• LecturehallCongenital Clubfoot (ICTEV)
  • Lecture Transcript
  • TAPE STARTS – [00:00]

    Unidentified Female Speaker: I have the honor of actually introducing the next speaker, Dr. Mark Bernard. He is Executive Director of the American Board of Podiatric Medicine, and he's formerly the organization's exam chair. He also serves on the Council of Podiatric Medicine, Educators' Collaborative Residency Evaluator Committee, charged with in-servicing site reviewers to residency program evaluation. He is also the Co-chair and President of the Baja Project for Crippled Children, an organization which over the past 40 years has had over 30,000 patient visits, and performed over 3,000 foot and ankle surgeries on children with congenital and acquired neuromuscular conditions. Incredible.

    The project has trained several hundred residents in the process. Dr. Bernard is a former chair of the Committee on Disaster Relief of the Rotary International District 5280. He is board-certified with both the American Board of Podiatric Medicine and the American Board of Podiatric Foot and Ankle Surgery and lectures nationally in all areas of pediatric and adult biomechanical surgery. We are very fortunate to have him here today and welcome.

    Dr. Mark Bernard: Hello everybody. We're going to delve into an area that some of you may encounter during the course of your careers. I certainly expect some of you to be encountering this in the First World environment such as the US in infancy. And if you delve into pediatrics, and you make the right connections, then you maybe referred children with congenital clubfoot. I'm going to be spending about an hour with you this morning talking about idiopathic congenital talipes equinovarus, which is clubfoot.


    Understand however, that there are multiple types of pathways that lead to a foot that forms into an adductus cavovarus foot type that are very different than this, and they have to be managed in a different way. And so, I could be spending literally the whole day talking about clubfoot, but I'm limiting it to the congenital variety for the sake of brevity and to give you an overview and it also limits the amount of variables with which you would have to deal, very many of which we do in a regular abroad with my group. Okay.

    These are the disclaimers and so forth, just give you an overview. This is just a sample or smattering of the kind of diagnosis and cases that my particular group sees at any given time on one of our surgical brigades down at the Central America and Mexico. And I expect, we'll be seeing the same thing in a couple of weeks when I leave for India with about half of our group is going to India for two weeks to do some surgery, and train the orthopods there in the methods that we use. To give you an idea, for those who aren't familiar, TEV is talipes equinovarus.

    So, take a look here at the number of TEV that you see there, and how many in an environment in which you have a neglected pathology. Look at how many talectomies we ended up doing. And for the older practitioners here who were told when we were trained that talectomy is not a good procedure, not that I'm going to focus on talectomy. I can tell you that it is a wonderful procedure if chosen well and well done. So, don't believe you read in the literature. I would tell experientially that that's not true. Okay.


    But let's talk about idiopathic congenital TEV. Worldwide, it's approximately one in a thousand live births, about a two to one male to female ratio, there is a strong association with genetics and environment. With this, they are both intertwined with the development of this. And to this day, for all of the myriad number of studies that have been done worldwide, and this has been extensively studied. To this day, people don't have a clear idea of the genetic pathway towards this disease. Half of the cases are bilateral, and to pound home the idea that this is indeed genetically mediated in many cases, there's about a third of a correlation in identical twins when presented with this deformity. So, a third of the identical twins born where one sibling has the condition, so is the other sibling. Okay.

    The most essential things to go over here in the short time frame that we've got is what is the essence of this pathology and subsequent to that, what are the secondary and tertiary positional deformities that occur as a result of it? The single most significant deformity within this from a primary basis is a primary germ cell defect in the tarsus and especially, the talonavicular joint. If you look at the MRI in the upper left, you can see the position, this is dorsal plantar of course. You can see the lateral malleolus, you can see medial malleolus and the trochlear surface. Look at the position of the talar neck and head. It is deviated medially, you can't see it at its plantar, but look at the position of the navicular, you noticed that it's rotated 90 degrees on the talar head.


    And this is the essence of the initial deformity from which all the remaining contractures reside and that which needs to be addressed. I point to the upper right because as you saw, we did a lot of talectomies. So, in the connection of that, this is not a lateral view of the talus. You are looking anterior to posterior. So, do I have a light bar here? I do. All right. So, if this is the trochlear surface of the talus, this is the lateral gutter, this is medial. Look at where the articular position is on the talar head. This is the adaptative position of the articulation because of where the navicular sits. Did everybody see that? Yeah? Okay.

    All right. Now, I put the term rigid in quotes because rigidity is a relative term. In infants, for those of you who don't encounter them. In infants, soft tissues are hard and osseous and cartilaginous structures are soft. So, there's always a quality of, depending upon how young the child is, flexibility to it if for no other reason. If you think about an infant's foot, the quality of the tissue being cartilaginous is more like your ear or the tip of your nose. There's mobility there. Nevertheless, the contractures around that, the ligamentous contractures and sometimes the tendon contractures can be much more rigid than the actual osseous or cartilaginous precursors to the osseous structures. Okay.


    As I said, it's not just the talus, the talonavicular joint that's contracted or subluxated, carried with that is the talocalcaneal navicular complex. Meaning, and I'll go through this, so you don't have to hurry up and memorize this. It's subluxated into a hyper supinated scenario and/or dislocated. Heel size is diminished, and I'll point out just how that plays out when you palpate it, and there are deep skin creases that are the sinequanon if you will of tipping you off to the fact that you've got an idiopathic congenital TEV rather than some other structures that if you're not well-versed in this pathology, you may misdiagnose.

    Cath atrophy is very often present in ambulatory clubfeet. Okay. So, if we now orient the foot in the cardinal planes, so, we're looking at each plane individually, the three cardinal aspects of this and there's a fourth, which I'll spend some time with all these. Forefoot adductus, now when I say forefoot adductus, you cannot in a patient this age because the midfoot is radiologically silent differentiate forefoot from metatarsus adductus. They will look alike from deep view, but the abduction is actually occurring at the midfoot on the hind foot.

    Yes, the metatarsals would look abducted, but that's carried through because the entire forefoot is abducted. The hind foot is equinovarus as you can see. And what you can't see or what you can see here, oops, I keep doing the same thing. Sorry again, I got to go backwards. And if you look here on the bottom, you see the equinus. Now, I want to point something out to you. I want you to look at the fissure that's on the superior aspect of the calcaneus on the bottom image.


    See that? That shows you where the top of the calcaneus is. If you wanted to know where the bottom of the calcaneus is, I'm going to make sure I have the mic. Where would you estimate the bottom of the calcaneus to be in an infant's foot? If this is the top of the calcaneus where the fissure is, where's the bottom of the calcaneus? Here? The fact is, it's right here. All of this is baby fat. All of this is baby fat. So, if this is the top of the calcaneus, this is the bottom of the calcaneus, and you'll appreciate this better when I show you the radiograph.

    You see the fissure here? Once you see a fissure here and here, you are dealing with a congenital clubfoot. If you had a severe metatarsus adductus, you're not going to see this and you're certainly not going to see this. So, bear that in mind. Okay. Now, there's another syndrome called medial malalignment, and what that is, is as these children become ambulatory, which is the world that I live in, and have lived in, in the last 40 years with all of this is as they start bearing weight. And this is not necessarily an absolute contraindication for these kids being able to walk.

    They are walkers. They become ambulatory, but they are late ambulators because of the position of the foot. And if I can get this to work, I will show you this. I may need a technical assist, but if you look at this, you see where the weight bearing surface is. You see adventitious bursa sitting over the cuboid and lateral calcaneus. And what that is due to is this position that the foot is in when the child weight-bearing and ambulatory. Got it? So, if you take a look at this, you can see that they can ambulate, but the foot is generally pointed backwards by the time they are this old.


    Okay. So, let's start looking at the radiology of TEV. So, there's stacking of the tarsus, all right? Kite's angle is very, very low and as you can see here at the two lines that are there, you see the parallelism between the bisection of the talus and the bisection of the calcaneus, and that's because of the stacking of the tarsus. Meaning, the hindfoot is supinated and the calcaneus is tucked under the talus just as a navicular is way medial on the talus, but you can't see that because in the foot that's this young, the navicular is radiographically silent. But positionally, you saw it on the previous image. Okay? As I said previously, the mid-foot and the metatarsals are abducted. On the lateral view, similarly, the talocalcaneal angle is low and once again, you see parallelism between the talus and calcaneus.

    So, you don't have convergency anteriorly as you normally would on a pediatric foot or even on an adult foot. What is causing this is not necessarily the talar declination, but it's the calcaneal declination. So, where this differs very significantly from cavus foot and one of the major takeaways I want for you residents to understand is that a clubfoot is not a cavus foot. It is an entity unto itself because in a calcaneus foot and I'll show you that later. In a cavus foot, the calcaneus is in calcaneus, meaning the pitch of the calcaneus is elevated. In a clubfoot, it's declinated, hence the parallelism between the talus and calcaneus. Everybody clear on that? Major differential between the two. Okay?


    Also, I want to make mention of what you see here on the bottom, flattening of the talar trochlear surface. In ambulatory clubfeet, because of the plasticity of the tissue and the abnormal stresses that are brought onto the foot, what will happen is the trochlear surface of talus would gradually flatten as the child gets heavier and heavier and develops more and more of an [indecipherable] [00:14:28]. But there is another thing that will create the illusion of the talar trochlear surface being flattened, and that is the fact that if you don't take your image properly, you are looking at the medial and lateral shoulder of the trochlear surface of the talus and as such, you are looking at two curves that's superimposed, and it makes it look like this calcaneus and talus are flattened. Thank you.

    So, if everybody can see what I'm saying, if you take a look here. This is not completely ossified, but if this was further ossified because of the position of the foot, you would be looking at the medial and lateral curves of the talar trochlear surface and it would give you a flattened appearance. That appearance may be real or that appearance maybe an optical illusion. It is therefore essential when you take your lateral view, you take a medial view as well to true up the ankle mortise in a lateral projection. In that way, you'll know whether the curvature of the trochlear surface of your talus is real or truly flattened. Why is that important? It relates to the prospect of you being able to reduce the equinus surgically.


    Any questions about that? So, the takeaway is, make sure you get a medial and a lateral view. Moving on along. I want to show you a comparative from an AP perspective of the difference between club foot and other adductory deformities that you may encounter. So, what you see on the left is metatarsus adductus. And there, you will see that kite's angle is normal or perhaps slightly wider than normal. If you look at a skew foot on the far right, you'll see that the forefoot and the metatarsals are extremely abducted. Look at the position of the talus and calcaneus, talus is very prominent. But if you look at the central view, which is a club foot, you'll see that the forefoot is extremely abducted, but look at the stacking of the tarsus. So, here's the talus, the talar head and neck and here's the calcaneus. Look how different these two are here, yet the forefoot is very much abducted. Okay?

    So, understand that the essential deformity of a club foot is unique to a club foot. Here, you see as I discussed before, the difference between a cavus foot, here's a pediatric cavus foot in the lower image and in the upper image, you have a club foot. Look at the position of the calcaneus. It's a drastic difference. Everybody see that? Okay. Concurrent with this become the soft tissue contracture surrounding it. So, you got the superficial deltoid, not the deep deltoid, but the superficial deltoid, which goes from where? From the medial malleolus to the calcaneus. Deep deltoid goes from where? Medium malleolus to the talus.


    So, because the calcaneus is so supinated under the talus, you've got contracture there. The plantar calcaneal navicular ligament or the spring ligament is likewise contracted because of the contracture of the plantar structures as you see there. And one of the things that's not well-appreciated by residents or practitioners because if they don't see feet that are this contracted, it seems normal. But the tibial navicular ligament is not something that we normally deal with, with otherwise normal feet. The tibial navicular ligament is very, very contracted and I will show you on the surgical series here, where that is and why that has to be addressed. Okay. Posteriorly, cardinal deformity and cardinal contractures would be the calcaneal fibula ligament, and the posterior talus fibula ligament.

    These are major obstacles to correction of a clubfoot and that's why when we get a little further into this lecture, I'll explain how Dr. Ignacio Ponseti changed the world with his methodology. Again, what you see in the lower left is that deep calcaneal fissure on the skin. Muscle tendon complexes that are contracted. Almost all of them, gastroc soleus, which would be obvious because of the position of the calcaneus. The deep posterior group becomes secondarily contracted. Tibialis posterior, FHL, FTL. Again, because of the equinus position of the foot, the peroneus are affected. Peroneus brevis is very stretched out because of the supinatory position. Peroneus longus on the other hand is contracted.


    Intrinsics, and neglected TEV. Neglected TEV, not congenital newborns, but neglected TEV, the intrinsics will be adaptatively contracted, especially when they become ambulatory. And again, in neglected TEV because of the position that you saw that little girl is standing in, you can imagine that tibialis anterior becomes severely contracted because of the dynamic imbalance of the supinating muscles versus the pronating muscles. There are no pronating muscle activity because of the position, not because of paralysis. Okay.

    I'm not going to get into any detail into this, other than to tell you that there are some well-accepted classification systems. This is the [de Mello 00:20:45] system, there's a Pirani system. And if you're in a scenario in which you are tracking this patient's foot position, as you're going through a period of serial casting, either concurrent with surgery or independent of surgery, especially if you have a multi practitioner clinic scenario, you need to make sure that you are recording this so that you know from week, to week, to week, or whoever is succeeding you in a clinic scenario, knows what that foot was like, in each position, and where it is that week when they take the cast off.

    So, be aware for no other reason that you are measuring this in the parameters that they are looking for is that. The joints that are affected, not to read this to death, would posterior ankle, posterior subtalar joint by way of the supination and the equinus. Medial subtalar joint, talar navicular joint, tibia navicular joint. I don't need to spend much time on this because I already talked about it. We're going to asses when you record this, the sagittal plane, the frontal plane, meaning forefoot to the leg, the calcaneopedal block, which is the entire foot position, which is a combination transfers and frontal relative to the leg, and the forefoot to rear foot.


    These are the parameters that you're looking for when correcting congenital clubfoot. Okay? I talked about Ignacio Ponseti, God was good to him, he died at 95, kept him on this earth a long time, and he practiced almost that entire time. He was a man who had a different idea. And the world was late to accept his, including the Baja Project for Crippled Children. We were skeptical about what he was saying. He was claiming that with his manipulation, he was getting 85% reduction in severe congenital TEV without having to do, posterior medial release. In other words, the very procedure that I'm going be taking you through. All he was doing was a subcutaneous Achilles tenotomy. And we said this is impossible. Nobody can get those kind of results.

    He was reporting these results and finally, the world caught up to him. We did 20 years' worth of doing it the wrong way, thinking we knew everything, so don't be cocky. You can do something for a long, long time wrong, and other practitioners who are lecturing to you have said this in so many words. Always keep an open mind. And 20 years into it, which is halfway into my professional career, we started making the changes and trying it Ponseti's way. And I'm going to take you through it because it's very, very specific. And over a period of about 6, 7 cast changes, you need to bring the foot from its initial position as you see in the upper left into its corrected position, at which point, you do a percutaneous Achilles tenotomy.


    And then in one or two cast changes after that, you can bring the foot into a corrected position. So, you could make the case that every case is surgical, but I'll certainly trade a percutaneous Achilles tenotomy to the procedure that I'm going to show in terms of morbidity, and the duration of physical therapy, and all of the work that you need to go through to get these feet rectus and flexible for an ambulatory patient. If you don't have the luxury of getting a child, basically within a couple of weeks of birth of starting this technique. Okay? It's a very gentle, very gentle specific manipulation of the foot to reduce the contractures. And in newborns typically, as I said, five to seven cast changes along with percutaneous Achilles tenotomy. Okay.

    So, if you can appreciate on the foot model, mimicking the position of – in a pediatric TEV, which you see in the upper right-hand corner. This shows you the calcaneal talus navicular complex that's abnormal. Take a look where the navicular is on the head and neck of the talus, how rotated underneath the talus is, the calcaneus is under the talus and of course the rest of the foot. Now because of that, residents don't fully appreciate the fact when we're training them of where the talus is. Because they think when they enter the foot medially, when we're making our medial incision, they're going to be seeing the talus, and you don't even come close to seeing the talus. Yes, the talus is slightly abducted relative – the head and neck of the talus is slightly abducted in the ankle mortise, but basically that's not where the deformity is.


    Where the rest of the foot is, relative to the talus. It's far more lateral than you would expect it to be, in terms of head and neck, when you approach this from the medial side, where you need to approach it. So, if you look at that foot and we move forward, the initial motion that you undertake with the Ponseti technique is to dorsiflex the first ray. Dorsiflex the first ray and this is something that we resisted for many, many years because it's counterintuitive. The foot is already excessively supinated, why am I supinating it even more? And what this has to do is, is stretch the medial structures, the medial contractures to create some stretch initially, and to free up in the sagittal plane, the navicular as it's rotated on the talus medially. From there, and it's very, very specific, you use counter pressure on the lateral aspect of the neck of the talus.

    As you move the fore foot in an abducted but supinated position, listen to what I just said. You're keeping the food supinated, but you're abducting in the plane of its supinated deformity. So, if you visualize this, you're going from dorsal medial to plantar lateral, you under to what I just said? Your dorsal medial on the medial side to plantar lateral, you're not going directly lateral. You're abducting it in its supinated position, why? Because what you need to do is swing the calcaneus around from under the talus. It's the tarsal staking that was missed for all of those years. You're swinging the calcaneus out from under the talus, and then the navicular follows it. Remember, you've got a bifurcate ligament that's connecting into a calcaneus to lateral navicular.


    And what you're doing is, as you swing the calcaneus out from under the talus, the bifurcate ligament is tethered to the lateral navicular and it's taking the navicular with it. Okay? You got to know your anatomy. You're going to be a surgeon, you got to know your anatomy cold, okay? So, as you're bringing the calcaneus out, the navicular comes around with it, but you've got to do it from a supinated attitude, and stay in the plane of supination as you abduct, A-B-duct, okay? Eventually, what will happen is, with these cast changes, kite's angle will open and as kite's angle open, the navicular starts getting brought around onto the front of the talus from its medial position.

    Now, the calcaneus as it's doing this, is simultaneously going from a less declinated position or from more declinated position to a less declinated position, but it's still declinated. There's no getting around it. You still have that parallelism between the calcaneus and the talus, even though you're bringing the foot around in the frontal and transverse plane simultaneously. And that's what see here. You see, if you look at where that yellow circle is, that shows you – look at where the medial calcaneus is, and how close it is to the medial malleolus, do you see it? You can barely see the talus. And that's showing you how contracted the superficial deltoid ligament is, and that's what needs to be stretched. Eventually, with this casting method, you're going stretch that out and you will bring the heel to erectus position.


    But In order to then continue with this correction by way of Ponseti, you've literally got to bring this foot in an abducted position, you've got open kite's angle to the point that that foot is about 70 degrees abducted, A-B-ducted, relative to the front of the leg before you attempt your Achilles tenotomy. I've tried to cheat this. In 40 years of doing this, if you can make mistakes, I've made them. My whole group has made them. So, if you want to know how to do it wrong, talk to me. We don't do it wrong anymore. So, you need to bring the foot into an abducted position right there before you attempt your Achilles tenotomy, then you do the percutaneous Achilles tenotomy, very easy to do. And for the adults in the room, who have been doing surgery a long time, Mike, others.

    Take a little of EMLA cream, put it on there, wrap it in saran wrap, I'll take the baby, and I'll have the parent lay on the table, you can do this in the office. Have the parent lay there, I'll have the baby lay on the parent's stomach. It's wrapped in EMLA cream, EMLA cream wrapped for 20 minutes in the waiting room. You unwrap it, go in with an 11-blade if you want, pop the Achilles tendon, doesn't need a suture, put a little piece of gauze on there, and continue with your casting. That's how easy it is, the child doesn't feel it. The EMLA cream just eliminates the need – any of the sensitivity on the skin. One, two, three, you pop it. And it's no different than doing a flexor tenotomy on the toe. And that's about the size of what the tendon is too. You see just how A-B-ducted you need to get the foot to make this position appropriate, okay? There you see it, and it's traumatic.


    And look at the position in the lower-left hand of abducted you need to have it, previous to getting that, to doing that, okay? Then post, you can't post cast a therapy, you've got to keep them in an abduction splint and an abduction bar, generally around six months, you like to keep them prolonged that way, because it does have a habit of reoccurring, even if they're non-neurologic patients, okay? So, Dr. Schoenhaus, even though the vast majority of these patients are nonsurgical, Dr. Schoenhaus asked me to include one of our slide series on our surgeries. So, I don't have every slide in the series, I don't have the time to convey that to you, it would take too long. So, I'm skipping some steps here. Obviously, you see the long hockey stick incision here, this is not the only way to do it.

    I would do this – in the States, I tend to do this bi-incisionally or I'll use what's called a Cincinnati incision, which is low incision that goes from medial to lateral. In the Third World environment, because of the dysvascularity in the central area, if you do that, we run the risk of getting a slough and it takes longer for the slough to heal than it does for the rest of tissues to heal. So, we didn't want to deal with it. So, what we do here, is either single incision, if there's enough flexibility in the foot, or we'll do it bi-incisionally and do low [indecipherable] [00:33:34] incision on the lateral side, and a hockey stick incision on the medial side. This is done with just a single hockey stick incision. So, as you can see, and I'll point out the structures to you, the tendo-Achilles becomes apparent there and look at the size of the tendo-Achilles to get the scale of this, if you look at the senn retractors, that's the entire Achilles tendon, right there.


    All right. What you see right here, right there, is the neurovascular bundle, here. What you cannot see, and residents expect to see it, is the deep posterior group. And you cannot readily see that. And you're all taught as residents, Tom, Dick, and a very nervous Harry, so you're expecting to see tibialis posterior. You will never see tibialis posterior in these feet, because it's buried in a sheath right behind and right up against the medial malleolus, and because you don't have enough flexibility on the foot to stretch it, you really can't see the motion of the tendon. So, you have to know it's there, and you need to incise it, the tendon sheath to be able pick up tibialis posterior. Okay. Once again, another view of that, you see the neurovascular bundle, you need to bring that very carefully, dissect around it, keep enough soft tissue around it.

    And then you either pick it up with a penrose drain or pick it up with vessel loops, however you want to do it, and gently retract it. If you want to know where tibialis posterior is, at this point, it's right there. You can't see it. And what I do when I train the residents is, you take freer elevator, palpate with the tip of the freer elevator, where the medial malleolus is. And then it will drop into – it will dip into the soft tissue right behind the medial malleolus, that's your sheath for tibialis posterior. Okay. At this point, wave identified tibialis posterior and you see it on the penrose drain, neurovascular bundle is posterior to it. Now, I used a different foot here because – not because I didn't have a picture in the other series, but it just didn't show as well as in this series.


    So, if you see, this is a slightly larger foot, but there's something I want to point out that's very important. That's FHL and FDL, and what you see is, when you bring your instrument under it and go, FHL will be easily seen. Once you get the neurovascular bundle out of the way and start flexing and extending the toes, you can see the tendon moving for the FDL. You can't see the FHL, you could see the FDL. But here's the clinical – the essence of what I want I want to talk about here is when you pick up either one of those tendons and stretch it, all the toes will contract. Whether you stretch FHL or put FDL on stretch, all the toes would contract. Does anybody want to tell me why? Can anybody think about why that might occur?

    There are two separate tendons going to – one goes to the hallux, one goes to the lesser digits. It's the Master Knot of Henry that does this, and because of the master Knot of Henry, even though the two tendons are independent and cross under the sustentaculum tali into the Master Knot of Henry, it binds them down, so that whether you pull one or pull the other, they will contract together, got it? Okay. So, continuing along, we're continuing to dissect and free up the neurovascular bundles, so we have enough motion in it that we can an anterior or posteriorly, so we can get to the posterior ankle, posterior subtalar joint, and get to the FHL. There you see it from posterior.


    Okay? I talked about the tibia navicular ligament. And in a normal foot, there's adequate length to it, and you're barely aware of the tibia navicular ligament, but in the clubfoot, because of where the navicular is, here's the medial malleolus. This is the navicular, the navicular, it's not the head and neck of the talus, this is the navicular. And it's tethered to the medial malleolus by the tibia navicular ligament what it's to be incised, everybody understand that? Another view as we're starting to develop the opening of this and this shows it little bit better, where this is navicular, this is tibial navicular ligament and there's a fat plug right there and that fat plug is carried here. At this point you see where we've entered from posteriorly and here is talus, here is calcaneus, we've opened up the medial side of the subtalar joint, got it?

    So, this inferior talus, superior talus, calcaneus is here. Okay? Continuing to develop and open up the navicular away from both superiorly and inferiorly, now we're working superior. You're getting a glimpse of the sheath of the anterior tip. Now, at this point, again, I've skipped along because it takes a long time to do this. We finally freed the talar head and neck from the navicular, and you see that there, and we've engaged it from posterior to anterior with a K-wire. And you can see the very tip of the K-wire here. Here, we come in from posterior to anterior, that's why you need to free up posteriorly so much to be able to have access to posterior subtalar joint, and that, and then now, you have access to the ankle joint, which is up here.


    Here is talus, here is navicular, got it? Now, when you're correcting this, everything needs to be in alignment, but the most critical aspect to align surgically, because if you don't get that right, it doesn't matter what else you'd do to the foot. Is realign talus and navicular joint. And not only do you need to realign it in the transverse plane, but you need to realign it in the sagittal plane. And what tends to happen with this is when you free all of this up, the navicular tends to ride high on the talus. So, one of the hardest things to do, is as you bring the navicular around from medial to anterior is to keep it inferior enough so that it's lined up with the talus, because as it comes around, it wants to ride up high.

    And if you do that, you'll end up with a foot that looks rectus, but a year later, when you check the foot out, the navicular is sitting on top of the neck of the talus. And you'll trade one deformity for another, okay? So, you've got to nail the position of the TN joint when you finally bring it around. Both on the transverse, frontal and sagittal planes. Without that, you'll get a suboptimal correction, okay? We're dealing with children, and so you don't have to be fancy at all with your fixation, okay? The tissue is very, very forgiving, children heal, the joke that we have, and for those of us in the room that do pediatric surgery, I know Mike does. If the two bones are in the same room, they're going to heal. Okay? Because we're dealing children, with hypervascularity, and a lot of aggressive capability to heal. That's not the issue.


    So, the issue is not healing, its alignment. And so, we align this on two ways, you see the K-wire that we have now cut, where we've aligned TN joint. And then on the bottom, you have options and I will show you. You see the K-wire that's coming from inferior, I don't do this in the US. I don't need to, because I have enough access to the patient. I'll just use single pin fixation in the US. But when we're going abroad and I can't control or we can't control all the parameters of who's going to be seeing that patient in between visits to make the cast changes, we hedge our bet, okay? So, what we'll do is we'll engage the subtalar joint with a pin, so that we're pinning TN joint, and we're pinning subtalar joint.

    Years ago, we used to run the pin up through the talus into the tibia, and that will give you great alignment, but down the road, if you do that, you'll end up with a stiff foot, and it'll very difficult to get good ankle joint motion after that. And so, we don't do that anymore, for a long, long time. It doesn't help to have a rectus foot that's stiff. You want to have a rectus foot that's flexible. So, in a Third World environment we pin both the TN joint, and we pin the subtalar joint, and then those pins are pulled down the road, and I'll give you that protocol in a minute. Okay. Essential, again, not to beat you over the head with this. TN joint, perfectly realigned. And here's the second key point from the sagittal perspective. Now, you've gone to all this trouble to do a posterior release because the calcaneus is pitched so far into equines.


    You've done a posterior, you've done an open TAL, you've done a posterior release, which includes posterior ankle capsule, posterior talus fibula ligament, calcaneal fibular ligament. You've opened up the back of the subtalar joint, along with the medial side. You've gone to all this trouble to open up those structures, and yet, having done all of that, it is essential that when you put your final position there, you must re-approximate tendo-Achilles under physiologic tension. If you leave it too loose, I guarantee you, then what will happen is you will trade a clubfoot for severe cavo adductovarus foot.

    If you make the posterior, meaning the gastric soleus too weak by way of lengthening, then the intrinsics, even if you do a [steinless] [00:44:58] stripping, even if – no matter how aggressive you are, if you do a plantar release with a steinless stripping and so forth, if you overlength in posterior group, then what will happen is the foot overtime will contract and you'll trade a clubfoot for a severe cavo adductovarus foot, all right? So, the two things that would essential would be nail to put – get the perfect position for TN joint, and physiologic tension for the gastroc soleus group by way of re-approximation of the tendo-Achilles. Everything is important, but if I had to prioritize, those are the two biggest priorities. Okay. What's our post OP protocol? We put them in an above knee cast for three weeks initially. The total casting time is about six weeks.


    You need put them in an above knee cast, you've gone to all this trouble to lengthen posteriorly, you want to make sure for two reasons that you cast them above knee. Because you want to make sure the knee doesn't move so that you have dynamic motion in the gastroc, right? Gastroc crosses the knee joint, so you want to make sure you let that sit in physiologic position. So, you want to engage the knee for that reason. The other reason is that children that other than infants, if you have children you would know this. If you haven't yet had children, you wouldn't. Infants don't have a whole lot of baby fat. But if you happen to be working on a foot like this, that's later in life, starting at about three month, six months, certainly a year, there's a lot of baby fat there. And these legs are shaped like snow cones. So, if you put a baloney cast on these kids, and these kids kick, they can actually displace the cast distally.

    So, there's both a reason from a surgical perspective, and a purely pragmatic perspective. You want to anchor the cast above the knee to have that other bend that you can anchor the cast. Everybody understand what I'm saying? Okay. So, at that point, at three weeks, we pull the first cast off, pull the pins, check the wound, and then reapply a cast for another three weeks. We used to cast these children longer than that. The problem with doing that is you're trading position for stiffness. So, what you want to do, is you want to – I tell you they heal so quickly that you want to limit the amount of fibrosis that you have, because you've opened all of these joints. So, what you want to do is you want to do aggressive range of motion, aggressive physical therapy, as early as you can on these feet, to make sure that you don't end up with a straight, but otherwise a stiff foot that's got limited sagittal plain motion. Okay.


    Again, post cast maintenance as I told you would be the same, but whether it's post OP, or whether it's post Ponseti casting. Now, if the child is already ambulatory, then I would suggest to you that you use some type of supramalleolar orthotic for at least six months, just to hedge your bet, and there are variety of companies that have supramalleolar orthosis. It doesn't have to be a rigid device. And it doesn't necessarily have to be – you don't want to do a true ankle foot orthosis, because you want to encourage ankle joint motion. So, you want to put them in a device that gives them enough ankle joint motion that they can ambulate and maintains them in a frontal position, because you don't want to have this foot in a rectus position in the frontal plane. I'm sorry, let me repeat that. You want to maintain them in a rectus position in the frontal plane, but you want to have adequate sagittal plane motion. Got it?

    And a supramalleolar orthotic will be adequate for that or would be appropriate for that. Why not just a foot orthotic? Remember back when I showed you, there's so much baby fat on the foot in this ankle. So, if this child is one year old, or one-and-a-half-year-old, and they're walking, there's so much baby fat. If you put a child in a foot orthosis, it's too low and they're rolling on their own fat layers. So, with children, you really want an orthotic that's up higher, all right? And yeah, you could say that a pre-fab that's got a 20-millimeter medial flange and lateral flange, it's fine. It may not be fine, put them in a supramalleolar orthotic. I think it's a safer way to go, and then of course, you're singeing it down by way of the Velcro straps, you have another means of anchoring the device on the child, all right.


    And if the child, these kids are creative, so you don't want to get kids where they can open the laces on their shoes and start playing with this and pulling this off. You may have to tape this down, so the kid can't get to their own orthidic, and pull their orthidic off. You want to protect your surgery, right? You want to protect the surgery from the child, you know what I'm saying? And those of us that operate on kids know what I'm talking about. You got to protect the surgery from the child, because they're going to bounce around, and once they know that it doesn't hurt, they're going to walk on this. Whether you did clubfoot surgery or any pediatric surgery, protect the surgery from the child. Because they'll bounce off the walls, and they'll break down their cast, they'll break down – they'll ruin your best efforts. All right. We have about seven minutes left for Q and A, if there are any questions about anything that I covered? Thank you.

    TAPE ENDS [00:51:05]