Introduction

CONGENITAL ANOMALIES CTEV (CLUB FOOT)

Congenital club foot is a gross deformity of foot present at birth. Talipesequinovarus is the term most commonly used for clubfoot. Talipes is a generic term for any foot deformity that centers the talus. Equinus implies that the foot is flexed in the plantar direction. Varus means inwards turning of the foot.

The incidence of congenital clubfoot is approximately one in every 1000 live births. I deformities occur in 50% of patients. Several theories have been proposed regarding the cause of clubfoot. One is that a primary germ plasm defect in the talus causes continued plantar flegiii inversion of this bone, with subsequent soft- tissue changes in the joints and musculotendinous complexes.

Another theory is that primary soft-tissue abnormalities within the neuromuscular unit secondary bony change. Clubfoot should best be thought of as a spectrum of deformities. Clubfoot may occur as an isolated disorder or in combination with various syndromes and other anomalies, such as arthrogryposis, sacral agenesis, amniotic bands, Larsen syndrome, diastrophic dwarfism, Freeman-Sheldon syndrome, and myelodysplasia or spina bifida: with or without meningoceal / myelomeningoceal.

Clinical features

Clinically, the deformity is readily apparent at birth. The child presents with the foot in severe supination with a fixed equinus deformity, heel varus, forefoot and midfoot adduction, and varying amounts of cavus deformity. The involved foot is generally smaller than the opposite side with varying amount of calf atrophy.

The head of the talus is prominent and easily palpable on the dorsolateral aspect of the foot. Depending on the severity of the cavus deformity, there may be a deep skin crease across the planter medial aspect of the midfoot. The foot cannot be passively manipulated into the neutral position

Investigation

Though, the deformity is very much evident on examination, but still X-rays must be taken to evaluate the problem

Radiography:

Radiographs should be included as part of the evaluation of clubfoot, before, during, and after treatment. In a nonambulatory child, standard radiographs include anteroposterior and stress dorsiflexion lateral radiographs of both feet. Antero -posterior and lateral standing radiographs may be obtained for an older child.

Important angles to consider in the evaluation of clubfoot are the talocalcaneal angle on the anteroposterior radiograph, the talocalcaneal angle on the lateral radiograph, and the talus-first metatarsal angle.

The anteroposterior talocalcaneal angle in normal children ranges from 30 to 55 degrees. In clubfoot, this angle progressively decreases with increasing heel varus. On the dorsiflexion lateral radiograph, the talocalcaneal angle in a normal foot varies from 25 to 50 degrees; in clubfoot, this angle progressively decreases with the severity of the deformity to an angle of 0 degrees. The tibiocalcaneal angle in a normal foot is 10 to 40 degrees on the stress lateral radiograph. In clubfoot, this angle generally is negative, indicating equinus of the calcaneus in relation to the tibia. Finally, the talus-first metatarsal angle is a radiographic measurement of forefoot adduction. This is useful in the treatment of metatarsus adducts alone, but is equally important in the treatment of clubfoot to evaluate the position of the forefoot. In a normal foot, this angle is 5 to 15 degrees on the anteroposterior view; in clubfoot, it usually is negative, indicating adduction of the forefoot.

Treatment

The goal of treatment in clubfoot deformity is to obtain and maintain the foot in plantargrade position: Treatment should be initiated immediately on diagnosis, preferably within the first week of life. Treatment for the newborn with clubfoot is by manipulation and then casting to maintain the correction obtained through manipulation. Corrections begun at a later age may be more difficult owing to ligamentous contracture and joint deformity. Toe-to-groin plaster casts are used to maintain the corrections obtained through manipulation. The equinus deformity is the last deformity corrected to prevent development of a rocker- bottom foot. Casts are changed at weekly intervals, and most deformities are corrected in 5 to 7 casts. Successful treatment rates by casting regimens alone vary in the literature from 85 to 95%.

Treatment consists of weekly serial manipulation and casting during the first 6 weeks of life, followed by manipulation and casting every other week until the foot is clinically and radiographically corrected casting should be as follows: first, correction of forefoot adduction; next, correction of heel varus; and finally, correction of hindfoot equinus. Correction should be pursued in this order so that a rocker-bottom deformity would be prevented by dorsiflexing the foot through the hindfoot rather than the midfoot.

The Ponseti method consists of two phases: treatment and maintenance. The treatment phase should begin as early as possible, optimally within the first week of life. Gentle manipulation and casting are done weekly. Each cast holds the foot in the corrected position, allowing it to reshape gradually. Generally five to six casts are required to correct the alignment of the foot and ankle fully. At the time of the final cast, most infants (70%) require percutaneous Achilles tenotomy to gain adequate lengthening of the Achilles tendon.

The first cast application corrects the cavus deformity by aligning the forefoot with the hindfoot, supinating the forefoot to bring it in line with the heel, and elevating (dorsiflexing) the first metatarsal. It may be easier to apply the cast in two stages: first, a short leg cast to just below the knee, then extension above the knee when the plaster sets. Long leg casts are essential to maintain a strong external rotation force of the foot beneath the talus and to allow adequate stretching of the medial structures, especially the posterior tibial tendon. One week after application, the first cast is removed, and after about 1 minute of manipulation, the next toe-to-groin cast is applied. Manipulation and casting at this stage are focused on abducting the foot around the head of the talus, with care to maintain the supinated position of the forefoot and avoid any pronation. During these manipulations, the navicular can be felt reducing over the talar head by a thumb placed on the head of the talus (left thumb for a right clubfoot and right thumb for a left clubfoot). A crucial point in the Ponseti technique is that the heel is never directly manipulated. With reduction of the talar head beneath the navicular, correction of the talus, navicular, and cuboid causes the calcaneus to abduct and evert.

Manipulation and casting are continued weekly for the next 2 to 3 weeks to abduct the foot gradually around the head of the talus. The foot should never be actively pronated; however, the amount of supination is gradually decreased over these several casts until the forefoot is in neutral position relative to the longitudinal axis of the foot.

The final cast is applied with the foot in the some maximally abducted position and dorsiflexed 15 degrees. In most children, a percutaneous Achilles tenotomy is done to prevent development of a rocker-bottom deformity. The foot is casted in the final position J approximately 70 degrees of abduction and 15 degrees of dorsiflexion for 3 weeks. Five or

casts usually are necessary to correct the clubfoot deformity.

Maintenance Phase

When the final cast is removed, the infant is placed in a brace that maintains the foot inift corrected position (abducted and dorsiflexed). The brace (foot abduction orthosis/Dennis Brown Splint) consists of shoes mounted to a bar in a position of 70 degrees of external rotation and 15 degrees of dorsiflexion. The distance between the shoes is set at about 1 inch wider than width of the infant's shoulders. This brace is worn 23 hours each day for the first 3 months casting and then while sleeping for 2 to 3 years.

If the patient comes late, then surgical intervention in the form of Postero-Medial release or application of JESS frame is required.