Aspects of current management SO teatente = ‘i % ‘THE MANAGEMENT OF CLUB FOOT: ISSUES FOR DEBATE 3 3 3 M.F.Macnicol 3 = % e Epidemiology and aetiology ‘able. Condions sox wi (yn) TEV ‘Congesital talipes equinovarus (CTEEV) is @ common aad challenging musculoskeletal deformity. The prevalence in a ‘cent prospective national survey is 0.89 por housand ve births! although rates of 124° oF have boon. ‘reported in the UK_TThus in a district general hospital with a Cclctiment popelation of 500 000 up to ten babies with (CTEY will present annually. Increasingly the presence of (CTEV can bo diagnosed prenatally by ultrasound. ‘Racial and genetic factors are influential. Maoris and ‘other Pacific islanders prosent with a mato of prevalence of 6 to 7 per thousand live births, whereas in the Chinese and Japanese the me is 0.5 per thousand.’ Some of this vari- tion may reflect different alitades to the inclusion of pos- ‘ural (resolving) deformities and of syndromic (non: idiopathic) club feot (Table 1). IdelRerger's twin stdies® ientified a monozygote concondance of 32.5%, strongly ‘suggesting a genetic influence since dizygotic twin concord ance was oaly 2.9%. Acquired oF modulating factors, leading to a multfac~ torial inheritance pattern are refloctadin the seasonal vara- ton of the coadition!~" and in the neurological deficit, ‘which may underly the deformity’! The proportion of ‘muscle fibre types in the calf have beon variously described ‘asnommal or abaormal bya large mumber of authors but may ‘be assconckry feature rather than a peimary alteration. Vas- ccilar anomalies have also been described along with many ‘oer intrinsic abnormalities involving the soft tissues ofthe affected foot!) Clinical assessment ‘The assessment ofthe club-foot deformity, and the imposi- tion of a clasifcation system, are conteatious, but neces- TLE Naeaeal WO FICK Cont Onion ‘he Las Usesty Hospi HS Tessa Hosa fe Sick Chi uk Seer Sap Seca ames oot Seto sate Antone Feat syatue Comps yong Dowson Dyin sary for roviow and comparison. The system necds to be ‘producible between observers, practical and reliable in its Clinical application, particulary in relation to prognostica- tioa, There is ao such classification in existance although the simple grading of Harrold and Walker"? has mach to commend it, Hoth these authors and others! have con firmed that the pretrestment assessment creates reason ably well with outcome. When different grades of staff and a physiotherapist assessed both normal and club fect before ‘operation, agreement between observers was highest using the Harrold and Walker clasification."* When normal fest ‘were exchided and the assessment confined to two experi- enced orthopaedic surgeons, the system used by Diméglio et al! was considered to be more reliable although it is com- plex to apply and the four-group system used by these authors is, somewhat confusing. Flynn, Donohoe and fel® noted that independent assessment of both the iméglio classification and the evaluation proposed by iran t al!” produced acceptable interobserver roiability Photographic and radiological assessment are static but offer a good record ofthe defermity “The dynamic portrayal of the deformity is difficult to quantify, but is important when stiffness is being assayed Since this is one of the main predictors of success or failure after treatment. It is also appropriate to recognise that the typical, idiopathic elub foot may differ in its response to tweatment from the atypical (syndromic) club foot. Adi- tionally, the severity of deformity, principally its rigicty, ‘muy affect the hindfoct, midfoot and forefoot differentially. The ‘grading of the foot does predict the ccatcome!™141 aihoagh this view is not universal" Com- parisons of management (both operative and mainly con Sservative) have suggested that the end result may besohanced by a more comprehensive release.”"™ Equally, ‘Laaves and Ponsati!? cautioned against the stiffooss and iatrogenic deformity which may follow inadequately per- ‘formed or excessive surgical release“) The effet of porsist- ‘ng nouromuscularimbalance i also poorly appreciated and a lack of recovery of the peroneal muscle after operation or persisting neurophysiologial deficit”! may beertcal. ‘Conservative management Advocates of a more conservative approach recommend ‘repeated manipulation of the deformed foot, with or without plaster splintage, whereby applied tension and subsequent relaxation ofthe tight soft tissues ultimately lead to correc- tion 5182729 The graduated improvement in anatomical alignment is achieved by sequential stretching ofthe differ- ‘nt components of the deformity. The Key to reduction, according to Ponsa is reversal of the cavus by dorsiflex- jon of the fist metatarsal during the intial stage of treat- ‘ment. Supimation and equinis are accepted until the ‘metatarsal is adequately dorsficned. Reduction inthe cavus ‘unlocks the midfoot, the forefaot being. allowed to remain spinal, Subsequent correction occurs by using the ‘uncovered talar head as a lateral fulerom. ‘The forefoot is progressively abducted but not pronated, achieving the normal anatomical divepence of the axes of the calcaneum and the talus. In turn, as the calcaneum dorsi- ‘exes daring its extemal rotation, the equinus is reversed although up to 90% of patients will require a tenotomy of tendo Acilis. Pressure over the lateral aspect of the hind- oot, in the vicinity of the calcaneacuboid joint, should be voided since this prevents abduction of the caleaneum, and ‘inhibits the corection of heel varus. ‘While the use of preliminary strapping and casts isthe mainstay of the early management of al types of club foot, some surgeons doubt whether these individual components ‘of the defaemity can be isolated for correction as suggested bby Ponset™ and his adherents. Furthermore, the release of tendo Achilis percuaneously is nocessarily ‘blind’, and secesive dorsifeioa of the foot subssqusntly may over- Jengthen the tendon and lead toa calcaneus deformity. Cor- rection and maintenance ofthe talonavicular dislocation are ‘ignored and the considerable deforming force ofthe tondon ‘f tibialis posterior, which is often equivalent in power to the calf muscle in its sistance, is nol addressed. ‘Ideally, longthoning of muscle should be the goal rather ‘than elongation ofthe tendon. If this can be achieved con- servatively, itis obviously preferable. Compression of the ‘cartilaginous tarsal bones occurs after both conservative or ‘surgical eatment and this process may not be eairelyiane- scent. ‘Remodelling’ occurs in response to tho altered mechanics produced by spintage, wilh changes in oth the shape ofthe bones of the hindfoot and midfoot and allerod ‘congnity ofthe joints. CCinicatly, manipulations for two to three minutes may be all thatthe surgeon can sive, so thal other therapists Including the parents, should be involved, Plaster-of-Paris| ‘casting, mainlaining the knoe in at least 70° of Hexion, should ensure that the postion is maintained after manipu- lution. These casts are a vital part of treatment (whether ‘conservative of postoperative) and therefore their procise sition must be maintained for five to seven days. Subse- ‘quent changes of cast repeat the process, and the corrected foot is finally immobilised for three wooks “in 70 deproes of ‘duction and 20 degrees of dersftesion”."* ‘After twa to three months ofthis treatment the splintage Js changed to afoot abduction bar, which restricts Une infant upto the age of approximately six months. Part-time use of the abduction har is recommended during periods of sleep unl the age of three to four years. Diméghio et a advo- ‘cate a more intensive programme of manipulation, necessi- {ating prolonged inpatient care for both physiotherapy and ‘continuous passive motion. This approach, although adaui~ rable, is unlikely to be cost-effective in most health-care ssystoms. While the earlier results of treatment in pastor” ‘gave results Which did wot soem tobe reproducible ‘ethers, recent application of the Ponseti ‘sug gests that greater attention to detail during the plastering. [Process yields correspondingly better results. The exact ‘umber of minor surpeal interventions required during this conservative’ approach is aot always clear, nor is patient and parental compliance assured when the period of splintage extends over many months and relies upon a foot ‘buction bar well into childhood. ‘Operative management 1 surpical treatment is recommended, most surgeons prefer to consider this at three to six months of age, oace the ‘effects of strapping and plaster splintage have become clear. ‘Neonatal surgical intervestion was advocated by RYOPRY aud and Pous and Diméglio,” but the general ‘view prevails that thie is too early. The operative field is restricted and the margin for error small. Some resolving, ‘club-Foot deformities may be operated on unnecessarily and the tiny, very stiff foot at birth represents a formidable pro- Position, even under magnification, Safe anaesthesia may also be a concern at this age in some hospitals, and plaster splintage is required until the child is walking. ‘The comparison of the results of early (three to six months of age) versus lator surgery are limited by the lack. of ive, matched series. Porat, Milgrom and ‘considered that ealier surgery was advantageous although the severity of the deformity in ther two treatment groups was unclear. DePuy and. ‘compared clini- ‘cal and radiological outcomes in children operated on at four, six and nine months of age. Early surgery produced the ‘deformity continues to improve with conservative treatment, ‘and also when the small and very siff foot is under consid ‘eration.‘The Cincinnati incision’ affords excellent exposure both posteromediaity and posterolterally although skin healing may be adversely affected i the foot is dorsflxed ‘oo rapidly after operation. For this reason, pinning of the ‘trsl bons isnot svete. The talonavicula joint can te -raduced adequately by abducting the forefoot using plasters, aud the restoration of the hindfoes relationships can only be achioved ina pradusted fashion since rapid stretching of the neurovascular handle and the soft-tissve structures may lead ‘tw complications. ‘There are many areas which are open to debate. Should ‘he interosseous subtalar ligaments be tansected? Is a cal ‘caneocuboid release ‘Do tho tendons of flexor hallucis longus and flexor digitorum merit elongation or not? Should the naviewlomedial cuneiform joint be opened? ‘How extensively should the eavus be releasad” ‘Complications “These can he grouped into three broad categories as follows: 1) Undercorection 2)Overcorraction. 3) Surgical err. ‘Undercorretion, whther after consarvative treatment oF a conventional surgical release leaves the Foot deformed at various sites, Supination and adduction are relatively ‘common and may improve with timo if adduction is the pro- “dominant appearance. When supination is mobile, transfer ‘of the tendon of tibialis anterior may be effective. If tne deformity is fixed. furthr release of the medial columa of ‘the foot will be eogaized, combined with shortening of the ‘tral column in he older child. Residual o recurrent equi- as, with or without varus of the hecl, may respond to 8 short course of sirtching casts. Further posteromedial roloase runs the risk of overcorreting the Rindfoot, thus producing a calcaneccavus or calcansovaleus deformity. It may be functionally better o leave the hindfoot slightly undorcorrecied than to produce a caleaneus hook. A cavo- ‘ras deformity results from inadequate release of the mic foot, including a failure to avidress the talonavicular subluxation and tight plantar strictures. Ifthe hindfoot is mobile, fanher soft-tissue release may suffice. If the hind- oct is fixed, an addtional calcaneal osteotomy may be indi- ‘cated, ‘Qvercorection produces a foot which may function very poorly. Overtengihoning of tendo Achilis and the tendon of tibialis posterior must be aveided at all casts. This risk is ‘enhanced when surgery is carried out pereutaneously of is repeated. Fixed valgus ofthe hindfoot is almost impossible ‘to correct although the use of an orhotic sappoet may limit its impact. Forcible manipalation ofthe club foat may result, in damage to the articular surfaces of the tarsal bones with gross changes in their shape. A ‘recker-hotiom’ foot of ‘dorsal subluxation ofthe naviculareannot be reversed Surgical error can only be avaidad by a thorough know sedge of the relevant anatomy and an appreciation that aber yor ssn 2 MARCH ‘ant structures and relationships characterise the club foot ‘Sharp dissection is vital during certain phases ofthe opers- tion bat may be damaging to neurovascular and cartagi- ‘nous tissues. Exoessive stripping of the tarsal bones and release of the subtalar intorossoous ligaments will proiuce vascular necrosis. Injury tothe posterior tibial nourovasea- lar bundle imperils the foot as the anterior tibial (dorsalis pedis) arterial supply is doficiont i varying dogree. Corract- fag the foot too mipidly postoperstively will also elimina ‘mich of the arterial supply and exacerbate oadema socond. ay 10 vonous stasis. Hypersensitivity of the scar, loss of sensation, skin sloughing and gangrene should be avoidable by careful supical technique and a graduated correction by plaster casting of the foot. Conclusions ‘The management of cub foot inthe infant contigs to pro- ‘mote much debaie. Al peesen, there is swing towards con- servative management, possibly because the results of surgical intervention are unpredictable. Uncertainties will incvitably persist bocause of the varying aotiology of the daformity and heace its prognoris. Grading systems are ‘simplistic and inadequate in their portrayal of the severity of | ‘he deformity before conservative or operative management. Underlying neurological deficits are poorly evaluated. Informed decision-making is hamporad by a lack of con vincing long-term reviews of trastment based on prospoc- tive assessment and unbiased comparisons of different techniques Ina review of this sort space restricts discussion of the use of distraction frames. whether initially or in the manape- ment of later relapse and deformity. References 1 Reker St, Mira Son ain = Arista MiSs accion mean LWyer tink Hag nd in-law commen Pepeenpemes ps einer pape rate ae Ligteas = ‘gir BS Ran SoS ernie ‘ToaTe na an 44 Til Fisk NM Morphy K Naot DA Cina ctr ofc. Cee Chapman; Stott NS, Part HY, Nel RO. Gent of cot Sa Met and icin poop. 00°70. Spar J. Cote lp indy. 4 Bon Say 19027 9 Farin 7. Cla AN, ara etal Moxie inns teasing, ofan ea ero wr a 40 Maciel ME. Naeem RD. Erion be domi ncnty zoey ed paca Bea So ur Be) 208pli penn peg mtn tel. Pei Crp 1 fhe A, Walter Ch. Tem and prog cogent far dow neigh sass 15. Maca ME, deo BDF MP cof ca ‘eileen compen ups estar ug gen ‘etc mete J Rela Ordo B30 9280 92 “M4 Yaowright AM, Ald Teen ME Teg TT cla tpn Caen 7 ef Bf STS oon pane eat Some Mc Flyan JM, Donohoe M, Machonse WE. A eccaeney Wis dubie decioinesgrome 1 der Onley £ WORT ae HL Moran M,Smamisky B.A mod of eal as sage ibe wid mierail therchore lab POWAmcaty, Mina era BO 7 ‘8 Peter BW, Juscemnenincongei tinea Sonn ad OTC 19 Lage 8, Pont 1. outs of rout cones bine a ie ‘rT ae Aaa 22 Mackay DW Nw con _ Teo Palas sade! Pel Grtop SST Taree VE Resinant congenial choot ax Soe a 2m Fgh Acer he ger) toad ca ‘eisaclnaiecuumen Sebbient I =e Acar ee ot ies or ea ih ih i. Co min Sea sansa’ ae spa cine by Dine Aca po iC slambas Caen sHsp Peet Drop 008.2 Alon, Compares oft it nae fr cubed 7 Petr Orhap NS 25 Simons Camp salar le inci Pu Src eee AL10S6-65. in 26 Radeon J dalam A, Newer isin cht bourse 1K. Pecne cin be ramet of cnn host J teed ag Ro ae tema H, Bae C Comment ea Ciarredaar 29. tom. oct age. eit Ory #2000207 B.D A eae Mean FD lV ohne ae Ee Sioa # Rar Ooops. a TE Rae BN, Ro re dia ete RAR a 2 Rage Sama Monde ee of oh ODES, Ser Tat eg ie) BEES “katy enter nat ner cuten Te Ny tame ans o ea Sas ate a — jeune acceedal ce! Palas Gnkp RAAT Sta Lees Gemstar seine (Gr 19855 ane % hal, Sth Cle AD Tee of naam 37. Crawler All, Marae JL, Oneal DI. The Cincinnati: = rel arent enigne iar hood. J Boe at Say a USE HSS [M.Thomcte JC, Simone CW. Defic f the calemeceubd ban Seeger cpm Fe aya 1 ‘9. Macaical ME, locke LL Calcenecibo mlaligamentin lb fot ‘Tchr Ortop BSTC