[10. Congenital clubfoot. b). The results of the early treatment of congenital clubfoot].
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Casts, Surgical↗
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Necrosis leading to amputation following clubfoot surgery.
Amputation after clubfoot surgery is a rare and catastrophic complication. This case report involves an amputation necessitated by postoperative necrosis on the medial side of the foot. To our knowledge, only one brief published report of necrosis following clubfoot surgery exists in the literature, and that report contains little clinical information. Although we know of several additional cases of necrosis following clubfoot surgery, the details of these cases remain unavailable to us for publication. The clubfoot deformity is almost always associated with vascular deficiencies involving the anterior tibial and dorsalis pedis arteries, as well as their derivatives. Since the area of necrosis in this case report coincided with the anatomic distribution of the derivatives of the congenitally reduced or absent dorsalis pedis artery, we suggest that insufficient blood flow to the dorsal and medial sides of the foot, and to the hallux contributed to the necrosis. In our opinion, the surgeon should assume that an abnormal vascular pattern, as described here, is present unless proven otherwise.
Amputation, Surgical↗
Tibial torsion in untreated congenital clubfoot.
Current methods of measurement were reassessed by the study of tibial torsion in 1000 normal legs using the tropometer, the caliper and X-rays. No significant difference in the reproducibility of results was found and the simpler clinical methods appeared to be satisfactory for practical purposes. The spontaneous evolution of leg torsion in clubfoot was studied in forty-two neglected and previously untreated cases, who were seen for the first time after they had begun walking. Comparison with the torsion observed in the legs of healthy children of a corresponding age proved that untreated clubfoot is not associated with pathological torsion. The place of rotation osteotomy in the treatment of clubfoot is discussed.
Adolescent↗
Incidence of congenital clubfoot in Sweden. 128 cases in 138,000 infants 1946-1990 in Malmö.
The incidence of congenital clubfoot, neurological disorders excluded, was studied over a period of 45 years (1946-1990). The number of children, born alive with clubfoot, and detailed census data for the period were available. Altogether 137,614 living infants were born and of these 128 had congenital clubfoot. 56 (44 percent) were bilateral and 101 (79 percent) were boys. The overall incidence was 0.93 per thousand children. The annual incidence rose during the 45-year-period. This was, however, fully explained by the higher incidence among children of non-Nordic extraction.
Clubfoot↗
Results of ultrastructural analysis of the calf muscles in clubfoot.
Open biopsies were carried out on the muscles of 23 clubfoot patients, ages 9 months to 4 years. Electron microscopic analyses of the so-called "clubfoot muscles" and the peroneal muscles were performed. The changes found were not present in every area of the muscles, but were surrounded by fields of normal structure. Fatty degeneration with fibrosis was observed as the consequence of immobilization. More marked loss was found in the contractile elements. The authors believe that neuromuscular atrophy is a primary cause of congenital clubfoot. The most seriously affected muscles in this study were the tibialis posterior and peroneal muscles. The material failed to prove correlation with age. Based on their observations, the authors suggest finishing all types of immobilization before 1 year of age, when children begin to walk.
Actin Cytoskeleton↗
Practical applications in idiopathic clubfoot: a retrospective multicentric study in EPOS.
We report a European study of idiopathic clubfoot that was compiled with the aid of a detailed questionnaire. The retrospective study was presented at the seventh meeting of the European Paediatric Orthopaedic Society (EPOS). Most EPOS members treat idiopathic clubfoot at birth with plaster cast, but a few use physiotherapy and splints. The results of this conservative treatment vary. Operation is usually indicated at an age ranging from 4 to 15 months. Some physicians perform extensive procedures, and others limit operation to the medial and posterior parts of the foot. We propose a classification system for idiopathic clubfoot in an attempt to standardize procedures.
Casts, Surgical↗
Histochemistry of the triceps surae muscle in idiopathic congenital clubfoot.
The histochemical composition of the triceps surae muscle was investigated in 13 previously unoperated children (age 9-24 months) with unilateral idiopathic clubfoot. On both the normal and the affected side, the percentage of type I fibers was significantly higher than that of the other fiber types. The muscle biopsies from the clubfoot side showed an increase in their connective tissue content. The affected side showed a nonsignificant higher percentage of type I fibers, whereas the average capillary density and capillary to fiber ratio were significantly lower.
Clubfoot↗
Clubfoot with supernumerary soleus muscle. Report of 2 cases.
In 2 cases of clubfoot with severe and rigid varus deformity, an accessory soleus muscle with attachment on the medial side of the calcaneus was found. After cutting the distal attachment of this muscle, the deformity diminished. The accessory soleus muscle is not interpreted as the primary cause of the clubfoot, but as a highly contributing cause to the rigid varus deformity.
Abnormalities, Multiple↗
A method of assessment of the clubfoot deformity.
The literature on clubfeet is inadequate because a common method language for assessing the deformity is lacking. Different severities of clubfoot deformity will give different results for a standard procedure: a less severe deformity can be corrected by limited releases, whereas a severe deformity requires radical procedures. This paper presents a language of assessment that has been used for a number of years. The importance of developing a language of assessment to be able to identify the various types of clubfoot deformity is important if the treatment of this condition is to develop within the field of pediatric orthopedics.
Clubfoot↗
The pathoanatomy of congenital clubfoot.
Patients with resistant clubfeet were reviewed in their second and third decades. For comparison, normal embryological and fetal feet, untreated clubfeet, a recurrent clubfoot, and an amputated foot were dissected. In no child with a resistant clubfoot was the bone architecture normal. In untreated and recurrent clubfeet we found the lateral malleolus to be directed posteriorly, the head of the talus pointed laterally, and the navicular subluxated medially toward the medial malleolus. An operative technique to restore normal alignment of the talus in the ankle mortice, of the navicular and talus, and of the talus and os calcis is described.
Adult↗
External rotation tibial osteotomy in clubfoot: adverse late effects.
In a review of 16 feet in clubfoot patients who had external rotation osteotomies to correct internal tibial torsion, 13 had the undesired effect of aggravating and increasing the varus deformity of the foot. External rotation osteotomy to correct internal tibial torsion seems contraindicated in the presence of clubfoot. If an indication does exist, the chances of late adverse effects can be decreased by deferring surgery until the child is over the age of 8, or by combining the procedure with lengthening of the long flexor tendons.
Braces↗
Early posterior ankle release in the treatment of congenital clubfoot.
Eighty-one patients (116 clubfeet) underwent posterior ankle release before the age of two years, following unsatisfactory responses to serial corrective casts applied according to the technique of Kite. Seventy-three per cent of these feet showed no or only mild talar flattening at an average follow-up of 7.5 years. Four years, following posterior ankle release there was a none-mild talar flattening rate of 69 per cent in this group compared to a 40 per cent none-mild rate in ankle release reduces the incidence of recurrent equinus deformity and the necessity for subsequent surgery in comparison to the results obtained with serial plaster casts or with tendo Achillis lengthening alone. Recent trends in clubfoot management have favored increasingly early operative intervention. Denham stated that "In the infant hard tissues (bone and cartilage) should be regarded as soft, and the soft tissues (tendon and ligament) as hard." Our operative experience with posterior ankle release supports this philosophy and indicates that early aggressive surgical management is the treatment of choice for the resistant clubfoot.
Age Factors↗
Short stature, Robin sequence, cleft mandible, pre/postaxial hand anomalies, and clubfoot: a new autosomal recessive syndrome.
We report on 5 unrelated Brazilian children with short stature, Robin sequence, cleft mandible, pre/postaxial hand anomalies, and clubfoot. Genetic aspects and phenotypic manifestations are compared with those of previous reports of acrofacial dysostoses and with other Robin sequence syndromes. We suspect that these patients present a previously undescribed autosomal recessive syndrome.
Abnormalities, Multiple↗
[The importance of the radiological angle between talus and calcaneus in patients with congenital clubfoot (author's transl)].
A reduction of the angle between the longitudinal axes of talus and calcaneus in the lateral X-ray view of a clubfoot is a sign of persistent supination of the subtalar joint and not due to anatomical changes of the bone. Correction of this deformity by closed manipulation produces a normal angle between talus and calcaneus. The angle between talus and calcaneus can thus be used as a guide for adequate correction of the subtalar deformity.
Anthropometry↗
Correction of clubfoot relapse using Ilizarov's apparatus in children 8-15 years old.
Treatment of relapsed or neglected clubfeet between the age of 8-15 years is at present unsatisfactory. Correction by triple arthrodesis with wedge osteotomies is not possible before the end of skeletal maturation. This caused us to use Ilizarov's external fixator, which made it possible to correct all components of clubfoot simultaneously by continuous guided distraction. Thirteen feet in 12 children were treated. A plantigrade foot was achieved in all cases. All patients were able to wear ready-made shoes. Complications were some slight and two severe pin track infections, temporary edema, and two relapses successfully treated by means of second procedures.
Adolescent↗
Treatment of clubfoot by posterior capsulectomy.
Posterior capsulectomy is a complete excision of the posterior tibiotalar and talocalcaneal capsule with a release of the distal tibiofibular connection. The operation is proposed for a resistant or relapsed clubfoot, where remaining equinus is the major problem. A follow-up of 29 operations showed that the average talocalcaneal angle became normal in the AP and lateral views. The best results were obtained with long postoperative cast immobilization, i.e. 6 months.
Achilles Tendon↗
A perspective focus on the indicated surgical treatment of resistant clubfoot in the infant.
Ligamentous contracture is the chief factor in maintaining clubfoot deformity. Precise plans of segmental ligamentous release are called "selective segmental syndesmotomies." Critical segmental assessment by roentgenograms is required to choose the proper syndesmotomy. Proper early correction of resistant subtalar and midtarsal deformity by selective segmental syndesmotomy can solve much of the persistent trouble confronting the surgeon.
Achilles Tendon↗
Avascular necrosis of the body of the talus after combined medial and lateral release of congenital clubfoot.
A retrospective study was made of 203 patients with 321 congenital clubfoot deformities who had at least one operative procedure at the Shriner's Hospital in Greenville, South Carolina, in a period from 1944 to 1973. The five cases of avascular necrosis of the talus occurred among the 35 patients having combined medial and lateral releases. These five clubfeet were recurrent and recalcitrant and required extensive soft tissue release to achieve sustained correction. It is recommended that dissection of the subtalar joint, except at the talonavicular joint, be avoided and that extensive lateral ankle dissection, especially when the sinus tarsi is included, should not be performed simultaneously with the medial release unless absolutely necessary to achieve the desired anatomic relationship.
Arteries↗