Congenital clubfoot.

Congenital clubfoot (equino-cava-varus deformity) is one of the most common developmental defects of the musculoskeletal system, which, according to various authors, accounts for 4 to 20% of all deformities.

ICD-10 code

Q66. Congenital deformities of the foot.

Epidemiology

The deformation is hereditary in 30% of patients. Clubfoot is most often found in boys. The birth rate of children with congenital clubfoot is 0.1-0.4%, while in 10-30% of cases there is a combination with congenital hip dislocation, torticollis, syndactyly, and non-closure of the hard and soft palate.

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What causes congenital clubfoot?

Congenital clubfoot develops as a result of the impact of endogenous and exogenous pathological factors (fusion of the amnion with the surface of the embryo and pressure of the amniotic strands, umbilical cord, uterine muscles; toxicosis during pregnancy, viral infection, toxoplasmosis, toxic effects, vitamin deficiency, etc.) during embryogenesis and the early fetal period of fetal development.

There are various theories of the origin of equino-cava-varus foot deformity - mechanical, embryonic, neurogenic. According to a number of researchers, clubfoot is a hereditary disease caused by gene mutation. Most authors believe that the leading role in the pathogenesis of congenital foot deformities and subsequent relapse after surgical treatment belongs to the nervous system - disruption of nerve impulse conduction and muscle dystonia.

Congenital clubfoot can be both an independent developmental defect and accompany a number of systemic diseases, such as arthrogryposis, diastrophic dysplasia, Freeman-Sheldon syndrome, Larsen syndrome, and also have a neurological basis in developmental defects of the lumbosacral spine, severe spondylomyelodysplasia.

How does congenital clubfoot manifest itself?

Congenital clubfoot is manifested by changes in the articular surfaces of the bones of the ankle joint, especially the talus, the joint capsule and ligamentous apparatus, tendons and muscles - their shortening, underdevelopment, displacement of attachment points.

The incorrect position of the foot in a child is determined from the moment of birth. The deformation in congenital clubfoot consists of the following components:

• plantar flexion of the foot (pes equinus);
• supination - rotation of the plantar surface inward with lowering of the outer edge (pes varus);
• adduction of the anterior section (pes adductus);
• increasing the longitudinal arch of the foot (pes excavates).

With age, clubfoot increases, there is hypotrophy of the calf muscles, internal torsion of the calf bones, hypertrophy of the outer malleolus, protrusion of the head of the talus from the outer-dorsal side of the foot, a sharp decrease in the inner malleolus, varus deviation of the toes. Due to the deformation of the foot, children begin to walk late. Congenital clubfoot is characterized by a typical gait with support on the dorsal-outer surface of the foot, with unilateral deformation - lameness, with bilateral - a gait with small steps, waddling in children 1.5-2 years old, in older children - with stepping over the opposite deformed foot. By the age of 7-9 years, children begin to complain of rapid fatigue and pain while walking. Providing them with orthopedic shoes is extremely difficult.

Depending on the possibility of performing passive correction of foot deformity, the following degrees of congenital clubfoot are distinguished:

• I degree (mild) - the deformation components are easily pliable and can be eliminated without much effort;
• II degree (moderate severity) - movements in the ankle joint are limited; during correction, springy resistance is detected, mainly from the soft tissues, which prevents the elimination of some components of the deformation;
• Grade III (severe) - movements in the ankle joint and foot are severely limited, correction of the deformity by hand is impossible.

Classification of congenital clubfoot

Clubfoot can be either bilateral or unilateral. With unilateral clubfoot, a shortening of the foot of up to 2 cm, sometimes up to 4 cm, is noted. By adolescence, shortening of the shin develops, sometimes requiring correction of its length.

The structure of the deformation is adduction of the anterior section, varus deformation of the posterior section, equinus position of the talus and calcaneus, supination of the entire foot and an increase in the longitudinal arch (cavus deformation), which determines the Latin name of the pathology - equino-cava-varus deformation of the foot.

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How is congenital clubfoot recognized?

The examination begins with a general examination of the child. Congenital clubfoot is often combined with disorders of the musculoskeletal system - congenital or installation torticollis, dysplasia of the hip joints of varying severity, dysplasia of the lumbosacral spine. Congenital bands on the shin are found in 0.1% of patients.

During the initial examination, attention is paid to the position of the child's head in relation to the skeletal axis, the presence of retractions, telangiectasias in the lumbar region, the degree of abduction and rotational movements in the hip joints. It is also necessary to note the presence of torsion of the shin bones.

If there are any deviations from the norm, additional examination is recommended - ultrasound of the cervical, lumbar spine and hip joints.

In case of decreased function of the finger extensors, hypotrophy of the muscles of the dorsum of the leg and foot, a neurological examination is necessary, supplemented by electromyography of the muscles of the lower extremities.

Various classifications have been proposed to determine the severity of deformation, but the most practical is the classification of F.R. Bogdanov.

• Typical form - mild, moderate and severe.
• The aggravated form is clubfoot with amniotic bands, arthrogryposis, achondroplasia, congenital defects of the bones of the foot and lower leg, pronounced torsion of the lower leg bones and neurogenic form of deformation.
• Recurrent form - clubfoot that develops after treatment of aggravated or severe degree of clubfoot.

The presented typical form of congenital clubfoot should be differentiated from atypical ones in arthrogryposis, amniotic band of the leg, spina bifida aperta in myelodysplasia.

• In arthrogryposis, along with the foot deformity of the clubfoot type from birth, contractures and deformations of the knee and hip joints are noted, often with hip dislocation, flexion contractures of the upper limb, more often of the wrist joint.
• Amniotic bands are formed when the amnion fuses with various parts of the fetus, often causing spontaneous amputations of limbs or forming, for example, deep circular retractions and deformations of the distal section (on the shin, like clubfoot) with functional and trophic disorders in the shin area.
• In spina bifida aperta, accompanied by spinal hernia and myelodysplasia, a clubfoot-type deformation is formed as a result of flaccid paralysis or paresis of the lower limb. Neurological symptoms (hyporeflexia, hypotonia with muscle hypotrophy of the limb), and dysfunction of the pelvic organs are detected.

How to correct congenital clubfoot?

Non-drug treatment

Congenital clubfoot should be corrected from the first days of a child's life using conservative methods. The basis of conservative treatment is manual correction of the deformation and maintenance of the achieved correction. Manual correction of the deformation consists of the following actions:

• retraining gymnastics, massage for clubfoot;
• sequential correction of the components of foot deformation: adduction, supination and equinus.

In case of mild deformation, corrective gymnastics is performed before feeding the child for 3-5 minutes, ending with a massage of the shin and foot, repeating 3-4 times a day. After gymnastics, the foot is held in the corrected position with a soft bandage made of flannel fabric (the length of the bandage is 1.5-2 m, the width is 5-6 cm) according to the Fink-Ettingen method. The sometimes appearing cyanosis of the fingers should disappear after 5-7 minutes. Otherwise, the limb should be bandaged again, loosening the turns of the bandage.

In case of moderate and severe degrees of deformation, the above-mentioned exercise therapy for clubfoot should be used as a preparatory stage for treatment with staged corrective plaster casts. Treatment of clubfoot is performed by an orthopedic doctor at the clinic, starting from the age of two weeks. The first plaster boot-cast is applied from the tips of the toes to the knee joint without correction of the deformation. Subsequently, with each change of plaster cast after 7-10 days, supination and adduction are consistently eliminated, then plantar flexion of the foot.

To correct clubfoot, the child is placed on his stomach, the leg is bent at the knee joint and fixed by the heel and lower third of the shin with one hand. With the other hand, with a light, non-violent movement, slowly, gradually stretching the soft tissues and ligaments, the correction is carried out. A plaster cast is applied to the leg with a cotton-gauze lining. The turns of the plaster bandage are carried out freely, in circular motions against the direction of the deformation, from the outside of the foot to the dorsal surface inward with careful modeling of the bandage. It is important to monitor the condition of the fingers. Elimination of the deformation is achieved after 10-15 stages, depending on the degree of clubfoot. Then, in the hypercorrection position of the foot, a plaster boot is applied for 3-4 months, changing it monthly. After removing the plaster boot, massage, therapeutic exercises, physiotherapy (warm baths, paraffin or ozokerite applications) are recommended. Shoes for clubfoot look like they have a pronator padded over the entire surface of the sole. To hold the foot in the corrected position, a plaster or polymeric material (for example, polywick) tutor is put on at night.

Immediately upon discharge from the maternity hospital, the child must be sent to a specialized institution where staged plaster corrections will be performed to correct the foot deformity.

Treatment started as early as possible has a significantly greater chance of achieving complete correction of the foot conservatively than delayed treatment.

Surgical treatment

Indications

If conservative treatment fails in children older than 6 months, as well as in cases of late treatment, surgical treatment is indicated - tenoligamental-tocalsulotomy according to the method of T.S. Zatsepin.

Technique of operation

A hemostatic and hemostopping tourniquet is applied to the lower third of the thigh. The operation is performed through four incisions:

• a 2-3 cm long skin incision along the plantar-medial surface of the foot. The plantar aponeurosis is determined by palpation, for which the assistant stretches it, pressing on the head of the metatarsal bone and the heel. A grooved probe is inserted under the plantar aponeurosis, and a fasciotomy is performed with a scalpel. Nodal catgut sutures are applied to the skin;
• a 4 cm long skin incision along the medial surface of the foot above the head of the first metatarsal bone. The tendon of the abductor muscle is mobilized and lengthened in a Z-shape. Nodal catgut sutures are applied to the skin:
• a skin incision extending from the middle of the medial plantar surface of the foot through the middle of the inner malleolus to the middle third of the shin. The skin is mobilized. The lacunar ligament is dissected, and the tendon of the sheath of the posterior tibial muscle and the long flexor of the fingers is opened along a grooved probe. A Z-shaped lengthening of the tendons of these muscles is performed. The medial, posterior (carefully - the vascular-nerve bundle) and anterior ligaments of the supratalar and subtalar joints are dissected with a scalpel. The wound is not sutured.
• a 6-8 cm long skin incision outward from the Achilles tendon (carefully towards the saphena parvel). The skin is mobilized. The tendon sheath is opened along the probe and a Z-shaped extension of the Achilles tendon is performed in the sagittal plane, leaving the outer half of the tendon at the heel. The dissected tendon is retracted, and the deep leaf of the fascia of the leg is opened in the depth of the wound along the midline. The tendon of the long flexor of the first finger is mobilized.

Following distally along the tendon (carefully - inwards the vascular-nerve bundle), dissect the posterior ligaments of the supra-talar and subtalar joints. The foot is brought to the middle position with the limb straightened at the knee joint and held in this position. Nodal sutures are applied to the elongated tendons. The tourniquet is removed. Nodal catgut sutures are applied to the tendon sheath, subcutaneous fat and skin.

Complications

It is necessary to strive to leave a wider “skin bridge” between the third and fourth incisions, since with a narrow flap and its extended mobilization, necrosis is possible in the postoperative period.

Some clinics use a modified technique. The operation is performed from one incision. It starts above the head of the first metatarsal bone, goes along the border with the plantar surface of the foot to the projection of the calcaneus and then up along the projection of the vascular-nerve bundle (the middle between the inner malleolus and the Achilles tendon). The skin and vascular-nerve bundle are mobilized. The latter is taken on rubber holders.

Next, the above-mentioned muscle tendons are lengthened and the supra-talar and subtalar joints are opened. The deformation is eliminated. The operation is completed as described above. The proposed method of operation allows for a wide opening of the surgical field and avoidance of damage to the vascular-nerve structures on the foot and lower leg. In the postoperative period, the risk of necrosis of the "skin bridge" between the ankle and the Achilles tendon disappears.

An aseptic gauze patch is applied. A circular plaster cast is applied from the foot to the middle third of the thigh. The cast is cut along the front surface. After the stitches are removed, a solid plaster cast is applied on the 12th to 14th day. One month after the operation, the cast is replaced with a plaster boot, which allows movement in the knee joint. The total period of immobilization in plaster is 4 months. Later, the child is given splints and undergoes rehabilitation courses (massage, exercise therapy, physiotherapy).

Early conservative treatment allows to obtain up to 90% favorable outcomes. It is possible to judge the complete cure of such a pathology as congenital clubfoot not earlier than after 5 years. Dispensary observation is necessary up to 7-14 years.

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