ORIGINAL ARTI! —————— ‘CONTROVERSIES IN CONGENITAL CLUBFOOT : LITERATURE REVIEW 8. Nordin, M. Aidura, 8. Razak, & WI Faisham Departinent of Orthopaedic, ‘School of Medical Sciences, Universiti Sains Malaysia 16150 Kubang Kerian, Kelantan, Malaysia Despite common occurrence, congenital talipes equinovarus (clubfoot) is still a subject of controversy. It poses a significant problem with its unpredictable ourcome, especially when the presentation for treatment is late, The true etiology remains unknown although many theories have been put forward. A standard ‘management scheme is difficult a: there ic no uniformity in the pathoanatomy, classification and radiographic evaluation, These differ according fo the age of the child and the severity of the co The paper discusses these controversies, with an emphasis on the proposed etiologies and types of treatment performed. Key words : congenital talipes equinovarus, controversies, management. ‘suommse-165.2001, Reneea20.12 2007, sceptse-20 22002 Introduction (Congenital talipes equinovamss (CTEV) or ‘clubfoot is a common condition. In Malaysia, owing to the ignorance of parents. clubfoot remains a significant problem and yields an unpredictable ‘outcome due to late presentation for treatment. Clubfoot deformity was documented as early as, ‘ancient Egypt. Smith and Waren in 1924 found that Pharach Siptah of the XIX Dynasty was afflicted ‘with clubfoot (1). Talipes Equinovaras was first sntroduced into the medical kterature by Hippocrates in 400 B.C.V. (1, 2). He recognized that some ‘lubfeet were congenital, while some were acquized in early infancy. The term talipes equinovarss is derived fiom Latin: talue (ankle) and peo (foot): ‘cqqninus: “horce like” (the heel in plantar flexion) and vam: inverted and addueted Hippocrates (1) also suggested that the trentment should start as soon, as possible after birth with repeated manipulations and fixations by strong bandages which should be maintained for a long time to achieve over conection. His teaching principles of treatment are as valid today as they were 2300 years ago. Incidence ‘The incidence of chubfoat varies widely with race and sex. The overall incidence of chubfoot was 1 to 2 per thousand live births (3.4). The incidence ‘in the United States is approximately 2.29 per 1000 live bixths (5); 1.6 per thousand live births in ‘Caucasians (6); 0.57 per thousand in Orientals; 6.5 to 7.5 per thousand in Maors (7); 0.35 per thousand in Chinese; 6 8 per thousand in Polynesians (8) and as high as 49 per thousand of live births in. fullblooded Hawaiians (9). Boo and Ong (10) reported the incidence of clubfoct in Malaysia 1.3, ex 1000 live births. Males outuumber females by 2:l with 50% of cases being bilateral (6) In those ‘with unilateral deformity. there was a sight sided predominance (11). A higher incidence of clubfoat ‘was also noted in patients with a positive family history G. 6). The possibility of elubfoot occurence in a sibling was 1 in 35 and if present in an identical ‘twin, the risk was 1 in 3 (12). Although this was probably due to polygenetic influences, it was suggested that it might also be due to an autosomal dominance of poor penetrance (13).Etiology ‘The tme etiology of clubfoot remains ‘unknown. Many theories have been put forward: 1. Mechanical factors in utero ‘Thic is the oldest theory and was firct proposed by Hippocrates (1, 2, 11), He believed that ‘the foot was held in a position of eqninovaras by extemal uterine compression However, Parker in 1824 and Browne in 1939 believed that dimimution of amniotic fluid, as in oligohydramaios. prevents fetal movement and renders the fetus vulnerable to extrinsic pressure (2). 2. Neuromuscular defect. Some investigators still maintain the opinion ‘that equinovarus foot is always the result of ‘neuromuscular defect (14-17). On the other hand, others have shown no abnormalities in their histological studies (19-20) and electromyographic studies of te nmscles in chabfoot 21. 22). 3. Primary germ plasma defect. Irani and Sherman (23) had dissected 11 equinovarus feet and 14 normal feet (18). In clubfoot. they found that the neck of talus was always short, with its anterior portion rotated medially and plantarly. They suggested that the deformity probably resulted from a primary gem plasma defect. 4. Amested fetal development 2) Intrauterine environment Im 1863, Heuter and Von Volkman first ‘proposed that the arrest of fetal development early in embryonic life was a cause of congenital clubfoot (Q). This theory wae maintained by Bohm in 1929 (1,22), However, the opponents of this theory were ‘Mau (1) and Bessel Hagen (2). 1b) Environmental influences ‘The harmful influence of teratogenic agents on fetal environment and development are well cexamplified by the effect of rubella and thalidomide in pregnancy. Many authors believe that there are ‘various environmental factors responsible for the appearance of a clubfoot, as there are various substances capable of producing a temporary growth arrest @21, 24, 25). 5. Hereditary ‘Clubfoot tends to be familial in @ significant number of eaves (6, 9, 19, 26) It ie inherited az ‘having a poligenie nmltifactorial trait (6, 10, 13, 24, 26). Wynne-Davis stated that polygenic inheritance is more susceptible tothe influence of environmetal factors (6). Pathoanatomy ‘Numerous anatomical studies of clubfoot ‘have confirmed the gross changes in the shape and position of the talus, navicular, calcaneum and cuboid (18, 27-31). The tendons, tendon sheaths, ligaments and fascia of the foot have undergone adaptive changes and became fibrotic or contractured (19, 28, 31-35). The talocalcaneocuboid joints are subluxated (2, 5, 23, 29, 36, 37). ‘Nevertheless, until today, the question still zaman fs to whether the initial anatomical changes first ‘occurred in the tarsal bones with cubsequent cof tiscue adaptation, of vice verea Classification ‘The purpose of a classification system isto help in subsequent management and prognosis. ‘Various classifications of clubfoot exist in the literature (1,3, 38-40). However. without a uniform standard, these classifications pose a major problem, Furtheriore, some are too comples for practical use ‘Dimeglio in 1991 divided clubfeet into 4 categories based on joint mation and ability to reduce the deformities (39. 1. Soft foot ~ may also be called postural foot and corrected by standard casting or physiotherapy ‘ueatment, 2. SoR> Stisf foot — 33% of cases. It is usually ‘a long foot which ia more than 50% reducible and reoponds initially to casting. However, if total conection hae not been achieved after 7 or § months, ‘surgery mnt be performed 3. Stiff> Soft foot — 61% of cases. It is less than 50% reducible and after casting or physiotherapy, it is released surgically according to specific requirements, 354. Stifé foot ~ it is teratologic and poorly, reducible. It is im severe equinus deformity. often bilateral and requires an extensive surgical ‘comection. Clinical Features Congenital clutfoot must be differentiated ‘fiom postural and structural or secondary type of lubfect. The postural clubfoot has the clinical fppearmce of congenital chubfbot, bu it can become folly correctable fo normal anatomic position at birth, or shortly thereafter following 4 period of manipulative strapping. The patieat should be ‘thoroughly examined t exclude features of paralytic clubfoot including multiple congenital malformations. Radiological Assessment ‘At present, there are no satisfactory methods ‘for an early objective assessment. In 1896, Barwell Introduced the tee of plain sadicgraphas to ascess the ‘exact status of clubfoot (1). However, at bizth, clinical examination is more informative than, radiological assessment, as only the ossification ‘centres of the talus, calcameum and metatarsals ae present. These two tarsal bones appear as small rounded ossicles. Thus, the plain radiograph film ‘does not help to evaluate the shape and orientation of the tarsal anlage. The tarsal bones become sufficiently ossified after 3 to 4 months. By then. radiological evaluations give a more accurate ‘objective record than does clinical evaluation. Some ‘authors have made radiological assessments by an. anteroposterior and lateral projection films before ‘and after surgical correction. (2, 11, 37, 41-43). Up to date , there is no consensus on the value of ‘radiographs in the routine management of congenital clubfoot. ‘Treatment ‘The management of clubfoct continues to present a formidable difficulty owing to the current ‘views om its pathoanatonay and treatment. The results ‘of any form of treatment vary according to the seventy of deformity and the surgeon's philosophy ‘on this deformity. The aim of treatment is to obtain aa anatomicaly and fuactionaly normal feet in all patients. (42). However. this is unrealistic as the ‘deformity of the joints and ligaments of the foot and the ankle are sometimes too severe to be corrected. ‘fully. Conservative treatment of clubfoot is well accepted and has been reported to result im good ‘conection ranging from a2 low ar 50 % to ac high ‘33 90% (42). Recent trends show that gentle plaster ‘manipulation is more popular than strapping. This serves fwo puposes = 1. Completely correcting the clubfoot as the definitive treatment. Mild chubfoot may fall into this, category. 2. _ Partially comecting a rigid clubfoot thereby ‘making the srgical approach less extensive (44, 45) (Casting tends to prevent further tightening of the contracted structures during the interval prior to surgery (44). The treatment should be started early ts the caslier the treatment is started, the easier and better the outcome of results are (46,~48). It will allow preservation of the articular cartilage, optimal growth of the bone particularly talus and ‘maintenance of joint mobility (49). ‘Manipulation ‘Manipulation should be gentle but yet strong enough to stretch the sof tissue contractures. Forceftl manipulation may xesult in @ spurious correction producing rocker bottom foot. ‘Traditionally ac enggested by Hippocrates (2), the components of clubfoot deformity were corrected ‘rom distal to proximal (Le. comection of supinatica, forefoot adduction and followed by equims) However, this concept is no loager popular, ao ‘equinus, varus and adduction deformities occur simultaneously and not as an isolated component. ‘Thins, attempts are made to comect al elements of the deformiticssinmiltancously. Following manipulation, an above knee plaster casts applied with the fot held in maximo conection. While the cast is setting, it is moulded around the heel to lock the caleaneum ia the conrected position. The amouat of correction amst ‘be monitored to avoid compromise to the blood ‘circulation 2, 46, 47. The cast is changed at weekly intervals forthe first 6 to 8 weeks, then at fortnightly Evaluation is done after three months of treatment Ifa satisfactory conection is demonstrated, the foot 4 held sn an overcomrected position by a series of plaster east or an orthotic splint. Dennis Browne Splint was popular at one time, but ito woe had been compounded by a high failure rate of skin imitation, apart from also being cumbersome (2, 50-52)Below knee casts are difficult to maintain without subsequent slippage in those with significant equinus, extremely small everted heels, chubby legs and short nid feet. ‘Unfortunately, some of these deformities recur or become resistant to further convervative ‘treatment. A foot is currently considered resistant when the deformity chows no evidence of further improvement after 3 months of adequate conservative treatment (53). Surgical treatment is mevitable then, However, opinion diverge: a to the proper surgical procedure of choice. Argument centers around the nature and the timing of the operation required for the resistant clubfoot, Recent ‘rend towards early soft tizoue releace betoreen 3-6 month: of age ic well supported by many authors 22 oufficient time iz allowed for the tarsal bone: to achieve maximum remodeling (4, $4.59). Thare is litle evidence thatthe children who are operated on ‘before 3 months of age have better results. This is owing to the small size foot and the difficulty in differentiating between the tendon: and nerves (2, 2). ‘The general concept in the surgical trextment of clubfoot is to achieve complete and permanent conection with one operation (2, 60) Deeision to choose the catezories of operative procedures depends on age of patient, dezree of rigidity and presence of deformity. The auical procedures that sre currently in uce can be divided into three basie groups. These procedures are 1. Soft tissue procedures 2. Combination of soft tissue and bony procedures 3. Bony procedures, The procedure that involve: soft tizaue consist ofvelesse or lengthening of tight , deforming :oft ‘tissue structures such as ligaments, joint eapsules and tendons, as well 2s performing tendon transfers. ‘The incision wed vary widely, but what performed ‘beneath the skin is far more important to the reault ‘than the incision itself. The -implest of tissue procedure is the posterior selense , which involves tendo Achilles lengthening, posterior capsulotomy of ankle and subtalar joints and sectioning of the calcaneofibular and posterior talofibular ligaments, a5 these ligaments prevent dorsiflexion of the talus (61). The comprehensive soft tissue release include the posteromedial release of Turco 91 and cireumferential release (49, 57, 62). tendon transfer is oceacionally performed to provide dynamic ‘balance between the evertors and inverters (63, 64) ‘Magone et al in 1989 reviewed all the thee soft tissue procedures done at Columbu: Children “Hospital and was unable to definitely state which ‘procedure is better (54). Other authors have reparted 70%91% of good to excellent correction on patient: ‘underwent posteromedial release before 6 months of age, and 50% relapse rate whan this procedure ‘was done after 9 months old (4, 55, 56, 65). Tn the child whove tarsal and metatarsal bones have become deformed and resist correction, a combination of soft ticoue raleace and various bony procedure: are considered (66-68). In older children ‘between fiveto eight years of age, 2 combination of ‘soft tiscue elease and Lichtblau procedure (resection of distal end of caleaneum) is recommended (69, 10), In those older than nine years of aze. the lateral column of the foot is shortened and stabilized by caleaneocuboid resection and fazion (66). A combination of oft tieoue release with 2 medial opening wedge oxteotomy of ealcaneum and insertion of a bony wedge is also deseribed (71). In general, bony proceduras are rarely if ever, indicated in the infant and young child as these will disturb the nomal growth and development of the foot. Ina cheletally mature foot (more than ten year old), oxtactomy of the o* caleiz, taal reconstruction and triple arthrodesis are required az calvage procedures (3, 72). Metatarsal osteotomy at their ‘bases will correct the varus footfoot, Dwyer: osteotomy of the calcaneus corrects hindfoot varus (70, 73) and medial rotation osteotomy of the tia ‘may be indicated to correct severe lateral rotational malalignment of the tibia and fibula (74). Occasionally, a talectomy ic performed (11). Conclusion Congenital elubfoot is still a subject of controversy and remain: 2 significant problem owing to the unknown aetiology and disputed pathoanatomy. Moreover, there are no satisfactory methods for early objective azsecsments and concensus on the value of radiographs in the routine ‘management. The results of any form of trestment -vary according to early presentation for treatment, ‘severity of the deformity and surgeon's philosophy on the deformity.nda ica Correspondence : Dr. Aidurs Mustafa, MMed, Department of Oxthopaedic, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia. email: sidurs@itb-wsm my References 1. 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