Congenital clubfoot

1. Congenital Clubfoot ( Talipes equinovarus ) Yasser Alwabli

2. Introduction – definition Developmental deformity of foot described as: Equinus Inversion (HF varus ) Cavus (FF pronation) Adduction

3. Introduction – definition

4. Epidemiology 1-2 in 1000 50% bilateral, Boys 2X Associations (20%) - SP, CP, AG ? DDH (Paton RW, 2009) Family studies: 30% in identical twins, one parent 3-4% and two parents 30%

5. Etiology Many theories: Mechanical, neuromuscular, vascular deficiencies Polygenic multifactorial trait AD with incomplete penetrance Environmental – early amniocentesis, maternal smoking Genetic – PITX1 gene

6. Pathoanatomy Talocalcaneonavicular (TCN) joint dislocation with soft tissue contractures

7. Soft tissue contractures Cavus  (tight intrinsics , FHL, FDL) Adductus  (tight tibialis posterior) Varus  (tight tendoachilles , tibialis posterior) Equinus  (tight tendoachilles )

8. Clinically Small foot Small calf Tibia - shortened Medial and posterior foot skin creases Foot deformities: Hindfoot - Equinus + Varus Midfoot -   Cavus Forefoot - Adduction

9. Imaging Antenatally – US X-Rays – not routinely done Views - AP and lateral in stress dorsiflexion. On AP view: Talocalcaneal angle (30-55˚) and the talo -first metatarsal angle (5-15˚ ). Lateral view: Talocalcaneal angle (10-40˚) and the tibiocalcaneal angle ( 10-20˚). Hindfoot parallelism All of these angles are decreased.

10. Classification - Pirani’s classification system ( Pirani et al, 1995)

11. Classification - Dimeglio classification ( Dimeglio et al, 1995)

12. Classification - Dimeglio classification ( Dimeglio et al, 1995)

13. Classification - Dimeglio classification (Dimeglio et al, 1995)

14. Treatment – Ponseti technique Since 1950 POSNA members – 96.7% (2010) Success rate – 90% Timing – first weeks of life Serial casting (average 4-5 casts) Long leg cast Dennis brown bar Achilles tenotomy – 70%

15. Dennis brown bar

16. Treatment – Ponseti technique

17. Treatment - French technique 74% success rate Daily manipulation by physiotherapist followed by immobilization with adhesive taping to maintain the correction achieved with stretching.  Daily for 2 months then 3/week till age 6 months. If successful in achieving correction, parents continue both the home exercises and night splints until the child reaches walking age.

18. Treatment – surgical options Posteromedial soft tissue release : Resistant cases Delayed presentation Syndrome-associated clubfoot M edial opening or lateral column-shortening osteotomy, or cuboidal decancellation – older children 3-10 years Tripe arthrodesis – refractory cases Talectomy – salvage procedure

19. Complications With nonoperative treatment: Relapse Dynamic supination With operative treatment: Residual cavus Pes planus Intoeing gait Dorsal bunion