M.S. FORMER CONSULTANT FORMER CONSULTANT ORTHOPAEDIC SURGEON,SGPGI ORTHOPAEDIC SURGEON,SGPGI Asso. Prof. Govt Medical College Asso. Prof. Govt Medical College Ambadkarnagar Ambadkarnagar Former VP,Secretary IFAS Former VP,Secretary IFAS Convener,ICFSG Apley Clinic Ortho Centre Gomti Nagar, Lucknow

Evalution of Resistant & Neglected Clubfoot Evalution of Resistant & Neglected Clubfoot

CLUBFOOT IS NOT A PROUD CLUBFOOT IS NOT A PROUD STORY IN ORTHOPAEDICS. STORY IN ORTHOPAEDICS. THE FINEST RESULT ALWAYS SHOWS SOME GIVEAWAY SIGNS. THE FINEST RESULT ALWAYS SHOWS SOME GIVEAWAY SIGNS.

C.T.E.V. Management Still Remains An Exciting Clinical Challenge VARIOUS INVASIVE / SEMI INVASIVE MODALITIES OF TREATMENT SOME TIME RESULT IN EITHER OVER CORRECTION OR LITTLE UNSATISFACTORY CORRECTION.

Child presented at 8 yr. neglected club foot walking on lat. border of foot with clawing of toes.

Such complex Equino varus foots have enourmous burden in India

WELL PLANNED ARTHRODIASTASIS RESISTANT RELAPSED NEGLECTED RIGID CLUB FOOT

Series of 1000s of cases managed by Semi Invasive modality in past about 18 years

There is no specific Thumb rule for managing such cases. There is no specific Thumb rule for managing such cases.

Clinically Complex clubfoot have rigid hind foot equinus and varus pattern (exceptionally tight Achilles tendon ), a deep transverse crease in the sole, severely adducted forefoot with all metatarsals are deformed,showing severe planter flexion with deformed other tarsals as well.

Extrinsic Type (Postural?) Intrinsic Type Flexible foot respond best to Ponsetti method but if deformity persist then become rigid. No gross abnormal bony relationship initally present.. Much rigid foot however after birth can be slightly corrected by manipulation. Gross abnormal bony relationship present.

Resistant ClubfootNeglected Clubfoot INTRINSIC CLUBFOOT, EXTRINSIC (NEGLECTED TYPE) HAVE GOT LARGE FAILURE RATE – RELAPSES ARE MORE AND MANY ARE RESISTANT TO THE TREATMENT.

8 year old Rigid C.T.E.V. severe adduction & hind foot varus. Walking on lateral fore foot

A SEMI INVASIVE TECHNIQUE/ Open surgical procedure

MOST RATIONAL METHOD SKELETAL PINS PLACED IN FOOT WITH DISTRACTION DONE CONCAVITY OPENS UP GRADUALLY MEDIALLY AND CONVEXITY IS REALIGNED TO PREVENT COMPRESSION RESULT

Fixator in position after 5 weeks At 6 months

Require a modality  Requirement of modality where minimal chances of recurrence should be there.  Where to gain a supple foot with all movement in tact.  To obtain a foot with minimal scar.

AT BIRTH BONES OF FOOT NORMAL IN SHAPE BUT ALTERED IN POSITION FOOT DEFORMITY PERSISTING FOR A LONG TIME LEDS TO BONY ADAPTIVE CHANGES Distraction done below the age of 7-8 years has got better result as much bony changes have not occurred by that time.

Delaying in the treatment is harmful No matter whether Extrinsic/Intrinsic type if proper correction is not achieved at proper time then bony changes are more faster & there is delay in development of ossification center of navicular (normally around 3-4 years). It is seen that as soon as correction of components occur the center appears. No matter whether Extrinsic/Intrinsic type if proper correction is not achieved at proper time then bony changes are more faster & there is delay in development of ossification center of navicular (normally around 3-4 years). It is seen that as soon as correction of components occur the center appears.

10 year old child with Severely Rigid Relapsed B/L club foot with Congenital band syndrome Swelling on entire dorsal surface of right foot with Congenital band

Left foot with hypertrophied incisional scar mark

Table top talus with deformed metatarsals seen Requiring Arthrodiastasis Severe adduction component present

Distraction in progress after three weeks (swelling still persisting)

At 3 months after the removal of fixator (Before giving POP)

All good result from a particular technique is not possible All good result from a particular technique is not possible One should always track records their own records and learn. One should always track records their own records and learn. Things To Remember

 Pre operative planning of assembly is important, specially in rigid & deformed foot where special care is made while selecting various sizes of distractor.  To avoid any over correction. (not to create a valgoid foot)

A Rigid Neglected Bilateral Case Operated In A Single Sitting Needs a Proper Pre surgical workup.

Resorption of Bunion in process with Ligamentotaxsis Be careful. Should not infect Resorption of Bunion in process with Ligamentotaxsis Be careful. Should not infect Distraction in progress after 3 weeks

Hinge distractor for severe rigid fore foot adduction

 Radiological correction should be assessed in between the distraction phase. Xray picture showing the positioning of meta tarsal and calcaneal wires

For preventing recurrence the static phase should be adequate (ideally double the distraction phase period). A rigid foot sometimes takes a longer time to correct then is not always possible to give full double static phase on fixator. Static phase is important to allow soft tissue maturation in the acquired elongated position. Rest of static phase given on POP

Reasons For Inadequate Correction Reasons For Inadequate Correction 1 Stiff / Rigid club foot with irreversible bony changes. 2 Over enthusiastic in correcting hindfoot equinus with out a complete hindfoot varus correction.

3 Actually not always a very satisfactory procedure in a rigid neglected case after years. Some times correction occurs with fibrous ankylosis resulting in painful foot, so better to go for bony procedures as a add on surgery later in such cases.

Challenges : We don’t have good control over Navicular so some time Adduction component remain uncorrected Solution: After dismantling assembly in between in OT do Ponseti Manipulation & reapply Fixator

Deformed talus ( Table Top Talus) require more static phase so that possible remodeling can occur in distracted ankle mortis

Normal Foot A.P & Lateral View Radiological Assessment for the Prognosis

1.Talo. Cal. Angle. (A.P. View)-20 0 to 40 0 (Kite’s angle) 2.Talo. Cal. Angle. (Stress Lateral View) to Talo. Cal. Index > Talo. First metatarsal angle (A.P. View)-0 0 to -20 0

Preoperative Xray of 6 year child with Rigid club foot

Post Fixator A.P & Lateral View Arthrodiastasis of mid tarsal joints seen in AP view

Roentgenographic evidence of satisfactory correction can be best appreciated by lateral view talo calcaneal angle  Taken in maximum dorsiflexion of foot. In this position normal overlap of anterior end of calcaneum & talus can be demonstrated.  In cases of incomplete subtalar correction there will be failure of calcaneum to dorsiflex.

 Ideally dorsiflexion of calcaneum should be demonstrated on regular follow ups several months to rule out any possibility of recurrence Lateral view two years after removal dorsiflexion is must to achieve squatting

TREATING RIGID CASES WITH J.E.S.S. SEEMS A BETTER CHOICE BECAUSE HERE CONTRACTED TISSUE CAN GROW Take Home Message

REFRENCES REFRENCES Attenborough CG (1966): Severe congenital talipes equinovarus JBJS (Br): 48-B: Attenborough CG (1966): Severe congenital talipes equinovarus JBJS (Br): 48-B: Brockman EP (1930): Congenital club foot J. Wright and Sons, Bristol. Brockman EP (1930): Congenital club foot J. Wright and Sons, Bristol. Garceau GJ (1940): Anterior tibial tendon transposition in recurrent congenital club foot JBJS 22:932. Garceau GJ (1940): Anterior tibial tendon transposition in recurrent congenital club foot JBJS 22:932. Gartland JJ (1964): Posterior tibial transplant in surgical treatment of recurrent club foot, JBJS Vol. 46-A: No. 6, Gartland JJ (1964): Posterior tibial transplant in surgical treatment of recurrent club foot, JBJS Vol. 46-A: No. 6, Main BJ, Crider RJ, Polk M, Lloyd-Roberts GC, Swann M, Kamdar BA (1977): The results of early operation in talipes equinovarus JBJS (Br), 59- B: Main BJ, Crider RJ, Polk M, Lloyd-Roberts GC, Swann M, Kamdar BA (1977): The results of early operation in talipes equinovarus JBJS (Br), 59- B: Ponseti IV, Smoley EN (1963): Congenital club foot the results of treatment; JBJS Vol. 45-A: No. 2, March. Ponseti IV, Smoley EN (1963): Congenital club foot the results of treatment; JBJS Vol. 45-A: No. 2, March. Turco VJ (1971): Surgical correction of the resistant club foot- one stage postero medial release with internal fixation. A preliminary report (AM) 53-A: Turco VJ (1971): Surgical correction of the resistant club foot- one stage postero medial release with internal fixation. A preliminary report (AM) 53-A:

A proper three dimensional correction of deformity is the Goal to achieve. A proper three dimensional correction of deformity is the Goal to achieve.