Treatment

summary

	MILD	MODERATE	SEVERE
Day 1	strap	SLPOP	SLPOP
Day 3	“	SLPOP	SLPOP
Day 5	“	SLPOP	SLPOP
Day 7	“	LLPOP	LLPOP ?GA
Day 9		LLPOP leave in if succeed	LLPOP remove if failed
Day 11	“	LLPOP
2 wks		LLPOP
3 wks	“	LLPOP
6 wks	“	strap
3 mths	stretching	AFO + DB bar fulltime to walking age resting to age 18 mths	surgery LLPOP 6 wks then DB

nonoperative

· in the form of manipulation and casting

· then maintenance with strapping and splinting

Timing

· casting begins as soon as diagnosis made

· ‘as feet exit birth canal”

Technique

First cast

· forefoot adduction and heel varus corrected first

· one hand grasps knee

· other hand grasps toes

· forefoot manipulated laterally to correct adduction

· equinus not corrected at this stage

· firm short leg cast applied over holder’s fingers

· end rolled into knob for ease of removal

· moulding applied as plaster sets

Subsequent short casts

· repeated second-daily until forefoot adduction corrected to neutral

· usually by fourth cast (1 week)

First long cast

· to correct heel equinus

· short cast applied with gentle correction of equinus

· moulded by pushing calcaneus upwards and pulling heel downwards

· avoid pushing on metatarsals

· may break foot through midtarsal joint

· results in rockerbottom foot

· cast extended to long-leg cast with some knee flexion

Subsequent long casts

· changed at 3 days then weekly depending on progress

· repeated until both forefoot adduction and hindfoot equinus corrected beyond neutral

· usually by 4th cast (to 3 weeks)

· last cast with full correction left on for 3 weeks (to 6 weeks)

Strapping

· manipulation and strapping commenced by physiotherapists

· continued for 6 weeks (to 3 months)

Splinting

· bivalved AFOs connected with Dennis-Browne type bar worn fulltime

· continued to walking age when splints removed to learn walking

· then AFOs and bar worn to age 18 months when resting only

Followup

· serial review to age 8

Results

· 50% will be corrected at the end of casting at 6 weeks

· 90% of mild form

· 50% of moderate form

· 10% of severe form

· if not corrected, surgery indicated

· no further nonoperative treatment until surgery

surgery

Indications

· failure of early casting

· failure of subsequent strapping or splinting

Timing

· varies enormously - 6 wks to 2 yrs

· average is 3 mths to 9 mths

· if early

· less time for bones to model into abnormal shape

· if late

· technically easier because anatomy more recognisable

· less time required in splints

Incision

Turco

· posteromedial approach

· curved incision

· from base of first metatarsal

· above posterior tuberosity of calcaneus

· to Achilles tendon

· disadvantages

· crosses skin creases on medial side of ankle

· difficult to expose plantar fascia

· difficult to expose posterolateral corner

Cincinnati

· posterior U-shaped incision around heel

· begins medially at base of 1st metatarsal

· curves around heel at level of posterior skin crease

· ends laterally at lateral part of talonavicular joint

· disadvantages

· risk of loss of heel flap

· difficult to expose plantar fascia

· difficult to proximally expose tendo Achilles

Norris Carrol

· two incisions

· curvilinear medial incision from centre of os calcis over talonavicular joint

· posterolateral incision halfway between lateral malleolus and tendo Achilles

· disadvantages

· two incisions required

Procedures

· neurovascular bundle identified and protected

Posterior release

· Z-lengthening of tendo Achilles

· capsulotomy of posterior ankle joint

· release posterior talofibular ligament as well

· capsulotomy of posterior subtalar joint

· division of calcaneofibular ligament

· may be sufficient to correct foot

· lengthening of FHL via intermuscular recession

· done at conclusion if hallux flexes when ankle dorsiflexed

· Z-lengthening of FDL

· done at conclusion if lesser toes flex when ankle dorsiflexed

Medial release

· required if persistent varus

· Z-lengthening of tibialis posterior

· complete release of talonavicular joint

· beware of damaging cartilagenous neck of talus

Plantar release

· for severe club-foot

· abductor hallucis reflected down

· release of

· master knot

· plantar fascia and FDB from calcaneus

· capsulotomy of medial subtalar joint

Lateral release

· for severe club-foot

· separate lateral incision

· release of calcaneo-cuboid joint

Pin fixation

· across talonavicular joint

· from posterior to dorsomedial

· under vision through joint

· across calcaneocuboid joint

· from posterior to dorsolateral

· across subtalar joint

· from heel upwards and forwards into talus

Postoperative

· short leg cast applied

· in equinus with Cincinatti approach to protect skin

· changed at 2 weeks and sutures and wires removed

· equinus corrected if required

· final cast removed at 6 weeks

· splintage as above

Results

· 80% good or excellent results

failure

· may be

· residual deformity postoperatively

· recurrence

· recurrence may occur up to age 7

· most common about age 2.5

· may be in form of

· forefoot adductus

· hindfoot varus

· curved lateral border of foot

· cavus

· repeat posteromedial release may be required

Forefoot adductus

Dynamic

· may see forefoot adductus and supination that is

· correctable passively

· most evident in swing phase

· can be corrected by SPLATT

· split tibialis anterior transfer

· lateral half transferred to lateral cuneiform

Fixed

· if not correctable, passively, need bony procedure

· best is cuboid decancellation

· calcaneocuboid joint released and reduced

· decancellation of of cuboid performed to shorten lateral column of foot

Hindfoot varus

Pure varus

· corrected by osteotomy

· best is lateral displacement sliding osteotomy of os calcis

· can also perform lateral closing wedge of os calcis

Salvage procedure

· triple arthrodesis for severely deformed foot