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Congenital talipes equinovarus (CTEV) also known as club foot is the most common congenital defect of the musculoskeletal system. And exactly for that reason it is the center of constant attention. For this defect it is typical to have a rotated foot in the joints of the back of the foot, and inner rotation in the joints of the forefoot. So there is a general deformity of the foot, which is in addition connected to hypotrophy (insufficient nutritioning and also restriction) of the muscles lower leg. The occurrence of the defect in Europe is 1-2 cases out of one thousand people, given the fact that boys are affected two times more often than girls, and by nearly one half, the defect manifests in both ways.
The cause and formation of the defect are still unclear. As one of many possible factors of origin, the genetic factors are usually mentioned, the effects of harmful substances during pregnancy and also the defective position of the fetus in the uterus are often mentioned. The accompanying findings have been taken into account as well as the various causes of leg defecation, such as neuromotor injuries of the leg but also anomalies of blood vessels and muscles, including changes in the presence of the muscle fibers. Nowadays, primary dysplasia (development or growth disorder) of the ankle bone is generally recognized as a basic pathological phenomenon which occurs in the early embryonic phase between 4 and 7 Week of pregnancy.
PATHOLOGICAL ANATOMY
The basic deformity by this defect is medial and plantar deviation of the neck and headpiece of the talus bone, which is followed with responding position of surrounding joints and bones. It leads to rotation of the heel bone (calcaneus), scaphoid bone and cuboid bone (one of the tarsus bones) downwards and inwardly. The position in the joints can be corrected in the beginning, but later it becomes fixed by the ligaments and muscles, which are shortened on the inner side of the foot and extended on the outer side of the foot. These bones are then composed as a whole, and thus they need to be corrected simultaneously with the treatment.
TYPES OF DEFORMITIES
The deformities can be categorized according to various aspects. The basic and simple clinical categorization in the treatment strategy derives the deformities according to:
- Position of the CTEV
- Right or also rigid (permanent, unchanging) CTEV
- CTEV during arthrogryposis (syndrome of multiple joint contractures - shortening)
- CTEV as a part of congenital syndromes and neuromuscular disabilities
Positional clubfoot can be easily corrected, in a clinical image there is no evident pathological position, and it can be easily treated with orthopedic cast. Right or also rigid type cannot be from the beginning fully corrected, and a surgery is usually needed. Very rigid defect by arthrogryposis (syndrome of multiple joint contractures - shortening) and further CTEV as a part of congenital syndromes and neuromuscular disabilities demand different tactics of surgical treatment. Nowadays, the classification into the four stages according to the options of correction of the defect is often used, and it is treated with corrective methods, according to the rigidity of the defect.
DIAGNOSIS
Determining can be done immediately during birth according to the typical shape and position of the legs. To specify the process of the treatment and during unsuccessful conservative treatment is X-ray imaging still very important. From the whole range of recommended images remains the most effective image of the feet in the corrected position according to Simons. Modern method that is used is ultrasound of the feet, because it can depict the position of the individual elements. The question is whether it can be diagnosed in prenatal period of the unborn child, there are ultrasound diagnostic processes, which can determine and differ the incorrect position of the foot, but it can be diagnosed only after 14th week of pregnancy, therefore clinically this fact has no particular meaning yet.
TREATMENT
Because of frequent failure with conservative and also surgical treatment, the treatment process is significantly differing across the world, but there are some basic principles which remain identical. Every facility prefers methods, with which they achieve the most success. The treatment process in Czech republic is identical with other central european countries and Germany. The treatment demands a lot of patience and cooperation of the family. The starting treatment is always conservative and if it’s unsuccessful it is followed with surgical treatment.
Conservative treatment
It can be split into two phases:
Rectifying (corrective) phase:
The treatment starts as soon as possible after the birth, ideally within 3 weeks, when the contracted structures can be extended, because they are amenable due to the mother’s hormone. The mother and baby are accepted within one week into the orthopedic department, and after application of orthopedic cast, the feet are nonviolently corrected. The correction and change of the cast is in done in a 48 interval by the doctor himself. The gypsum cast is always applied all the way above the knee, which is held in a 70 - 90 degree angle. The child is then released home after fifth replacement of the cast, from then on the cast is replaced once a week. The goal of the conservative treatment is correction of all deformities, which flow out of the principle of rotation of the heel bone. The corrective casting demands perfect knowledge about the problematics and experience with the treatment. It is important to highlight that it is nonviolent and gradual correction of the defect. There is an important principle that you should never try to correct the defect in one sitting, which could cause damage to the cartilage base of the foot, and undesirable rupture in the lisfranc joint. Corrective phase of the treatment ends in the third month of the baby’s life. In this period it should be clear whether to continue in conservative treatment or step to surgical treatment.
Retention phase:
Reaching the correction (by the positional CTEV after 3 - 4 cast replacements) X-ray imaging is done in the corrected position and the treatment continues with applying another cast, which will be replaced in 2 - 3 week interval. Casting should take enough time - by a positional defect it is at least 2 - 3 months, by a rigid defect it takes about 6 - 7 months. After reaching full correction, plastic retention splints are used. The splints are reaching again slightly above the knee, and they are used till the baby starts to walk. And they can be also used during the night further on. The treatment with the splints should take up to 2 - 3 years as a prevention in case the defect would appear again. Part of the treatment is also passive exercising and stimulation of the muscle activity in order to reach muscle balance, contributing to keeping the shape of the foot. Correctly healed food does not require to wear any special orthopedic footwear. But it is recommended that the child should use shoes with firm heel and forefoot support till the age of six, which will prevent any repetition of the defect.
Operative treatment
Positional defects can be treated conservatively, rigid CTEV needs in various stages further correction through surgery, in 50 - 90% cases. Timing and deciding the type of operation are depending on the age of the child, size of the foot and magnitude of the defect. The goal of the operation is to achieve normal position of the foot, able of physiological type of walking and bear the pressure, and at the same time to reach enough mobility in the joints. The goal is to remove all the deformities with one operative intervention.
Releasing and extending the Achilles tendon:
If the pathological position of the back of the foot is persisting in the age 3 - 4 months, the release of the dorsal (back) talocalcaneal joint and tibiotalar joint with extension of the Achilles tendon. The heel bone is derotated and fixed with two Kirschner wires and cast for 6 weeks. Further treatment with splints and orthopedic footwear is identical with the conservative treatment process.
Complete peritalar release:
In the case of persisting defect in age above 6 months and length of the foot over 8-9 cm, a complete subtalar release (under the ankle bone) is usually performed, which means severing most of the fibrous structures fixing the whole set. Dorsal (back) relaxation can only be done where correctional valgosity and adduction are achieved and only equinosity persists (depression of the toes). Since 1984, is performed posteromedial release instead of the complete peritalar release described by McKay in 1982, derived from the principle of subtalar (under the ankle bone) root bone derotation. This is a technically demanding operation, but in the hands of an experienced surgeon it is a very effective method of treatment. The introduction and expansion of the method in the Czech Republic was mainly due to the Professor Dungl. Even though this operation has not been accepted by some orthopedists, it remains the world's most respected and most effective surgical method. It is performed at the age of 3 years. That is followed by cast fixation and plastic splints - again as with conservative treatment.
Operative treatment in the age 3 - 7 years:
Children older than 3 years, have already visible changes in the skeleton of the foot. In case of untreated deformities, which are rare nowadays, but especially by the recurring defects, the subtalar relaxation (under the ankle bone), but in addition the plantar fascia will be intersected ( ligamentous sheath of the foot muscle), and short flexors of the foot, that is called Steindler operation . At this age, it is necessary to shorten the overgrown lateral column of the foot, which, even after correcting the individual elements, prevents the return of the wrong shape of the foot. From a number of methods, the surgical reduction of the cuboid bone and removal of the spongy bone, has proven to be successful. If the deformity does not require complete peritalar release, the surgical methods will be selected according to the current condition.
Operative treatment in age 7 - 10 years:
In the age above 7 years, the bones and soft tissues are so deformed and contracted that even complete peritalar release can not achieve full correction. In this case, an individual approach is chosen with a combination of corrective osteotomy (heel bone or tarsus) methods with the release of some shortened ligamentous structures. Another, but demanding method is also gradual correction of the foot with a circular outer fixator - the Ilizarov apparatus.
Treatment above the age 10 years:
The surgical methods at this age are similar to the previous age group and are again selected individually. By skeletally mature legs at the age of 12-14 years, are serious deformities mainly resolved by arthrodesis (surgical immobilization) of the lower ankle joint (triple arthrodesis). This operation restores the right shape of the foot, eliminating painful bumps, but it comes at the cost of mobility loss. Therefore, this method is chosen as an extreme and definitive "rescue" surgery.
Treatment of the remaining deformities
After successful operation it is possible to wear normal mass produced shoes. However, because it is congenital defect with programmed failure in the growth of the ankle bone, its repetition may occur during the growth period. Static deformity can occur or dynamic deformity as a result of persistent muscle dysbalance, which is easily corrected. Static deformities are mainly corrected by osteotomy (severing the bone) of all metatarsal bones (instep) and reduction of the cuboid bone. Dynamic deformities are caused due to the weakness of the finger extensors and peroneal muscles. Temporary transposition has proved to be effective treatment (change of position) of the tibial anterior muscle on the outer foot.
The mentioned treatment algorythm is used since 1984. Till 2000 there have been 450 individuals operated. 60% of them have primary deformity, 40% had repeated operations and recidivism by patients sent to various parts of the republic. The results were processed in detail and it showed that 95% of the primary operated feet and 75% of repeatedly operated feet were achieved satisfying results. Satisfying result can be taken as a foot which is able to walk with the whole sole with enough mobility left. It is important to note that the result of the disorder of the bone growth in case of these defects there cannot be achieved normal condition. On the other hand the healthy foot side is left
The mentioned treatment pattern has been used since 1984. By the year 2000, a total of 450 affected people have been operated. 60% of these were primary deformities, 40% had recurrent operation. The results were processed in detail and the results showed that 95% of the primary cases and 75% of the cases with repeated operation, achieved satisfying results. A satisfactory result can be considered a leg capable of striding on the entire sole of the foot while maintaining sufficient mobility. It should be noted that due to growth disorder of the bones, it is not possible to achieve a completely normal condition and shape of the leg. In contrast to the healthy side, the affected leg remains shorter and weaker. However, if a static deformity occurs, the result can not be considered satisfying and the patient can not settle for adjusted footwear or special shoes, the defect has to be re-operated. However, dynamic deformities do not fall into category of unsatisfying results because they can be easily corrected by muscle transposition (position change). An important part of the treatment is continuous positioning of the affected foot in orthosis between the age 3 to 6 years, in order to achieve muscle balance the individual has to exercise and stimulate the foot. It is also recommended to wear orthopedic footwear, which controls the position of the foot up to the age of 3-6 years. During the growth of the leg, there may be a recurrence of the defect at any time, therefore it is necessary to observe the child until adolescence when the leg stops growing.
In conclusion, the treatment of these deformities is a very difficult area of children’s orthopedics. In case of unprofessional conservative and mainly surgical treatment, it can lead to crippling and disfigurement of the foot. Operational treatment should be therefore concentrate in workplaces with appropriate experience offering the above mentioned surgical methods. By strictly adhering to the principles of the treatment, it is possible to achieve very good results, enabling the affected person to engage in normal life without significantly limiting the physical activity.
Author: FYZIOklinika physiotherapy Ltd., Prague, Czech Republic
Source: MUDr. Jiří Chromiak, Orthopedic clinic IPVZ, FN Bulovka, Prague
