Objectives Identification and Management of ClubfootLearn about the genetics, characteristics, and...

Learn about the genetics, characteristics, and history of this well-known deformity.

Identification and Management

of Clubfoot

Learn about the genetics, characteristics, and history of this well-known deformity.

Identification and Management

of Clubfoot

Objectives1) To know the nature of clubfoot de-

formity, including the general incidence,genetics, and clinical characteristics.

2) To know and evaluate the basictheories for the origin of clubfoot.

3) To know the natural history of sur-gically corrected and non-surgically cor-rected clubfoot.

4) To know the clinical characteristicsof clubfoot at all different stages, includ-ing infant, childhood, adult, and ne-glected clubfoot.

5) Specifically to know the general na-ture of the operations for clubfoot de-formity, including the Turco procedureand the complete subtalar joint release.

6) To know the results of studiescomparing the Turco procedure andthe complete subtalar joint release andto know the advantages and disadvan-tages of each operation.

7) To be aware of the managementof clubfoot at all different stages, in-cluding infant, childhood, adult, andneglected clubfoot.

OCTOBER 2002 • PODIATRY MANAGEMENTwww.podiatrym.com 131

forefoot adductus, forefoot varus,and ankle equinus (Figure 1). Ap-proximately 1/1000 births is a club-foot, with males affected two timesas frequently as females, the rightfoot involved more commonly thanthe left and 50% bilateral.1-3 Afterone child in a family is born with a

clubfoot, the risk to a second childis increased to one in twenty or ap-proximately five percent (Table 1).4

Not only does the risk of clubfootincrease after a previous child isborn with the deformity, but the de-formity is more rigid as well.

Continued on page 132

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Incidence and GeneticsCongenital talipes equinovarus

(clubfoot) is one of the most in-stantly recognizable birth defectsconsisting of rigid hindfoot varus,

By Ellen Sobel, DPM, Ph.D. and RenatoGiorgini, DPM

Continuing

Medical Education

C L I N I C A L P O D I A T R YC L I N I C A L P O D I A T R Y

Clubfoot occurs in all races and ethnicities; how-ever, Asians have the lowest incidence (about .57 per1,000 live births) and Polynesians have the highest rateof clubfoot (Almost 7 per 1,000 live births).5-8 There arefour categories of clubfoot: postural (positional and cor-rects with casting), congenital (rigid clubfoot, isolateddeformity), teratological (e.g., associated with spina bi-fida), and clubfoot occurring as part ofa syndrome.10 The most commonform of congenital clubfoot, the idio-pathic variety, is inherited by a poly-genic multi-factorial inheritance witha sex-linked threshold effect.7

The clubfoot deformity cannotoccur until the number of abnormalgenes exceeds the threshold level. Thethreshold is sex-related, with a highertolerance being found in females. Fe-males need more genes to have a clubfoot, but whenthey do exceed the threshold number of genes the de-formity is worse than in males. The deformity is less se-vere in males because males with clubfoot have fewerclubfoot genes. However, we have found that the fe-male clubfoot patients correct more easily and needfewer surgeries, perhaps due to the inherently greaterdegree of ligamentous laxity in females.

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132 www.podiatrym.comPODIATRY MANAGEMENT • OCTOBER 2002

Figure 1. Congenital clubfoot with characteristic de-formed small foot with hindfoot equinus and inversion ofthe foot.

EtiologySeveral theories have evolved to explain the still un-

known etiology of clubfoot. More than 2400 years ago,Hippocrates believed that intrauterine pressure andrapid skeletal growth were responsible for the malposi-tion of clubfoot.11 Brown12 attributed congenital club-foot to a mechanical deformity of intrauterine crowd-ing or packaging. However, deformities caused by in-trauterine crowding, also known as postural defects

(e.g., congenital hip dislocation,metatarsus adductus, and calcaneoval-gus) are more common in firstborns,which is not the case with club-foot.5,6,13

In 1929, Bohm14 noted that inthe fifth week of gestation, there is nodifference between the normal footand the eventual clubfoot. Thus,Bohm felt that the cause of clubfootwas a developmental arrest, which oc-

curred during pregnancy. A study of 147 specimensfrom the eighth to the twenty-first week of gestationalage showed that at the ninth week of pregnancy thenormal foot was structurally similar to a clubfoot, butby the eleventh week the normal foot developed out ofthe clubfoot position.15

The germ plasm defect theory states that a defect inthe primary germ plasm of the talus results in plantarflexion and inversion of the talar head and neck withsecondary soft tissue changes.16-19 The talar deformity isnow considered secondary to muscle imbalance, softtissue contractures rather than the primary deformity.

There may be a primary deformity in neurogenictissue creating a type I fiber predominance leading tocontractile imbalances, which eventually result in


Treatment for the true clubfoot

invariably requires surgery.

clubfoot.20-22 Studies have found adefect in innervation of muscles ofthe lower extremity in infants withclubfoot.23-24 Other neurologic theo-ries include peroneal nerve com-pression25, and enteroviral infectionof the anterior horn cells duringpregnancy.26

Muscular and collagen dysfunc-tion localized to the posterior andmedial aspect of the foot and legmay induce the development ofclubfoot some time during the mid-dle of pregnancy.27 Ippolito andPonseti28 found that the distal mus-cles on the posteromedial aspect ofthe foot showed decrease in size andnumber of muscle fibers and in-creased fibrous connective tissuewithin the muscles, tendon sheathsand fascia with shortening to thetendoAchilles (retracting fibrosis).After also finding that the spinalcord from a 17-week old fetus wasnormal histologically, they conclud-ed that clubfoot was not secondary

Clubfoot... Both the talus and calca-neus are in equinus. The calca-neus is in a plantarflexed and in-verted position. The talonavicularand calcaneocuboid joints are devi-ated medially and plantarly. Thetendo Achillis, tibialis posterior, andtoe flexor are shortened while theperoneal muscles are stretched andweakened.34

The posterior muscle group, theinvertors and the intrinsic foot mus-cles are tight. Contracted ligamentsinclude the long and short plantarligaments, the spring ligament, thecalcaneofibular ligament, talofibularligament. The posterior ankle jointcapsule, the talonavicular joint cap-sule, the calcaneocuboid capsule,and the plantar fascia are also con-tracted.

Clinical & RadiographicCharacteristics

The clinical diagnosis of club-foot is obvious (Figure 1), especiallywhen unilateral presenting with a

to neuromuscular defects.The posterior tibial artery is the

most dominant vessel in the club-foot with the dorsalis pedis beinghypoplastic.29 This is theorized to re-sult in medial foot and ankle tether-ing with secondary scarring, whichresults in the clubfoot.

PathoanatomyThe clubfoot is a small, deformed

foot with rigid hindfoot varus, fore-foot adductus, forefoot varus, andankle equinus. The head and neck ofthe talus is deviated medially andplantarly.17,30-32 The navicular is dislo-cated medially and in severe clubfootmay abut against the medial malleo-lus.33 Although the talar head andneck are medially and plantarly devi-ated, the body of the talus is actuallylaterally rotated on its longitudinalaxis and the ankle mortise.31 This re-sults in posterior displacement of thefibula, and the lateral malleolus maybe posteriorly displaced off its articu-lar talar facet, which is known as ahorizontal breach.

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the clubfoot side also having aslightly shorter limb and shorterfoot. We have found that in chil-dren with clubfoot the foot length,limb length and calf girth are ap-

proximately one inch less on the af-fected side.36

The most common radiographsare the weight bearing anteroposte-rior (AP) and lateral radiographswith the foot held in maximum dor-siflexion. The AP talocalcaneal angle(angle of Kite) is a reflection of varus

deformity of the rearfoot (Figure 2).The normal value for the AP talocal-caneal angle is between 20 to 40°and is reduced in a clubfoot. Thelateral x-ray demonstrates equinusdeformity. In the lateral view offorced dorsiflexion, the calcaneusand talus are both in equinus andalmost parallel to each other (Figure3). The normal value for the lateraltalocalcaneal angle is 20 to 40° andis also reduced in the clubfoot. Thevalues of the AP talocalcaneal angleand the lateral talocalcaneal anglecan be added together to give thetalocalcaneal index, which isthought to be more accurate thanone value alone. Normal values forthe talocalcaneal index are from 40to 70°. The degree of adduction ofthe forefoot is measured by the APtalar first metatarsal angle. Normalis zero degrees to minus 20°. Theclubfoot shows increased adductionof the forefoot.

Conservative TreatmentTreatment of congenital clubfoot

generally consists of ma-nipulation and serialcasting followed by sur-gical intervention in ap-proximately 50% ofcases (Figure 4).36-39 Re-cently, there has been aresurgence of non-surgi-cal techniques as the soletreatment for club-foot.27,41,42 Results of stud-ies of conservative treat-ment report success ratesas high as 95 to 100%.41-45

Treatment beginsshortly after birth or ap-proximately three to fivedays after birth46 takingadvantage of the favor-able fibroelastic proper-ties of the connectivetissue, which forms theligaments, joint capsulesand tendons.40 Clubfeetbecome stiffer withdelay in onset of treat-ment.34 Mild clubfoottreated immediatelyafter birth may easilycorrect, but may takemonths of serial castingif treatment is delayedfor only a few weeks.47

small, short, stiff, deformed-look-ing foot with prominent ankle equi-nus as compared to the non-affectedside. In some infants, there is a deepplantar medial transverse and poste-rior crease. The heel of the clubfootstays in a fixed varus and equinusposition. Hindfoot equinus is causedby plantarflexion of the talus, con-tracture of the posterior ankle cap-sule and shortening of the ten-doAchilles. The heel looks small andhigh, and, upon palpation, feels likethe heel pad is empty. The forefootis adducted and held in a fixedvarus attitude. The forefoot positionis due to and follows the mediallyand plantarly directed talar headand neck deformity.

The calf muscles are shortenedand underdeveloped. Calf atrophy,formerly thought to be caused bywearing a cast for a long period, isan inherent part of clubfoot35 and isnoticeable in older children particu-larly with unilateral clubfoot, with

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The authors prefer a modified Turco

procedure, ideally performed

between the ages ofabout 9 months

and 2 years.

TABLE 1:HEREDITY OF CLUBFOOT

INCIDENCE PERCENT

General population 1/1000 0.1%

Risk to 2nd child after 1st child born with clubfoot 1/20*-1/50 2-5%

Risk to 3rd child after 1st two children born with clubfoot 1/7* 14%

Risk to 4th child after three children born with clubfoot 1/2* 50%

One parent has clubfoot/1st child born with clubfoot- 1/4** 25%Risk to 2nd child of being born with clubfoot

Risk to first degree relatives (I.e., brother) ~1/50 2.5-2.9%

Risk to second degree relatives (I.e., aunt) 5-6/1000 .5-.6%

Risk to third degree relatives (I.e., cousin) 2/1000 .2%

Fraternal twins (both affected) ~1/20 2.9-5%

Identical twins (both affected) 1/3 33%

Associated with malformations of the extremities 1/20 4-5%

*Wong HB: Genetic Aspects of foot deformities. J Sinapore Paediatr Soc 29: 13-22, 1987.

**Cowell HR: The genetics of foot disorders. Orthop Rev 7: 55-8, 1978.

Above knee casts are required bysome,27 but others prefer below kneecasts.34 Although a plaster cast moldsbetter, recently some surgeons havefound that fiberglass casts hold thefoot better than plaster casts.48

Magnetic resonance imaging hasdemonstrated that the talonavicularand calcaneocuboid joints remodeland become congruent in the cor-

Clubfoot... 85% of individuals func-tioned as well as a comparativenon-clubfoot group.51 However, pa-tients with clubfoot who were en-gaged in sedentary occupations andwere non-obese, tended to have thebest functioning feet.51

Surgical CorrectionTreatment for the true clubfoot

invariably requires surgery. In fact itis not uncommon for a second sur-gery to be necessary three to fouryears after the original operation.52,53

The second surgical procedure fre-quently involves repeat soft tissuerelease with additional bone work asneeded. In a recent study we foundthat more than one clubfoot opera-tion was required in 56% of 27

clubfeet.53

Age forSurgery

The exactage for surgeryis a controver-sial subject andquite variable.While neonatalclubfoot surgeryhas producedgood results54, itis not frequent-ly performedbecause of theincreased inci-dence of post-

operative fibrosis, scarring and stiff-ness. Surgery between three and sixmonths of age may optimize re-alignment of the talus, calcaneus,and navicular and results in betterremodeling of the articular sur-faces.49 The risks of general anesthe-sia are reduced after the age of sixmonths.77 Turco76 thought that chil-dren should be operated on whenthey are older than 1 year of age. Hefelt that operations in very youngchildren were technically more diffi-cult to perform and that errors ofover-correction or under-correctionwould be magnified with subse-quent growth. If the child was readyto walk when the casts were re-moved, the natural dorsiflexionforce produced by weightbearingwould make recurrence less likely.In another large study good or ex-cellent results were obtained in 94%

rected position after four to sixweeks of manipulation and serialcasting.27 The need for casting muchbeyond three months is indicativethat non-surgical treatment is un-likely to be effective.49 Further cast-ing past the point of resistance orrelapse increases the risk of develop-ing a rocker bottom foot.

Ponseti TechniqueThe Ponseti technique involves

serial casting combined with ten-doAchilles lengthening when neces-sary.50 Denis-Browne Bar splinting isused for three months full-time andat night for two to four years to pre-vent relapse. A recent thirty year fol-low-up of 71 clubfeet treated withthe Ponseti technique showed that

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Figure 2. Angle of Kite (talocalcanealangle), on dorsoplantar (DP) radio-graph, is reduced.

Figure 3. Lateral Talocalcaneal angle is reduced to zero de-grees due to calcaneus and talus being parallel to each other.

Figure 4. Twister cables with braces, corrective shoes, and casts used in the con-servative treatment of clubfoot in this child.

weighs at least 12 pounds and isthriving well.

Nature of the Surgical ProcedureThe initial clubfoot surgery al-

most always involves pure soft tis-sue release of the deforming con-tracted tight structures with nobony procedures. There are a vari-

ety of soft tissuereleases, whichdiffer mostly indegree.

TurcoProcedure

Turco intro-duced the onestage soft-tissueposteromedial re-lease82 with inter-nal fixation,which is still usedwidely today.36

The Turco proce-dure serves as thebaseline from

which many modifications and vari-ations have evolved. The posteriorand medial soft tissue contracturesare released to permit the realign-ment of the abnormal anatomy ofthe bones and the corrected realign-ment is fixed with a single Kirschnerwire through the talonavicular joint.The postoperative stiffness of thefoot with the Turco procedure isconsiderably less than the more ex-tensive soft tissue releases.33

Modified Turco TechniqueThe authors prefer a modified

Turco procedure, ideally performedbetween the ages of about 9 monthsand 2 years (Figure 5). A tourniquetis not used because of the irregulari-ties of vasculature in the club-foot.29,83-85 A 15-centimeter hockeystick incision is made starting fromabove the malleolus and running tothe base of the first metatarsal (Fig-ure 6). A medial linear incisionshould never be done because it is

of patients operated on betweenthe ages of six months and fiveyears.78 Simons60 recommends thatthe foot should be at least 8 cm long(3 inches) prior to surgery. Giuriniand Carroll34 operate when the childis more than three months old,

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Figure 5. Notice the small size of the infant foot at the be-ginning of surgical procedure.

Figure 6. 15 centimeter hockey stick incision on medial as-pect of foot.

Figure 8. At the end of the surgical procedure the foot canbe dorsiflexed to a right angle to the leg and the talonavic-ular joint is relocated from its subluxed position and percu-taneously fixed with .45 k-wire to maintain correction.

Figure 7. Identification of flexor digitorum longus, flexorhallucis longus, Achilles tendon, and vascular bundle.

Figure 9. Above knee plaster cast applied immediatelypostoperatively.

foot shoes, and night splint-ing are frequently used until ma-turity to prevent relapse.

Cincinnati IncisionThe Cincinnati incision is a trans-

verse incision for increased exposureto the medial, lateral, and posterioraspect of the foot and ankle. The in-cision extends from the medial to

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to six weeks (Figure 9). A plaster castis used for the best molding with afiberglass top layer to make the castmore durable. A second above kneecast is applied for another threeweeks bringing the patient to theeighth week of surgery. Below kneecasting may be continued for up tosix months to correct any residualdeformities. Tone reducing anklefoot orthoses during the day, club-

Clubfoot...

not long enough to open the de-sired areas.

The medial release is performedfirst to correct the hindfoot varusand adductus. The medial release in-cludes: posterior tibial tendonlengthening, talonavicular joint cap-sulotomy, superficial deltoid liga-ment release, spring ligament release,subtalar joint release of capsules andnavicular realignment, which re-quires K-wire fixation (Figure 7).

The master knot of Henry is at-tached to the navicular and enclosesthe FHL and the FDL as they crosseach other under the navicular. Thisfibrous tissue must be released toallow for an adequate soft tissue re-

lease although lengthening of theFDL and FHL may not be necessary.Of these two tendons the FDL is themore deforming factor.

The posterior release correctsankle equinus and includes “Z” plas-ty of the tendoAchilles for lengthen-ing, ankle and subtalar joint capsu-lotomy, calcaneofibular ligament re-lease, and superficial deltoid liga-ment release, interosseous ligamentrelease, and tibiofibular ligament re-lease. Note that if the clubfoot willnot reduce unless the interosseousligament is released. Avoiding re-lease of the deep deltoid ligamentwill prevent over-correction.

A plantar release may be added tohelp to reduce residual metatarsusadductus. This involves release of thefirst layer of plantar intrinsic musclesto include the abductor hallucis, theabductor digiti quinti, the flexor digi-torum brevis, and the plantar fascia.At the end of the surgery the footshould reduce to a neutral position(90° foot to the leg) (Figure 8).

An above knee cast is appliedpostoperatively during the first four



The childhood clubfoot has frequentlybeen altered by serialcasting and surgical

correction.

above and so-called complete cir-cumferential soft tissue releases isthat the latter involves total releaseof the subtalar joint. When this isdone surgical pin fixation and cast-ing must be left in place for three tofour months. Complete subtalarjoint release has been advocated bya variety of authors.60,66,87,88-90 McKaybelieves that the calcaneus is rotatedaround a vertical axis with the ante-rior calcaneus internally rotated andthe posterior calcaneus externally

rotated.87 The operation involves ro-tating the calcaneus at the subtalarjoint level.89,90 The McKay one-stagesubtalar soft-tissue release is a cir-cumferential soft-tissue releasewhich involves releasing the posteri-or, medial, lateral, and plantar softtissues of the foot.78,87,91

In one study comparing theMcKay complete circumferential re-lease with the Turco posteromedialrelease, patients with the more com-

the lateral aspect of the foot overthe posterior aspect of the ankle.86

Crawford and associates86 used theCincinnati incision to perform a pos-teromedial release in 38 clubfeet andreported excellent results.

Complete Subtalar Joint Release/Circumferential Release

The major difference betweenthe Turco procedure as described

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TABLE 2:Calf Girth, Foot Length, Limb Length Discrepancy,

Results of Studies

CALF GIRTH CALF GIRTH (INCHES)

Laveeg & Ponseti, 1980 (96) 0.9Ghali, Smith, Clayden, Silk, 1983 (97) 0.5Ricciardi-Polini, Ioppolito, Tudisco, Farsetti, 1984 (98) 1.4Magone, Torch, Clark, Kean, 1989 (88) 1.3Aronson & Puskarich, 1990 (35) 0.3Atar, Lehman, Grant, Strongwater, 1991 (61) 1Devalentine & Blakeslee, 1992 (99) 1.1Cohen-Sobel, Caselli, Giorgini, Giorgini, Stummer, 1993 (36) 1Blakeslee, 1997 (100) 0.83Uglow & Clarke, 2000 (71) .5 (mild clubfoot)

.72 (moderate clubfoot)

.72 (severe clubfoot)Reichel, Lebek, Milikic, Hein, 2001 (80) 0.6

FOOT LENGTH FOOT LENGTH (INCHES)

Bjonness, 1975 (101) 0.8Laaveg & Ponseti, 1980 (96) 0.5Magone, Torch, Clark, Kean, 1989 (88) 0.5Atar, Lehman, Grant, Strongwater, 1991 (61) 0.6Aronson & Puskarich, 1990 (35) 0.5DeValentine & Blakeslee, 1992 (99) 0.8Cohen-Sobel, Caselli, Giorgini, Giorgini, Stummer, 1993 (36) 0.8Blakeslee, 1997 (100) 0.6Huang, Lei, Zhao, Wange, 1999 (78) 0.6Reichel, Lebek, Milikic, Hein, 2001 (80) 0.4

LIMB LENGTH DIFFERENCELIMB LENGTH DIFFERENCE (INCHES)

Laaveg & Ponseti, 1980 (96) 0Ghali, Smith, Clayden, Silk, 1983 (97) 0.5Hutchins, Foster, Paterson, Cole, 1985 (55) 0.4Atar, Lehman, Grant, Strongwater, 1991 (61) 0.5

*Numbers in parenthesis refer to reference list.

tion.92 More recently, Haasbeek andWright93 compared the results ofposterior release with those of com-prehensive release with an average

21-year follow-up. They found thatthe group with comprehensive re-leases had fewer surgeries, moreplete release had more complete

correction and greater range of mo-

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TABLE 3:CLINICAL RESULTS OF CLUBFOOT STUDIES

(Forefoot Adductus/Heel Varus/Heel Valgus/Cavus/Ankle Dorsiflexion)

FOREFOOT ADDUCTUS PERCENT

Attenborough, 1972 (102)* 79%Low & Hannon, 1973 (103) 52%Main & Crider, Polk, Lloyd-Roberts 1977 (56) 78%Main & Crider, 1978 (104) 69%Hutchins, Foster, Paterson, Cole, 1985 (55) 20%Otremski, Salama, Khermosh, Wientraub, 1987a (62) 48%Otremski, Salama, Khermosh, Wientraub, 1987b (105) 9%Brougham & Nicol, 1988 (66) 66%Yamamoto & Furuya, 1988 (106) 34%Lau, Meyer, Lau., 1989 (68) 17%Magone, Torch, Clark, Kean, 1989 (88) 51%Porat & Kaplan, 1989 (69) 18%Yngue, Gross, Sullivan, 1990 (74) 28%Tarraf & Carroll, 1992 (70) 81%DeValentine & Blakelee, 1992 (99) 41%Cohen-Sobel, Caselli, Giorgini, Giorgini, Stummer, 1993 (36) 60%Blakeslee, 1997 (100) 41%Rumyantsev & Ezrohi, 1997 (75) 12%Simbak & Razak, 1998 (107) 63.9% (Metatarsus adductus)Joseph, Ajith, Varghese, 2000 (79) 24%Uglow & Clarke, 2000 (71) 18.5% mild clubfoot

39% moderate clubfoot22% severe clubfoot

Reichel, Lebek, Milikic, Hein, 2001 (80) 13%Faraj & Nevelos, 2001 (81) 31% mild forefoot adductus

HEEL VARUS PERCENT

Laaveg & Ponseti, 1980 (96) 27%Hutchins, Foster, Paterson, Cole, 1985 (55) 17%Otremski, Salama, Khermosh, Wientraub, 1987b (105) 9%Yamamoto & Furuya, 1988 (106) 11%Lau, Meyer, Lau., 1989 (68) 5%Magone, Torch, Clark, Kean, 1989 (88) 6%Tarraf & Carroll, 1992 (70) 38%Cohen-Sobel, Caselli, Giorgini, Giorgini, Stummer, 1993 (36) 35%Blakeslee, 1997 (100) 3%Rumyantsev & Ezrohi, 1997 (75) 3%Simbak & Razak, 1998 (107) 11%Joseph, Ajith, Varghese, 2000 (79) 7%

HEEL VALGUS (Excessive) PERCENT

Turco, 1979 (76) 8%Ghali, Smith, Clayden, Silk, 1983 (97) 12%Otremski, Salama, Khermosh, Wientraub, 1987b (105) 4%

*Numbers in parentheses refer to reference list. Continued on page 142


complete correction of heel varus,and better subtalar motion thanthose with posterior releases.

Simons also advocates a one-stage circumferential subtalar jointrelease, which differs from theMcKay procedure in emphasizingthe release of the interosseous talo-

Clubfoot... displaced laterally beneaththe talus, causes severe valgusdeformity.75 Over-correction is pre-vented by preserving the deep ante-rior portion of the deltoid ligamentand the interosseous ligament be-tween the talus and calcaneus,avoiding over displacing the navic-ular laterally, and not over-length-ening the tendo Achilles or the tib-ialis posterior.49

Carroll’s surgical technique in-volves internally rotating the talusin the ankle mortise, which requiresextensive soft tissue release withcomplete plantar, lateral, medialand posterior release.94 Posteroplan-tar and posterolateral release are ad-ditional variations of soft tissue re-lease procedures.80,81,95

Results & Evaluation of SurgeryTreatment for clubfoot never re-

sults in a normal foot. Calf atrophy,difference in foot size, limb-lengthdifference (Table 2), limitation ofankle joint and subtalar joint mo-

calcaneal ligament as well as theposterior talofibular ligament. Hestresses intraoperative radiographsto verify the correction.89,90 Most re-cently, Simons’ complete subtalarjoint release was found to be themost efficient method of surgeryboth functionally and radiogologi-cally, in cases of idiopathic clubfootin infants, as compared with Turco’s

posteromedial re-lease.65 Over-cor-rection and sec-ondary multi-pla-nar foot deformi-ties are the mainproblems withextensive com-plete subtalar re-lease75 and in onestudy were avoid-ed by the use ofperioperative ra-diographs.65

I n a c c u r a t et a l o c a l c a n e a lpinning, whenthe calcaneus is

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Figure 10. Residual rearfoot varus in child with clubfoot.

a painless, aesthetically pleasingand functional plantigrade foot(Table 4).36

The patient’s gender, whetherthe deformity is unilateral or bilater-

al, age at which the child firstwalked, age at which surgery is per-formed, the exact nature of the op-eration, and the type of postopera-

bility, and in-toe gait are commonregardless of treatment (Table 3).36,53

However, treatment should result in

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TABLE 3:CLINICAL RESULTS OF CLUBFOOT STUDIES

(Forefoot Adductus/Heel Varus/Heel Valgus/Cavus/Ankle Dorsiflexion)

HEEL VALGUS (Excessive) PERCENT

Yamamoto & Furuya, 1988 (106) 11%Lau, Meyer, Lau., 1989 (68) 6%Porat & Kaplan, 1989 (69) 9%Yngue, Gross, Sullivan, 1990 (74) 4%Cohen-Sobel, Caselli, Giorgini, Giorgini, Stummer, 1993 (36) 9%Rumyantsev & Ezrohi, 1997 (75) 9% (>10 degrees)Reichel, Lebek, Milikic, Hein, 2001 (80) 13%

CAVUS PERCENT

Attenborough, 1972 (102)* 16%Otremski, Salama, Khermosh, Wientraub, 1987b (105) 15%Magone, Torch, Clark, Kean, 1989 (88) 40%Tarraf & Carroll, 1992 (70) 30%Cohen-Sobel, Caselli, Giorgini, Giorgini, Stummer, 1993 (36) 18%Blakeslee, 1997 (100) 22%Simbak & Razak, 1998 (107) 11%

EQUINUS PERCENT

Thompson, Richardson, Westin, 1982 (108) 13%Addison, Fixsen, Lloyd-Robert, , 1983 (109) 38%Otremski, Salama, Khermosh, Wientraub, 1987b (105) 2%Tarraf & Carroll, 1992 (70) 15%Blakeslee, 1997 (100) 3%Rumyantsev & Ezrohi, 1997 (75) 3%Joseph, Ajith, Varghese, 2000 (79) 0%Reichel, Lebek, Milikic, Hein, 2001 (80) 2%

ANKLE DORSIFLEXION DEGREES

Laaveg & Ponset, 1980 (96) 13 degreesHutchins, Foster, Paterson, Cole, 1985 (55) 0 degreesPorter, 1987 (110) 15 degreesYamamoto & Furuya, 1988 (106) 12 degreesLau, Meyer, Lau., 1989 (68) 7.3 degreesPorat & Kaplan, 1989 (69) 12 degreesYngue, Gross, Sullivan, 1990 (74) 11 degreesAronson & Puskarich, 1990 (35) 9.3 degreesMcHale & Lenhart, 1991 (111) 5 degreesCohen-Sobel, Caselli, Giorgini, Giorgini, Stummer, 1993 (36) 4 degreesHudson & Catterall, 1994 (95) 15 degreesFaraj & Nevelos, 2001 (81) 20 degrees


(Continued)

tive management are all related tothe outcomes of surgery.71 However,it seems that the out-come of treatment inidiopathic clubfoot hasalso been stronglylinked to the severityof the initial clubfootdeformity.57,70,71,78,112-114

For this reason, therehas been emphasis ondividing clubfoot intocategories of simpleand resistant cases inan attempt to predictwhich will correctmost easily.

A t t e n b o r o u g h 1 1 2

separated clubfootinto easy and difficultclubfoot. He felt thatcases which resolvedwith strapping or seri-al casting involved thesole deformity of ex-cessive medial devia-

Clubfoot... vided the clubfoot into fourcategories of increasing severity.The first group was the completelycorrectable soft postural clubfeet

which these authors feltshould not even be in-cluded in rating the re-sults of clubfoot surgerybecause they tend to in-crease good results.Grade 2 were consid-ered moderate clubfoot.Grade 3 are the resistantbut partially reducibleclubfeet. Grade 4 werethe total stiff teratologi-cal clubfeet usually asso-ciated with a syndromesuch as arthrogryposis.This grading system hasbeen used in studies ofthe functional outcomeof surgery.71

Childhood ClubfootThe childhood

clubfoot has frequently

tion of the talar neck at birth.Harold and Walker113 grouped the

clubfoot into three grades based onfoot flexibility. Dimeglio et al.114 di-

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Figure 11A. Left clubfoot is oneinch shorter than other side,resulting in pes planovalgusright foot.

Figure 11B. Posterior view ofpatient from Figure 11A show-ing compensatory right hind-foot valgus.

been altered by serial casting and surgical correction.However, residual deformities are extremely common(Table 2 & 3).3,36 Paradoxically, while rearfoot equinusdeformity is the most common reason for initial sur-gery, forefoot adduction is the most common residualproblem after clubfoot surgery and results in a notice-able in-toe gait. In-toe gait is the most frequent seque-lae of the Turco procedure, reported to occur in one-third of all patients. Compensatory lateral tibial torsionmay develop to correct the in-toe gait. Residual equi-nus, varus, and mild cavus deformity is also common(Figure 10).

Generally, ankle and subtalar joint range of motionis found to be reduced in children with clubfoot. Chil-dren who can bring their foot to a right angle with theleg (0 degrees dorsiflexion) usually function quite well(Table 3).36

During childhood, differences in size between theclubfoot side and the normal side become more appar-ent. As compared to the normal lower extremity, thelower extremity with the clubfoot is about 1/2 inchshorter, the calf is about one inch thinner and theclubfoot is about an inch shorter in width than thenormal foot (Figure 11A/B). Smallness of the foot andcalf are an inherent and permanent part of the club-foot and are not improved by exercises or surgery.

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These differences are less pronounced when the club-foot is bilateral.

Treatment of Childhood ClubfootIn-toe gait can be treated with shoes with a

straight or abducted last. In young children, theBebac shoe can be used. The Wheaton Brace andother forms of night-splinting may also be helpful.



Figure 12. Left hindfoot varus in adult with clubfoot.

Figure 13A. Neglected clubfoot in an adult male. Noticenonplantigrade left foot.

Figure 13B. Same patient from Figure 13A. When this manwalks forward he has a -60° angle of gait on the left.

If residual equinovarus is se-vere, daytime bracing may be nec-essary. Bracing may include theplastic shoe insert type orthosis,which cannot be seen underslacks, or the double or single up-right Phelp’s brace. If residualequinovarus and forefoot prob-lems become particularly severeso that the child is tripping andhaving difficulty walking, repeatclubfoot surgery may be neces-sary. Approximately 25-50% of allpatients require repeat surgery forclubfoot.

Clubfoot in AdultsThe adult with clubfoot usually

has some of the same deformitiesthat are seen in children (Figure12).3 The side with the clubfoot isshorter, the calf is thinner and thefoot is smaller. The forefoot mayactually be quite wide in relationto the heel from years of walkingmore on the front part of the foot.

Clubfoot... Treatment of AdultClubfoot

In treating the adult with club-foot who has had casting and sur-gery, residual deformities such ashindfoot varus and equinus andforefoot adductus must be ad-dressed. Initial debridement of pain-ful calluses on the plantar lateral as-pect of the foot brings the patientgreat relief. Patients with anklesprains and lateral instability arehelped by high-top shoes and addi-tions to the lateral aspect of theshoe, such as lateral valgus wedgingon the sole of the shoe and lateralbuttressing on the outer side of theshoe. Stirrup and cloth ankle bracesmay be used to support the laterallyunstable ankle.

At skeletal maturity, the correct-ed clubfoot is one-half shoe sizesmaller than the non-affected foot.Usually buying shoes to fit the larg-er foot is sufficient. A 1/4 inch heellift inside the shoe is generallyenough to balance a limb length

Calluses on the outer aspect of thefoot, especially the base and headof the fifth metatarsal and the lat-eral heel, as a result of increasedpressure on the lateral side of thefoot, are deep and painful. Pa-tients may complain of lateral

ankle sprains, and pain from fre-quently walking on the outside oftheir feet. Range of motion of theankle joint and subtalar joint areusually limited. A recent studyfound that adults with clubfootusually gravitate to more seden-tary occupations.

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At skeletal maturity, the corrected clubfoot is one-half shoe size

smaller than the non-affected foot.

placed on the outside of the shoe.Foot orthotics should have good

shock absorption, as the clubfoot isoften somewhat rigid and is not a

good shock absorber. Foot orthosesmay also contain lateral valguswedging and high lateral flanges.discrepancy. If more than a 1/2

inch lift is required, it must be

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TABLE 4:FUNCTIONAL RATINGS OF CLUBFOOT STUDIES

NEVER/RARELY HAVE PAIN

Laaveg & Ponseti, 1980 (96) 59%Hutchins, Foster, Paterson, Cole, 1985 (55) 80%Yamamoto & Furuya, 1988 (106) 93%Aronson & Puskarich, 1990 (35) 93%Yngue, Gross, Sullivan, 1990 (74) 68%Cohen-Sobel, Caselli, Giorgini, Giorgini, Stummer, 1993 (36) 93%Sobel, Giorgini, Michel, Cohen, 2000 (53) 95%

PAIN ONLY AFTER ACTIVITY

Green & Lloyd-Roberts, 1985 (58) 13% (pain during activity)Porter (1987) (110) 50% (Aching legs after exercise)Lau, Meyer, Lau, 1989 (68) 11% (pain with strenuous activity)Ynge, Gross, Sullivan, 1990 (74) 26% (Pain with mild activity)Devalentine & Blakeslee, 1992 (99) 40% (ccasional pain caused by limping)

CAN PERFORM FULL PHYSICAL ACTIVITY

Bjonness, 1975 (101) 72%Laaveg & Ponseti, 1980 (96) 72%Addison, Fixsen, Lloyd-Roberts, 1983 (109) 76%Hutchins, Foster, Paterson, Cole, 1985 (55) 90%Porter, 1987 (110) 100%Brougham & Nicol, 1988 (66) 75%Lau, Meyer, Lau, 1989 (68) 90%Cohen-Sobel, Caselli, Giorgini, Giorgini, Stummer, 1993 (36) 80%Sobel, Giorgini, Michel, Cohen, 2000 (53) 95%

SAME SIZE SHOES

Bjonness, 1975 (101) 95% (Shop shoes)Laaveg & Ponseti, 1980 (96) 99%Ghali, Smith, Clayden, Silk, 1983 (97) 10%Yamamoto & Furuya, 1988 (106) 86%Aronson & Puskarich, 1990 (35) 62%Cohen-Sobel, Caselli, Giorgini, Giorgini, Stummer, 1993 (36) 84%Uglow & Clarke, 2000 (71) 91% (for mild clubfoot)

61% (for moderate clubfoot)25% (for severe clubfoot)

LIMPING

Laaveg & Ponseti, 1980 (96) 0%Yamamoto & Furuya, 1988 (106) 11%Cohen-Sobel, Caselli, Giorgini, Giorgini, Stummer, 1993 (36) 9% (mild limp)

27% (marked limp)Uglow & Clarke, 2000 (71) 11%


13Ching GHS, Chung CS, Nemechek RW: Genetic and epi-demiological studies of clubfoot in Hawaii: ascertainment and inci-dence. Am J. Hum. Genet. 21:566, 1969.

14Bohm M: The embryologic origin of clubfoot. J Bone Joint Surg.11:229, 1929.

15.Kawashima T, Uhthoff HK: Development of the foot in prena-tal life in relation to idiopathic club foot. J. Pediatr. Orthop. 10:232-237,1990.

16Bleck EE: Clubfoot. Develop. Med Child Neur. 35:927-31, 1993.17Irani RN, Sherman MS: The pathological anatomy of clubfoot. J.

Bone Joint Surg. 45A:45-52, 1963.18Shapiro F, Glimcher MJ: Gross and histologic abnormalities of

the talus in congenital clubfoot. J. Bone Joint Surg. 61A: 522-530, 1979.19Tachdjian M: The Child’s Foot. Philadelphia: WB Saunders Com-

pany, 1985, p139.20Handelsman JE, Badalamente MA: Clubfoot-a neuromuscular

disease. Dev Med Child Neurol. 24:3-12, 1982.21Maffulti N, Capasso G, Teta V, et al: Histochemistry of the triceps

surae muscle in idiopathic congenital clubfoot. Foot Ankle Int 13:80-84, 1992.

22Sirca A, Erzen I, Pecak F: Histochemistry of abductor hallucis mus-cle in children with idiopathic clubfoot and in controls. J Pediatr Or-thop. 10:477-482, 1990.

23Gray DH, Katz JM: A histochemical study of muscle in club foot.J. Bone Joint Surg. 63B:417-423, 1981.

24Isaacs H, Handelsman JE, Badenhorst M, Pickering A: The mus-cles of club foot: a histological, histochemical and electron microscopicstudy. J. Bone Joint Surg. 59B:465-472, 1977.

25Goldner JL, Fitch RD; Idiopathic congenital talipes equinovarus

Continuing

Medical EducationOrthotic materials are variable and may include leather,thermoplastics, and polyethylene foams.

Adult Neglected ClubfootMany individuals in developing countries receive

no treatment for clubfoot either through ignorance orlack of access to medical care.115 In these countries,clubfoot is a major crippling disorder. Neglected club-foot contains all the features of congenital clubfootwith secondary changes from weightbearing and walk-ing. Rigid hindfoot equinus and varus and forefootvarus result in a stiff and non-plantigrade foot, whichforces the individual to walk on the dorsum of the foot(Figure 13A/B). The skin on the dorsolateral aspect ofthe foot becomes hypertrophied and pigmented anddevelops a large subcutaneous bursa. The untreatedadult clubfoot is small because the abnormally tight lig-aments and tendons present during infancy act as atether to prevent further growth. Although the foot isstiff and grossly abnormal in shape, pain and os-teoarthritis are surprisingly minimal.

Treatment of Adult Neglected ClubfootThe greatest challenge for these patients is wearing

shoes. Their feet are severely deformed and they usuallyare unable to fit into off-the-shelf shoes. Molded shoes area necessity for these individuals. Surgery is challenging inadults with neglected clubfoot, and is usually done forcosmetic appearance and to give the patient greater self-esteem. Operations for the neglected adult clubfoot in-volve major bony reconstruction and triple fusions. n

References1Drvaric DM, Kuivila TE, Roberts M: Congenital clubfoot. Etiology,

pathoanatomy, pathogenesis and the changing spectrum of early man-agement. Orthop Clin. North Am. 20: 641-647, 1989.

2Thompson GH, Simon GW; Congenital talipes equinovarus(Clubfoot) and metatarsus adductus. In Drennan JC, ed. The Child’sFoot and Ankle, New York, Raven Press, Ltd., 1992; pp. 97-133.

3Sobel E, Giorgini R: Clubfoot: A comprehensive overview from in-fancy to adulthood. Podiatry Today, 31-45, May, 2000.

4Wong HB: Genetic aspects of foot deformities. J. Singapore Paedi-atric Society 29:13-22, 1987.

5Kite JH: Non-operative treatment of congenital clubfeet: A reviewof one hundred cases. S. Med J. 23(4):337-342, 1930.

6Wynne-Davies R: Family studies and the cause of congenital club-foot-talipes equinovarus, talipes calcaneovalgus and metatarsus varus. J.Bone Joint Surg. 46B:445-463, 1964.

7Wynne-Davies R: Genetic and environmental factors in the etiol-ogy of talipes equinovarus, talipes calcaeal valgus and metatarsus varus.Clin. Orthop. Rel. Res. 84:9-13, 1972.

8Wynne-Davies R, Littlejohn A, Gormely J: Etiology and interrela-tionship of some common skeletal deformities. J Med. Genet. 19:321-328, 1982.

9Yamamoto H: A clinical genetic and epidemiologic study of con-genital clubfoot. Jap. J. Hum. Gen. 24:37-44, 1979.

10Cowell HR, Wein BK: Genetic aspects of club foot Current Con-cepts Review. J Bone Joint. Surg. 62A:1381-1384, 1980.

11Hippocrates: The Genuine Works of Hippocrates. Baltimore;Williams & Wilkins, 1939.

12Browne D: Congenital deformities of mechanical origin. Arch.Dis. Child. 30:37-40, 1955.

Clubfoot...



mens. J. Bone Joint Surg. 45A:1341-1354,1963.

33Cummings RJ, Lovell WW: Operativetreatment of congenital clubfoot Current Con-cept Review. J. Bone Joint Surg. 70A: 1108-1112, 1988.

34Gourineni P, Carroll NC. The ClubfootDiagnosis and Treatment in Infancy. FootAnkle Clin. 3(4): 633-647, 1998.

35Aronson J, Puskarich CL: Deformity anddisability from treat clubfoot. J. Pediatr. Or-thop. 10: 109-119, 1990.

36Cohen-Sobel E, Caselli M, Giorgini R,Giorgini T, Stummer S: Long-Term Follow-upof clubfoot surgery: Analysis of 44 Patients. J.Foot Surg. 32(4): 411-423, 1993.

37Bensahel H, Catterall A, Chir M,Dimeglio A: Practical applications in idiopath-ic clubfoot: a retrospective multicentric studyin EPOS. J Pediatr. Orthop. 10: 186-8, 1990.

38Blakeslee TJ, DeValentine SJ: Manage-ment of the resistant idiopathic clubfoot: TheKaiser experience from 1980-1990. J. FootAnkle Surg. 34:167-76, 1995.

39Ponseti IV: Treatment of congenitalclubfoot. J. Bone Joint Surg. 74A:448-54, 1992.

40Ponseti IV: Common errors in the treat-

ment of congenital clubfoot. Intern. Orthop.21:137-141, 1997.

41Ikeda K: Conservative treatment of idio-pathic clubfoot. J. Pediatr. Orthop. 12: 217-223, 1992.

42Yamamoto H, Muneta T, Morita S: Non-surgical treatment of congenital clubfoot withmanipulation, cast, and modified DenisBrowne Splint. J. Pediatr. Orthop. 18: 538-542,1998.

43Bensahel H, Csukonyi Z, Desgrippes Y,Chaumien JP: Surgery in Residual Clubfoot:One-Stage Medioposterior Release “a LaCarte”. J. Pediatr. Orthop. 7:145-8, 1987.

44Wedge J, Alms M: Technique. A methodof treating clubfeet with malleable splints. J.Pediatr. Orthop. 3:108-112, 1983.

45Delgado MR, Wilson H, Johnston C,Richards S, Karol L: A preliminary report of theuse of botulinum Toxin Type A in infantswith clubfoot: Four case studies. J. Pediatr. Or-thop. 20:533-538, 2000.

46Wenger DR; Clubfoot. In Wenger DR,Rang M, eds. The Art and Practice of Chil-dren’s Orthopaedics. New York; Raven Press,1993; pp 138-167. Chapter 5.

(clubfoot), In Jahss M., ed. Disorders of theFoot and Ankle, Part III, 2nd Edition, Philadel-phia; W.B. Saunders, 1991; pp. 771-829, Ch.33.

26Robertson WW, Corbett D: Congenitalclubfoot. Month of conception. Clin. Orthop.Rel. Res. 338:14-18, 1997.

27Ponseti IV: Clubfoot Management. J. Pe-diatr. Orthop. 20(6):699-700, 2001.

28Ippolito E, Ponseti IV: Congenital club-foot in the human fetus. A histological study.J. Bone Joint Surg. 62A:8-22, 1980.

29Greider TD, Siff SJ, Gerson P, DonovanM: Arteriography in clubfoot. J. Bone JointSurg. 64A:837-840, 1982.

30Downey DJ, Drennan JC, Garcia JF:Magnetic resonance imaging findings in con-genital talipes equinovarus. J. Pediatr. Orthop.12: 224-8, 1992.

31Herzenberg JE, Carroll NC, ChristofersenMR, Lee EH, White S, Munroe E: Clubfootanalysis with three-dimensional computermodeling. J. Pediatr. Orthop. 8:257-62, 1988.

32Settle GW: The anatomy of congenitaltalipes equinovarus: sixteen dissected speci-

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TABLE 5:SUMMARY OF TREATMENT FROM INFANT TO ADULT

INFANT CLUBFOOT

• Serial casting for 3-6 months• Surgical treatment—posterior medial plantar release performed between age 1 and 2

CHILDHOOD CLUBFOOT

• Straight last shoe, abducted last shoe or Bebac shoe for in-toe as a result of forefoot adductus• High top shoes may be more comfortable if residual equinovarus is present• Heel lift usually no greater than 1/4–1/2 inch is sufficient to balance limb length difference• Nightsplinting after surgery may be required to maintain correction until maturity.• Day time bracing to control residual equinus may be necessary until maturity.• Repeat surgery soft tissue release is common for residual equinovarus, cavovarus, and forefoot adductus

ADULT CLUBFOOT

• Debridement of deep callosities on lateral plantar aspect of foot.• High top shoes, valgus heel and sole wedges, lateral build up on outside of shoes, lateral buttress, lateral float for

lateral ankle instability.• Stirrup or cloth ankle brace to support varus foot and ankle.• Heel lift from 1/4 to 1/2 inch usually sufficient to balance limb length difference.• Shoe fitting to larger foot or two different size shoes may be necessary if pronounced difference in size of feet.• Soft foot orthoses made of leather, foams, spenco, to accommodate and provide shock absorption for rigid

clubfoot.

NEGLECTED ADULT CLUBFOOT

• Molded Shoes• Radical surgery to include total realignment and possibly triple arthrodesis

47Cowell HR: The management of club-foot. J. Bone Joint Surg. 67A:991-2, 1985.

48Coss HS, Hennrikus WL: Parent satisfac-tion comparing two bandage materials usedduring serial casting in infants. Foot Ankle Int.17(8):483-486, 1996.

49Carroll NC: Clubfoot: What have welearned in the last quarter century? (Editorial).J. Pediatr. Orthop. 17: 1-2, 1997.

50Ponseti IV, Smoley EN: Congenital club-foot: The results of treatment. J. Bone JointSurg. 1963; 45A:261, 1963.

51Cooper DM, Dietz FR: Treatment of idio-pathic clubfoot: A thirty-year follow-up note. J.Bone Joint Surg. 77A(10):1477-89, 1995.

52Lehman WB, Atar D, Grant AD, Strong-water AM: Treatment of failed clubfoot sur-gery. J. Pediatr. Orthop. Part B 3:168-170,1994.

53Sobel E, Giorgini R, Michel R, Cohen S:The Natural History of the Surgically Correct-ed Clubfoot. J. Foot Ankle Surg. 39(5): 305-320, 2000.

54Ryoppy S, Sairanen H: Neonatal opera-tive treatment of clubfoot: a preliminary re-port. J. Bone Joint Surg. 65B:320-5, 1983.

55Hutchins PM, Foster BK, Paterson DC,Cole EA:Long-term results of early surgical re-

Clubfoot... (Turco operation) for the treatment ofclub foot. J. Pediatr. Orthop. 7:149-151,1987a.

63Betham D, Weiner D: Radical one-stageposteromedial release for the resistant club-foot. Clin. Orthop. Rel. Res. 131:214-223,1978.

64DePuy J, Drennan JC: Correction of idio-pathic clubfoot: A comparison of results ofearly versus delayed posteromedial release. J.Pediatr. Orthop. 9: 44-48, 1989.

65Centel T, Bagatur AE, Ogut T, Aksu T:Comparison of the Soft-Tissue Release Meth-ods in Idiopathic Clubfoot. J. Pediatr. Orthop.20:648-651, 2000.

66Brougham DI, Nicol RO: Use of theCincinnati incision in congenital talipesequinovarus. J. Pediatr. Orthop. 8:696-698,1988.

67DeRosa GP, Stepro D: Results of postero-medial release for the resistant club foot. J Pe-diatr Orthop 6:590-5, 1986.

68Lau JHK, Meyer LC, Lau HC: Results ofsurgical treatment of talipes equinovarus con-genital. Clin. Orthop. Rel. Sci. 248: 219-226,1989.

69Porat S, Kaplan L: Critical analysis of re-sults in club feet treated surgically along theNorris Carroll approach: seven years of experi-

lease in clubfeet. J. Bone joint Surg. 67B:791-799, 1985.

56Main BJ, Crider RJ, Polk M, Lloyd-Roberts GC: The results of early operation intalipes equinovarus. J. Bone Joint Surg.59B:337-341, 1977.

57Porter RW: Congenital talipes equino-varus I: Resolving and resistant deformities. J.Bone Joint Surg. 69B: 822-825, 1987.

58Green ADL, Lloyd-Roberts GC: The re-sults of early posterior release in club feet. J.Bone Joint Surg. 67B:588-593, 1985.

59Porat S, Milgrom C, Bentley G: The his-tory of treatment of congenital clubfoot at theRoyal Liverpool Children’s Hospital: improve-ment of results by early extensive posterome-dial release. J. Pediatr. Orthop. 4:331-338,1984.

60Simons GW: Complete subtalar releasein club feet : part II comparison with less ex-tensive procedures. J. Bone Joint Surg. (Am)67:1056-65, 1985b.

61Atar D, Lehman WB, Grant AD, Strong-water AM; Revision clubfoot surgery. In JahssM, ed. Disorders of the Foot and Ankle, PartIII, 2nd ed., Philadelphia; W.B. Saunders,1991; pp 830-840, Ch. 34.

62Otremski I, Salama R, Khermosh O,Wientroub S: An analysis of the results of amodified on-stage posteromedial release

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proach to Clubfoot Treatment section II. Cor-rection of the Clubfoot. J. Pediat. Orthop.3:10-21, 1983a.

88Magone JB, Torch MA, Clark RN, KeanJR: Comparative review of surgical treatmentof the idiopathic clubfoot by three differentprocedures at Columbus Children’s Hospital.J. Pediatr. Othop. 9:49-58, 1989.

89Simons GW: Symposium: Currentpractices in the treatment of Idiopathic Club-foot in the Child between Birth and FiveYears of Age-Part I. Contemp. Orthop. 17:63-98, 1988a.

90Simons GW: Symposium: Current prac-tices in the treatment of idiopathic clubfoot inthe child between birth and five years of age -Part II. Contemp. Orthop. 17:61-78, 1988.

91McKay DW: New concept of and ap-proach to Clubfoot Treatment. Section I. Prin-ciples and Morbid Anatomy. J. Pediat. Orthop.2:347-56, 1982.

92Flugstad DL, Staheli LT: The posteroinfe-rior release for the treatment of clubfoot. Or-thop. Trans. 9:37, 1985.

93Haasbeek J, Wright JG: A comparison ofthe long-term results of posterior and compre-hensive release in the treatment of clubfoot. J.Pediatr. Orthop. 17:29-35, 1997.

94Carroll NC, Gross RH: Operative man-agement of clubfoot. Point/Counterpoint. Or-thopedics 13:1285-96, 1990.

95Hudson I Catterall A: Posterolateral re-lease for resistant clubfoot. J. Bone Joint Surg.76B: 281-4, 1994.

96Laaveg SJ, Ponseti IV: Long-term resultsof treatment of congenital club foot. J. Bonejoint Surg. 62A: 23-31, 1980.

97Ghali NN, Smith RB, Clayden AD, SilkFF: The results of pantalar reduction of con-genital talipes equinovarus. J. Bone Joint Surg.65B:1-7, 1983.

98Ricciardi-Pollini PT, Ioppolito E, TudiscoC, Farsetti P: Congenital clubfoot: results oftreatment of 54 cases. Foot Ankle 5: 107-117,1984.

99DeValentine SJ, Blakesless TJ; Congenitaltalipes equinovarus. In DeValentine SJ, ed.Foot and Ankle Disorders in Children, NewYork, Churchill Livingstone, pp 89-155. Ch. 6.

100Blakeslee TJ: Congenital idiopathic tal-ipes equinovarus (Clubfoot) Current Con-cepts. Clin. Podiat. Med. Surg. 14:9-56, 1997.

101Bjonness T: Congenital clubfoot: A fol-low-up of 95 persons treated in Sweden from1940-1945 with special reference to their socialadaptation and subjective symptoms from thefoot. Acta Orthop. Scand. 46:848-856, 1975.

102Attenborough CG: Early posterior soft-tissue release in severe congenital talipesequinovarus. Clin. Orthop. Rel. Res. 84:71-78,1972.

103Lowe LW, Hannon MA: Residual ad-duction of the forefoot in treated congenitalclubfoot. J. Bone Joint Surg. 55B:809-813,1973.

104Main BJ, Crider RJ: An analysis of residu-al deformity in clubfeet submitted to early op-eration. J. Bone Joint Surg. 60B:536-543, 1978.

105Otremski I, Salama R, Khermosh O,Wientroub S: Residual adduction of the fore-foot. A review of the Turco procedure for con-genital clubfoot. J. Bone Joint Surg. 69B:832-4,1987.

106Yamamoto H, Furuya K: One-stage pos-teromedial release of congenital clubfoot. J. Pe-diatr. Orthop. 8:590-595, 1988.

107Simbak N, Razak M: Residual deformityfollowing surgical treatment of congenital tal-ipes equinovarus. Med. J. Malaysia 53: 115-120, 1998.

108Thompson GH, Richardson AB, WestinGW: Surgical management of resistant con-genital talipes equinovarus deformities. J. BoneJoint Surg. 64A:652-5, 1982.

109Addison A, Fixsen JA, Lloyd-RobertsGC: A review of the Dillwyn Evans type collat-eral operation in severe clubfeet. J Bone JointSurg. 65B:12-14, 1983.

110Porter RW: Congenital talipes equino-varus II. A staged method of surgical manage-ment. J. Bone Joint Surg. 69B:826-831, 1987.

111McHale KA, Lenhart MK: Treatment ofresidual clubfoot deformity-The “Bean-Shaped”Foot-by opening wedge medial cuneiform os-teotomy and closing wedge cuboid osteotomy,clinical review, and cadaver correlations. J. Pedi-atr. Orthop. 11: 374-381, 1991.

112Attenborough CG: Severe congenitaltalipes equinovarus. J. Bone Joint Surg. 48B:31-9, 1966.

113Harold AJ, Walker CJ: Treatment andprognosis in congenital clubfoot. J. Bone JointSurg. 65B:8-11, 1983.

114Dimeglio A, Bensahel H, Souchet Ph,Mazeau Ph, Bonnet F: Classification of Club-foot. J. Pediatr. Orthop. Part B 4:129-136, 1995.

115Sobel E, Giorgini R, Velez Z: Surgical Cor-rection of adult neglected clubfoot: Three casehistories. J Foot Ankle Surg 35:27-38, 1996.

ence. J. Pediatr. Orthop. 9: 137-143, 1989.70Tarraf YN, Carroll NC: Analysis of the

components of residual deformity in clubfeetpresenting for reoperation. J. Pediatr. Orthop.12:207-216, 1992.

71Uglow MG, Clarke NMP: The functionaloutcome of staged surgery for the Correctionof Talipes Equinovarus. J. Pediatr. Orthop.2000; 20:517-523, 2000.

72Preston E, Fell TW. Congenital idiopath-ic clubfoot. Clin. Orthop. Rel. Res. 16: 93-98,1959.

73McKay DW: New concept of and ap-proach to clubfoot treatment section III: evalu-ation and results. J. Pediatr. Orthop. 3:141-8,1983b.

74Yngue DA, Gross RH, Sullivan JA: Club-foot release without wide subtalar release. J. Pe-diatr. Orthop. 10:473-476, 1990.

75Rumyantsev NJ, Ezrohi VE: Completesubtalar release in resistant clubfeet: A criticalanalysis of results in 146 cases. J. Pediatr. Or-thop. 17:490-495, 1997.

76Turco VJ: Resistant congenital clubfoot-one stage posteromedial release with internalfixation. J. Bone Joint Surg. 61A:805-814,1979.

77White R, Blasier D: Clubfoot Nature andTreatment. Today’s OR Nurse 16:29-35, 1994.

78Huang YT, Lei W, Zhao L, Wange J: Thetreatment of congenital club foot by operationto correct deformity and achieve dynamicmuscle balance. J. Bone J. Surg. 81B:858-62,1999.

79Joseph B, Ajith K, Varghese RA: Evalua-tion of the Hemi-Cincinnati incision for pos-teromedial soft-tissue release in clubfoot. J. Pe-diatr. Orthop. 20:524-528, 2000.

80Reichel H, Lebek S, Milikic L, Hein W:Posteroplantar release for congenital clubfootin children younger than one year. Clin. Orth.Rel. Res. 387:183-190, 2001.

81Faraj AA, Nevelos AB: Posterolateral re-lease for idiopathic clubfoot: Review of 18 pa-tients. J. Foot Ankle Surg. 40:91-95, 2001.

82Turco VJ: Surgical correction of the resis-tant club foot: One-stage posteromedial releasewith internal fixation: A preliminary report. J.Bone Joint Surg. 53A:477-497, 1971.

83Sodre H, Bruschini S, Mestriner LA, et al:Arterial abnormalities in talipes equinovarus asassessed by angiography and the Dopplertechnique. J. Pediatr. Orthop. 12:514-517,1992.

84Stanitski CL, Ward WT, Grossman W:Noninvasive vascular studies in clubfoot. J. Pe-diatr. Orthop. 12:514-17, 1992.

85Kitziger K, Wilkins K: Absent posteriortibial artery in an infant with talipes equino-varus. J. Pediatr. Orthop. 11:777-778, 1991.

86Crawford AH, Marxen JL, Osterfeld DL:The Cincinnati incision: a comprehensive ap-proach for surgical procedures of the foot andankle in childhood. J. Bone Joint Surg.64A:1355-1358, 1982.

87McKay DW: New Concept of and Ap-

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Ellen Sobel, DPM, Ph.D. is Professor ofPodiatric Orthopedics, New York Col-lege of Podiatric Medicine, Division ofOrthopedics. Diplomate, AmericanBoard of Podiatric Orthopedics andPrimary Podiatric Medicine. Renato J.Giorgini, DPM is Professor and formerChairman, Division of Surgery, NewYork College of Podiatric Medicine.Podiatric Surgery and Residency Di-rector, North General Hospital, NewYork City and Fellow, American Col-lege of Foot and Ankle Surgeons.

and flexor digitorum brevisD) Peroneus longus and per-oneus brevis

6) When a child has a unilateralclubfoot, the clubfoot as com-pared to the unaffected “normal”side is usually:

A) Shorter leg and thinner calfgirth than the normal sideB) Shorter leg, but not thinnercalf girth than the normal sideC) Thinner calf girth, but notshorter leg than the normalsideD) Approximately the sameleg length and calf girth ascompared to the normal side

7) You are x-raying an infant witha left clubfoot. The angle of Kiteis 15°. The lateral talocalcanealangle is 20°. What conclusionscan you draw from these results?

A) The infant does not haveclubfoot.B) There is a severe equinusdeformity with little or norearfoot varus but the talocal-caneal index is normal.C) There is a rearfoot varusdeformity, the angle of Kite isabnormally low and the talo-calcaneal index is abnormal.D) There is both rearfootvarus and equinus deformity,but the talocaneal index isnormal.

8) Which of the following is IN-CORRECT regarding serial castingfor clubfoot?

A) Serial casting may involveabove knee or below kneecasts.B) Serial casts can be con-structed of plaster or fiber-glass.C) Ideally casting should beperformed immediately afterbirth or may be delayed tofive days after birth.D) For very severe rigid club-foot serial casting should beavoided.

1) Which statement is INCOR-RECT about the incidence of club-foot?

A) 1/1000 neonates is bornwith a clubfoot.B) Males are affected withclubfoot two times more fre-quently than females.C) The left foot is more fre-quently involved with clubfootthan the right foot.D) 50% of clubfoot is bilateral.

2) Although females are less fre-quently affected with clubfoot de-formity, when a female does havea clubfoot, it is likely to have amore severe clubfoot deformitythan in males with clubfoot. Thisis due to:

A) Autosomal dominant inher-itanceB) Autosomal recessive inheri-tanceC) Sex-linked threshold effectD) Polygenic multifactorial in-heritance

3) The risk of clubfoot to a secondchild after the family has givenbirth to a first born with clubfootis:

A) 1 in 100B) 1 in 20C) 1 in 7D) 1 in 5

4) What is the cause of congenitalclubfoot?

A) Multi-factorial genetics, butthe actual etiology is largelyunknownB) Retracting fibrosisC) MuscularD) Primary germ plasm defectof talar neck resulting in plan-tar flexion and inversion of thetalar neck

5) Which muscle/tendons arestretched and weakened in club-foot deformity?

A) TendoAchillesB) Tibiales posteriorC) Flexor digitorum longus

9) What is the Ponseti Technique?A) Serial casting combinedwith tendoAchilles lengtheningwhen necessary.B) Soft tissue release.C) Posterior medial release.D) Combines only conservativemeasures to correct clubfoot, in-cluding serial casting for long pe-riods and Dennis Brown splinting.

10) The best time for a child withclubfoot to undergo surgery is:

A) As soon after birth as possible.B) After the child begins walking.C) Before the child beginswalking.D) Between 3 months and 1year of age.

11) The initial clubfoot surgery isusually:

A) Soft tissue releaseB) Soft tissue release combinedwith appropriate bony proce-duresC) Ponseti procedureD) Soft tissue release and cal-caneal osteotomy

12) What is the Turco procedure?A) Posterior plantar releaseB) Posterior medial releaseC) Posterior medial plantar re-leaseD) Medial release

13) What is a key advantage of theTurco procedure in correction ofclubfoot over more extensive softtissue releases?

A) It requires no internal fixation.B) There is less postoperativestiffness.C) It can be performed at anearlier age.D) It requires only one incision.

14) What type of incision is usedfor the Turco procedure?

A) Hockey stick incisionB) Medial linear incisionC) Cincinatti incisionD) Double incision

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15) When performing a complete subtalar jointrelease, over-correction can be prevented bypreserving the:

A) Spring ligamentB) Subtalar jointC) Master knot of HenryD) Deep Deltoid Ligament

16) The purpose of the plantar release as part ofthe Turco procedure to correct clubfoot is to:

A) Correct rearfoot varusB) Correct equinusC) Correct metatarsus adductusD) Correct calcaneus

17) The main problem in extensive soft tissuerelease of McKay and Simons is:

A) Over-correctionB) Long-term reduced range of motionC) Poor radiographic resultsD) Patients tend to need more operations

18) Recent studies seem to show that surgicalclubfoot patients who had more completecorrection of heel varus and better subtalarmotion had undergone:

A) Comprehensive soft tissue releasesB) Turco releaseC) Cincinnati incisionD) Ponseti technique

19) According to the results of most studies itwould appear that the most important factorwhich determines the outcome of surgery is:

A) The age at which the initial operation isperformedB) The initial severity of the clubfootC) The type of soft tissue release performedat initial operationD) Whether the clubfoot is unilateral orbilateral

20) Neglected clubfoot refers to:A) Very severe clubfootB) Clubfoot with a particularly strong equinuscomponentC) Adult clubfoot with no surgical correction,generally most common in so-calleddeveloping or third world countriesD) Any clubfoot partially corrected by serialcasting only, with no surgery.

E X A M I N A T I O N

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LESSON EVALUATION

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EXAM #8/02Clubfoot

(Sobel/Giorgini)

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Objectives Identification and Management of ClubfootLearn about the genetics, characteristics, and...

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