1. Treatment of Clubfoot deformities Prof. Dr. Greta Dereymaeker, MD, PhD Catholic University of Leuven Department of Biomechanics University Hospital of Antwerp Member of Artsen zonder Vakantie - MSV Belgium

2. CLUBFOOT Treatment algoritm Primary Neglected Clubfoot

3. Talipes equinovarus • 0.5 - 1% of all babies born alive • Genetic factor?? - unknown origin • 70% boys • 50% bilateral cases • Often associated with other orthopaedic deformities: hipdysplasia and spine! • Intra-uterine malposition or intra-uterine growth disturbance • Neurological defects

4. Pathology • Abnormal positioning of hindfoot bones: • Talus quite often deformed • Calcaneum • Navicular • Soft tissue retraction and stifness especially posterior and medial side • Stifness of the postero-medial capsule of • Tibio-talar and subtalar joint • Talo-navicular joint • Achilles tendon • Tibialis posterior • Flexor hallucis longus • Flexor digitorum longus • Leg and Foot dystrofia is often present

5. Classification • Ponsetti • Supple • Rigid • Teratologic • Dimeglio • Soft-soft : benign supple (intra-uterine malposition) • Soft-Stiff: semi-rigid form ( but reducable) • Stiff-Soft: more rigid and resistant to reduction • Stiff-Stiff : Not reducable (arthrogryposis, teratologic)

6. Treatment (1) • At Birth: as soon as possible • Make a classification • Look for other orthopaedic deformities • Hip • Spine • Start manipulations or • Corrective casting • First correction of adductus of midfoot • Folowed by correction of heel varus • Finally correction of the equinus

7. How do we do corrective serial casting?

8. Casting technique video

9. Treatment (2) • At 6 to 8 weeks • Corrective serial casting weekly to 2 weekly • Continue progressive correction of the equinus of the hindfoot • Keeping foot in pronation correction of adductus of midfoot Cave Rocker Bottom !!!! • If no correction of equinus can be obtained of the hindfoot Consider subcutaneous Achilles tendon lengthening • Continue corrective serial casting up to 3months

10. Treatment (3) • At 3 months upto 1 year • Dennis Brown splint or abduction boot with spring when sleeping during day and night • Continue careful observation for recurrence of deformity • When starting making efforts to walk wear straigth shrank or abducted shrank shoe • When full correction is obtained at 1 year or walking • Continue with normal shoewear • Discontinue nightsplints • Observe for leg length discrepancy

11. Treatment (4) • At 8 months to 1 year • In case of recurrence of deformity specially • varus of heel and/or • adduction of midfoot • Consider surgical correction • Continue corrective casting 2 to 3 weekly for at least 12 weeks • Until walkingwhen sleeping during day and night: • Dennis Brown splints or • Abduction boot with spring

12. Treatment (4) • Consider surgical correction • at 8 months to 1 year • Open Achilles tendon lengthening • Lengthening of tendons • Tibialis posterior • Flexor Hallucis longus • Flexor digitorum longus • Posteromedial release • tibio-talar joint and subtalar joint • Reduction of talus in the ankle mortise • Release of talo-navicular +/- Nav-cuneiform joint • Fixation of Talo-navicular-cuneiform joints by K-wire

13. Postero-medial Release • Differentiate, dissect and free • Flexor Hallucis Longus • Neurovascular Bundle: mark with vessel loop • Tibialis posterior • Flexor Digitorum Longus • Open tibiotalar joint and remove part of the capsule • Retact Neurovascular Bundle anterior/ FHL medial • Open subtalar capsule • Following the FHL at his lateral site

14. Posterior Capsulectomy • Tibio talar joint and subtalar joint • Retract Neurovascular bundle anterior • Retract FHL medial and follow distal part • Move the foot up and down • Section capsule with eletric bistouri • Remove part of the capsule if necessary • Go up to fibula posterior border

15. Treatment (5) • Up to 12 years- Adolescence • In case of recurrence of deformity • varus of heel • And/or adduction of midfoot • Still consider surgical correction • Soft tissue • Bony procedures • Osteotomies • Arthrodesis • Corrective casting until consolidation of bony procedures

16. Treatment (5) • In Adolescence surgical correction: ’’ à la carte’’ • Open Achilles tendon lengthening • Posteromedial release of tibio-talar joint and subtalar joint • Eventually lengthening of • the tibialis posterior tendon • flexor tendons • Release of soft tissues around talo-navicular-cuneiform joint • Osteotomy of calcaneus: Dwyer procedure to correct varus of heel • Osteotomy of Cuboid of • Osteotomies of the midfoot: at base of metatarsals to abduct and pronate forefoot • Reduction of • The talus in the ankle mortise • Subtalar and chopart joint • If necessary :Triple arthrodesis • Rotational skinflap over dorsum of the foot

17. Treatment (6) • In the adult foot: Surgery ̏ à la carte˝ • Treatment adapted to major deformity location • Open Achilles tendon lengthening • Posteromedial release of tibio-talar joint and subtalar joint • Release of talo-navicular joint cut springligament • Triple arthrodesis • Talectomy in severe cases • +/-Lengthening of the tibialis posterior tendon- FHL and FDL • Rotation of skinflap over dorsal of foot

18. Treatment (6) • In adolescence and the adult foot: • Surgery ̏ à la carte˝ • Treatment adapted to major deformity location • Post operative follow-up :important • Serial casting until consolidation of the bony procedures • Keep foot aligned with orthosis during at least 1year • Dynamic splints during the day if neccessary

19. View from anterior View from posterior Untreated congenital clubfeet 14year old boy February 2005

20. Bilateral congenital untreated clubfeet

21. 14 months after surgery • Posteromedial capsulectomy • Tendon lengthening : A/TP/FDL/DHL • Triple arthrodesis

22. 17 year old boy congenital untreated clubfeet February 2005 View from anterior View from posterior

23. 17 year old boy congenital clubfeet February 2005 View from anterior

24. 17year old boy congenital clubfoot 14 months after Bilateral talectomy and posteromedial release

25. 14 months after bilateral talectomie