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    Clubfoot - Dr. Ucok Siregar

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    Bayu Aditya
    New Concept of Treating Congenital Clubfoot This document discusses controversies in treating congenital clubfoot and proposes new concepts. Clubfoot is a complex deformity with unclear causes and pathology. Treatment approaches include non-surgical manipulation and casting or surgical release. The Ponseti method uses gentle manipulation and weekly casting, often with a small percutaneous heel cord release. Surgical release is considered if non-surgical treatment fails to fully correct deformities. The document compares various treatment methods and grading systems, and discusses complications of surgery and goals of achieving a plantigrade, pain-free stable foot.

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    Clubfoot - Dr. Ucok Siregar

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    Bayu Aditya
    278 views25 pages
    New Concept of Treating Congenital Clubfoot This document discusses controversies in treating congenital clubfoot and proposes new concepts. Clubfoot is a complex deformity with unclear causes and pathology. Treatment approaches include non-surgical manipulation and casting or surgical release. The Ponseti method uses gentle manipulation and weekly casting, often with a small percutaneous heel cord release. Surgical release is considered if non-surgical treatment fails to fully correct deformities. The document compares various treatment methods and grading systems, and discusses complications of surgery and goals of achieving a plantigrade, pain-free stable foot.

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    New Concept of Treating Congenital Clubfoot This document discusses controversies in treating congenital clubfoot and proposes new concepts. Clubfoot is a complex deformity with unclear causes and pathology. Treatment approaches include non-surgical manipulation and casting or surgical release. The Ponseti method uses gentle manipulation and weekly casting, often with a small percutaneous heel cord release. Surgical release is considered if non-surgical treatment fails to fully correct deformities. The document compares various treatment methods and grading systems, and discusses complications of surgery and goals of achieving a plantigrade, pain-free stable foot.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    278 views25 pages

    Clubfoot - Dr. Ucok Siregar

    Uploaded by

    Bayu Aditya
    New Concept of Treating Congenital Clubfoot This document discusses controversies in treating congenital clubfoot and proposes new concepts. Clubfoot is a complex deformity with unclear causes and pathology. Treatment approaches include non-surgical manipulation and casting or surgical release. The Ponseti method uses gentle manipulation and weekly casting, often with a small percutaneous heel cord release. Surgical release is considered if non-surgical treatment fails to fully correct deformities. The document compares various treatment methods and grading systems, and discusses complications of surgery and goals of achieving a plantigrade, pain-free stable foot.

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    of 25

    FACULTY OF MEDICINE UNIVERSITY OF INDONESIA Jakarta

    CLUB FOOT :
    Tibiotalar plantar flexion Medial displacement of navicular Wedge-shaped head of talus

    Wedge-shaped Navicular
    Adducted and inverted calcaneus Medially displaced cuboid

    New Concept of Treating Congenital Club Foot

    CLUB FOOT :
    Many Controversies A Comparative Deformity Still poorly understood Relapses Do Occur

    New Concept of Treating Congenital Clubfoot

    CONTROVERSIES
    1. Causes 2. Pathology Anatomy 3. Evaluation dx. Technique (Grading of Severity) 4. Treatment Assessment a. Type of non operative treatment b. When to do surgery 5. Evaluation of result

    New Concept of Treating Congenital Clubfoot

    ETIOLOGY
    Genetic gene mutation Enterovirus 8 weeks gestation Abnormal intra uterine force Arrested fetal development Abnormal muscle and tendon insertion Abnormal rotation talus Germ plasma defects (primary bone dysplasia of the talus

    New Concept of Treating Congenital Clubfoot

    PATHOLOGY
    Histology : Abnormality in almost tissue Ultra structural Type I : Type II musclefiber ratio : 1 : 2 7 : 1

    MRI : * Medial angulation of the neck talus * Medial tilting and rotation of body talus

    Varus deformity of hind foot Supination of the fore foot

    Ponsetti : Retraction and fibrosis of distal muscle

    New Concept of Treating Congenital Clubfoot

    PATHOLOGY

    Electron Microscopic (Zinny) Myobifroblast contracture and deformity


    Immuno histochemical + Electro Microscope (Sano) Contractile protein gradation - Deformity in clubfoot cell from fibroblast to myofribrolast
    - Common recurrence

    Vascular anomalies Hypoplasia / absence of A. tibialis anterior Dysplasia of A. tibialis arterior

    Deformity

    Classification :

    Grading of Severity : Dimeglio Classification


    20 points
    Equinus : 4 points Internal Rotation : 4 points

    Sagittal plane evaluation of equinus

    Horizontal plane evaluation of derotation of the calcaneopedal block

    Varus : 4 points

    Adduction : 4 points

    Frontal plane evaluation of varus

    Horizontal plane evaluation of forefoot Relative to hindfoot

    DIMEGLIO CLASSIFICATION

    New Concept of Treating Congenital Clubfoot

    GRADING OF SEVERITY
    Grade 1 Grade 2 Grade 3 Grade 4 Postural Not requiring surgery Considerable reducibility Resistant and partially reducible

    New Concept of Treating Congenital Clubfoot

    GRADING OF SEVERITY
    Classification Ucok

    : 16 points
    :0 :1 :3 :0 :1 :2 :2 :2 :1 :2 :2

    Age : - less than 9 months - more than 9 months - more than 18 months Passive fore foot abduction to - beyond midline - only to midline - no abduction Cavus No active dorsoflexi Leg Atrhophy No dorsasl MP joint creases No increased ligamentum laxity

    Severity Score :
    1. Mild 2. Moderate 3. Severe 12 35 6 - 16

    New Concept of Treating Congenital Clubfoot

    Grading of Severity

    M. Kamegaya Chiba MRI study Talar neck angle (TNA) Medial / lateral shift of navicular TNA > 35 Severe

    Medial shift navicular

    Surgery

    TREATMENT
    NON SURGICAL :

    New Concept of Treating Congenital Clubfoot

    - Shortly after birth - Gentle manipulation (should not injure cartilage) - Retention cast Controversies - Weekly cast changes

    SURGICAL :
    - When no further correction by manipulation - Posterior release alone only after complete correction of fore foot adduction and hind foot varus / non operative treatment ATL

    Non surgical treatment :


    a. Ponsetti method >>minimal invasive surgery b. Kites and Lovell <<minimal invasive surgery c. French method
    Newer Non Operative Treatment Physiologic motion Dennis Brown 1937 Shoes and Bar : Progressive external rotation Physical therapy Bensehal / French Stretching + Continoues passive motion Dimeglio

    Botox to grastrocnemeus + Soleus and tibialis posterior Reduce tone Lengthening by stretching

    New Concept of Treating Congenital Clubfoot

    PONSETTI
    1. Cavus Correction 2. Mid foot Alignment

    3. Hind Foot Correction equinus and varus ATL Local Anaesthesia 4. External Rotation

    FRENCH METHOD
    A B
    C

    Correction of the forefoot adduction and heel varus

    Reduction of talonavicular displacement

    Derotation of calcaneopedal block

    Manipulation of heel varus, Calcaneusmedially, Forefoot ext rot

    Manipulation of equinus

    Source : Herring JA(ed): Tachdjians Pediatric Orthopaedics, ed3. Philadelphia. PA: WB Saunders. 2001. pp 933 -934

    Kites Method
    Abduction of fore foot in pronation the cavus becomes more severe Calcaneus locked (jammed) under the head of talus; mid foot and forefoot are twisted eversion

    Calcaneo-cuboid is used as fulcrum which is pressed medial ward while fore foot is moved lateral ward (abduction);

    Calcaneus will not move lateral ward (no abduction) the varus will not be corrected ; only naviculare and fore foot will move lateral ward.

    NEW BORN

    MANIPULATION CASTING
    NO FURTHER CORRECTION DEFINITIVE SURGERY

    EQUINUS (complete correction of fore foot Adduction & hind foot varus

    NEUTRAL

    Heel cord release percutaneus 3 months Local anasthesia MANIPULATION & CASTING

    MANIPULATION AND CASTING

    DENNIS BROWN SPLINT (3 months)


    RELAPS

    MANIPULATION CASTING

    SURGERY :

    New Concept of Treating Congenital Clubfoot

    Good correction a la carte approach Incision : 1. Hockey stick / posteromedial Turco 2. Circumferential Cincinnati 3. Two incision Carroll Navicular Reduced : - Pin centrally in the head of talus - Pin in line with the first metatarsal

    New Concept of Treating Congenital Clubfoot

    Complication Surgery :
    1. Recurrence
    2. Over correction 3. Stiffness 4. Pain

    Age of Patient at Time of Revision

    Step Method of Treament 1 2 3 Revision soft-tissue clubfoot release If prominent plantar crease, add plantar release If forefoot adductus is not corrected, add capsulotomies (navicular-first cuneiform or first cuneifor-first metatarsal) as needed If forefoot adductus is not fully corrected after steps 1, 2, and 3, add excision of cartilage of calcaneocuboid joint or decancellation of cuboid If forefoot adductus is not fully corrected after steps 1 through 4, add one of the following steps Fusion of calcaneocuboid joint (Dillwyn Evans procedure) Excision of distal part of calcaneus (Lichtblau procedure) Cuboid decancellation Opening-wedge osteotomy of first cuneiform

    6 mo to 2 yr

    2 to 4 yr

    4 to 8 yr

    5
    5A B 5C 5D

    Age of Patient at Time of Revision Step Method of Treament

    4 to 8 yr

    5E 5F 6

    Tarsometatarsal capsulotomies Metatarsal osteotomies (for patients > 5 yr old) If patient has overactive tibialis anterior tendon and weak peroneals, add tibialis anterior tendon transfer If varus angulation of heel remains uncorrected, add osteotomy of heel (Dwyer procedure) Midtarsal osteotomy for persistent cavus Distraction osteogenesis (Ilizarov) as only procedure Triple arthrodesis as only procedure

    8 to 10 yr

    8 9 10

    > 10 yr

    New Concept of Treating Congenital Clubfoot

    Result Not Completely Normal Goal of Treatment Plantigrade foot Pain free Stable over time Near anatomically normal Normal shoes

    No satisfactory standardized evaluation Radiology no correlation with the function

    Celebrities/Athletes born with Clubfeet:


    Kristi Yamaguchi: 1992 Olympic Figure Skating Gold Medalist: treated with serial manipulations/casting

    Troy Aikman: Quarterback Dallas Cowboys: treated with serial manipulations/casting


    Source : The American Academy of Orthopaedic Surgeons (AAOS) - Information on Clubfoot The American Orthopaedic Foot and Ankle Society

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