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We report a prospective study about congenital clubfoot in 20,000 alive newborns and also a critical analysis about the treatment results. The frequency was 1.65 per thousand and sex ratio almost 2:1 for males. In springtime the incidence was higher. Surgical treatment was performed in less than 50% of the affected feet. There were excellent and good results in 90% of the feet.
In addition to general radiologic aspects there are special orthopedic considerations in interpretation of x-rays of the foot. This is especially important for the diagnosis of orthopedic foot diseases. In clubfoot x-rays are useful for therapeutic planning and control. Even in the first months of life radiographs can show important disturbances of growth of the foot and displacement of the bones of the tarsus. In other congenital foot deformities x-rays are important for diagnostic reasons: they prove luxations or skeletal deformities. The most important acquired foot disease is the pronating foot. X-rays do not only show the amount of joint damage and structural changes of bones but also allow to draw conclusions to be drawn about the causes of static and dynamic changes of the foot skeleton. Functional diagnostic radiological investigation is of decisive importance for evaluation of infantile pronating foot. X-rays allow the differentiation to be made between physiological and pathologic changes. Subtle radiographic investigation is essential while planning operative treatment in childhood, as in adults.
This is a review article of the past 40 years of research in Britain on the etiology of developmental disorders of the skeleton, covering both rare unifactorial diseases (chondroosteodystrophies) and common localized disorders (e.g., clubfoot and congenital dislocation of the hip) of multifactorial inheritance.
Congenital inferior tibiofibular diastasis is a rare condition of unknown etiology, possibly a form of tibial hypoplasia, marked by a clinical triad of talipes equinovarus, ankle diastasis, and limb length inequality. An analysis of 10 cases reported previously is given with two additional examples. Ankle mortise reconstitution and clubfoot correction by surgery have been the basis of treatment. We present two cases in which no ankle reconstruction was done with good results. Syme amputation is considered for cases with severe tibial shortening. Prognosis for a plantigrade foot is encouraging if limb length inequality is corrected operatively or non-operatively as indicated.
The campomelic syndrome is a skeletal dysplasia of unknown aetiology which is apparent at birth and is characterized by bilateral bowing of the tibiae, clubfoot and other multiple congenital abnormalities. Up to 50% of cases are either stillborn or die within 24 hours of birth in respiratory distress. With a few exceptions, the remainder die within 10 months. The patient in this report demonstrated characteristic features of the syndrome which were detected antenatally by ultrasound and confirmed after delivery. The apparently female infant died 2 hours postpartum in respiratory distress, but was subsequently found to have a 46,XY chromosome constitution. Autopsy and postmortem radiographs revealed multiple congenital abnormalities consistent with the campomelic syndrome. The findings in this case are discussed and the possibility of antenatal diagnosis is raised.
In a colony of Shih-Tzu dogs, familial cleft palate frequently associated with hind leg deformity was demonstrated. Colonies of dogs centered around purebred wirehaired terrier females or a mongrel collie male, both with isolated cleft palate did not result in cleft offspring with one exception. Reproductive fitness of a low order was encountered as expected. Difficulty was experienced in raising affected animals. Multiple associated congenital anomalies were found. These include convulsive disorders, clubfoot and dysgenesis of musculature of the thigh.
Talipes equinovarus is a complex triplane deformity of the foot and lower leg. Clubfoot should be treated early and aggressively--but gently. Conservative therapy is often successful if begun early. Surgery should follow a progressive approach.
The congenital clubfoot of infancy to-day is curable in 90% of cases. Aim of the treatment is normalization of form, function and growth. With combined therapy according to Imhäuser optimal results are possible: 1. Immediately after birth--depending on the general condition of the newborn--reposition of all components without the talipes equinus component; plastercasts are changed frequently till the third or fourth month of life; 2. surgical development of the heel; calcaneal equinus is corrected by elongating the tendocalcaneus combined with arthrolysis of the ankle joint; 3. intensive clinical treatment by physiotherapy; 4. ambulant orthopedic controls at regular intervals till the end of skeletal growth.
At Rancho Los Amigos Hospital on the Children's Orthopedic Service, 43 patients underwent anterior transfer of the posterior tibial tendon through the interosseous membrane between 1969 and 1979. This included 74 procedures for the following diagnoses: Duchenne muscular dystrophy, club-foot, cerebrospastic disease (cerebral palsy and head injury), Charcot-Marie-Tooth disease, scapuloperoneal dystrophy, and peroneal palsy. The purpose of this paper is to present the 54 of these transfers that have a minimum 2 year follow-up were performed with a uniform surgical technique, and had uniform postoperative management. This series is analyzed and compared with a review of the literature in order to set down guidelines for the use of the procedure. The analysis reveals that the patient with Duchenne muscular dystrophy who has decreasing gait function or brace fitting problems is the ideal candidate for the procedure with 26 of 28 satisfactory results. Gait electromyography was critical to the selection of the cerebrospastic patient for the transfer with those patients demonstrating swing-phase function of the posterior tibialis muscle yielding the best results. Finally, posterior tibial tendon transfer is generally not indicated in congenital clubfoot with six unsatisfactory results in 10 procedures, and the procedure should not be done in Charcot-Marie-Tooth disease as part of staged treatment that includes a possible future hindfoot stabilization.
Thirty-two patients with treated unilateral clubfoot deformity were followed for a period of 13 to 30 years. The functional results were satisfactory in 28 feet. A comparison of the skeletal features of the normal and the clubfeet was made on roentgenographs. Many clubfeet had small, slightly flattened talar heads, decreased talocalcaneal angles, undersized or misshapen facets of the subtalar joint, and medially displaced navicular. The residual deformity of the hindfoot was compensated by the lateral displacement and lateral angulation of the cuneiforms with respect to the navicular resulting in a normal alignment of the forefoot in relation to the hindfoot. The range of ankle dorsiflexion, subtalar and midtarsal joint motion was restricted in the clubfeet.
The center of pressure paths of foot-floor contact were examined in detail in normal subjects and a group of 44 patients with treated clubfeet. The foot-floor contact areas were wide and the center of pressure paths more variable in clubfeet patients. The center of pressure paths did not always distinguish between normal and abnormal subjects nor between abnormal subjects with varying functional ratings. Foot prints are not sensitive enough to be a diagnostic aid and are of only limited application to the problem of evaluation of treatment of clubfoot deformity.
A previously unreported anomaly of a clubfoot in a 14-month-old boy was associated with an absent posterior tibial tendon and a tarsal coalition.
Analytical radiography enables the surgeon to plan, carry out, and verify correction of the clubfoot once conservative treatment has reached a plateau. The method helps the surgeon to diagnose the presence of one of the 7 possible deformity combinations and choose the appropriate steps of the progressive surgical approach. The method allows the surgeon to ascertain whether he has achieved correction or whether he has achieved correction or whether the next step in the progressive approach is required. Finally, because it is possible to determine the results of surgery with this method, the incidence of recurrent clubfeet may be considerably reduced. To obtain intra-operative films requires a minimal increase in operative time and greatly increases the probability of full correction with only a single operative intervention.
A series of 20 feet in 17 children (12 females, 5 males) treated surgically with medial cuneiform osteotomy and bony bloc insertion to correct forefoot adduction has been assessed. Primary diagnosis were: congenital clubfoot (17 feet), skewfoot (2 feet) and congenital fibular aplasia (1 foot). The average age at the operation was 4.5 years (range from 23 months to 8 years 2 months). Five children (7 feet) were operated before 4 years of age. Medial cuneiform osteotomy has been combined with complete subtalar release from Cincinnati approach, wedge resection of the cuboid and Dwyer procedure. The follow-up was 18 months on an average (6-30 months). Correction of the deformity has been assessed clinically and radiologically (angles: tarsal-metatarsal I, tarsal-metatarsal V and first ray angle ray angle according to Barriolhet. In all cases accurate position of the forefoot has been achieved.
It has been hypothesized that the pathogenesis of idiopathic talipes equinovarus (ITEV, or clubfoot) is explained by genetic regulation of development and growth. The objective of the present study was to determine whether a single Mendelian gene explains the probability of having ITEV in a sample of 143 Caucasian pedigrees from Iowa. These pedigrees were ascertained through probands with ITEV. Complex segregation analyses were undertaken using a regressive logistic model. The results of these analyses strongly rejected the hypotheses that the probability of having ITEV in these pedigrees was explained by a non-Mendelian pattern of transmission with residual sibling correlation, a nontransmitted (environmental) factor with residual sibling correlation, or residual sibling correlation alone. These results were consistent with the hypothesis that the probability of having ITEV was explained by the Mendelian segregation of a single gene with two alleles plus the effects of some unmeasured factor(s) shared among siblings. The segregation of alleles at this single Mendelian gene indicated that the disease allele A was incompletely dominant to the nondisease allele B. The disease allele A, associated with ITEV affection, was estimated to occur in the population of inference with a frequency of .007. After adjusting for sex-specific population incidences of ITEV, the conditional probability (penetrance) of ITEV affection given the AA, AB, and BB genotypes was computed to be 1.0, .039, and .0006, respectively. Individual pedigrees in this sample that most strongly supported the single Mendelian gene hypothesis were identified. These pedigrees are candidates for genetic linkage analyses or DNA association studies.
Anterior abdominal wall defects are not too rare between developmental abnormalities. A case of abdominal wall defect associated with complex malformations diagnosed prenatally is reported in the paper. In the present case of limb-body wall complex a right sided abdominoschisis was associated with rotational abnormality of the lower limbs, clubfoot, scoliosis, meningomyelocele, lack of developed pelvic organs, consecutive dilatation of the upper urinary tract, anal atresia, lack of external genitalia, lack of diaphragm and hypoplastic lungs. Review of the pertinent literature has revealed over 100 cases that clearly indicate the possible phenotypic variation of the limb-body wall complex. These data add further evidence to support the existence of two different phenotypes and possibly pathogenesis under the heading of limb-body wall complex. The three principal theories on the possible aetiology of the complex are also discussed. Because the limb-body wall complex is incompatible with life, it is important to diagnose the lesions prenatally, and to differentiate them from other anterior abdominal wall defects. Serum alpha-fetoprotein measurement, and ultrasonographic examination are the key to prenatal diagnosis.
A series of 101 patients (146 feet) with resistant clubfoot corrected by complete subtalar release is presented. A detailed rating system was used to evaluate the results. Minimum follow-up was 2 years. Fourteen feet (9.6%) had undergone additional surgical procedures at the time of review, and 101 feet (69%) had excellent or good functional ratings at that time. The mean total ankle motion was 34.2 degrees (range, 8-56 degrees). The better results occurred in feet without previous surgery. Final ankle range of motion was increased by using a special flexed-knee cast with reserve space above the foot. Longer follow-up is needed to determine the optimal age for surgery.
Despite a tendency for rotational abnormalities of the lower leg in children to improve spontaneously over time, some fail to correct and require corrective derotation osteotomy. In this retrospective study, we report the technique and results of the distal transverse tibial and fibular derotation osteotomy with Kirschner-wire fixation performed in 63 limbs of children with cerebral palsy, clubfoot, idiopathic tibial torsion, and myelomeningocele, as well as other less common conditions. There were no significant infections, neurologic complications, delayed or nonunions, or compartment syndromes as a result of the osteotomy. There were three (4.8%) complications, including late fracture (one), cross-union (one), and distal physeal closure (one). We conclude that transverse, same-level, distal tibial and fibular osteotomy fixated with crossed Kirschner wires is a safe, efficient, and effective surgical approach to the treatment of children with tibial torsion in a variety of clinical conditions.