Disorders of the foot in childhood• Club foot• Vertical talus• Pes adductus • Tarsal coalition

Club foot (pes equionovarus congenitus)Incidence: 1-2%Inheritable disorder (poygenetic inheritance)Boy/girl = 2:1Aetiology: unknown

Hyppocrates was the first to describe this condition Deformities: • ankle joint in equinus (plantar flexion

deformity),• subtalar joint in varus, • forefoot in plantar flexion

Tibia internal torsion, atrophyic muscles of the leg

Typical appearance of club foot in a newborn infant

1. Ankle in equinus2. Subtalar joint – hindfoot - in varus3. Midfoot and forefoot in adduction and

supination

Shape and position of normal foot and club footNOTE: the condition is bilateral in 1/3 of cases

a. „true clubfoot” – fixed deformity, can not be corrected manually

b. „postural” club foot – easily correctible passively

c. True clubfoot – heel is higher, than forefootd. Forefoot points downwards and inwards

Pes Equinovarus Congenitus:Aetiology:

1. Primary 2. Neurological condition (eg. myelomeningocele) –leg muscles are paralytic3. Generalized abnormalities (eg. arthrogryposis congenita)4. May be associated with other congenital abnormalities, eg. congenital heart defect !!!

If club foot deformity (talipes equinovarus) is found, always check for other congenital skeletal malformations (hips!! spine!!) and check for potential congenital abnormalities of internal organs!!

Meningocele (due to spina bifida) and club feet

Open defect of the spinal canal due to lack of closure of the vertebral arch – spina bifida, associated with protrusion of the dura (meningocele) or myelon (myelomeningocele)

Arthrogryposis multiplex congenitaCongenital disorder, with multiple joint contractures- in most cases all 4 limbs are involved (wrists and fingers in flexion contracture)- most typical deformity is bilateral rigid club foot.

Typica Features:

Pathological changes in pes equinovarus congenitus:1. Fibrous tissue in tendons, muscles and fasciae of the leg and ankle at the postero- medial

aspect2. Achilles tendon is shortened and thick3. Posterior capsule of the ankle is thick4. Tibia in internal torsion

Aim of treatment of club foot deformity:Achieve and maintain correction of the footRestore normal joint anatomy and function of the ankle, subtalar and midtarsal jointsRestore muscle balance

Advanced cases of club foot:

First line treatment is non-operative:• Should begin immediately after birth• Conservative treatment should be tried first• Correction: with straps (elastoplast) or - better - in plaster• If correction is succesful, plaster to be changed weekly, until full correction is achieved• Strapping of the foot to achieve and maintain correction

Correction above knee: to relax gastrocnemius muscle – to achieve correction

Correction with casting, later maintenance of the corrected position either ankle- foot orthosisor special shoes (Dennis- Brown shoes)

Operative management of club foot in cases, that are resistant for conservative treatment:Achilles- tendon lengthening is the most frequent soft tissue procedure , especially in recurrent club foot deformity

Correction with external fixator (Ililzarov- type) – slow, gradual correction can be achieved and maintained – if necessary - for 6-12 weeks (the right pic)

1) Typical view of club foot - child in prone position2) Postero- medial release in club foot: Achilles tendon lengthening Transsection of medial part of tendon distally, and lateral part of tendon proximally3) Postero- medial release(cutting) of soft tissues of the foot Release of soft tissues above the flexor hallucis tendon4) Postero - medial release Subtalar joint capsule is opened Peroneus tendons are visible5) Postero- medial release - correction achieved6) Suture of Achilles- tendon in lengthened position7) Postoperative view following medial release of soft tissues in club foot

Postoperative management:• Change of plaster between 4-6 weeks• Use of corrective splints until walking begins• Physio, selective electrotherapy of peroneal muscles

Operative management of club foot in cases, that are resistant for conservative treatmentIlizarov- external fixator, used in cases, where „simple” soft tissue release is not sufficient

Congenital vertical talus – „rocker bottom” footworst form of congenital flat footProblem: soft tissues (tendons and capsule) are contracted in abnormal position

Operative management of congenital vertical talus• - surgery is usually delayed until child is about 12 to 18 months old

Operative management of congenital vertical talus soft tissue and bone operations tendo Achilles lengthening extensive posterior capsule releases to relocate talonavicular and subtalar joints; peroneus tendons may be transferred to the insertion of the tibialis anterior tendon, or tibialis posterior tendon (tendon transfer) is transferred

• talonavicular joint is transfixed with Kirschner- wires temporarily (bony procedure)• postoperative casting is for 12 weeks;

Rocker bottom foot (vertical talus ) – foot immobilized in plaster in corrected position

Pes adductus deformityOperation: tibialis anterior tendon transfer1) Tendo transsected at attachment2) Detached tibialis anterior tendon is pulled through3) Drill hole in 4th metatarsal to receive transposed tibialis anterior tendon4) Drill hole in 4th metatarsal5) Tibialis anterior tendon pulled into drill hole6) Final position2 weeks in plasterSelective electrical stimulation from week 3Full weight bearing after 4 weeks

Tarsal coalition: bony bar between talus- calcaneus or calcaneus- cuboid or talus – navicularSymptom: painful foot in a childTreatment: surgical removal – excision- of the connecting bony bar

Chopart line/joint (=transverse tarsal joint)

Lisfrenc joint (=tarsometatarsal articulation)

Lisfranc ligament/s