Chapter 29 Clubfoot

2 Types
1) Congenital
2) Acquired

Possible Etiologies
1) Hereditary
2) Interuterine Mechanics
3) Arrested embryonic development
4) Neuromuscular disorders
5) Circulatory disorders of tarsal precursors
6) Rotational or torsional abnormalities
7) Primary osseous deformation (most accepted)

Deformation primarily in talus where normally the head is adducted 15-20 degrees in
clubfoot its 80-90 degrees. In the sagittal plane the head is normally plantarflexed 25-30
degrees in clubfoot its 45-65 degrees.

The navicular may appear to articulate with the tibia medially, and even though the talar
head is medial, the body rotates laterally and can be palpated just anterior to the lat
malleolus.

Classification
1) Congenital – idiopathic and is divided into 2 types
a. Intrinsic clubfoot – rigid deformity
b. Extrinsic clubfoot – supple deformity
In the intrinsic type you see significant muscle atrophy and decrease heel size, see
deep seated skin creases along the medial aspect. Medially, the malleolus and the
talar head are not easily palpated. Laterally, the malleolus and sinus tarsi are
obliterated due to the calcaneal adduction and varus. Intrinsic deformities
classically require operative treatment, whereas extrinsic can be treated
conservatively. Also extrinsic deformities can become rigid over time.

2) Acquired Clubfoot – caused by disease states or trauma

a. Neuromusclar causes
i. Meningitis, Poliomyelitis, Post CVA, CP (Little’s dz), Spinal
disorder/tumor, diastematomyelia
b. Posttraumatic effects
i. Spinal cord trauma, peripheral nerve trauma, tendon laceration,
fracture malunion/non-union, volkmann’s contracture, post burn
contracture
Pathologic Anatomy
Classic are forefoot adductus, rearfoot varus and rearfoot or ankle equines. The talar-
navicular-calcaneal complex is subluxed in all planes. The anterior calcaneous is
displaced medially and plantarly, and is hypoplastic. The talus is rotated laterally.the
nvicular is medially and dorsally located, with minimal articulation of the talar head. A
pseudoarticulation is formed between the navicular and the tibia medially. The remainder
of the lesser tarsal bones are relatively normal. The soft tissue triceps surae posterior
ankle joint capsule and the subtalar joint capsule are tight. The CF lig and the PTF lig are
contracted, these structures must be released. Medially, the post tibial, FHL and FDL are
short. Also the deltoid and calcaneonavicular ligs are taught. Also the plantar fascia, long
and short plantar ligs and the interosseous talocalcaneal ligaments are taught. During the
medial release serial release of each of these are necessary. In the lateral release, the
bifurcate and the lateral talar ligs must be released. The long extensors and the peroneals
are elongated and it may be necessary to tighten them surgically to create balance.

Radiology
In light of CT, MRI and ultrasound, the standard x-ray views are most beneficial. Proper
positioning of the child may be difficult but is required for proper evaluation and surgical
planning. May need sedation, but its imparative that the heel be parallel to the film.

Things to consider when evaluation of x-ray:

1) Relative “hardness” v/s “softness”
a. Pre-manipulation compared to post-manipulation films may shed light on
the relative suppleness of the deformity
2) Monitoring response of therapy
a. Serial radiographs can aid in the assessment of treatment modality
3) Detection of spurious correction
a. Detection of subluxations or AVN or flattop talus can be evaluated on
serial x-rays

Important angles to assess

On and AP View
1) Talocalcaneal
a. Normal 20-40 in clubfoot approaches 0 degrees.
b. Restoration of this angle is critical in successful surgery
2) Talar-1st met angle
a. Normal 0-15 degrees
b. Clubfoot is greater than 15 degrees
When the talarcalcaneal angle is less than 15 and the talar 1st met is greater than 15 then
talarnavicular subluxation is likely. This is helpful because the navicular is not present in
a young child and if the “rule of 15s” is met then this represents a difficult area to treat in
clubfoot.

On Lateral view
 1) Lateral talocalcaneal angle
a. In a neonate normal = 35-55 degrees
b. In clubfoot the angle approaches 0 degrees

Conservative Treatment
“Each day a clubfoot remains deformed is a day of golden opportunity lost forever”
Lenoir

Treatment should begin at birth. In infancy the “hard parts” (tendon, capsule and
ligaments) are unyielding. Marjor concept is that progressive gentle manipulation and
loosening are the rule. The mainstay today is gentle manipulation followed by
immobilization splints (ie. Denis Browne, Fillauer, and Ganely). Manipulation should
simulate straightening a bent wire. The cast is not the only aspect of the correction the
cast merely holds the gentle manipulation in place. The order should be adductus, then
varus, then equinus. If one corrects the equinus early, you get exacerbation of heel varus,
midtarsal breach, injury to the talar dome, and possible injury to the distal tibia epiphysis.

Technique: distal traction on the forefoot while simultaneously pushing rearfoot and
ankle in the opposite direction. This mobilizes the midtarsal joint. Second, gentle distal
traction is placed on the heel while the operator’s other hand supplies countertraction in
the opposite proximal direction. This helps loosen the posterior structures. At this point
the biplane abduction and rearfoot eversion are performed. Multiple repetitions up to 10
minutes per foot may be required to provide laxity after which the cast is applied. Not a
lot of padding except for boney prominences. Cast changes are performed once or twice
per week until the child is 3 months old. After 3 months, interval may be extended to 1-2
weeks. Above knee casts may be needed to remove traction form the head of the
gastrocnemius. Parents should soak the cast in 50-50 warm water and white vinegar the
morning of the visit to avoid use of cast saw. Serial casting should be employed even if
future surgery is anticipated due stretch of soft tissue and NV structures. X-ray should be
taken periodically to evaluate treatment progress.

Surgical Treatment
A lot of controversy over when to perform surgery, however over the last 20 years it has
been determined that earlier and more aggressive intervention be performed if the foot
stops correcting via conservative means or if the casting is causing a iatrogenic
subluxation (ie midtarsal breach, etc,). In the neonate, most surgery is soft tissue in
nature.

Soft Tissue Procedures

Posterior Release
Indicated when the foot component (ie adductus and varus) has been corrected via
manipulation but the equines persists or if a rocker bottom breach with dorsiflexion of the
midfoot.
Incision is curvilinear lateral to Achilles, avoid placing directly over tendon due to scar
and vascularity. Then do Z lengthening of Achilles with distal lateral half remaining
attached to calcaneous to reduce varus. Then dissect through the deep posterior
compartment to the level of the FHL. Manipulate Hallux to identify FHL, then release it
from steida’s process and retract it and the NVB medially in order for protection when
performing the Ankle capsulotomy. At this point perform the complete posterior ankle
capsulotomy and also release posterior talofibular ligament, and the Post tibiofibular
ligament. If addition correction is necessary, can release posterior STJ capsule. Two
additional structures may need to be legthened fist is the calcanealfibular ligament as it
may restrict dorsiflexion and the inferior aspect of the tib/fib syndesmosis, which may
allow the anterior talar dome more freedom for movement. If the syndesmosis is released,
it should be cut midline to slightly lateral to avoid the anterior tibial NVB.

Posterior Medial Release

Indicated when the foot components and the equines has not been corrected via
manipulation. The posterior portion is performed as previously described. For the medial
portion the incision is carried as a hockey stick posterior to the medial malleolus over the
medial column to the base of the 1st met. It should be noted only those structures
preventing talocancaneal-navicular relocation should be released. Most commonly this
includes the Posterior tibial tendon, the digital flexors, the deltoid (esp tibiocalcaneal and
tibionavicular slips), the medial column joint capsules (ie. Talar-navic, Navic-cuneiform,
and cuneiform-1st met) the spring ligament, and most important the interosseous
talocalcaneal ligament. Once the talus is placed in the corrected position, one can use k-
wires to stabilize the talar-navic and talar calcaneal positions. Adjunctive releases include
the plantar fascia and abductor hallucis.

Lateral or Circumferential Release

Reserved for persistent clubfoot not responding to the posterior and medial releases. It
combines the Posterior and medial releases and adds the release of bifurcate, calcaneal
cuboid and lateral talocalcaneal releases. (Book does not go into detail of procedure)

Osseous Procedures
As a rule osseous procedures are performed in conjunction with or preceded by soft tissue
procedures. Surgical goal is to shorten the lateral column and elongate the medial. One
can shorten the lateral column by CC arthrodesis or lateral wedging either from CC or the
Cubiod and 3rd cuneiform. Lateral fusion procedures should only be used in older
children where adaptive changes have occurred. Anterior calcaneal resection and the
CC/3rd cuneiform wedge can be used in younger child (2-6years) to avos growth arrest
fusion. Fowler described taking a closing wedge from cubiod/3rd cuneiform and plcing it
into an opening wedge of the medial cuneiform this procedure is useful in an older child
(3-10 years). For persistent forefoot adduction after clubfoot repair you can do met
osteotomies as described for met adductus.

Neglected Clubfoot
Fusions and valgus producing heel osteotomies are needed in neglected clubfoot. The
triple remains a valuable stabilizing procedure for clubfoot, however because often the
amount of wedging needed is large little of the tarsal bone may be left. Another option is
the talectomy. Performed through a generous anteriorlateral incision. The attempt is to
remove the talus intact. The space between the tibia and calcaneous usually forms a
painless pseudoarthrosis. The limitation is the forefoot correction so wedges from the
forefoot may be adjuctive procedures. Ideally the procedure is performed in the child’s
2nd-5th year, but the procedure has expanded to adults in the Baja project. Often in the
adult navicular and fibular osseous remodeling needs to be done following the talectomy/