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Treatment with Mini External Fixator for Correction of Clubfoot

Volume 2 | Issue 1 | Jan-Apr 2016 | Page 6-9|Sandeep Patwardhan1, Chintan Doshi1 Authors :Sandeep Patwardhan[1], Chintan Doshi[1] Sancheti Institute for Orthopaedics and Rehabilitation, Shivaji nagar, Pune, India Address of Correspondence Dr Sandeep Patwardhan Sancheti Institute for Orthopaedics and Rehabilitation, Shivaji nagar, Pune, India Email: sandappa@gmail.com Abstract Background: Clubfoot is one of the oldest […]

Neglected clubfoot: Patho-anatomy and clinical features

Volume 2 | Issue 1 | Jan-Apr 2016 | Page 2-5|Mandar Agashe Authors : Mandar Agashe [1*] Director, Centre for Paediatric Orthopaedic Care (CPOC) at Dr. Agashe’s Hospital, Kurla, Maharashtra, India Address of Correspondence Dr Mandar Agashe Centre for Paediatric Orthopaedic Care (CPOC) at Dr. Agashe’s Hospital, Kurla, Mumbai, India. Email: mandarortho@gmail.com Abstract Neglected clubfoot […]

Treatment with Mini External Fixator for Correction of Clubfoot

Neglected clubfoot: Patho-anatomy and clinical features

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Treatment with Mini External Fixator for Correction of Clubfoot

Volume 2 | Issue 1 | Jan-Apr 2016 | Page 6-9|Sandeep Patwardhan1, Chintan Doshi1

Authors :Sandeep Patwardhan[1], Chintan Doshi[1]

Sancheti Institute for Orthopaedics and Rehabilitation, Shivaji nagar, Pune, India

Address of Correspondence
Dr Sandeep Patwardhan
Sancheti Institute for Orthopaedics and Rehabilitation, Shivaji nagar, Pune, India
Email: sandappa@gmail.com

Abstract

Background: Clubfoot is one of the oldest and commonest congenital deformities of mankind since man has adopted erect posture [1]. The ideal treatment of clubfoot still remains controversial, because its cause remains unknown, its pathological anatomy is uncertain and its behavior is unpredictable [2]. Few authors concluded that there are different etiological factors responsible for resistance to correction or recurrence after correction. The goal of any type of CTEV management is to reduce, if not to eliminate all elements of the clubfoot deformity, hence achieving a functional, pain free, normal looking plantigrade, mobile, callous free and normally shoeable foot [3]. Treatment of the idiopathic clubfoot by Ponseti method is accepted as a standard treatment when patient presents early [4]. Methods available to correct a clubfoot deformity follow a sequence of treatment which includes manipulation of soft tissues, repositioning of foot, holding the position in POP or by tape. This sequence leads to dynamic functional correction. However it is not always possible to use manipulation by Ponseti for neglected, late presenters and syndromic cases. These deformities can be corrected with the use of external device in the form of universal mini external fixator (UMEX) or a JESS fixator
Keywords: Congenital talipes equino varus, mini fixator, distraction histogenesis

Introduction
Clubfoot is one of the oldest and commonest congenital deformities of mankind since man has adopted erect posture [1]. The ideal treatment of clubfoot still remains controversial, because its cause remains unknown, its pathological anatomy is uncertain and its behavior is unpredictable [2]. Few authors concluded that there are different etiological factors responsible for resistance to correction or recurrence after correction. The goal of any type of CTEV management is to reduce, if not to eliminate all elements of the clubfoot deformity, hence achieving a functional, pain free, normal looking plantigrade, mobile, callous free and normally shoeable foot [3]. Treatment of the idiopathic clubfoot by Ponseti method is accepted as a standard treatment when patient presents early [4]. Methods available to correct a clubfoot deformity follow a sequence of treatment which includes manipulation of soft tissues, repositioning of foot, holding the position in POP or by tape. This sequence leads to dynamic functional correction. However it is not always possible to use manipulation by Ponseti for neglected, late presenters and syndromic cases. These deformities can be corrected with the use of external device in the form of universal mini external fixator (UMEX) or a JESS fixator.

What is a Mini Fixator?
Dr. B. B. JOSHI in 1990 developed a plain unconstrained simple, versatile, cheaper and light fixator system on the basis of biologic law of tissue histiogenesis of all tissues when they are put under gradual stretch. This system is termed as JESS, Joshi’s External Stabilization System. Universal mini external fixator (UMEX) was designed on similar principle. This fixator had a different design of the clamp to enhance stability and fixation. The concept of controlled differential distraction prevents crushing of tissues on the convex lateral side and limb lengthening along with correction of deformity takes place gradually and effectively to achieve supple foot [5].

Where can Mini external fixator be used in CTEV?
Mini external fixator is used for instrumented manipulation in practically almost all cases with CTEV [5]. However with the other non invasive methods like Ponseti method with similar results, mini fixator is now mostly used in late presenters, non idiopathic rigid feet (syndromes) and in cases with post surgical relapses.
Mini external fixator is useful method as the stretching is done four times in a day, repositioning is required once a week, position is hold with use of fixator and application of brace after correction is achieved to maintain correction.

What are the advantages of using mini external fixator?
It is a semi invasive procedure.
Gradual differential distraction allowing simultaneous correction of all the deformities.
Allows for three dimensional control and correction of deformity.
Because of distraction the corrected foot achieved is longer in length.
Excessive cartilage compression and chondrolysis of lateral growing bony structures caused by forceful manipulations is avoided.
It is possible to correct rigid, severe, relapsed clubfoot without shortening of foot.
It has direct purchase over distorted bony anatomy and hence better correction of bony alignment and remodeling.
It adds to tissues by distraction histogenesis as opposed to open surgery which leads to fibrosis and shortening.
Allows for scope of revision and rethinking.

What are the principles of use of universal mini external fixator in CTEV?
The basic principle of universal mini external fixator is the same as advocated by Ilizarov [6]. Physiological tension and stress applied to the tissue stimulates histogenesis of tissues, while controlled differential distraction gradually corrects the deformities and realigns the bones. Correction using mini external fixator is based on understanding that clubfoot deformity has 3 components, the leg, the hindfoot and the forefoot.
Thus it is essential to achieve skeletal hold in each component thus mini fixator system in CTEV correction involves use of 3 blocks the forefoot block, the hindfoot block and the leg block.
Distraction corrects only 1 axis. Differential distraction can correct 2 axis deformity. However to correct a 3 dimentional deformity in CTEV it is necessary to uncouple the distracters from the frame leaving the three blocks intact and manipulate the foot weekly to achieve manual derotation.
Following this the blocks are reconnected using the distracters and distraction protocol is continued over a week. This process is continued till over correction.

Technique of universal mini external fixator application –
The procedure is carried out under general anesthesia with the patient in supine position. The procedure consists of important steps of insertion of pins and formation of blocks and attachment of distracters between the blocks.
Insertion of Pins –
Technique of forefoot pins (Fig 1)–
One transfixing K-wire was passed through the necks of first and fifth metatarsal from lateral to medial side in such a way that the K-wire engaged the two metatarsals. Two additional wires were passed parallel to and 10 to 12 mm apart from either side, one engaging the first and second metatarsals and another engaging the fifth, fourth and third metatarsal. Take precaution that third metatarsal is not transfixed from both sides.

Fig 1. Insertion of forefoot pins. One pin transfixing the 1st and 5th metatarsal heads. Another pin engages 1st and 2nd metatarsals. Third pin engages 5th to 3rd Metatarsals.

Technique of hind foot pins (Fig 2)–
Two parallel K-wires were passed through the tuber of calcaneum from medial to lateral side taking care that they were well away from the course of the neurovascular structures on the medial side. Pins should exactly mimic the deformity. One additional half pin K-wire was passed from the posterior aspect of the calcaneum along the long axis. The entry point was below the insertion of the tendo-achilles in the midline using distractor as the guide.

Fig 2 – Hind foot pin and block. 2 Pins passed from medial to lateral aspect in calcaneum in a direction that mimic the deformity. One axial calcaneal pin from posterior aspect. These pins are connected to form foot block.

Technique of leg pins (Fig 3)–
With the patient in supine position and extended limb, two parallel K-wires were passed in the proximal tibial diaphyses from the lateral to the medial side. The wires were about 3 to 4 cm apart and run parallel to the axis of the knee joint at safe distance distal to tibial tuberosity. The K wires are passed using Z rod as a guide. In older children 3 wires were passed to increase the stability. Additional pin in saggital plane prevents rocking and loosening.

Attaching Connecting rods to complete fixation blocks
Two ‘Z’ rods were attached to the tibial pins, one on either side. The wires were prestressed before the link joints were tightened. Two transverse bars were attached to the ‘Z’ rods, one anteriorly and one posteriorly. Calcaneo-metatarsal distractors were then attached to the K-wires. Two ‘L’ rods were attached to calcaneal K-wires and two other ‘L’ rods were attached to the metatarsal K-wires one on either side with the arms of the ‘L’ rods facing posteriorly and inferiorly. One posterior transverse bar was attached to the posterior calcaneal half pin and the posterior arms of the ‘L’ rods. Two additional transverse rods were attached to the inferior arms of the ‘L’ rods which took the toe sling which provided dynamic traction to prevent flexion contracture of the toes as the deformity was being corrected.

Attach paired distracters (Fig 4) –
Paired distracters were attached between the forefoot block and the hindfoot block. Also another pair of distracter was attached between the hindfoot block and leg block.

Fig 4 – Placement of paired distracters. 2 distractors connecting leg block to hind foot block and 2 distractors connecting hindfoot block to forefoot block

Attach anterior spacer rods –
The transverse anterior rod of the tibial block and metatarsal block was connected on either side with anterior static spacer connecting rod. This provided tension force and kept the anterior portion of the joint open. It also prevented crushing of the articular cartilage and provided better glidage to the talus while correcting the hindfoot deformity of equinus.

Protocol of distraction and correction of deformity –
Distraction phase –
Medial distraction is carried out at a rate of 1/4th turn (0.25mm) four times a day (cumulative of one turn in a day which is 1mm) and lateral distraction is carried out at a rate of 1/4th turn(0.25mm) twice a day (cumulative of half a turn in a day which is 0.5mm)
Manual Repositioning –
Distraction is continued for 1 week following which patient is called for manual repositioning. Manual repositioning is carried out on OPD basis weekly occasionally with sedation if required.
During manual repositioning the distracters are uncoupled from the frame leaving the three blocks intact and the foot manipulated to achieve derotation. Following this the blocks are reconnected using the distracters and distraction protocol is continued over a week. This process is continued till over correction.
Holding phase –
It is important at the end of correction and achieved functional position to stop distraction and hold the corrected position. Holding mode is to continue frame for 6 to 8 weeks after completion of distraction phase

Bracing period –
Following the removal of mini external fixator system at the end of holding phase, the child is put in a brace. Bracing is continued to maintain the corrected position.

The illustration video demonstrates the process of differential distraction and correction of deformity
Fig 5 – Flowchart explaining the method of correction

Problems and Complications [7,8, 16] –
The method of differential distraction using universal mini external fixator also encounters certain problems and difficulties during the procedure. The conditions which need attention during the method are described here.
Flexion or clawing of the toe is seen during the distraction phase due to shortened and stretching of the flexor tendons. This can be managed during the distraction phase by use of straps or footplate. However after removal of the distracters the clawing is markedly reduced.
Acute over distraction needs urgent attention as it causes necrosis. Thus it is mandatory to observe the child at regular intervals.
Another important issue with use of mini external fixator is possibility of pin tract infection. Pin tract infection is managed by observing the foot at regular intervals with periodic pin tract dressings with betadine, tightening of loose screw, use of short course oral antibiotics and in rare cases revision of pin if needed.
Loosening of components is frequently seen when patient is coming on regular follow up. This can be managed by periodic retightening when they come for repositioning.
Compliance is a problem for any type of management in CTEV. The non compliance in relation to distraction protocol, bracing after complete correction will lead to recurrence of the deformity.

Discussion
The goal of any club foot surgery is to obtain a cosmetically acceptable foot, pliable, functional, painless, plant grade foot and to spare the parent and the child from frequent hospitalization and years of treatment with casts and braces [1, 9, and 10]. Physiological tension and stress applied to the tissues stimulates histoneogenesis, while controlled differential distraction gradually corrects the deformities and realigns the bones [11, 15]. External fixators are a versatile method of correcting complex three-dimensional deformities of the foot such as clubfoot. The major difference between the mini fixator or JESS fixators and circular fixators described by Ilizarov was that the wires in this study were not tensioned but only prestressed to prevent them from cutting through the soft bones. Mini external fixators are also lighter in weight, shorter, cheaper, and have an easier application than Ilizarov’s fixators. The absence of hinges also fails to correct rotational deformities [5]. Thus it is required to remove the distractors at regular intervals of distraction and manually reposition the foot and reattach the distractors. This continues till complete correction is achieved.
Correction by distraction has distinct advantage of histoneogenesis, lack of scar tissue formation and the absence of further shortening of the foot. There are many reports of the fixator assisted distractor correction of clubfoot with variations in the technique with good outcome (5 – 8). Suresh et al found JESS to be ideal for correction of residual and relapse clubfoot in their study involving 26 children with 44 clubfeet (7). Similar results were found by Oganesian and Istomina (14). Short-term assessment of results of clubfeet correction with JESS distractor by Anwar and Arun showed excellent and good results in 59.7% of cases (8).
Thus the evidence from various studies show that correction by mini external fixator is a useful method for the management of clubfoot in neglected and resistant cases.

References

1. Ajai Singh , Evaluation of Neglected Idiopathic Ctev Managed by Ligamentotaxis Using Jess: A Long-Term Followup SAGE-Hindawi Access to Research Advances in Orthopedics 2011 :218489 ,6.
2. J. J. Gartland, “Posterior Tibial Transplant in the Surgical Treatment of Recurrent Club Foot,” The Journal of Bone & Joint Surgery, Vol. 46, No. 6, 1964, pp. 1217-1225.
3. K. Ikeda, “Conservative treatment of idiopathic clubfoot,” Journal of Pediatric Orthopaedics, vol. 12, no. 2, pp. 217–223, 1992.
4. I. V. Ponseti and E.N. Smoley, “Congenital clubfoot-the results of treatment,” The Journal of Bone and Joint Surgery, vol. 45, no. 2, pp. 134–141, 1963.
5. Joshi BB, Laud NS, Warrier S, Kanaji BG, Joshi AP, Dabake H. Treatment of CTEV by Joshi’s External Stabilization System (JESS). In: Kulkarni GS, editor. Textbook of Orthopaedics and Trauma. 1st ed. New Delhi: Jaypee Brothers Medical Publishers; 1999.
6. Bradish CF, Noor S. The Ilizarov method in the management of relapsed club feet. J Bone Joint Surg Br. 2000; 82:387-91.
7. Suresh S, Ahmed A, Sharma VK. Role of Joshi’s external stabilisation system fixator in the management of idiopathic clubfoot. J Orthop Surg (Hong Kong) 2003; 11:194-201.
8. Anwar MH, Arun B. Short term results of Correction of CTEV with JESS Distractor. J.Orthopaedics 2004;1:e3
9. Jason A. Freedman, Hugh Watts, and Norman Y. Otsuka , The Ilizarov Method for the Treatment of Resistant Clubfoot: Is It an Effective Solution J Pediatric Orthop 2006; 26:432-437 .
10. Grant AD, Atar D, Lehman WB. The Ilizrov technique in correction of complex foot deformities. Clin Orthop 1992; 280:94-103.
11. Galante VN, Molfetta L, Simone C. The treatment of club foot with external fixation: a review of results – Current Orthopaedics 1995; 9.
12. Wallander H, Hansson G, Tjernström B. Correction of persistent clubfoot deformities with the Ilizarov external fixator. Experience in 10 previously operated feet followed for 2-5 years. Acta Orthop Scand 1996; 67:283-7.
13. Ferreira RC, Costa MT, Frizzo GG, Santin RA. Correction of severe recurrent clubfoot using a simplified setting of the Ilizarov device. Foot Ankle Int 2007;28:557-68.
14. Oganesian OV, lstomina IS. Talipes equinocavovarus deformities corrected with the aid of a hinged-distraction apparatus. Clin Orthop 1991; 266:42-50
15. Kite JH. (1939). Principles involved in the treatment of congenital clubfoot. The results of treatment. J Bone Joint Surg, 21, 595–606.
16. Atar D, Lehman WB, Grant AD. Complications in clubfoot surgery. Orthop Rev 1991; 20:233‑9.

How to Cite this Article:Patwardhan S, Doshi C. Mini Fixator for Correction of Neglected Clubfoot. International Journal of Paediatric Orthopaedics Jan-April 2016;2(1):6-9.

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Neglected clubfoot: Patho-anatomy and clinical features

Volume 2 | Issue 1 | Jan-Apr 2016 | Page 2-5|Mandar Agashe

Authors : Mandar Agashe [1*]

Director, Centre for Paediatric Orthopaedic Care (CPOC) at Dr. Agashe’s Hospital, Kurla, Maharashtra, India

Address of Correspondence
Dr Mandar Agashe
Centre for Paediatric Orthopaedic Care (CPOC) at Dr. Agashe’s Hospital, Kurla, Mumbai, India.
Email: mandarortho@gmail.com

Abstract

Neglected clubfoot still remains a great problem in developing countries like India especially in the rural population with limited access to modern healthcare. It is the most common congenital problem leading to locomotor disability, so much so that the government of India has, in recent years added congenital clubfoot in one the eight notifiable conditions at birth with the hope of eliminating the scrouge of neglected clubfoot. With the popularity of the Ponseti method, more and more cases of congenital clubfoot are being treated at the time when they should be ideally treated- ie neonatal period and early infancy. However there are still some lacunae in the healthcare delivery system in India, leading to persistence of these neglected cases in rural population. The obstacles of poverty, lack of awareness and lack of medical facilities in accessible locations means that treatment is either not initiated or incompletely performed.
Since the deformity in neglected cases is a complex three-dimensional one, it is essential to understand the pathoanatomy of the same before embarking on the treatment. In this article, we deal with the detailed pathoanatomy as well as the clinical features related to neglected clubfeet.
Keywords: Congenital talipes equino varus, clubfeet, neglected

Introduction:
Neglected clubfoot still remains a great problem in developing countries like India especially in the rural population with limited access to modern healthcare[1,2]. It is the most common congenital problem leading to locomotor disability, so much so that the government of India has, in recent years added congenital clubfoot in one the eight notifiable conditions at birth with the hope of eliminating the scrouge of neglected clubfoot. With the popularity of the Ponseti method, more and more cases of congenital clubfoot are being treated at the time when they should be ideally treated- ie neonatal period and early infancy[1]. However there are still some lacunae in the healthcare delivery system in India, leading to persistence of these neglected cases in rural population. The obstacles of poverty, lack of awareness and lack of medical facilities in accessible locations means that treatment is either not initiated or incompletely performed[3,4].
Since the deformity in neglected cases is a complex three-dimensional one, it is essential to understand the pathoanatomy of the same before embarking on the treatment. In this article, we deal with the detailed pathoanatomy as well as the clinical features related to neglected clubfeet.

Pathoanatomy
The pathological anatomy of the neglected clubfoot can be divided into that related to bone and joints and that related to soft tissues (ligaments, muscles and tendons).

Bones and joints[5,6] [Figures 1,2,3]
The talus is the bone which is most affected in neglected clubfoot [blue arrow]. The talus is severely plantarflexed. The body is small and altered in shape. The talus becomes severely inverted in the ankle mortice. The trochlea is shorter than normal. Only the posterior portion of the talus articulates with the tibia in the ankle joint while the anterior portion is just covered with thin and stretched out ankle joint capsule. Normally, the posterior-most portion of the talus is extra-articular. However in neglected clubfeet with severe planter-flexion, the posterior portion of the talus becomes intra-articular and is covered by joint capsule. The neck of the talus develops significant medial angulation and the head becomes wedge shaped. There are two surfaces of the talus- the anterolateral and anteromedial. The anterolateral surface of the talus is left uncovered by the medially displaced navicular and is now covered by just thin joint capsule which is stretched out, and the skin. This is the part which is palpable just underneath the skin. The anteromedial surface now articulates with the navicular which is displaced medially and proximally.
The navicular is also very severely affected in neglected clubfeet [white arrow]. It is flattened or wedge-shaped and medially displaced, adducted and inverted. It articulates with the anteromedial surface of the talus and in some severe cases, even has a pseudo-articulation with the medial malleolus. The enlarged tibialis posterior is attached to a wide area on the navicular along with the medial malleolus.
The calcaneus also undergoes a significant alteration [black arrow]. The body of the calcaneus is severely plantarflexed and medially bowed. It is adducted and the lateral process of the calcaneum is under the talus, rather than being lateral to it. In severe neglected cases, the body of the calcaneus also undergoes severe changes, leading to it being bean-shaped rather than rectangular on the axial plane. The axes of the calcaneum and talus are parallel to each other. The cuboid is also medially displaced at the calcaneo-cuboid joint so that only the medial surface of the anterior process of the calcaneum articulates with the cuboid.
The cuneiforms and metatarsals also undergo secondary changes though to a lesser extent than the talus, calcaneum and navicular. The cuneiforms are medially displaced and have very haphazard articulations with the navicular and the cuboid. The metatarsals are shortened.
The talonavicular joint is entirely medially displaced. This articulation is between the anteromedial surface of the talus and the proximal surface of the navicular. There develop pseudoarticulations between the navicular and the tibia (at the medial malleolus) and also between the navicular and the calcaneum. In some cases, there is a fibrous band which is formed between the navicular and the calcaneum, almost like a fibrous calcaneonavicular bar.
The three talcalcaneal joints (anterior, middle and posterior) are also very abnormal. The anterior facet remains very narrow while the middle facet is variable. The posterior facet is short. The sustentaculum tali is left uncovered to a large extent. In very severe neglected clubfeet, the talo-calcaneal joints are almost in the weight bearing axis due to the severe inversion so that the talus assumes the weightbearing position.
The calcaneocuboid joint orientation is very important for the treatment of neglected clubfeet. The calcaneocuboid joint is very obliquely placed with the cuboid being subluxed anteriorly and medially while the lateral aspect of the calcaneum is left uncovered. The other joints of the foot (ie the intercuneiforms and intermetatarsals) follow the course of the main joints of the midfoot and hindfoot. The point to remember is that the first two metatarsals are severely pronated while the lateral three metatarsals are supinated. The degree of pronation will determine the cavus, which in turn will determine the fate of the foot in terms of whether the child walks on the lateral border or the dorsal surface.

Pathoanatomy of soft tissues (ligaments, muscles and tendons)[5-7]
The soft tissues in clubfeet also undergo a significant amount of secondary changes. They are subclassified as:
1) Changes in muscles:
The triceps surae and the tendoachilles is the most severely affected amongst all muscle tendon units in neglected clubfeet. The severity of neglected clubfoot depends mainly on the amount of shortening of the tendoachilles.Both the triceps surae and the tendoachilles are foreshortened and the tendon is significantly longer than the muscle. The tendoachilles is inserted medially on the calcaneus and is one of the deforming forces to pull the heel in varus.
Amongst the other muscle tendon units affected, the tibialis posterior is very important. The tibialis posterior becomes very broad and hypertrophied and is inserted over a very broad area on the inferomedial surface of the navicular and the medial cuneiform. This is the most important cause of supination of the foot. In some very severe cases, the tibialis posterior also seems to have an additional thick fibrous band which is attached to the cuboid, which pulls the cuboid medially. This itself leads to the significant displacement of the calcaneocuboid joint, which is seen in some cases.
The tibialis anterior undergoes some amount of hypertrophy. This is more apparently seen in incompletely treated clubfeet, in which the tibialis anterior causes a dynamic supination deformity during the swing phase of gait. The other muscles of the flexor compartment of the foot also undergo foreshortening with resultant clawing.
2) Changes in ligaments and other soft tissues:
The plantar fascia is very tight and results in the cavus component of the deformity. The amount of tightness of the plantar fascia and the cavus, decide how the child walks in neglected clubfeet[4-6]. If the cavus is moderately severe, the child walks on the lateral border of the foot. However if the cavus is exceedingly severe, the child starts walking on the dorsal surface of the foot, making normal ambulation exceedingly difficult.
In the ligaments, the deep layer of the deltoid ligament is very thick and forms a part of the pseudoarticulation between the medial malleolus and the medially displaced navicular. The tibianavicular and the calcaneonavicular ligaments are thickened and shortened. The ligaments on the medial, plantar and the posterior aspect of the foot undergo severe thickening with shortening and are the main tethers against effective closed manipulative treatment of neglected feet. Amongst them, the medial talo-calcaneal ligament and the plantar calcaneonavicular ligaments are very important. The eponymous “knot of Henry” becomes a thick fibrous band which extends from the undersurface of the navicular till the plantar surface of the medial cuneiform and the talus in neglected clubfeet.
Thus to conclude, neglected clubfoot is a three dimensional deformity, with severe secondary changes in bones, muscles, tendons and ligaments, all of whom have to be corrected for effective clinical management.

Clinical features
The neglected clubfoot, by definition is a foot which has experienced no or minimal surgical or non-surgical management[6] [figure 4]. In this case, the deformity starts increasing after the child starts weightbearing. This is because the structures which are never meant to bear the weight of the body are now in a weight bearing position, the weightbearing starts happening on the side and dorsum of the foot and secondary contractures start developing on the plantar-medial and posterior side of the foot. There is usually a large bursa or callosity at the lateral aspect of the foot, which on prolonged weight-bearing leads to skin breakdowns, ulcerations and infections. It is often difficult or impossible to wear normal shoes for ambulation.

Patterns of deformity[6]
Just like clubfoot deformity in the neonatal and infantile period, there are different patterns of deformity in a neglected clubfoot. Though all the major components of the deformity, ie cavus, forefoot adductus, heel varus and equinus are present in all patients, the exact combination is the main causative factor for a particular type of deformity. As a result, there are various feet with different grades of stiffness, mobility and deformity. This led a few investigators to subclassifiy the deformities in neglected clubfeet into three patterns of deformity since the treatment modality followed and prognosis depends on each of these patterns.
1) Moderately flexible: The foot can be considerably corrected to neutral position
2) Moderately stiff: There is some correctability but not to neutral position and with moderate deformity persisting
3) Rigid: There is almost no correction of deformity.
The classification can be applied either to the entire foot, or separately to the midfoot and hindfoot. Of course, the standard classifications of Pirani[8] and Dimeglio[9] can still be used additionally.
As explained previously, the degree of cavus determines whether the child walks on the lateral border of the foot or the dorsum of the foot. In lesser degree of cavus, the child walks on the lateral border while in greater degree of cavus the child walks on the dorsal surface itself. In the presence of this severe cavus, it is very difficult to appreciate the amount of equinus actually present. This usually gets unmasked once the cavus and adductus gets corrected.

Socio-economic factors
The kids with neglected clubfeet eventually learn to walk with no or some modified footwear[6]. However, it is a condition which is fraught with numerous struggles. This deformity poses a significant disability in young children, preventing access to education and social activity[10]. Many of them are outcast or even deemed as “cursed” with very little social interaction due to the obvious grotesque deformity[6]. Social stigma of having “reverse feet” is also very great, and many girls find it difficult to get married due to this[4]. They are unable to squat for toileting purposes which is an essential function especially in rural population[3,4]. There is significant pain, difficulty in locomotion over long distance, with frequent skin breakdowns, infections and callosities. The skin breakdowns and infections can sometimes be so severe that it may lead to amputations.

Conclusion
Congenital clubfoot is a complex problem which requires proper understanding of the anatomy as well as realistic goals for treatment before embarking on attempting to treat it.

References

1. Gadhok K, Belthur MV, Aroojis AJ, Cook T, Oprescu F, Ranade AS, Morcuende JA. Qualitative assessment of the challenges to the treatment of idiopathic clubfoot by the Ponseti method in urban India. Iowa Orthop J. 2012;32:135-40.
2. Lohia LK, Meena S, Kanojia RK Comparative study of complete subtalar release and Joshi’s external stabilization system in the management of neglected and resistant idiopathic clubfoot..Foot Ankle Surg. 2015 Mar;21(1):16-21.
3. Shingade V, Shingade R, Ughade S Single-stage correction for clubfoot associated With myelomeningocele in older children: early results Curr. Orthop. Practice 2014;25(1),64-70.
4. Shingade V, Shingade R, Ughade S. Correction of neglected or relapsed clubfoot deformity in an older child with single stage procedure: Early results. Curr. Orthop Practice. 2012; 23(2), 122-129.
5. Ponseti IV. Congenital clubfoot: Fundamentals for treatment. Oxford: Oxford University Press: 1996.
6. Penny JN. The neglected clubfoot. Techniques in Orthopaedics Vol 20. Philadelphia: Lippincott Williams & Wilkins Inc.; 2005: 153–166.
7. Scott WA, Hosking SW, Caterall A. Clubfoot. Observations on the surgical anatomy of dorsiflexion. J Bone Joint Surg (Br) 1984;66: 71-6.
8. Pirani S. A reliable and valid method of assessing the amount of deformity in the congenital clubfoot. Presented at the Pediatric Orthopaedic society of North America, May 2004; St. Louis.
9. Demiglio A, Bensahel H, Souchet P, et al. Classification of clubfoot. J Pediatr Orthop (B) 1996;4:129-136.
10. Owen RM, Penny JN, Mayo A, Morcuende J, Lavy CB. A collaborative public health approach to clubfoot intervention in 10 low-income and middle-income countries: 2-year outcomes and lessons learnt. J Pediatr Orthop B. 2012 Jul;21(4):361-5.
11. Sengupta A. The management of congenital talipes equinovarus in developing countries. Int Orthop 1987;11: 183-187.

How to Cite this Article: Agashe M. Neglected clubfoot: Patho-anatomy and clinical features. International Journal of Paediatric Orthopaedics Jan-Apr 2016;1(2):2-5.

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Authors :Sandeep Patwardhan[1], Chintan Doshi[1]

Abstract

References

Authors : Mandar Agashe [1*]

Abstract

References

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