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1. CLUB FOOT Presented By Dr. Karrar Al- Jubory Orthopedic Surgeon

2. Introduction It is a congenital malformation of the lower extremity that affects the lower leg, ankle, and foot. Club foot, also called congenital talipes equinovarus (CTEV ) The affected foot appears to have been rotated internally at the ankle . Approximately 50% bilateral club foot . It occurs in males twice as frequently as in females. Without tx , people with club feet often appear to walk on their ankles or on the sides of their feet. However with tx , the vast majority of patients recover completely during early childhood and are able to walk and participate in athletics.  Because of poverty, lack of education and socioeconomic reasons many of our children (more than 60%) are neglected and remain untreated.

3. Regions

4. Nomenclature Planus : flatfoot Cavus : highly arched foot Talipes : Latin talus (ankle) + pes (foot). Equino : indicates the heel is elevated (like a horse's) Varus : heel going towards the midline Valgus : heel going away from the midline Adduction : forefoot going towards the midline Abduction : forefoot going away From the midline

5. ankle joint plantarflexed /equines subtalar joint inverted/ varus forefoot adducted Mainly three bones are affected ; Talus Calcaneus Navicular Idiopathic Clubfoot Secondary Clubfoot Arthrogryposis Diastrophic dysplasia Streeter`s dysplasia Freeman Sheldon Syndrome Mobius syndrome Three basic components Etiology

6. Risk factors Sex . Clubfoot is more common in males. Family history. If either one of the parents or their other children have had clubfoot, It's also more common if the baby has another birth defect. Smoking during pregnancy. her baby's risk of the condition may be 20 times greater than average Soft tissue contractures:  Cavus (tight intrinsics , FHL, FDL)  Adductus (tight tibialis posterior)  Varus (tight tendoachilles , tibialis posterior)  Equinus (tight tendoachilles )

7. Clinical symptoms The top of the foot is usually twisted downward and inward, increasing the arch and turning the heel inward. The foot may be turned so severely that it actually looks as if it's upside down. The calf muscles are usually underdeveloped. The affected foot may be up to 1/2 inch shorter than the other foot.  Small foot  Small calf  Tibia - shortened  Medial and posterior foot skin creases  Foot deformities: ◦ Hindfoot - Equinus + Varus ◦ Midfoot - Cavus ◦ Forefoot - Adduction

8. Complications Clubfoot typically doesn't cause any problems until a child starts to stand and walk . If the clubfoot is treated, the child will most likely walk fairly normally . He or she may have some difficulty with :  Mobility. The child's mobility may be slightly limited .  Shoe size. The affected foot may be up to 1 1/2 shoe sizes smaller than the unaffected foot. However, if untreated  Arthritis.  Poor self-image. The unusual appearance of the foot  Abnormal walking. he or she may walk on the balls of the feet, the outside of the feet or even the top of the feet  Muscle development problems. These adjustments may prevent natural growth of the calf muscles, result in an awkward gait.

9. Diagnosis Ante-natal ultrasound scan. After birth it can be detected by means of looking at the shape and position of the foot. X-ray>> to fully understand how severe the clubfoot is, but usually X-rays are not necessary It's possible to clearly see some cases of clubfoot before birth during a baby's ultrasound examination. If clubfoot affects both feet, it's more likely to be seen in an ultrasound.

10. Treatment Ponseti Method Weekly serial manipulation and casting Every weekly for 1st 6 week Or f ortnightly till 6 months correction acheived Perform a minor surgical procedure to lengthen the Achilles tendon (percutaneous Achilles tenotomy) toward the end of this process Dennis Brown Splint For 6 – 18 months CTEV shoes ( up to 3 years ) Surgical Treatment  Soft tissue operations Release of contractures, tendon elongation, tendon transfer, restoration of normal bony relationship  Bony operations U sually accompanied with soft tissue operation Types: - Osteotomy, to correct foot deformity or int. tibial torsion, Wedge excision, Arthrodesis (usually after bone maturity) Salvage operation to restore shape

11. Congenital Vertical Talus(CVT) Tachdjian describes as the “ teratologic dorsolateral dislocation of the talocalcaneonavicular joint with rigid hind foot equinus ” • Incidence 1 in 10,000 • Male=female • B/L -50% CVT-fixed dorsal dislocation of the navicular on the talar head and neck and fixed equinus contracture of the hindfoot resulting in rigid flatfoot deformity. • Idiopathic /or associated with other neuromuscular or genetic disorder .

12. Etiology  Idiopathic  Genetic/ syndromic : Spina bifida, trisomy, marfan syndrome  Neuromuscular: Congenital myopathies and distal arthrogryposis  Abnormal variation in muscle fiber size, type I muscle fiber smallness, and abnormal fiber type predominance (Merrill )  Contracture of the tendo -Achilles, EDL, EHL, tibialis anterior

13. Clinical Presentation  Rigid flatfoot with a rocker-bottom appearance of the foot  Persian slipper appearance  Calcaneus in fixed equinus  Achilles tendon is very tight  The hindfoot is in valgus  The head of the talus is found medially in the sole  The forefoot is abducted and dorsiflexed

14. Imaging Studies  AP: increased talocalcaneal angle  Plantarflexed lateral: fixed forefoot dorsal dislocation  Dorsiflexed lateral: fixed equinus of hindfoot  Lateral radiographs of the foot in maximal plantarflexion can reveal if the navicular is reducible

15. Nonoperative Treatment  Serial casting to stretch the foot in plantarflexion and inversion while counterpressure is applied to the medial aspect of the talus  Reverse Ponseti method  Complete correction rarely achieved Surgical Treatment  single-stage surgical correction  Cincinnati approach or the dorsal approach ( Seimon )

16. Tarsal coalition Condition in which there is a bridge of bone or cartilage which causes restricted or absent motion between two or more tarsal bones. Mesenchymal origin  Incomplete division leads to tarsal coalition Rigid flat foot in children is most often due to tarsal coalition. Classification  Acquired :: Arthritis, Infection, Neoplasia, and Trauma  Congenital (Most common) Tissue type( pathoanatomic )  Bone -- synostosis  Cartilage -- synchondrosis  Fibrous tissue-- syndesmosis

17. Classification Anatomical  Talo -calcaneal Calcaneo-navicular  Post talo -calcaneal  Cubo-navicular  Talo-navicular  Calcaneo -cuboid  Juvenile (Osseous Immaturity)  Adult (Osseous Maturity ) Calcaneo-navicular usually 8-12 years old (most common) Talo-calcaneal usually 12-15 years old

18. Pathoanatomy G ait mechanics Sub- talar joint will normally rotate 10 degrees internally during stance phase I n presence of coalition, internal rotation does not occur Deformity flattening of longitudinal arch abduction of forefoot valgus hindfoot peroneal spasticity (also known as  peroneal spastic flatfoot )

19. Pain Generator Theories - Ossification of previously fibrous or cartilaginous coalition - Microfracture at coalition bone interface - Secondary chondral damage or degenerative changes - Increased stress on other hindfoot joints Associated Conditions Non- syndromic autosomal dominant Syndromic fibular hemimelia carpal coalition FGFR-associated craniosynostosis Apert syndrome, Pfeiffer, Crouzon , Jackson-Weiss and Muenke

20. Symptoms Asymptomatic most coalitions are found incidentally 75% of people are  asymptomatic Pain sinus tarsi and inferior fibula suggests  calcaneonavicular distal to medial malleolus or medial foot suggests  talocalcanea onset of symptoms correlates with age of ossification of coalition calf pain Signs hindfoot valgus forefoot abduction pes planus limited subtalar motion heel cord contractures arch of foot does not reconstitute upon toe-standing

21. Imaging Anteroposterior view Standing lateral foot view 45-degree internal oblique view Harris view of heel Calcaneonavicular coalition >> "anteater" sign T alocalcaneal coalition >> talar beaking on lateral radiograph C -sign

22. CT and  MRI R ule-out additional coalitions D etermine size, location and extent of coalition May be helpful to visualize a fibrous or cartilaginous coalition

23. Treatment Nonoperative Observation, Shoe Inserts Immobilization With Casting, Analgesics(below-knee Walking Cast For Six-weeks) Up To 30% Of Symptomatic Patients Will Become Pain-free With A Short Period Of Immobilization Operative C oalition resection with interposition graft, +/- correction of associated foot deformity 80-85% will experience pain relief S ubtalar arthrodesis T riple arthrodesis

24. Anatomy o f the Arches of Foot Two longitudinal arches – Medial longitudinal arch – Lateral longitudinal arch Transverse arch • Anterior transverse arch • Posterior transverse arch

25. Use o f the Arched Foot  Supports body weight in upright posture  Acts as a lever to propel the body forwards in walking, running and jumping  Acts as a shock absorber  Concavity of the arches protects the soft tissues of the sole against pressure

26. Medial longitudinal arch • Higher than lateral • Composed of – Calcaneous - Talus - Navicular - 3 cuneiform – 3 metatarsals • Talar head is key stone of this arch >> Tibialis anterior attached to – 1st metatarsal , medial cuneiform – strength for this arch. >> Peroneus longus tendon – pass laterally to this arch providing support

27. Lateral longitudinal Arch • Flatter than medial longitudinal arch. • Rests on the ground during standing. • It is made up of – calcaneous , cuboid, 2 lateral metatarsals.

28. Integrity of bony arches Passive factors • Shape of the united bones • Four successive layers of fibrous tissue – bowstring the longitudinal arch – Plantar aponeurosis – Long plantar ligament – Plantar calcaneocuboid (short plantar) ligament – Plantar calcaneonavicular (spring) ligament Dynamic supports – Flexor hallusis and digitorum longus – longitudinal arch – Fibularis longus and tibialis posterior – transverse arch • Plantar ligaments and plantar aponeurosis bear greatest stress and important in maintaining arches

29. Definition • Cavus is an acquired or congenital deformity of the foot ,characterized by excessive high longitudinal plantar arch combined with clawing of the toes Charcot Marie Tooth disease • Friedrich’s Ataxia • Roussy -Levy syndrome • Poliomyelitis • Cerebral Palsy – Spina Bifida – Talipes Equinovarus – Myelodysplasia – Clubfoot Iatrogenic – Post surgery or trauma – Peroneal nerve injury – Syphillis – Poliomyelitis Idiopathic – Most common Development of the deformity • The intrinsic musculature normally flexes the metatarsophalyngeal joint and extends the interphalyngeal joint . When the long flexor contracts on the straight digit it slings up the heads of the metatarsals and prevents the drop of the forefoot on the hind foot • In the absence of lumbricals ,the long flexor pulls the toes into flexion and no longer supports the metatarsal head.

30. Etiology … So the forefoot drops and the lax structures in the sole contracts and forms claw foot. • Dropping of fore foot on the hind foot followed by a contracture of the plantar fascia and clawing of the toes

31. Clinical Features • High arch ., • Hyper extension of toes at metatarso-phalyngeal joint • Hyper flexion at the inter- phalyngeal joints. • Pronation and adduction of the fore foot • Lengthened lateral border of foot and shortened medal border. • Callosities beneath the metatarsal heads • A bony dorsum of mid-foot with wrinkled skin folds on the medial plantar aspect

32. Radiographic findings P es cavus standing weight bearing antero –posterior and lateral views X Rays taken to d emonstrate the apex of the deformity • Talo calcaneal angle • Calcaneal pitch • Degree of plantar flexion of the great toe • Asess the contribution of cavus by hind foot , midfoot and fore foot

33. Treatment Conservative : metatarsal bar on the shoe, metatarsal pads. Surgical measures : Soft tissue procedure( release and transfer) Bony osteotomy Arthrodesis Structures to cut • Abductor halluces • FDB • Abductor digiti minimi • Long plantar ligament • Plantar fascia

34. Flat feet( Pes planovalgus, Fallen arches ) Absence of normal medial longitudinal arch • Instep of the foot collapses and comes in contact with the ground. • In some individuals, this arch never develops Other abnormalities • Heel valgus • Mild subluxation of subtalar joint(talus tilts medially and plantarwards ) • Eversion of the calcaneus at the subtalar joint • Lateral angulation of midtarsal joints ( Talo Calcaneal , Calcaneo Cuboid) • Supination of forefeet

35. Flat feet are a common condition. • In infants and toddlers, the longitudinal arch is not developed and flat feet are normal. • The arch develops in childhood • By adulthood (12-13yrs), most people have developed normal arches

36. Types Flexible –on weight bearing it disappears and on non weight bearing it reappears • Flexible, painless is most common Etiology  Developmental – the most common Hypermobile (ligamentous hyperlaxity ; Ehlers- Donlos , Marfans )  Neurogenic( rare and usually cause the reverse-Pes Cavus ) • Rigid – acceptable medial longitudinal arch does not seen even on non weight bearing Etiology  Congenital (Tarsal coalition,Vertical talus)  Aquired )inflammatory)

37. Symptoms Deformity • Foot pain ,ankle pain, leg pain • Heel tilts away from the midline of the body more than usual • Abnormal shoe wear Tendonitis of PTP and it can either fail, rupture, stretch or just hurt. This condition is called (PTD OR TPD) • Arthritis. • Plantar fasciitis • Bunions & Hammertoes • Corns and callosities

38. Radiography • Asymptomatic flatfoot radiological evaluation unnecessary • First Antero posterior and Lateral views of the foot • Antero-posterior ankle to rule out valgus at the distal end of tibia • Special view - 45 degree eversion oblique for accessory navicular bone AP standing view is to asses heel valgus , Talocalcaneal angle more than 35 degree is associated with incresed heel valgus • CT scan accurately defines anatomy of subtalar joint , allows surgical plannig if it is involved.

39. Meary’s Angle Most common angle to indicate flat foot Intersects at apex of the deformity • Meary’s angle - between long axis of talus and long axis of first metatarsal on a standing lateral X ray Normal Meary's angle long axis of the talus should bisect the navicular and first metatarsal – Normal 0 – 15 degrees – Mild 15 – 40 degrees – Moderate > 40 degrees – Severe The long axis of the talus is angled plantarward in relation to the first metatarsal, consistent with pes planus

40. Treatment >> 0-3 years old: > No treatment unless very strong family hx of persistent flatfeet  Orthotic shoes with thomas heels ,medial heel wedges and navicular pads  Convince the parents. >> 3-9 years • Conservative management • No surgery • Custom orthosis inserted with leather ,cork, propylene . >> 10-14 yrs • No symptom- No treatment • Symptomatic – conservative management initially • Surgical

41. Surgical treatment Surgical treatment Indications 1.pain 2.failure to respond to orthotic control 3.Ulceration or callus under the head of the plantiflexed talus 4.Excessive shoe wear The surgeon , patient, and parents must be willing to exchange loss of eversion and inversion of the foot for relief of pain and disability

42. Thanks For Your Attention