Salter ; page 138
A congenital club foot consist of a combination of deformities, including forefoot adduction and supination through midtarsal joint, heel varus through the subtalar joint, equinus through the ankle joint and medial deviation of the whole foot in the relation to the knee.
The medial deviation of the foot results partly from an angulation in the neck of the talus and partly from internal tibial torsion. The degree severity of the deformity, which may be mild, moderate, or severe is better assessed by its feel of flexibility or conversely or rigidity or resistance to correction than by its appearance.
Incidence :
Congenital clubfoot is common (incidence of 2 in 1000 live births), is bilateral in half of the afflicted children, and affects boys twicw as often as girls. A genetic factor would seem to be responsible in about 10% of the children, but iini the remainder the abnormality appears to be caused by an initial mutation in the family tree. However, if one parent and one child have clubfeet, the chances of a subsequent child being so afflicted is one in four.
Etiology and Pathology :
The cause of congenital clubfoot remains one of many unsolved puzzles of the musculoskeletal system, although the ultrastructural and histochemical studies of handelsman suggest a neuromuscular cause.
The deformity is known to exist from the early stages of embryonic development when the foot first begins to form. the muscles on the posterior and medial aspect of the leg (particularly the calf muscle and the tibialis posterior) are unduly short and in addition the fibrous capsules of all the deformed joints are thick and contracted on the concave side of the deformity.
The soft tissue contractures become progressively resistant to correction as the weeks go by -both before and after birth- and lead to secondary changes, not only in the shape of the actively growing bones but also in the involved joints.
An appreciation of this observation should serve to emphasize the tremendous importance of early treatment. The pathological anatomy of clubfoot (as well as its surgical correction is well described by Caroll.
Diagnosis :
Although the typical clubfoot of moderate severity is easily diagnosed. the mild clubfoot must be distinguished from positional equinovarus, which results simply from intra uterine position and can therefore be readily corrected to a normal position.
The severe true clubfoot must be differentiated from the less common, but more troublesome, teratologic type of severe clubfoot deformity associated with either spina bifida and arthrogryposis (amyoplasia congenita).
Treatment :
One of your responsibilities is to reassure the anxious parents at the outset that with early and expert treatment, their child will not be "crippled" rather that he or she will be able to enjoy a normal life, including sports, both as a child and as an adult. The general principles of treatment, which should be applied early - at least within the first few days of life - include gentle passive correction of the deformities, maintenance of correction for a long period, and supervision of the of the child until the end of growth. even after full correction of a clubfoot, the apparent failure of the contracted soft tissues to grow adequately in length tends to produce some degree of limited motion in about half of the children;furthermore, possible reccurence of deformity should be watched for and treated, particularly during periods of rapid skletal growth. Consequently, these children should be seen at regularly intervals until they have reached skletal maturity.
The spesific methods of treatment of clubfoot vary considerably, but the following general plan of treatment, which has proved extremely satisfactory, is suggested for average clubfoot seen within the first month of life. Nevertheless, it must be remembered that the treatment of an individual clubfoot must be tailored to fit the needs of that particular foot.
1. Plaster casts are applied weekly (following gentle and progressive correction of deformities in the aforementioned order). This phase of treatment requires about 6 weeks.
2. Cast treatment may then be continued or the feet may be strapped to a denis browne type of clubfoot splint by adhesive tape. The affected foot is progressively turned outward and into valgus. The adhesive is changed weekly for about 8 weeks and, during this phase of treatment, correction of the deformity is maintained while some movement is allowed in the involved joints.
3. Either a Denis Browne type of boot splint or an articulated ankled foot orthosis (AFO) is to be worn day and night (and removed only for bathing) during the ensuing 3 months, following which it is left off for longer and longer periods until the child is walking. It is most important that the splint be used at night for at least another year or longer to decrease the chances of reccurence.
4. Straight last or outflare boots are used for day wear until the child is 3 years of age; occasionally an outside sole wedge is added. Approximately 40% of congenital clubfeet treated early by these nonoperative methods will have responded satisfactorily within the first 3 to 4 months of treatment. Assessments of the completeness of correction of all components of the clubfot deformity requires specific radiographic examinations.
The remaining 60% of congenital clubfeet are resistant to these methods and consequently, under these circumstances, continuation of nonoperative treatment leads to eventual failure, either because of persistent incomplete correction or reccurence of the deformity. Immobilization of an incompletely corrected in a forced position in a cast can even cause iatrogenic lesion of pressure necrosis of joint cartilage as described in chapter 3.
In such resistant clubfeet, it is judgment to perform a meticulous soft tissue correction of all tendon and joint contractures at 4 to 6 months for resistances rather than to delay surgical treatment and to be forced to perform a major operation at a later date for reccurence, at which time are less satisfactory.
Following this type of early surgery, the aforementioned non operative plan is resumed to maintain the correction. Even with excellent correction of the foot deformity, the child's calf will always be smaller than normal but not significantly weaker. Neglected clubfeet and recurrent clubfeet always require operative treatment, the extent of which depends on the severity of the various components of the residual deformity.
In general, soft tissue operations (such as capsulotomies, tendon lengthening, and tendon transfer) are effective in the first 5 years of life but become less effective in older children because of the increasingly abnormal shape of the bones. Thus, in older child, bony operations (such as arthrodesis of the subtalar and midtarsal joints) are usually necessary to correct any residual deformity but are best deffered unil the age of about 10 years.
The relatively recent emphasis on eraly surgical correction for resistant clubfeet at 3 to 4 months of age has greatly decreased the number of reccurences and has been important factor in improving the overall results of treatment for this serious congenital abnormality.
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