Persistent Clubfoot
Deformityy Following
g
Treatment by the
Ponseti Method
W.B. Lehman, M.D.
Alice Chu
Chu, M.D.
MD
New York Ponseti Clubfoot Center
Department of Pediatric Orthopaedic Surgery
Financial Disclosure
The authors have not received any financial support for
th preparation
the
ti off thi
this work.
k
Wallace B
B. Lehman
Alice Chu
Group 1 - Those maintained in an ankleankle-foot
foot--orthosis (AFO) - 97
97%
% success rate
Group 2 - Those not maintained in an AFO (noncompliant) - Recurrence rate 50
50%
%
or greater
What is a
Persistent or Recurrent
Clubfoot Deformity?
Persistent Clubfoot Deformityy
A clubfoot that has not been fully corrected and will NOT fit into or
b controlled
be
t ll d iin an ankleankle
kl -foot
f t orthosis
th i (AFO).
(AFO) It will
ill therefore
th f
lead
l d
to failure or full recurrence and the patient may present with:
1. Equinus – most
common
2. Midfoot adduction
3. Varus of the heel
4. Cavus deformity
5. Midfoot rocker
bottom deformity
Recurrent Clubfoot Deformityy
A fully corrected clubfoot maintained in a proper
AFO that shows evidence of a recurrent (relapse)
d f
deformity
it severall months
th or years after
ft treatment.
t t
t
The patient may present with:
Recurrent Clubfoot Deformityy (cont.)
1. Heel elevation – equinus
2. Rocker bottom deformity – midfoot dislocation (midfoot breach –
Noonan) through the talonavicular and calcaneocuboid joints
3 Cavus
3.
C
d
deformity
f
i
4. Varus of the calcaneus
5. Callus at lateral aspect of the foot
6. Inability to shoe correctly, i.e. due to recurrent deformity
7. Midfoot adduction – navicular not corrected over the talus
8. Forefoot adduction – adduction through
g Lisfranc’s jjoint
9. InIn-toeing gait – corrected clubfoot and flexible foot with
overactive anterior tibial tendon
10. Complete recurrence to original clubfoot deformity
Recurrent Clubfoot Deformityy (cont.)
1. Heel elevation – equinus
Recurrent Clubfoot Deformityy (cont.)
2. Rocker bottom deformity – Chopart’s joint
Recurrent Clubfoot Deformityy (cont.)
3. Cavus deformity
Normal
arch
cavus
cavus
Recurrent Clubfoot Deformityy (cont.)
4. Varus of the calcaneus
Recurrent Clubfoot Deformityy (cont.)
5. Callus at lateral aspect of the foot
Recurrent Clubfoot Deformityy (cont.)
6. Inability to shoe correctly
7. Midfoot adduction
Recurrent Clubfoot Deformityy (cont.)
8. Forefoot adduction
Lisfranc’s joint
Recurrent Clubfoot Deformityy (cont.)
9. In
In--toeing gait – corrected clubfoot and flexible foot with
overactive anterior tibial tendon
10.. Complete recurrence to original clubfoot deformity
10
Most Common Causes of Persistent or
Recurrent Clubfoot Deformities
1. Feet prone to persistent or recurrent deformities.
deformities Such as:
A. Clubfoot due to unrecognized syndrome i.e. arthrogryposis
B. Complex or atypical clubfoot
described by Morcuende and Ponseti
Short first toe
Bean--shaped foot
Bean
Plantar crease
Ponseti technique will fail unless modified
Ponseti, 1996
Oxford University Press
Most Common Causes of Persistent or
Recurrent Clubfoot Deformities (cont.)
C Patient initially treated after seven months of age?
C.
D.
D Unrecognized neurological clubfoot ii.e.
e spastic or paralytic deformity
(Frick, S. Drop Toe Sign. COOR.2009
COOR.2009))
E. Foot previously treated with “supposed” Ponseti technique that failed
(Helig: Current Management of Idiopathic Clubfoot Questionnaire.
JPO 2003
JPO,
2003)) (26
26..2% correction with the Ponseti technique)
Most Common Causes of Persistent or
Recurrent Clubfoot Deformities (cont.)
2. Failure to maintain correction – usually a deformity that was
uncorrected and forced into an AFO
3. Noncompliance with regard to use of the DB bar (AFO?)
Treatment of Persistent Clubfoot Deformity:
A Uncorrected
An
U
t dF
Foott Treated
T t d by
b the
th Ponseti
P
ti Technique
T h i
1. Start from the beginning using all the steps of the Ponseti technique
2. This may require more casts than the usual foot and each step of
casting
ti may have
h
tto b
be repeated
t d severall titimes
Treatment of Persistent Clubfoot Deformity:
A Uncorrected
An
U
t dF
Foott Treated
T t d by
b the
th Ponseti
P
ti Technique
T h i
3. Percutaneous tenotomy may have to be repeated as
well. Note: The tenotomy is only done when the head of
talus is covered by the navicular
navicular. Otherwise a rocker
bottom deformity may occur. The head of the talus can be
felt laterallyy when not covered.
Dobbs/Schoenecker; JPO,Vol24, No.4,2004
Treatment of Recurrent Clubfoot Deformity:
A Previously
P i
l C
Corrected
t dF
Foott
The first decision to be made is - which part of the deformity has
recurred? Attention must then be directed to that part of the foot.
• Equinus – the foot is corrected except that dorsiflexion cannot
go beyond neutral position.
Decide from the following:
A Physical therapy – French method?
A.
B. Recasting
C. Repeat percutaneous tenotomyy
D. Posterior release – Formal: Includes Achilles
tendon release (Strayer procedure), ankle
j i t release,
joint
l
and
d release
l
off th
the subtalar
bt l jjoint.
i t
Treatment of Recurrent Clubfoot Deformity (cont.)
Midfoot Adduction
Chopart’s joint
A.
A Mild deformity may persist throughout life and may only require
intelligent neglect
B. If it occurs early after treatment, recast being sure to cover head of
talus, followed by maintenance with AFO fitted into a shoe for walking
Treatment of Recurrent Clubfoot Deformity (cont.)
• Midfoot Adduction
C If persistent
C.
persistent, may require release of adductor muscle
muscle, surgical release of
talonavicular joint, plus or minus a release of the first cuneiform -navicular
D. In older children ((5
5-10 y
years of age),
g )
it may be necessary to perform a
calcaneocuboid fusion or a first
cuneiform opening wedge osteotomy
and a closing wedge cuboid
osteotomy, or a complete midtarsal
osteotomy
calcaneocuboid
fusion
McHale
1991
E. If associated with heel varus, a
closing wedge osteotomy of the heel
may be necessary in addition to the
other procedures – what we refer to
as a triple osteotomy involving the
cuneiform, cuboid and calcaneus
Dwyer
Treatment of Recurrent Clubfoot Deformity (cont.)
• Metatarsus Adductus
F Before maturity – soft tissue Lisfranc’s
F.
Lisfranc s release (Heyman) Not effective
After maturity a transmetatarsal osteotomy or triple arthrodesis may
be necessary
Transmetatarsal osteotomy
Triple arthrodesis
Treatment of Recurrent Clubfoot Deformity (cont.)
• Cavus Deformity
A Under the age of 5 – Soft tissue and/or plantar release;
A.
B. Over the age of 5 – Plantar release and base of the first
metatarsal osteotomy and heel osteotomy or midtarsal osteotomy.
Kösse, 1999
Treatment of Recurrent Clubfoot Deformity (cont.)
• In
In--toeing Gait
If foot is fully corrected (not stiff) and gait is related to overactive
anterior tibial tendon and weak peroneal power, the anterior tibial
tendon may be transferred to the lateral or medial cuneiform after
the age of 5 when the cuneiform is ossified
Anterior tibial tendon transfer
Treatment of Recurrent Clubfoot Deformity (cont.)
• InIn-toeing Gait Due to a Supinated Midfoot
• This means that the navicular is not completely covering the head
of the talus. This must first be corrected by casting and/or a
talonavicular release, and then laterally transferring the anterior
tibial tendon. Do not transfer the tendon if the foot is stiff and the
midfoot is not corrected. The tendon will not move a fixed foot.
• If internal tibial torsion persists, tibial osteotomy (?)
Tibial osteotomy
Treatment of Recurrent Clubfoot Deformity (cont.)
• Rocker
oc e Bottom
otto Deformity
eo
ty
This is due to aggressive dorsiflexion of
the foot against
g
a hindfoot contracture.
A Stop treatment and allow the midfoot to correct itself or cast in
A.
a vertical talus position
B Release the hindfoot
B.
hindfoot, Achilles tendon and posterior structures
structures,
and cast in a congenital vertical talus position
C A fixed
C.
fi d rocker
k b
bottom
tt
deformity
d f
it is
i difficult
diffi lt tto treat
t t and
d may
require aggressive management, similar to releasing a vertical
talus
Treatment of Recurrent Clubfoot Deformity (cont.)
• Major Recurrence
“A la carte” treatment as reported
by the late Dr
Dr. Henri Bensahel
Bensahel.
Each patient must be treated
y, and in most cases
individually,
tendon releases, hindfoot releases,
and/or midfoot releases will do. It is
rarely
l necessary tto perform
f
a
complete subtalar release that was
popular in the past and very often
resulted in stiff, painful feet.
Treatment of Recurrent Clubfoot Deformity (cont.)
• Major Recurrence – gradual external fixator correction
In summary:
Gentle manipulation of the clubfoot +/+/- percutaneous Achilles
tenotomyy (Ponseti
(
technique)
q ) will be effective if done p
properly
p y
in all clubfoot deformities at least 80 - 90
90%
% of the time.
Persistence off clubfoot
f
deformity
f
is most likely due to
incomplete correction of the deformity.
Recurrent deformity has to be addressed depending upon
which p
part of the deformity
y recurs and when.
Bibliography for Persistent Clubfoot Deformity
Following Treatment by Ponseti Method.
1. Abdelgawad, A.A., Lehman, W.B., van Bosse, H.J.P., Scher, D.M. and Sala, D.A.: Treatment of idiopathic
clubfoot using the Ponseti method: minimum 2-year follow
follow--up.
up J Pediatr Orthop B
B, 16
16::98
98--105
105,, 2007
2007..
2. Bensahel, H., Csukonyi, Z., Desgrippes,Y., and Chaumien, J.P: Surgery in residual clubfoot: One stage
medioposterior release “a la carte.” J Pediatr Orthop, 7:145145-148,
148, 1987.
1987.
3. Dobbs, M.B., Rudzki, J.R., Purcell, D.B., Walton, T., Porter, K.R. and Gurnett, C.A: Factors predictive of
outcome after use of the Ponseti method for the treatment of idiopathic clubfeet. J Bone Joint Surg (Am),
86A(
86
A(1
1):
):22
22--27,
27, 2004.
2004.
4. Koureas, G., Rampal, V., Mascard, E., Seringe, R. and Wicart, P: The incidence and treatment of rocker
bottom deformity as a complication of the conservative treatment of idiopathic congenital clubfoot. J Bone
Joint Surg (Br), 90B:
90B:57
57--60,
60, 2008.
2008.
5. Lehman,
L h
W
W.: R
Revision
i i Cl
Clubfoot
bf
S
Surgery. IIn IInstructional
i
lC
Course L
Lecture, AAOS
AAOS. J B
Bone JJoint
i S
Surg (A
(Am),
)
Vol 84
84--A, No 2, p.
p.303
303,, Feb. 2002
6. Noonan, K.: Management of persistent clubfoot deformity following management via the Ponseti method.
AAOS Instructional
I t ti
l Course
C
Lecture
L t
Handout.
H d t Course
C
titl
title: Ponseti
P
ti Clubfoot
Cl bf t Method:
M th d Technical
T h i l Skills
Skill
Course #7
#7SK, San Diego, California, February 15
15,, 2007.
2007.
7. Ponseti, I.V.: Congenital Clubfoot: Fundamentals of Treatment
Treatment.. Oxford University Press, London, 1996
1996..
8. Ponseti, I.V, Morcuende, J.A, et al: Atypical clubfoot. In: Staheli, L, ed., Clubfoot: Ponseti Management
(3rd edition). Global
Global--HELP Organization, 2009
2009,, http://global
http://global--help.org/publications/books.
Thank
You
You
New York Ponseti Clubfoot Center
Department of Pediatric Orthopaedic Surgery
and
G db
Goodbye