Congenital clubfoot is an abnormal unilateral or bilateral foot shape found after birth showing inversion, pronation, and horseshoe deformity.
Causes
1.The theory of abnormal development of the primitive bone matrix: Defective primitive germ in the talus causes persistent plantarflexion 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.inversion of the foot.
2.Plantar flexion of the ankle.
3.Forefoot inversion.
4.Internal rotation of the tibia.
5.Passive correction of the affected foot cannot 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 most children do not need to undergo these tests.
(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 with dorsal extension.
2. congenital vertical talus: this kind of children have foot deformity caused by abnormal talo-boat relationship, and 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 dislocated talus head, and the range of motion of ankle joint is reduced, and the talo-boat joint is dislocated in extreme plantar flexion on X-ray.
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 discomforts, 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 spondylolisthesis, spinal cord embolism, hereditary neurological demyelination disease, cerebral palsy sequelae, etc., such children are treated for foot deformity is more rigid and easy to recur, treatment should also be carried out early, but postoperative brace is required to maintain.
Treatment of diseases
(A) Early treatment non-surgical treatment options
1.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 wrenching, plaster fixation (Ponseti plaster fixation): applicable to children within 1 year old, the components of deformity will be corrected one by one according to certain procedures, and then fixed with plaster tube type (usually 4-6 times of 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.Wear Dennis-Brown orthopedic shoes after surgery for further treatment, usually until 4 years old.
2. French massage technique.
Newborns should be treated immediately by manipulation, operating at 90 degrees bending the knee, holding the heel with one hand and pushing the front half of the foot outward with the other hand to correct forefoot adduction, followed by holding the heel for valgus, and finally the palm of the Yee hand 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, the corresponding symptomatic surgical treatment will be performed according to their different conditions.
1.Extensive soft tissue release: The general principles of any one-stage extensive release for the treatment of equine clubfoot include.
① loosening the tourniquet at the completion of surgery and electrocoagulation to stop bleeding.
(ii) placing the foot in plantar flexion if necessary, and carefully suturing 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 descends need to perform Achilles tendon lengthening, the Achilles tendon line z-incision. Postoperative cast fixation for 6 weeks.
3, tibialis anterior muscle external transfer: for children with early mild recurrence of clubfoot, 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 tissues 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 three deformities: metatarsal adduction, hindfoot inversion and plantar flexion; this surgery can be considered.
Evaluation and treatment guidelines
Guidelines for assessing the severity of congenital clubfoot
Degree of deformity Dimeglio score reversibility age very severe 15-20<10% hard-hard resistant >5 years severe 10-14>50% hard-soft resistant partially reversible 3-5 years moderate 5-9>50% soft-hard reversible partially resistant 1-3 years mild 1-4>90% soft-soft no resistance
Pre-walking (<1 year)
Dimeglio horseshoe foot severity score
Measured parameters Reproducibility score Plantarflexion in the sagittal plane (Figure A) 90 to 45°4 Exostosis in the coronal plane (Figure B) 45 to 20°3 De-rotation of the heel-plantar block in the horizontal plane (Figure C) 20 to 0°2 Inversion of the forefoot relative to the midfoot in the horizontal plane (Figure D) 0 to -20°1 <-20°< td="">0 Other factors to be considered Significant folds posteriorly 1 Significant folds in the middle of the foot appendage 1 Contracture of the metatarsal muscles or bowed foot 1 Poor generalized muscle condition 1 Total possible score 20 points
Admission criteria
1. At the time of outpatient Ponseti treatment: radiographs and routine physical examination were suggestive of: clubfoot deformity, after 4-6 sessions of plaster fixation treatment in outpatient clinic. The child’s foot deformity has been partially corrected with more than 75 degrees of abduction.
2, when the deformity recurrence: regardless of when, as soon as it is found, immediately admitted to hospital.
3.Children over the age of 1 year need to be admitted to hospital for external plaster fixation treatment.
Complications of surgery and treatment
Common complications of congenital clubfoot include
1, skin pressure sores: children will have skin pressure sores more or less after plaster fixation treatment, once the plaster pressure is lifted the pressure sores can be cured by changing medication, disinfection and other measures after 1 week. No special treatment is needed. There is no need to apply antibiotic treatment.
2, early treatment of the horseshoe foot there is a cast fixed orthopedic effect is not satisfactory, usually and the doctor’s orthopedic techniques and the degree of release of the Achilles tendon, the Achilles tendon is not enough release will appear rocking chair foot and other deformities, abduction is not enough will appear forefoot adduction deformity, usually after the cast fixed abduction more than 75 degrees, the natural state of the foot abduction before you can be admitted to the hospital for surgery.
3, surgery for orthopedic surgery, often recurrence of horseshoe foot, etc., after surgery need to strictly wear brace until 4 years old, so that the recurrence rate is reduced to a minimum. Once there is a recurrence of deformity such as forefoot inversion timely outpatient consultation to guide further treatment.
4, skin necrosis: the use of external fixation stent, soft tissue release surgery and other surgical methods can cause skin necrosis, need to be timely detection and timely treatment, local topical medication, suspension of extension.
Follow up guidance
1. regular follow-up, outpatient review after 3 weeks of orthopedic shoe replacement, guidance on treatment. wear orthopedic shoes and crossbars throughout the day for 23 hours in 3 months.
Clubfoot (3 pictures)
After 3 months, crossbars were worn for 12 hours/day. Followed up until 4 years of age. The foot deformity recovered well and there was no recurrence after 4 years of age. There was no impairment in walking with both feet.
2.Children who underwent non-Achilles tendon release surgery need to be followed up regularly, and the treatment will be adjusted according to the different surgical conditions.
3.The following emergencies need to return to the hospital or to the local hospital in time.
Loosening of the cast; retention of purulent fluid in the cast; poor blood flow to the toes; poor wearing of orthopedic shoes
4. Gait analysis will be performed after all treatments are completed to assess the recovery of the child’s lower extremity.