Brace?

Pathoanatomy & Conservative
Treatment of Clubfoot
충남대학교 의학전문대학원 정형외과학교실
신현대
Introduction
The affected foot
 Restricted motion
 Diminished muscle strength
 Predisposed to deg. arthritis of ankle & knee
 Small foot & LLD
Four classes of clubfoot
Idiopathic variety
 Otherwise normal children
 Not resolve without intensive Tx
Postural variety
 Resolve completely with manipulation, or with one or two casts
Neurogenic clubfoot
 Myelomeningocele
Syndromic clubfoot
 Other anomalie, tend to be rigid & quite resistant to Tx
Mosca, Lovell & Winter’s Pediatric orthopaedics, 5th ed. 2001
Clinical Features
Characteristics
 Equinus of the hindfoot
 Varus of subtalar joint complex
 Cavus of the forefoot
 Adductus of the forefoot
Talar head
 Palpated on dorsolateral aspect
 Excessive inversion of subtalar joint complex
 Examiner's thumb, as a solid fulcrum
• Externally rotate & everte foot
Pathoanatomy of
Clubfoot
Pathoanatomy
Deformities of the clubfoot
 Deformation in shapes of bones
(Intraosseous deformity)
 Malalignment of bones at joints
(Interosseous deformity)
 Soft tissue contracture
Deformation
in shapes of bones
(Intraosseous deformity)
Talus
Main pathologic structure
 Medial & Plantar deviation of anterior end
 Short talar neck projecting from dysmorphic small body
 Talar neck-body declination angle
: Invariably decreased (N : 150-160°)
A. Shortened & med deviated neck
Navicular articulation on the med side of
the talar head
B. Medial & Plantar deviation of the
navicular articulation
C. Equinus of the neck in relation to
tibiotalar articular surface
Shapiro F, Glimcher, JBJS, 1979; 61-A: 552
Calcaneus
Normal contour, Small size
 Underdeveloped sustentaculum tali
• Dysplasia of talar facet
 Medially deviated & deformed anterior articular surface (varus
deformity)
• Interosseous deformity of calcaneocuboid joint
Navicular & Cuboid
More normal shape
 Misshapen only by interosseous relationship with calcaneus & talus
 Hypertrophied medial tuberosity of navicular
Malalignment
of bones at joints
(Interosseous deformity)
Talocalcaneonavicular joint
"Acetabulum pedis"
(AP, Sarrapa, 1995)
“Pes acetabulum"
(Scarpa, 1994)
Ellipsoid articular cavity, holds & rotate around talar head
Bony element
 Post. articular surface of navicular
 Ant. & middle facet of calcaneus
Transverse plane of ankle
Tibial torsion & Position of talus : Controversy
 True medial tibial torsion : Unusual
 McKay (JPO, 1982)
: Neutral aligned Talus
 Goldner (Curr Pract Orthop Surg, 1969)
: Talus is internally rotated
 Carroll (Orthop Clin North Am, 1978)
: Talus is externally rotated
Recent 3D MRI study
 Externally rotated position of talus
Talonavicular Joint
Calcaneocuboid joint
• Navicular articulate with medial neck of the talus
• Due to equinus, Tibia & fibula are visible
• Cuboid is displaced medially on the distal end of calcaneus
Carrrol NC, etc, Orthop Clin North Am, 1978; 9: 225
Coronal plane of ankle
Talus
 Pronation or "intorsion" deformity
Calcaneus
 Inverted or Supinated
Associated structure
 Ligament of tibiotalar & subtalar joint
Subtalar joint complex
 Severely inverted (combination of int. rotation, supination, plantar flexion)
 Axis of rotation
: Interosseous talocalcaneal lig.
Pronation or Intorsion of Talus
• Rotated Talar articualr surface
: conterclockwise “intorsion”
to med malleolus
• Supination & Varus of the heel
Release of the most posterior connection
of the talus to the medial malleolus
(post deltoid lig)
•Talar articular surface
: perpendicular to the
long axis of the tibia
Tachdjian’s Pediatric Orthopaedics, 3rd ed, vol 2
Navicular
Displaced medially & plantarward on the talar head
False articular relationship
 To the medial malleolus
Medial displacement of navicular
 Uncovered articular cartilage of talar head, laterally
Associated structure
 Tibionavicular (anterior deltoid) lig. & Tibialis posterior
Calcaneus
Medially rotated in the mortise in the transverse plane
 Midfoot "varus" or adductus
Associated structure
 Calcaneocuboid & Calcaneonavicular lig.
Tethered post part of calcaneus to the fibula
 Calcaneofibular lig.
Cuboid
 Displaced medially on the ant. end of calcaneus
Contracture
of periarticular soft tissue
Suspected Pathogenesis
Fibrosis of tissue
 Plantar fascia
 Calcaneonavicular("Spring") lig.
 Tibionavicular lig.
 Master knot of Henry (FHL & FDL at their decussation)
Suspected Pathogenesis
Associated structure
 Mobility of navicular
• Tibialis posterior & master knot
 Mobilizing talus & calcaneus out of equinus
• Achilles tendon
 Rotation of talar body & calcaneus
• Peripheral subtalar capsule
But…..
Clubfoot is
???/%*#!!!
Goal of Tx & Conservative
Goal of Treatment
To achieve
 plantigrade
 supple
 painless foot (looks normal)
Goal of Conservative
 To achieve above goal
 To achieve partial correction of deformity
• Decrease the extent of surgery
Mosca, Lovell & Winter’s Pediatric orthopaedics, 5th ed. 2001
Normal
Clubfoot
Conservative Treatment
of Clubfoot
Classification
(By Dimeglio A, Bensahel H,1997)
• Equinus
• Varus
• Adduction
• Internal rotation
Principle of Conservative
Initial Tx for idiopathic clubfoot should be nonoperative
The earlier the Tx is begun,
The more likely that it will be successful
Modalities
 Serial manipulation & casting, Taping, PT & splinting, CPM
exercise…
Stretching & Manipulation
Widely performed 2 methods
 Kite & Lovell Technique
The clubfoot, New York: Grune and Stratton, 1964
 Ponseti Technique
Treatment of congenital clubfoot, JBJS Am, 1992
Ponseti Technique
Correcting all component simultaneously
Ponseti's significant difference from Kite's technique
 Calcaneus could be corrected out of varus/inversion by adducting
forefoot
 Correcting forefoot adduction first & individually
: Interfered with correction of heel varus
Ponseti Technique
Emphasized the correction of forefoot cavus
 Forefoot should be corrected by supination
 Dorsiflexion of 1st metatarsal
Shifting navicular, cuboid, calcaneus in relation to the talus
 Abducting the foot in supinated position
Ponseti Technique
Heel was not constrained(Kite)
 Calcaneus could evert during maneuver
Percutaneous achilles tendon lengthening at final casting
 85% of patient
Denis Browne bar
 Full time & part time application for up to age 6 years
Model of clubfoot
•Talus & calcaneus : severe flexion
•Calcaneus, navicular, cuboid : adducted, inverted
•Navicular tuberosity : closed to med malleolus
•Metatarsus : adducted
1st metatarsal more flexion
than other metatarsal
: causing Cavus deformity
Cavus correction
: Extending 1st metatarsal
& Supinating the forefoot
Must never pronated !!!!!
Varus & Adduction correction
• Abducting supinated foot
• Counterpressure applied
on the lateral aspect of
the head of the talus
• Index finger rest over
post surface of medial
malleolus
Complete correction of clubfoot
• Heel must not be touched
• Calcaneus abducts by rotating & sliding under talus
• Heel varus correction
• Weekly manipulation, long leg cast
• 1st – 4th cast
4 to 7 wks
• 5th & Final cast immobilization
(Percutaneous achilles tenotomy)
20 degree Dorsiflexion
70 degree External rotation
• Denis Browne bar
23 hr for 3 month, night time 3-4 years
• Tibialis anterior transfer to 3rd cuneiform
2.5~4 years, in 20-30%
Case I
Clubfoot Lt
(1 week after delivery)
Ponseti Serial
Cast correction
( 24 week)
Case II
Clubfoot Rt
(4 week after delivery)
Ponseti Serial
Cast correction
( 27 week)
Common error of
Manipulative reduction
Ponseti, I.V., Int Orthop. 1997
Common error of Manipulative reduction
: Pronation or eversion of foot
• Increasing the cavus
• Locking the adducted
calcanus under the talus
• Midfoot & forefoot
twisted into eversion
Increased Cavus
Bean-shaped foot
Common error of Manipulative reduction
: External rotation of foot with calcaneus in varus
Posterior displacement of
lateral malleolus
by externally rotating the
talus in the ankle mortise
(iatrogenic deformity)
•Abducting supinated foot
•counterpressure applied on
lateral aspect of head of talus
Common error of Manipulative reduction
: Abducting the foot with thumb
near Calcaneocuboid joint
“Kite’s error”
•Abduction of calcaneus
is blocked
•Interfering with the correction
of heel varus
•Grasping the heel with hand
prevent calcaneus from
abducting
“Calcaneus can evert only when it is abducted
(i.e. laterally rotated) under talus”
Common error of Manipulative reduction
: Attempt to correct equinus
before heel varus & foot supination
• Residual tight tendo Achilles
• No function in the TP, FHL, FDL
• Ligament laxity
Rocker bottom foot
Other Common error of
Manipulative reduction
Manipulation with no casting
Failure to use Denis bar splint
 3 months full time application 2-4 years night time application
Attempt to obtain perfect anatomic correction
Risk factor for recurrence of the
deformity
Non-compliance with the use of foot-abduction orthosis
(primary risk factor)
Level of parental education
Recurrence is not dependent on
 The initial severity of the deformity
 The age of the initial treatment
 The number of casts required for correction
 Whether the patient had previous non-operative treatment of the
deformity
A. Siapkara, R. Duncan. JBJS Br 2007
Preparation for Percutaneous TAL
1.
2.
3.
4.
5.
6.
7.
8.
Admission 1 day before surgery
No need for IV line maintenance.
Lidocaine jelly is applied 12 hrs. before tenotomy.
2-3 hours duration of NPO time is enough.
Pocral sedation; just before taking to the op. room &
keep another one as a reserve.
Mother is invited to op. room to soothe baby;
prepare milk feed bottle filled with water.
If the baby is fully sedated, perform Percutaneous
TAL under local anesthesia; w/ EKG, BP monitoring
Discharge on the op. day; cast change at 2-3 weeks
later – total period 4-6 weeks
T/F from Other Hospital (6 month / Male)
After Ponseti manipulation from post-delivery 2 month
( d/t Failure to use Denis bar splint )
TAL & Cast
correction
Bracing following correction of
idiopathic clubfoot using the
Ponseti method
2010 AAOS
Brace?
Ponseti method for the management of idiopathic clubfoot
 Popular & excellent outcomes
Achieving a successful outcome
 Not in correcting deformity but in preventing relapse
The most common cause of relapse
 failure to adhere to the prescribed postcorrective bracing regimen
New, more user-friendly braces have been introduced
in the hope of improving the rate of compliance
Controversy
Denis Browne bar VS AFO
Origin of the Foot Abduction Orthosis
Original Denis Browne splint
 Bar with an L-shaped metal foot plate at either end
 Designed to forcibly evert the foot without abducting the calcaneus
Ponseti
 Maintain correction by externally rotating the shoes on the bar
to maintain the degree of foot abduction achieved by manipulation
and cast application.
Modified Denis Browne splint
 Prevent recurrence of a corrected clubfoot
 Medical personnel began referring to this device
Rationale for Bracing
Ponseti
 Relapse typically occurs by age 5 years
 The time when most relapses occur corresponds to a period of
rapid growth of the foot
 The more important relapses, which occur in the hindfoot
-> related to retracting fibrosis of the ligaments &
musculotendinous
units of the posterior and medial ankle
Anderson et al
 Foot achieves half of its adult length by age 2 years
 Much earlier than is seen for lower limb length
 Rapid growth rate of the foot during infancy -> risk of relapse
Proper Use of the Foot
Abduction Orthosis
Successful use of the FAO ; obtaining full correction of the
clubfoot
Achilles tenotomy
 Required to obtain the 15° to 25° of dorsiflexion necessary to allow
proper use of the brace
 Inadequate dorsiflexion : heel to pull up out of the shoe
-> irritation and skin ulceration.
The heel should easily sit in the shoe
The width of the shoe should accommodate the width of the
foot
Proper Use of the Foot
Abduction Orthosis
Before treatment with
the Ponseti method
Posttenotomy cast removal
15° to 25° of dorsiflexion
Proper Use of the Foot
Abduction Orthosis
FAO components
 A bar with shoes attached to hold the affected foot
in approximately 70° of external rotation
 Unilateral deformity -> unaffected foot positioned in 40° of
abduction
 Placed at shoulder width for comfort
 Ends of the bar bent or adjusted to allow 5° to 10° of dorsiflexion
FAO use
 23 hours per day for 3 months following cast removal from a fully
corrected foot.
 The hour off is for bathing and a brace-free play period.
 After 3 months, the brace is worn at night time & nap time
Proper Use of the Foot
Abduction Orthosis
The foot grows quickly during infancy
 Up to two new pairs of orthotic shoes needed during the first year
of bracing and
 One new pair of shoes will be required for each year thereafter
 Complete overlap of the toes at the edge of the sole
: Indication that the infant is outgrowing the shoes
Proper Use of the Foot
Abduction Orthosis
Duration of FAO use
 Not thoroughly studied
 Ponseti and Smoley
; Bracing be continued until the child achieved age 3 to 5 years
 Ponseti (later)
; Brace should be worn at night for 2 to 4 years
 Abdelgawad et al
; No longer convincing the affected child to sleep with the brace
applied by the time the child reached age 3 years
; Device be continued as long as the child could tolerate it at night
Proper Use of the Foot
Abduction Orthosis
Recurrence management
 2 to 3 manipulations and cast applications at 1- to 2-week intervals
 If dorsiflexion is limited
; Age < 1 year -> achilles tenotomy may be repeated
Age > 1 year -> open Achilles tendon lengthening is preferred
In general, full-time bracing is recommended for infants
who developed a recurrence early in their treatment course
Proper Use of the Foot
Abduction Orthosis
Repeated recurrences management




Family is having difficulty complying with use of the FAO
Reinstituting bracing is usually optimal
Anterior tibial tendon transfer may be the best option in this situation
In these difficult cases, it is preferable to maintain bracing until the
child is aged approximately 30 months
Ossific nucleus of the third cuneiform is usually
sufficiently large to permit anterior tibial tendon
transfer
Proper Use of the Foot
Abduction Orthosis
Tendon transfer
 Prevent further relapse without the need for bracing
 Long-term outcome following tendon transfer
; Equal to that attained without transfer
 If the foot is not passively correctable to neutral,
Serial casts should be applied to situate the heel in valgus
before performing the tendon transfer
Commonly Available Orthoses
The Markell (M. J. Markell Shoe Co, Yonkers, NY) brace
 Used in most of the published reports on the Ponseti method
 New braces have been
Mitchell-Ponseti brace & Dobbs articulated brace
 In an effort to improve adherence with postcorrective bracing
The Steenbeek brace
 Inexpensively and easily made for use in developing nations
Markell Brace
Standard FAO at the University of Iowa for decades
Components
 A pair of open-toed shoes mounted on an aluminum spreader bar
 The flat bar is available in various sizes to allow widening of the
distance between the shoes as the child grows
 Aluminum foot plates attached to the bar by a stainless steel bolt that
fixes a serrated disk -> adjustment of the rotation of the foot plates
Mitchell-Ponseti Brace
Windows located at the counter
-> proper placement of the heel can be easily determined
Modified with a quickrelease mechanism to allow the
sandals to be applied before inserting them on the bar
Dobbs Dynamic Brace
Articulated FAO that allows active flexion and extension of
each leg separately while maintaining the necessary
external rotation of the foot (by Chen et al)
Components
 Custom-molded insert that fits into a solid ankle-foot orthosis
 Detachable bar to facilitate donning and doffing
Expensive than Markell brace and Mitchell-Ponseti brace
But, improve brace wear compliance
Steenbeek Brace
Designed and produced in the developing world
Components
 Outer sole made of plywood
 Inner sole made of card board
Attached to a simple metal plate that is riveted to the bar
Strategies for Improving
Postcorrective Orthosis Use
Ponseti method
 Noncompliance with the use of a postcorrective FAO
-> ranging from 32% to 61%
 The success of the Ponseti method is dependent on
parents’ ability to faithfully apply the postcorrective brace
Important to develop strategies to enlist their cooperation
The importance of postcorrective bracing should be stressed
to the family at the start of treatment and reinforced weekly
at each cast change
Strategies for Improving
Postcorrective Orthosis Use
Strategies to Improve the Use of Postcorrective Bracing Following
the Management of Clubfoot With the Ponseti Method
 See the family weekly after the brace is applied until the physician and/or
clinic staff is certain that the infant is tolerating the device
 Assess brace adherence at each patient visit and avoid criticism of the
parents when addressing problems that may have arisen
 Schedule regular follow-up appointments and use telephone calls or
certified letters to remind parents of missed appointments
 Address skin problems immediately
Strategies for Improving
Postcorrective OrthosisUse
Noncompliance is the result of misunderstood or forgotten
instructions
 Anxiety has been shown to impair memory
 Minimize anxiety in theparents or caregivers during the visit
At each visit to the clinic, should assess whether the parents
are following the recommended brace protocol
 The physician should ask,
“How many hours is the infant using the brace each day ?”
“Is there are any problems ?”
 The brace should be inspected for signs of appropriate wear
 Slight narrowing of the ankle -> “hallmark of a compliant family”
Useful early in the treatment course when the patient is using
the brace full-time
Strategies for Improving
Postcorrective OrthosisUse
At each visit to the clinic, should assess whether the parents
are following the recommended brace protocol
 Slight narrowing of the ankle -> “hallmark of a compliant family”
Useful early in the treatment course when the patient is using
the brace full-time
 If the family is noncompliant, the physician should refrain from
criticizing them so as to maintain trust in the therapeutic relationship
Strategies for Improving
Postcorrective Orthosis Use
One of the more common reasons for removing the brace
is sporadic crying of the infant
 Recommend that the parents apply the brace whenever the child is
placed in the crib or bed to sleep so that wearing the brace becomes an
invariable part of going to bed
Regular follow-up visits are important
 After switching to nighttime and nap-time use,
followed every 3 to 4 months during the 1st year
Strategies for Improving
Postcorrective Orthosis Use
Newer method of
Nonoperative treatment
French technique
 Johnston & Richards
POSNA, 1999
 Dimeglio method
J Pediatr Orthop B, 1996
Delgado, Botox
J Pediatr Orthop, 2000
Johnston & Richards
Manipulative therapy using a minimum of immobilization
Manipulation
 Disengage navicular fom med. malleolus
 Derotation of calcaneus & foot, as a unit (Calcaneopedal bloc)
 Downward traction to lengthen heel cord & distract hindfoot joint
 Forefoot correction into abduction combined with heel eversion
 Foot immobilized with elastic bandage
 Supplemented by rigid foot plate
French Technique
(manipulation & taping)
Dimeglio method
Continuous passive motion (CPM) machine
 During earliest portion of Tx.
Residual hindfoot equinus
 m/c persistent deformity
 Requiring “Limited posterior release"
Complication of Conservative
treatment
Cavus deformity
Rocker bottom deformity
Bean shaped foot
Flat top talus
Skin ulcer
Stiffness
Incomplete correction
Flattening of the prox. surface of the talus increase stiffness
Thank you for your attention