate. Recurrent deformity can be treated with further plasters, but a tibialis anterior tendon transfer (TATT) may be required around the age of 2.5–4 years for persisting dynamic supination. Feet treated with the Ponseti method are less sti ff , less likely to be painful and less subject to overcorrection than those treated surgically . The Ponseti method also works reasonably well in non-idiopathic feet but both the failure and relapse rates are higher. Surgical treatment If conservative treatment fails, surgical intervention is required, ideally before walking age; this is more likely in non-idiopathic deformities. Surgical release is generally performed ‘à la carte’, with sequential release of the pathologically tight structures via either Turco or Cincinnati incisions to reduce the subluxated joints. Stabilisation may include temporar y Kirschner wire fixation. Following correction, wound closure can be di ffi cult but the Cincinnati incision heals well by secondary intention during the postoperative casting period. Ignacio Ponseti , 1914–2009, faculty member of the University of Iowa, USA. Born in Menorca, fled Spain during the Civil War because of the political situation, worked as a general practitioner in Mexico and then went to Iowa to train in orthopaedics. The technique that bears his name only became popular years after he retired – but it brought him back to work for another 20 years. Vincent J Turco , 1916–1999, Chief of Orthopedic Surgery , St. Francis Hospital, Hartford, CT , and Assistant Clinical Professor, Yale University Medical School, New Haven, and the University of Connecticut Medical School, Farmington, CT , USA. Martin Kirschner , 1879–1942, Professor of Surgery , Heidelberg, Germany , introduced the use of skeletal traction wires in 1909. - Good or excellent results can be achieved but sti ff ness and over- or undercorrection are common complications. ). Surgery for recurrent deformity r equires a careful assess - ment of the forefoot, hindfoot and tibial torsion. The foot becomes progressively sti ff er with each surgical intervention. Summary box 44.13 Treatment of club foot /uni25CF /uni25CF /uni25CF

Multiplanar deformity: hindfoot equinus and varus, midfoot adductus and forefoot cavus Incidence is 1–6 per 1000 live births, more common in boys and with a familial tendency Most cases are idiopathic but neuromuscular causes include spina bi /f_i da and arthrogryposis Scoring systems (Pirani/Diméglio), are used to assess severity Corrected Uncorrected Figure 44.30 A series of casts documenting the stepwise correction of the foot deformity with the Ponseti method of serial manipulation and casting. The Ponseti method of serial casting is successful in 95% of feet when de /f_i ned as avoiding formal surgical release The standard sequence of manipulations is: C – correction of the apparent forefoot cavus by elevation of the /f_i rst ray A – gradual forefoot abduction to 60°, and simultaneous V – correction of the hindfoot varus E – correction of hindfoot equinus usually follows a percutaneous Achilles tenotomy, which is an integral part of treatment TATT is used to correct dynamic supination in older children If the Ponseti method fails: Surgical release addresses posterior, medial, plantar and lateral structures, and results in a stiffer foot than one treated conservatively

Congenital talipes equinovarus (the ‘club foot’)

In true congenital talipes equinovarus (CTEV) the three- dimensional deformity is fixed ( Figure 44.29 ). Intrauterine moulding can cause an identical pattern that is postural and therefore correctable. Incidence and aetiology The incidence varies from 1 to 6 per 1000 live births, depending on ethnic di ff erences. It is more common in boys and is bilateral in 50% of cases. A family history is common but inheritance is multifactorial. The diagnosis may be made during an antenatal ultrasound: the sensitivity is higher in bilateral cases, which are more likely to have a syndromic association. In some countries, the detection of CTEV may be grounds for a termination of the pregnancy but the parents should be reassured that, with treatment, their child will function as well as his/her peers. Most cases are idiopathic but because the outcome varies with the aetiology it is important to consider the cause when planning treatment ( Table 44.10 ). Many idiopathic cases will have some weakness of the evertor muscles. Pathology The talonavicular joint is subluxed, with the navicular displaced medially with respect to the talar head. Ligaments, particularly the calcaneofibular ligament, and tendon sheaths, such as the posterior tibial tendon sheath, are shortened and thickened and contain contractile myofibroblasts. The gastrocsoleus and posterior tibial muscles are smaller than normal, with reduced myofibrils and increased connective tissue, possibly because of a local neuromuscular abnormality . The vascular supply via the dorsalis pedis may be diminished. It remains unclear which abnormalities are primary and which occur as the deformity develops. Clinical assessment The postural club foot may benefit from physiotherapy stretches but, by definition, it must be normal by 3 months of age. Shafique Pirani , contemporary , Clinical Professor, Department of Orthopaedic Surgery , University of British Columbia, V ancouver, Canada. Alain Diméglio , contemporary , orthopaedic surgeon, Montpellier, France. In contrast, the structural idiopathic club foot has fixed deformity with elements of hindfoot equinus and varus, midfoot adductus and pronation of the first ray , giving the appearance of forefoot cavus. The heel feels ‘empty’ as the calcaneus is pulled up by the shortened tendo-Achilles. There is a deep medial and a single posterior crease. All children with structural club-foot deformity will have a small calf and foot. Tibial shortening may become apparent with growth. Children should be examined carefully for signs of intraspinal pathology . Both the Pirani and Diméglio classification systems ar e based on the appearance of the foot in its position of max - imal correction. They predict tr eatment response and hence outcome.

TABLE 44.10 Several different types of club foot are recognised. Type Example Postural Idiopathic Neuromuscular Spina bi /f_i da; arthrogryposis Syndromic Trisomy 15 or Disastrophic Dysplasia or Amniotic Band Syndrome (b) Figure 44.29 (a) Anteroposterior photograph of a foot showing the classic deformities associated with a club foot. The hindfoot (not seen) is in equinus and varus, there is midfoot cavus and the forefoot lies adducted and apparently supinated, although it is actually pronated relative to the hindfoot. (b) Untreated congenital talipes equinovarus in a child aged 7 years. Shoe wear is dif /f_i cult although some indepen

dent mobility is possible.

Club foot /uni25CF /uni25CF /uni25CF /uni25CF Treatment Ponseti method The Ponseti method corrects foot deformity in 95% of idio pathic cases without the need for a formal surgical release and is the treatment of choice for all feet. Treatment commences within a few weeks of birth. A specific set of manoeuvres, followed by a series of well-moulded above-knee plaster casts, results in gradual correction of the deformity ( Figure 44.30 The head of the talus is the fulcrum around which the rest of the foot rotates. After the forefoot has been corrected, most feet lack 15° of dorsiflexion and require a percutaneous Achilles tenotomy (performed under local anaesthetic in the clinic setting). Once corrected the foot position is maintained by a foot abduction orthosis (FAO) that holds the foot in external rotation and slight dorsiflexion. The FAO is worn full time for 3 months and at ‘night and nap time’ f or up to 4 years. Poor compliance with the FAO is associated with a higher relapse rate. Recurrent deformity can be treated with further plasters, but a tibialis anterior tendon transfer (TATT) may be required around the age of 2.5–4 years for persisting dynamic supination. Feet treated with the Ponseti method are less sti ff , less likely to be painful and less subject to overcorrection than those treated surgically . The Ponseti method also works reasonably well in non-idiopathic feet but both the failure and relapse rates are higher. Surgical treatment If conservative treatment fails, surgical intervention is required, ideally before walking age; this is more likely in non-idiopathic deformities. Surgical release is generally performed ‘à la carte’, with sequential release of the pathologically tight structures via either Turco or Cincinnati incisions to reduce the subluxated joints. Stabilisation may include temporar y Kirschner wire fixation. Following correction, wound closure can be di ffi cult but the Cincinnati incision heals well by secondary intention during the postoperative casting period. Ignacio Ponseti , 1914–2009, faculty member of the University of Iowa, USA. Born in Menorca, fled Spain during the Civil War because of the political situation, worked as a general practitioner in Mexico and then went to Iowa to train in orthopaedics. The technique that bears his name only became popular years after he retired – but it brought him back to work for another 20 years. Vincent J Turco , 1916–1999, Chief of Orthopedic Surgery , St. Francis Hospital, Hartford, CT , and Assistant Clinical Professor, Yale University Medical School, New Haven, and the University of Connecticut Medical School, Farmington, CT , USA. Martin Kirschner , 1879–1942, Professor of Surgery , Heidelberg, Germany , introduced the use of skeletal traction wires in 1909. - Good or excellent results can be achieved but sti ff ness and over- or undercorrection are common complications. ). Surgery for recurrent deformity r equires a careful assess - ment of the forefoot, hindfoot and tibial torsion. The foot becomes progressively sti ff er with each surgical intervention. Summary box 44.13 Treatment of club foot /uni25CF /uni25CF /uni25CF

Multiplanar deformity: hindfoot equinus and varus, midfoot adductus and forefoot cavus Incidence is 1–6 per 1000 live births, more common in boys and with a familial tendency Most cases are idiopathic but neuromuscular causes include spina bi /f_i da and arthrogryposis Scoring systems (Pirani/Diméglio), are used to assess severity Corrected Uncorrected Figure 44.30 A series of casts documenting the stepwise correction of the foot deformity with the Ponseti method of serial manipulation and casting. The Ponseti method of serial casting is successful in 95% of feet when de /f_i ned as avoiding formal surgical release The standard sequence of manipulations is: C – correction of the apparent forefoot cavus by elevation of the /f_i rst ray A – gradual forefoot abduction to 60°, and simultaneous V – correction of the hindfoot varus E – correction of hindfoot equinus usually follows a percutaneous Achilles tenotomy, which is an integral part of treatment TATT is used to correct dynamic supination in older children If the Ponseti method fails: Surgical release addresses posterior, medial, plantar and lateral structures, and results in a stiffer foot than one treated conservatively