Congenital clubfoot
Congenital clubfoot is an abnormal unilateral or bilateral foot shape found after birth, showing inversion, inversion and horseshoe deformity.
Causes
1.The theory of abnormal development of the primitive bone matrix: Defective primitive germ in the talus causes persistent plantar flexion and inversion of the talus, and secondary soft tissue changes in several joints and muscle-tendon complexes.
2.Neuromuscular theory: primary abnormalities of soft tissues within the neuromuscular unit cause secondary bony changes and significant atrophy of the calf muscles, which do not improve significantly after treatment.
Diagnostic points
(A) Clinical manifestations
The foot of the child may have
1.Foot entropion;
2.Ankle plantar flexion;
3.Forefoot inversion;
4.Tibial internal rotation;
5.Passive correction of the affected foot can not be dorsal extension.
(B) Auxiliary examination
This disease can be diagnosed according to the clinical manifestations, and generally does not require auxiliary confirmation of the diagnosis.
1.X-ray examination: for the diagnosis of the degree of clubfoot deformity and objective evaluation of the treatment efficacy. The anteroposterior and extreme dorsal extension lateral films of the foot are compared bilaterally, and the orthopantomographs of children with clubfoot show that the heel talus overlaps and both face the fifth metatarsal, and the heel talus angle disappears.
2.B ultrasound examination: It is a routine examination that can be used to diagnose horseshoe foot in infants and children, and it has a role that cannot be replaced by X-ray for the observation of cartilage.
MRI and CT scan are also recommended for the preoperative and postoperative evaluation of congenital clubfoot deformity, but these tests are not necessary for most children.
(C) Differential diagnosis
1, congenital metatarsal inversion: similar in appearance to congenital clubfoot, easily misdiagnosed, with anterior foot inversion and postural foot inversion, but no horseshoe deformity, which can be found on radiographs with normal heel-distance angles, and the ankle joint can be dorsally extended to a normal degree (more than 30 degrees) in children in dorsal extension.
2. congenital vertical talus: this kind of children have foot deformity caused by abnormal talo-boat relationship, its appearance is obviously different from congenital horseshoe foot, but still pay enough attention to the child’s foot bottom can be touched an obvious raised bone, which is the dislocated talus head, the ankle joint range of motion is reduced, the radiograph in extreme plantar flexion talo-boat joint is dislocated.
3. Flatfoot deformity: The child may have flat feet, which are not obvious in infancy and early childhood. However, older children may have foot pain and other discomfort, and radiographs suggest that the heel distance angle is normal and the arch disappears. No special treatment is needed.
4.Polyarticular contracture: Congenital polyarticular contracture refers to the congenital contracture of 2 or more joints at birth, and the foot may show a bilateral horseshoe inversion deformity. Most children are treated satisfactorily with early manipulation in infancy and early childhood. Treatment during the first 4 months of life is crucial. Manipulation can improve joint mobility, maintain and enhance muscle growth, and reduce surgery.
5, neurogenic: various neurological causes of clubfoot deformity, including: spinal cord spinal membrane expansion, spinal cord embolism, hereditary neurological demyelination disease, cerebral palsy sequelae, etc., such children treatment of foot deformity is more rigid and easy to recur, treatment should also be carried out early, but the postoperative need to wear a brace to maintain.
Treatment of diseases
(A) Early treatment non-surgical treatment options
Ponseti orthopedic method: It has been recognized worldwide, and its specific treatment methods are as follows (applied to children younger than 2 years old).
1.Manipulation and plaster fixation (Ponseti plaster fixation): applicable to children within 1 year old, the deformed components are corrected one by one according to certain procedures, and then fixed with plaster tube type (usually 4-6 times for outpatient fixation).
2.Plaster fixation can be performed when the foot abduction is 75 degrees or more. The cast is fixed for 3 weeks after surgery, and the cast is removed after 3 weeks, while the orthopedic shoes are replaced.
3.Wearing Dennis-Brown orthopedic shoes after surgery for further treatment, usually until 4 years old.
French massage technique.
Newborns should be treated immediately by manipulation, operated by bending the knee 90 degrees, holding the heel with one hand and pushing the front half of the foot to abduction with the other hand to correct forefoot inversion, followed by holding the heel for valgus, and finally Yi palm dragging the sole of the foot for dorsal extension to correct the horseshoe, with multiple manipulations daily until the deformity is corrected.
(B) Surgical treatment
However, for children who miss the timing of non-surgical orthopedic treatment or children who wear orthopedic brace after orthopedic treatment due to the failure to follow medical prescriptions causing the recurrence of deformity, the corresponding symptomatic surgical treatment will be performed according to their different conditions.
1.Extensive soft tissue release: The general principles of any phase of extensive release for clubfoot treatment include.
① Loosen the tourniquet at the completion of surgery and electrocoagulate to stop the bleeding;
②If necessary, put the foot in plantar flexion and carefully suture the subcutaneous tissue and skin to avoid excessive skin tension;
③When replacing the cast for the first time 2 weeks after surgery, the foot can be placed in a fully corrected position.
2, Achilles tendon lengthening: for children who miss the age of Achilles tendon release surgery (generally 2-3 years old) need to release the Achilles tendon, so that the Achilles bone drop needs to carry out Achilles tendon lengthening surgery, the Achilles tendon line z incision. Postoperative cast fixation for 6 weeks.
3, the tibialis anterior muscle external transfer: for children with early mild recurrence of horseshoe foot, or residual forefoot inversion deformity after treatment.
4.External fixation brace: For children with stiff clubfoot of older age (generally above 5 years old), the foot bones have ossified and the deformity cannot be corrected by soft tissue alone, external fixation brace technique can be used, and the brace needs to be adjusted regularly after surgery, and the appearance is basically satisfactory, but there will be residual foot and ankle stiffness.
5.Foot osteotomy orthopedic surgery: there are many surgical methods, generally the child is older than 5 years old, according to its deformity, choose different parts of the osteotomy, can be combined with external fixation bracket to correct horseshoe inversion deformity.
6.Triple joint fusion: indications: children over 10 years old; combined with metatarsal inversion, hindfoot inversion, plantar flexion three kinds of deformities; can be considered for this operation.
7.For difficult cases, Ilizarov technique can produce miraculous results.