(6) Congenital Talipes Equinus Varus

8/9/2019 (6) Congenital Talipes Equinus Varus

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CONGENITAL TALIPES EQUINUS VARUS

Abstract:

Talipes equinus varus or clubfoot is the most common congenital orthopaedic

anomaly seen in pediatric orthopaedic clinics. The etiology and pathological anatomy

are still controversial. Diagnosis can be easily made when the child presents to the

clinic. Initial treatment consists of non-operative intervention and surgical options are

reserved for those that failed conservative treatment.

Case Report:

A 9-month-old boy presented to our clinic with deformity in both his feet since birth.

Birth history was uneventful .e was born as a full term normal vaginal delivery. is

milestones were generally normal .is speech was normal. !n e"amination# he was

adequately built for his age and height. There was no other congenital anomaly

detected .is spine was normal .The muscle tone of his upper and lower limb were

normal. ip e"amination revealed no dislocation or sublu"ation. $"amination of his

feet revealed a gross deformity .The right and left foot were in adduction# varus and

equinus position. There was a prominent medial transverse crease line on both foot

.!n attempting to correct the deformity% it was noted to be rigidly fi"ed. An&le

dorsifle"ion was less than '( degrees and both feet were in severe equinus.

)ray of both feet were ta&en in the anterior-posterior and lateral views. !n anterior-

posterior view# the talo-calcaneal angle of the left foot was '*degrees as compared to

'+ degrees on the right# the talo-first metatarsal angle was minus '( degrees on the

left and minus , degrees on the right and the vertical talo-first metatarsal angle on

lateral view was '( degrees on the left and '* degrees on the right.

A diagnosis of bilateral congenital talipes equinus varus /0T$12 and the patient was

planned for bilateral posterior medial and lateral release using the Turco method. In

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our patient conservative method li&e manual correction with application of serial

corrective cast or special foot wear was not tried because his deformity was rigidly

fi"ed. An attempt to correct the deformity manually was not successful.

3nder general anaesthesia and tourniquet control# the child was placed in a prone

position. Both feet were operated on simultaneously by two teams. 3sing the posterior

lateral incision starting from the distal half of the calf the incision was e"tended to

below the lateral malleolus and then distally to the calcaneocuboid 4oint .The short

saphenous vein and sural nerve were preserved during the dissection and the tendon

sheath of the peronei was opened and retracted after incising the e"tensor

retinaculum. The posterior talofibular ligament and the calcaneofibular ligament were

then incised. The lateral part of the an&le and subtalar 4oint capsule were sectioned as

were the calcaneocuboid ligament and capsule. 5e"t a posterior medial release was

done. A curvilinear incision was made e"tending from the base of the ' stmetatarsal to

the medial malleolus and then ascending pro"imally and posteriorly to the center of

the distal third of the calf.

The neurovascular bundle were preserved and the dissection was continued till the

fle"or tendon were e"posed .The tendocalcaneus sheath was opened and a 6 plasty

was preformed The tendon sheath of the fle"or hallucis longus /782 and fle"or

digitorum longus /7D82 were opened and followed till the master &not of enry. A 6

plasty of both the tendon and the tibialis posterior /T2 tendon was then preformed.

The posterior capsule of the an&le and subtalar 4oint were incised and the 4oints

e"posed .The deltoid ligament was sectioned e"cept the anterior and deep parts. Theinterrossei ligament was also preserved .The spring ligament# plantar aponeurosis and

taolnavicular 4oint capsule were also released .The foot was then manipulated into a

reduced position and the 6 plasty was completed. emostasis was secured and the

subdermal layer was closed with vicryl :( and the s&in with subcuticular sutures.

Both the feet were placed in a below &nee cast and held in a reduced position with the

an&le 4oint in neutral position.

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The child was discharged on the second post-operative day and the cast was planned

for ; wee&s. '((( live births and is even higher in first

degree relatives being =.>'((( live births .It is seen more commonly in boys than

girls# the ratio being =>'.It has been associated with autosomal dominant inheritance

pattern# autosomal recessive and ) lin&ed recessive inheritance pattern. The etiology

of clubfoot is un&nown several theories have been postulated which include germplast

defect# developmental arrest theory and fetal theory. andelsman and Badalamente

/cited in 0umming# '9,,2 in their study of muscle biopsy specimen ta&en from

clubfoot pateints found presence of ultrastructural abnormalities and concluded that

neurogenic disorder could be a pathogenesis in clubfoot. ?yogenic theory postulates

that the primary defect is in the muscle# as evident by calf atrophy in all clubfoot

patients. Developmental arrest theory put forward by Bohm # suggest that arrest of

embryogenic development during the first few wee&s of life could cause clubfoot.

This is due to the fact that the foot during this period is in the position of adduction.

$mbryological review of anatomy of fetus with clubfoot by


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is also in equinus .The cavus deformity of the foot is the result of contractures present

in the palmar aponeurosis# abductor hallucis and fle"or digitorum brevis. #9?c @ay

in '9,= reported on the notion in clubfoot that the talocrural# talocalcaneal#

talonavicular and calcanealcuboid 4oints are sublu"ed or dislocated are not true# rather

they are fi"ed in e"tremes of equinus and inversion. e believed that ma4or deformity

in clubfoot is the inward rotation of the whole foot on the talus involving mainly the

talocalcaneal# talonavicular and the calcanealcuboid 4oints .In the talocalcaneal 4oint#

there is not only horiontal rotation of the calcaneus around the interosseous ligament

but also rotation around the coronal plane. As a result not only the heel tips into varus

position# the calcaneal fibular# posterior talocalcaneal ligaments# superior peroneal

retinaculum and the peroneal tendon sheath become shortened and thic&ened. '(

In the talonavicular 4oint # the navicular has moved around the most medial and

plantar side of the talus head .As a result # the cartilage on the lateral aspect of the

talus head atrophies and results in growth of the talus in the medial and plantar

direction .tructures that resists realignment of the 4oint are posterior tibial tendon #

deltoid ligament # spring ligament# entire talonavicular ligament #bifurcate ligament #

inferior e"tensor ligament and cubonavicular ligament.

In the calcanealcuboid 4oint# the cuboid is displaced medially on the calcaneus and

under the navicular and cuneiform bones .As internal rotation continues# the bifurcate

ligament# the long plantar ligament# plantar calcanealcuboid ligament# navicular

cuboid ligament# inferior e"tensor retinaculum# dorsal calcanealcuboid ligament all

get contracted causing supination in the midfoot and adduction of the forefoot.

0lassification of clubfoot is related to its severity of involvement. In assessing the

interobserver reliability of clubfoot classification# 7lynn et al concluded from their

study using the irani et al and Dimeglio et al classification# that both types of

classification had good interobserver reliability ;. owever the most widely used

classification system is the Dimeglio system# which is graded as

'2 postural or mild clubfoot

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=2 moderate clubfoot

2 severe clubfoot

2 very severe or defiant clubfoot

In the postural type# which is uncommon# the foot can be corrected passively with

little difficulty .The moderate type# which is the largest is fairly supple# transverse

crease is absent and the heel is definable. The severe clubfoot is less common and

almost always requires surgery .The foot is short# e"hibits a transverse crease and has

tight s&in .The defiant foot is one which there is difficulty in palpating the calcaneus

0atterall on the other hand had also classified clinical types of 0T$1. They are

divided into either

i2 postural resolving - where there is no fi"ed deformity

ii2 tendon contracture type - no fi"ed deformity in the midtarsus or forefoot

but tight structures are present posteriorly

iii2 4oint contracture type - there is fi"ed deformity in both forefoot and

hindfoot

Diagnosis is one of clinical. ?anagement includes investigation and treatment of the

deformity. Investigation includes "-ray of the foot in anterior posterior and lateral

view while standing and a lateral view in ma"imum dorsifle"ion. ' The anterior

posterior radiographs are ta&en with the beam at ( degrees to the vertical. This view

allows for measurement of the talocalcaneal and talo-firstmetatarsal angles. The

talocalcaneal angle which is the angle between the long a"is of the talus and calcanealis an inde" of varus deformity .The talo-first metatarsal angle which is the angle

between the long a"is of the talus and the first metatarsal is an inde" of adduction

deformity.

!n the lateral view in ma"imum dorsifle"ion# the tibiocalcaneal angle measures the

inde" of equinus deformity and from lateral standing radiograph the vertical talo-first

metatarsal angle measures inde" of cavus deformity.

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The choice of treatment of clubfoot still remains controversial. All associated

disorders should be treated otherwise recurrence is common. ?ost surgeons agree that

initial treatment should be non-operative even with a severe deformed foot# which is

less li&ely to respond to non-operative treatment.

The more common non-operative method is by gentle manipulation or realignment of

the foot followed by application of a series of carefully molded corrective plaster

cast .(C to *(C of foot treated by this method eventually need surgical correction. =

The plaster cast is used to maintain the position of correction but not to produce the

correction .The principle of correction is to correct the forefoot adduction and varus

then correction of hindfoot supination and lastly correction of equinus

Technique for correcting the deformity include applying force on the lateral side of

the talus head# then traction is applied to the ' stray to stretch the tibialis posterior

tendon and correct the forefoot adduction and supination. 5e"t the talonavicular 4oint

is reduced by observing the navicular drawing away from the medial malleolus. !nce

this is done# the equinus can be corrected by pushing upon the front of the calcaneus

and pulling the calcaneus down and away from the fibula. * The plaster is then

applied to maintain the reduction .It is important to correct all elements of the

deformity because failure to correct any of it will require operative intervention. !nce

cast is applied# it is repeated wee&ly till the deformity is corrected. ome surgeons

prefer to overcorrect the deformity slightly as they believe that the foot will usually

tend to revert slightly to its previous deformity .If good correction cannot be obtained

at the end of months# it is unli&ely that non-operative treatment will be successful.!n the other hand if correction is achieved# it is maintained by having the child to

wear on an&le foot orthosis /A7!2 during his unattended hours at the same time

e"ercising the foot and an&le regularly to prevent stiffness and maintain an&le

motion .This is continued for many months to years .!ther forms of non-operative

treatment include adhesive strapping # taping on a Denis Brown splint # orthosis and

special foot wear .Denis Brown splint has been used since '9'. Brown initially used

the splint to maintain either partial or total correction after manipulation to give the

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foot a normal range of movement and position of rest .But this resulted in difficulty to

hold the hindfoot and to correct the equinus deformity .ence Thopmson modified

this and applying his principle that the deformity should be allowed to correct by the

infants own &ic&ing and hence evolved the use of modified Denis Brown splints . It

wor&s on the principle that when one leg e"tends # the other fle"es in the splint and

the foot of the fle"ed side is forced into dorsifle"ion # abduction and eversion /cited

in amamoto # '99(2 . 7urther amamoto et al modified the Denis Brown splint

using Thompson principle and used it to treat 9' infants with clubfoot. '

They replaced footplates or shoes by plastic shoes made from molding plastic sheets

over a corrected cast and held it to a cross bar at an angle of =*degree to +* degrees

as apposed to the Denis Brown splints where the shoes are held at +( degrees of

e"ternal rotation . They believe that as the angle increases# the calcaneum is abducted

and by fitting it to a corrected cast# the forefoot adduction and together with the

displaced navicular acts effectively when the child &ic&s. In assessing clubfoot

correction# 8aaveg et al found that the lateral talocalcaneal angle to be a more

accurate indicator +.

The timing for operative surgery remains controversial. ?ost surgeons agree that it

should be done within the first year of life appro"imately to ; months of age. The

reason being that there is a lot of growth in the foot during the first year of life and

hence if the bony architecture is properly aligned# there is great potential to remodel

and congruent development of the foot. 8evin et al also reported better result in those

that were operated before one year of age.9

Before months it is not advisable tooperate because the foot during this period has abundant fatty tissue and the bones are

small and cartilaginous.

urgical procedures currently used to treat clubfoot can be divided into basic

groups '%

i2 those that involve soft tissue

ii2 those that involve bone

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iii2 combined soft tissue and bony procedure

The principle of surgery is to correct the bony architecture of the foot and to balance

the muscle forces so that the correction obtained at surgery will be maintained as the

child grow. oft tissue procedure consists of either release or lengthening of tight

deforming soft tissue structures li&e ligaments# 4oint capsules and tendon as well as

tendon transfer. Tendon transfer are only done after all fi"ed deformities are corrected.

Eelease procedures commonly done are the posterior release# posterolateral release #

posteromedial release # combination of both or circumferential release.##*#''

osterior release must not be done until the adduction of the forefoot and varus

deformity of the heel has been completely corrected. osterior release can be done by

using a posterior lateral incision which consists of an oblique incision running down

from the midline of distal calf posteriorly to a point midway between the

tendocalcaneus and lateral malleolus .A complete release consists of lengthening of

tendocalcaneus # posterior capsulotomy of the tibiotalar and subtalar 4oint # sectioning

the posterior talofibular ligament and the calcaneofibular ligament . These structures

must be released to permit normal e"cursion of the fibula and dorsifle"ion of the

talus .

The posteromedial release or Turco procedure was introduced in '9+, by Turco and is

widely used nowadays. # The aim of this procedure is to e"cise or release all of the

pathologically contracted soft tissue that prevents the complete correction of the

deformity .It involves 6 plasty of the tendocalcaneus# tenotomy of the tibialisposterior tendon# 6 plasty of the 78 and 7D8 tendons# plantar fascia release#

capsulotomy of talonavicular# subtalar and calcaneocuboid 4oints including the

naviculocuneiform and cuneiform metatarsal 4oints# sectioning the talocalcaneal

interroseous ligament# deltoid ligament# spring ligament and the naviculocuneiform

ligaments. !nce corrected alignment is achieved# it can be maintained with ' or = @-

wires.

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8evin et al reported on the in their study on long-term follow up of patients who with

posteromedial release before one year of age# had better results than other method of

release and similarly less post operative stiffness .9 Among the drawbac& are that the

incision crosses the medial s&in crease # e"posure of the plantar fascia is difficult and

difficult to see structures in the posterolateral aspect of the foot .

Another release which is gaining popularity is the circumferential one stage subtalar

release as described by ?c @ay. 3sing a circumferential or 0incinnati incision# soft

tissue release of the posterior# medial# lateral and plantar aspect are done. It was

designed to correct the horiontal subtalar rotation of the calcaneum. ?c @ay also

showed that this procedure alone not only mar&edly improve an&le motion but further

improvement of an&le motion can be obtained when this procedure is combined with

sheath recession and hinge cast brace .''

In a study carried out by 7lugstad and taheli /cited in 0ummings# '9,,2 comparing

Turco one stage posteromedial release and ?c @ay one stage circumferential release#

they concluded that ?c @ay Fs one stage procedure showed better outcome in terms

of correction of deformity# range of an&le motion and fewer complications.

0ircumferential subtalar release described by imon differ from that of ?c @ay in

that in the former# there is in addition the release of interroseous talocalcaneal

ligament as well as posterior talofibular ligament aiding in better correction of the

deformity. #?c @ay did not advocate releasing the structures because he thought

that it lead to subtalar instability with a valgus heel resulting in poor an&le motion .''

In cases of bilateral clubfoot # some surgeons prefer to do them at wee&s apart as itwill enable them to change the cast . owever simultaneous procedure on both foot

has also been advocated by some with no significant difference in outcome. If

transfi"ation pins were used at the initial surgery# they were removed at ; wee&s post-

operative .The use of Denis Brown splint during sleep after surgery is still a

controversy but it is usually the preference of the surgeon.

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Tendon transfer procedures are usually not indicated at the initial surgery. It may be

used if there is tendency for the forefoot to supinate during gait. ere either the lateral

half of the tibialis anterior can be transferred to the =nd or rd cuneiform or

transplantation of the tendon of tibialis posterior to the middle of the dorsum of the

foot may help in correcting the problem.

Eelease involving the forepart of the foot have also been described which includes

release of tarsometatarsal and intermetatarsal 4oint structures mainly to correct the

adduction of forefoot .owever this procedure has questionable benefits because the

deformity tends to recur and residual pain and stiffness have been reported . ain is

usually felt at the anterior aspect of the an&le # the heel and sinus tarsi . ost

operatively either a above or below &nee cast is applied for , wee&s changing at

wee&ly interval. !n removal of cast# the child is put on an orthosis until he is wal&ing

and there is clinical and radiological evidence of plantigrade foot.


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should be delayed till the patient Gs s&eletal age is about '= years. This may help

reduce the rate of pseudoarthrosis and shortening of the foot.

At an average =(C of patients treated with surgery has poor results . Atar et al

reported a =*C poor result for operated clubfoot.= Among the possible e"planation

include presence of talocalcaneal bar# over correction of the deformity and scarring of

the tendons that were lengthened. !ne way to overcome the scarring of the tendon is

to perform fractional lengthening of the tendon. This is done by finding the

intramuscular portion of the tendon to be lengthened and to interrupt it at that point

leaving the muscle intact. As a result# the muscle is intact throughout their e"cursion. '

0ombined soft tissue and bone procedure has also been preformed to some success.

Among them were those that were described 8undberg /cited in 0ummings# '9,,2

where he combined posteromedial release with medial opening wedge osteotomy of

the calcaneus. $vans procedure is another e"ample# which is mainly used to correct

residual adductus deformity. ere a closing wedge resection of the calcanoecuboid

4oint is done to shorten the lateral column of the foot combined with a medial and

posterior release. offmann et al /cited in 0ummings# '9,,2 also described an

opening wedge osteotomy of the first cuneiform combined with a radical plantar

release to correct residual adductus deformity. e found good success rate using this

method. !ther bony procedure include cuboid decancellation # talectomy and wedge

tarsectomy .

In correcting severe deformity# problem may arise with s&in closure. This can beavoided by one of these methods>

i2 primary closure in the undercorrected position followed by wee&ly

manipulation till full correction is achieved

ii2 using lateral s&in release and flap

iii2 using myocutaneous or fasciocutaneous flaps or

iv2 using tissue e"panders pre-operatively=

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In conclusion# in all degree of clubfoot# initial treatment should always be gentle

corrective manipulation and serial casting. urgery is indicated only if complete

correction cannot be obtained and maintained. oft tissue release are favored over

bone procedure which should be regarded as salvage procedure and done only in older

children.

References:

'. Atar D, Lehman W.B, Grant A.L and Strongwater A.. Eevision urgery

in 0lubfoot. 0lin. !rthop. '99= % =, > ==-==9

=. Atar D, Lehman W.B , Grant A.L and Strongwater A.. 7ractional

lengthening of the fle"or tendon in clubfoot surgery . 0lin. !rthop. '99' %

=; > =;+-=;9

. Cana!e S.". The ediatric 7oot . 0ampbell Fs !perative !rthopaedics '99,%

9th$d > 9+-9*'

. Cummings R.#. and Lo$e!! W.W. 0urrent 0oncepts Eeview . !perative

treatment of congenital Idiopathic 0lubfoot . H Bone Hoint urgery '9,, % +(-A

. 5o + > ''(,-'''=

*. Dee .R .rinciples of !rthopaedic ractice % =nd$d '99+> ,(-,=(

;. %!&nn #., Donohoe , '.". and ac(en)ie W.G. An Independent

assessment of two 0lubfoot 0lassification ystems . H. ediatr. !rthop '99,%

1ol ', 5o > =-=+

+. Laa$eg S.#. and 'onseti *.+.8ong term results of treatment of congenital

clubfoot . H Bone Hoint urgery '9,(% ;=-A > =-(

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,. Law #..-, e&er L.C. and Law .C.Eesults of surgical treatment of

talipes equinus varus congenita . 0lin. !rthop '9,9 % =, > ='9-==;

9. Le$in . , -uo -. , arris G.% and atesi D. +. osterior medial

release for Idiopathic Talipes $quinusvarus . 0lin. !rthop '9,9 % == > =;*-

=;,

'(. c -a& D.W. 5ew 0oncept of and approach to 0lubfoot treatment > ection I

rinciples and morbid Anatomy . H. ediatr. !rthop '9,= % 1ol = 5o > +-

*;

''. c -a& D.W. 5ew 0oncept of and approach to the 0lubfoot treatment >

ection III- $valuation and results . H. ediatr. !rthop '9, % 1ol 5o = >

''-',

'=. /trems(i *, Sa!am R , -hermosh / and Weintroub S. Eesidual adduction

of the forefoot . H. Bone Hoint urgery '9,+ % ;9-B > 5o * > ,=-,

'. Waisbrod . 0ongenital 0lubfoot. An Anatomical tudy . H Bone Hoint

urgery '9+% 1ol ** 5o > +9;-,('

'. 0amamoto and %uru&a -. Treatment of 0ongenital 0lubfoot with a

modified Denis Brown plint. H. Bone Hoint urgery '99(% 1ol +=-B # 5o >

;(-;

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(6) Congenital Talipes Equinus Varus