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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 ¬ 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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