Renato James Giorgini, DPM provides an overview of childhood clubfoot and a brief discussion of neglected adult clubfoot. Dr Giorgini emphasizes the causes, assessment, treatment and goals in management of Congenital Idiopathic Talipes Equinovarus.
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Release Date: 03/16/2018 Expiration Date: 12/31/2018
Renato Giorgini, DPM
Doctor of Podiatric Medicine
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Male Speaker: The next speaker is with great pleasure I have the opportunity to introduce Renee Giorgini. He has been a great friend of mine for 45 years when he threw me out of the operating room at the hospital when I went as a student to watch surgery and he looked at me says, “What are you doing here?” I said, “I'm a first year podiatry student, I want to become a surgeon.” He said, “Get the hell out of here. Come back when you’re later on.” So here we are, we laugh about it. I tell that story every time. He’s a great friend and he has a lot to share with these experiences on clubfoot. So please welcome, Renee Giorgini.
Renee Giorgini: See, I knew his potential that’s why I throw him out. Made him nervous to be better than he is. Okay. Well anyway, we go back a long way, that’s true and things evolve and former residents always call me and say, “How do you do this?” And I said, “I don’t do it that way anymore. We’ve evolved so you got to keep evolving.” That’s very important. So we’re going to talk about the Management of Congenital Idiopathic Talipes Equinovarus Deformity, which is a topic that I’ve been involved with for the last 25 or 30 years. What are the goals to treat that? I’m going to make this a very simple lecture because it took me years to figure out the process and I still don’t know if I have figured it out completely. You really want to get a plantigrade functional and stable foot. When you’re operating on children of this nature and this young, it’s a whole different category. You can’t fuse joints. You can’t do a lot of things. We have to do a lot of tissue releases and you have to do manipulations of the foot. I think some of the surgery that’s out there from past is diminished a little bit because of the Ponseti method, which I’m sure you’re all familiar with when you had the school with the casting technique and the manipulation and the tenotomy of the Achilles tendon. But there’s always those few cases that don’t address themselves to that and you have to know a little bit about the history and how you could take care of them, of the 10% that don’t respond to Dr. Ponseti’s method. But what is the incidence? You’ve heard this one in a thousand live births. It’s a two to 2.5 male to female ratio. It’s 50% bilateral. If you look at in your pictures of a foot, you can see the development of the foot is almost normal than in the first trimester and then it evolves over a period of time after that. So you have to say to yourself, “What prevented that foot or what cause that foot to be in a clubfoot position?” It’s multifactorial. If multifactorial etiology is that it could be a germ plasma defect beginning and from advancing. It could be arrest of the fetal development. The arrest of abnormal muscles and tendon insertions can cause that deformity and you can have an imbalance between the fast and what they call the slow twitch fibers which was postulated by the pediatric orthopedists at the Long Island Jewish and he and I were working with a lot of this together at one time. But you can see if you're in development of this, the positioning of the foot with little metadductus and what caused that and why did it stay in that position. So you can have an absence sometimes of the dorsalis pedis or it could be a vascular compromise that maybe didn’t make it grow so high or grow to the position as it should or abnormal rotations of the talus and intrauterine position used to be the one that everybody said, “Well, it’s a big child growing in a small compartment and they were in a fixed position for a long period of time.” Nobody really knows the answer and you can see that the circulation in those fetal pictures shows you that it’s very small. So if you would compromise that circulation anyway, you could get an arrested development. Some authors have postulated that it’s a result of a neurological deficit as well and there were studies that we’re done on that and they said there was spinal cord injuries associated with it or defects in the spinal cord as it went down and that caused to not form in a correct position. Then you have to look at this when you evaluate these children. You have to look and say, “Well, what are the pathological conditions that can be associated with it?” You can have proximal femoral focal deficiencies, you can have congenital bifurcation of the femur, Pierre Robin which is a neurological syndrome, Larsen’s, amniotic band syndrome, myelodysplasias and you can have arthrogryposis multiplex congenita and you can have a diastrophic dwarfism. May have to be evaluated as well. My daughter, who studied in Rome, she does pediatric and adult orthopedics. She was a podiatrist and then became an MD and she practice in Rome because she met her husband there.
I thought she’s going to practice with me, but she left which is okay. I got great-grandchildren. They used to document these things. This was in a museum that they had in the orthopedic hospital, La Sapienza of how to document. So I thought it was an interesting thing. They would take these plaster molds of all these deficiencies. We used to take slides and I have digital pictures of everything [indecipherable] [05:28] 100, 150 years ago, that’s what they did and I guess they started out like Michael Angelo doing the same thing. But this you can see as a multifactorial deficiency in a young child has got spinal deficiencies, has leg deficiencies. This is your multiplex congenital deformities and you can see the feet in the position scoliosis. This is the ultimate end of deficiencies. Of course, the most of the clubfoot that I treated were idiopathic nature. It didn’t have that much neurological deficit. You should always have these children clear for that prior to doing any invasive surgery. Once you see any clubfoot, you know it’s like you see a cavus foot or you see a flatfoot, you know what it looks like. Obviously, it has forefoot adduction, has heel varus and has ankle equinus and there’s some questions whether there is internal or external rotation of the talus or is there internal rotation of the tibia associated with it because you can fix the clubfoot and the child still toes in when he go through wear gait. Morphological features, you have a shorter extremities, smaller calf and a smaller, shorter foot if it’s unilateral. If it’s bilateral, then they may appears the same. When you try to do a radiological assessment of these children, it’s difficult because the navicular doesn’t ossify until the third year. You have an eccentric ossification, nucleus of the talus, which means it’s not the true shape of it when you take an x-ray of it. You have a lateral rotation and calcaneal inversion which is unidentifiable. The foot must be in a maximally correct position. So it’s very hard to hold the child’s foot and get a really good x-ray of it. But you try. Of course, everybody has heard of Kite’s angle or the talocalcaneal angle and the talo-first metatarsal angle. You can see a representation here of the talo-first metatarsal angle and the Kite’s angle at the base as well. It’s nice if it looks like that and it’s a normal type of foot, but the reality, she get a foot that’s in a deform position and it’s a little bit harder to measure. When you line this up, you can see that the talo-first metatarsal angle was very high and you could see that the Kite’s angle is getting smaller and smaller and those are the keys that you look for to see the aggression of the deformity, is it getting better through casting and manipulation as well. The same thing with the lateral talocalcaneal angle should be reduced. If you look at the bisection of the talus and the calcaneus in a schematic normal foot, but the reality is you don’t see that type of foot, you see one like this with severe equinus and the bisecting of the talus and the calcaneus. The lines almost become parallel and the angle was not as visible. Here is another representation as well. But these are the standard, the goal standards that you try and follow to see if the child improving, if not, what are you going to do? Radiological assessment says you can do tomography which really isn’t done before, arthrography is not. But probably the x-ray, CAT scan is okay. They have the 3D CAT scan, MRI modeling, but it’s a lot a radiation for a young child and the MRI. You have to those under sedation if you’re operating. If the child is so small, they have to be sedated because they can’t have any movement, whatsoever. When you do treat this? Well, as soon after birth as possible because the tissues are pliable, soft tissues and ligaments when you have in the early discrimination between the flexible and the rigid types. The treatment review the index [indecipherable] [09:15] annual bibliography of the orthopedic surgery show that from 1971 to 1989, the treatment was for an aggressive surgical trend. Ponseti was postulating many, many years before that, that you could do this with manipulation and casting and then it fell out of favor and surgery was the one because everybody more feel like casting these kids in their office for six to seven weeks and then having to see them weekly and then change them. But it’s proven in that from MRI studies and advancement that this is the case, that it does work and it’s effective but there is a 10% that doesn’t respond to that type of therapy. The aggressive surgical trend now was like diminished and it’s more of the conservative trend.
We found that when we did operate on these children at a younger age that if we got them earlier like at the eight, ninth or tenth month, we got a higher cure rate on them and if we waited until 30, 40 or 50 months out. So what is the treatment? Usually in the beginning, Ponseti’s manipulation in serial casting is the goal standard weekly for 6 to 12 weeks of life. Gentle but firm force with 10 to 15 minutes and he can show you his whole series of casting where he doesn’t really correct the equinus at all during the casting. He manipulates it in an equinus position and tries to maintain the talocalcaneal joint and swing the navicular around the front of the talus by pushing its lateral impression on to realign the joint. So it’s gentle but firm force for 10 to 15 minutes of doing casting and doing a series of casting. By the time he gets up to the six to seven cast and he will do a tenotomy. Not a full tenotomy across the Achilles tendon to affect the dorsiflexion and relax the other structures. So the treatment is manipulation serial casting while attempt to reduce all components from the start. You want to treat the forefoot adduction, the hindfoot varus and the hindfoot equinus. Reduce the foot equinus less because you don’t want to get a rocker bottom foot. But remember that manipulation and stretching will correct but casting maintains the position. Not only do you do casting and even when you do surgery, you want to maintain the position by bracing or any other device that you have with you here to maintain until they reach scale a little maturity so that there isn’t a recurrence of that deformity and everybody will indicate you on the lectures that you have when you follow children out for a long time, there can be a recurrence of deformity and they may have to be operated on two or three years over that 18 to 20-year period when you saw them when they’re very young. So manipulation in serial casting, we all know should be that, you don’t want to do below knee cast because they fall out, but you want to do above knee cast to control the rotation and correction. We look at the assessment of nonsurgical treatment satisfactory clinic on radiographic corrections and no further correction then the failure of surgical treatment, you want to do a comprehensive soft tissue release between three and 12 months. Well, three is a little bit on the younger side. You like to get them just about a month before they reach the 12-month period because in the cardiovascular and their respiratory systems have developed enough that they can tolerate the general anesthetic. Treatment selection of the proper manager depends on the type and everybody said to you first, do no harm but it’s also depends on the type of deformity and the skill of the surgeons. We will take you through this lecture and showing you that what do you do for a child that has an idiopathic clubfoot and you got them early and you’ve cast them and then you’ve had to operate because the casting has failed and then I’ll talk to you about neglected clubfeet. They were never treated and they're in their 30s and that becomes a different situation. A child that you can get with manipulation in soft tissue releases meet the older neglected clubfoot is usually all osseous., a combination of soft tissue as well. So the treatment started basically in ‘71 with Turco for surgical, it was one stage posteromedial release and then McKay did a posteromedial lateral releases and Simons was the complete subtalar release. I think Simons has probably fallen out of favor a little bit because it was a very gross over the section, and they thought that the more you did, the better you had. But in the developmental structures in the growing child, you want to do the least amount and get the maximum result and you can start doing a lot of things more percutaneous now. So the incisions that were postulated that time was a Turco which is a posteromedial incision and it was a transverse incision of Cincinnati which was Crawford and it was a two-incision technique of Carroll. So it’s just a surgical planning and surgical approach is anatomically. The Cincinnati incision was extended around the back of the heel and when you open up the heel to operate, you end up with a fishmouth incision. It gave you good exposure for the soft tissue release but these advantages was, there was a potential for skin necrosis. So that’s just Cincinnati incision. This picture doesn’t really show it well because when you put the foot up into a neutral position, it looks like a big fishmouth because it fits in equinus and you do it. Then what they use to have do in those days is they used that because they couldn’t get the skin to come back together. They would put it back in equinus and then manipulate it out over several weeks with casting. The two-incision approach of Carroll was there was a decrease of potential for skin necrosis and reduces the postsurgical scarring and shows one on the medial side like a hockey-stick type incision and then one on the lateral side to treat it, to give you better exposure if you had two releases on the lateral side.
The fixation was usually to maintain the correction. It was a smooth K-wire across the talonavicular joints, sometimes the talocalcaneal joint. Now with absorbable pins, you might want to consider that too because then they’ll dissolve as long as the child doesn’t get a foreign body reaction, but I traditionally put Kirschner wires in. Our technique for the talipes equinovarus for the clubfoot deformity was an incision of a Turco. You can see the clubfoot there. Also, you have to incorporate a plantar release as well which is to release the first muscle layer and that’s the plantar fascia as well as the abductor, adductor and the plantar muscle structure as well. You can do that through a percutaneous incision on the lateral side. You go above the first muscle layer and then you go below the plantar fascia and just take a straight tenotomy type of scissor and you just section that. We found that by doing that, we had less metatarsus adductus that reoccurred down the road later because it was like the cavus foot by releasing that struck for you, we’re able to lengthen the foot and prevent the recurrence of the metatarsus adductus. You can see a picture of it there. Then we went over and did our Turco standard procedure and then you have to take down all the structures on the medial aspect. Now, you have to understand that when they say a posteromedial plantar release, on the medial side of the foot, you have the four tendons, the posterior tibial tendon, the Tom, Dick and Harry. You have to avoid the neurological structures and raises, “When do you stop?” Well, you stop when you get a correction. See, sometimes, you have to lengthen the tibialis anterior, the posterior tibial and the flexor digitorum longus, the flexor hallucis longus tendons as you go up. Then you have to do tenotomies and capsulotomies of the metatarsophalangeal joint, the metatarsal cuneiform joint, the talonavicular joint and sometimes the posterior or subtalar joint as well. One of the things when you do clubfoot on children is you never release the deep deltoid ligaments and release the superficial deltoid. Because if you release the deep deltoid ligaments, then you’re going to get ankle instability, and when the child grows and stand, you’re going to have a valgus foot instead of a slight varus or a cavovarus foot that they have. This is the takedown on this and you have to tag off all the structures. The dissection takes longer than the actual procedures and sometimes if the child foot is small, if you look at the size of my finger in here, sometimes this is a bit longer as your index finger depending on the age and the morphology of the foot. Then you go back and you want to do the posterior compartment. The posterior is usually a tendo Achilles lengthening, a Z-plasty and then you have to release the posterior subtalar joint and the posterior ankle joint capsulotomy. You do capsulotomies with that and you swing the foot over and if it reaches a good position and this just shows you the posterior with the hemostasis, the Achilles tendon is lengthening and that’s your posterior tibial tendon. Actually, it’s the flexor digitorum longus tendon and then there’s the tibialis anterior tendon dorsal to that neurovascular bundles. You have to consider the master knot of Henry which you probably remember from your anatomy but that’s where the flexor digitorum longus and the flexor hallucis longus tendon that’s not around then if you don’t release that then you have more chance of getting recurrence of your deformity later on with less tendon glide and slide. Now, you don’t have to lengthen every tendon because you’re doing the stepwise fashions. Stepwise fashion is to go from proximal to distal. Once you get in, in the good position, you’re going to close the wound, put a K-wire in. This is just a representation of what these children look like. Sometimes you get hypertrophic scars but they usually fade with time and you can see it’s in a functional position and it’s a normal foot, well somewhat normal. This is a representation of the clubfoot. So this is before on the left and this is after as well, your right. It’s before and after what the child looks like. This is another one before and that’s after. The child’s grown up a little bit more there. That’s before and this is after. There’s another case, if this is neglected too long, and I want you to fixate on this picture a little bit because I’m going to show you what a neglected clubfoot looks like. We had done the one foot at the child at that time on the left but she developed some respiratory problems and we’re unable to treat it until she was about 18 or 19 months old.
Also she started ambulating on the right foot. It was a bilateral case. If you look over, you’ll see over here, it’s like an adventitious bursa because she was rolling off the top of her foot every time she walked. She had one foot to walk comfortably but this one, she developed this adventitious bursa. You can see here. So this was the corrected foot here and this is the one we were forced to delay. It’s tough to do both feet at the same time, like do one and then do another one later on. But you just resect out. Now I don’t even resect them because they’ll usually absorbed by themselves, but you can. So we took that down, took out this adventitious bursa, close it up then made our incision again. That’s my approach. Of course, this is one of the early stages where we then used to many tourniquets on these children because they were so small and we were afraid that we might compromise some of the circulation and you just have to tag everything off that’s possible. You’re just seeing all those structures easily and you have to identify. I'll get to a good picture in a second. It’s messy, so I’m going to put the gore through there. Alright. The other thing is you have to fixate the talonavicular joint then you go through a set of serial casting. You don’t want the correction to slip out because basically it’s a subluxation of the talonavicular joint and then you’re going to do above knee casting and follow up with that. As a kid that’s 14 years postop it’s very hard to tell which foot we did. Alright, we did the right one, okay. But as 14 years postop and we did a followup study of this, so I guess we have some evidence based medicine to follow up. We had a long term followup of analysis of 44 patients that we did and that was my self on the paper and actually, my daughter was a student then, [indecipherable] [22:00] Dr. Collin and a couple of other students. It was difficult to compare when you take everybody through the literature to compare our results with other people’s result because everybody measure it differently. But there were no two clubfeet of the same before treatment, there was lack of universally accepted rating system, clinical radiological functional criteria or combination. It was difficult to compare to observe error, subjective description of the treated clubfoot and radiographic positioning. It was inadequate, inaccurate. But if you had an excellent result that would mean that it was painless plantigrade, good range of motion, propulsive gait, near anatomic normal and the correction of deformity components, excellent to good. I’ll just go through this fast, cosmetically pleasing maintains lasting correction. The results of clubfoot treatment will not result in a completely normal foot but in actuality, you do have a little bit of calf atrophy especially if it’s unilateral. You have asymmetrical foot size if it’s unilateral. You have a limited subtalar joint range of motion, forefoot abductus and you had heel varus and a little bit of an in-toe gait which is from the external rotation. We did a questionnaire on all these patients which took into account function, knee position, heel position, ankle dorsiflexion, all tried et cetera, et cetera. Our study, which was done as a biomechanical study, we have forefoot adduction in about 17% of the patients. We had limited ankle joint subtalar range of motion 70% and a heel varus in approximately 35%. But they could all function and fit into a shoe adequately. Our study compare with other studies that the talocalcaneal angle was 16 degrees, but it’s normal, but we got it down to 16 degrees normal, almost 15 to 30. The lateral talocalcaneal angle of 21 degrees normal is 35 to 50. The talocalcaneal index which is 37, we all fit into the parameters. Okay. I’m just going to jump ahead. So our results were comparable to other studies. Now, the other problem is we work paper on three patients who had neglected clubfoot which is a whole different stories to the young fellow who is in Puerto Rico and he got one of his baby pictures but he came to me like, you see the patient on the left there. It’s hard to evaluate this patient. You can see if you look at the CAT scan of his foot on your right just like roll over where he’s walking on the top of his foot and he’s developing an adventitious bursal sac right over here. That’s like that little baby we showed earlier in the presentation. That’s pretty hard foot to evaluate biomechanically as well and that’s what he looks like postop.
I think he’s nine years postop but somebody just sent me a picture, he came through one of the class I was at, so he’s about 20 years postop. Our first surgery was one operation extensive soft tissue release wedge resection of the calcaneocuboid joint that was the neglected clubfoot and we had to do a wedge transfer of the talonavicular joint. We remove the rearfoot varus, we had minimal shortening, we have normal plantigrade position, satisfactory cosmetic appearance. The patients could wear commercial shoe here, they could walk barefoot, they had some pain two out of three. All were employed, but they had some limited physical activities. And then of course I’ll just mention real quickly, the Ilizarov method for doing this, that stretch this out. It was like manipulative casting as well and you can stretch it out and it’s a whole complex problem worth putting this on as everybody knows and just some cases event. Our goals were to get a plantigrade functional stable foot. Clubfoot treatment will not result in a completely normal foot, selection of proper management depends on the type, the formula skill of the surgeon and of course first do no harm. Thank you.