Congenital clubfoot

Congenital clubfoot (equinoqua-varus deformity) is one of the most common malformations of the musculoskeletal system, which, according to different authors, is 4-20% of all deformities.

ICD-10 code

Q66. Congenital deformities of the foot.

Epidemiology

Deformation is hereditary in 30% of patients. The most common clubfoot is found in boys. The birth rate of children with congenital clubfoot is 0.1-0.4%, while in 10-30% of cases, a combination with congenital hip dislocation, torticollis, syndactyly, and hard and soft palate is observed.

[1], [2], [3], [4], [5], [6],

What causes congenital clubfoot?

Congenital clubfoot develops due to the influence of endogenous and exogenous pathological factors (fusion of the amnion with the surface of the embryo and pressure of amniotic cords, umbilical cord, musculature of the uterus, toxicosis during pregnancy, viral infection, toxoplasmosis, toxic effects, avitaminosis, etc.) during embryogenesis and early fetal period of development of the fetus.

There are various theories of the occurrence of equinoqua-varus deformation of the feet - mechanical, embryonic, neurogenic. According to a number of researchers, clubfoot is a hereditary disease caused by a gene mutation. Most authors believe that the leading role in the pathogenesis of congenital deformities of the feet and subsequent relapse after surgical treatment belongs to the nervous system - the violation of the nerve impulse and muscular dystonia.

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

How does congenital clubfoot appear?

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

Incorrect position of the foot in the child is determined from the moment of birth. Deformation with congenital clubfoot consists of the following components:

• plantar flexion of the foot (pes equinus);
• supination - turning the plantar surface to the inside with the lowering of the outer edge (pes varus);
• reduction of the anterior part (pes adductus);
• increase in the longitudinal arch of the foot (pes excavates).

With age, the clubfoot is increased, hypotrophy of the calf muscles appears, the internal torso of the shin bones, the hypertrophy of the external ankle, the distance of the head of the talus from the external-rear side of the foot, the sharp decrease in the inner ankle, the varus of the fingers. In connection with the deformation of the foot, children begin to walk late. Congenital clubfoot is characterized by a typical gait with support on the rear and outer surface of the foot, with one-sided deformation - lameness, with a two-sided walk - small steps that fall in children 1.5-2 years old, in older children - with stepping over the opposite deformed foot. By the age of 7-9, children begin to complain of rapid fatigue and pain while walking. Providing them with orthopedic footwear is extremely difficult.

Depending on the ability to perform a passive correction of foot deformation, the following degrees of congenital clubfoot are distinguished:

• I degree (light) - the components of the deformation are easily compliant and are eliminated without much effort;
• II degree (moderate severity) - movements in the ankle are limited, when corrected, spring resistance is determined, mainly on the side of soft tissues, preventing the elimination of certain components of deformation;
• III degree (severe) - movements in the ankle and foot are severely limited, correction of deformation by hands is impossible.

Classification of congenital clubfoot

The clubfoot can be both bilateral and one-sided. With one-sided clubfoot, shortening of the foot is noted up to 2 cm, sometimes up to 4 cm. By the adolescence, shortening of the shin develops, sometimes requiring correction along its length.

The deformation structure is the reduction of the anterior part, the varus deformity of the posterior part, the equinus position of the talus and calcaneus, supination of the whole foot and the increase of the longitudinal arch (caudex deformation), which determines the Latin name of the pathology - equinoqua-varus deformity of the foot.

[7], [8], [9], [10], [11],

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 adjusting torticollis, hip dysplasia of various severity, dysplasia of the lumbosacral spine. Congenital constrictions on the lower leg meet in 0.1% of patients.

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

In case of abnormalities, an additional examination is recommended - ultrasound of the cervical, lumbar spine and hip joints.

With a decrease in the function of extensor fingers, hypotrophy of the muscles of the rear part of the lower leg and the foot, a neurological examination is necessary, supplemented with electromyography of the muscles of the lower extremities.

Various classifications are proposed for determining the severity of deformation, but the most practical classification is FR. Bogdanova.

• A typical form is an easy, medium and heavy degree.
• Weighed form - clubfoot with amniotic constrictions, arthrogryposis, achondroplasia, congenital defects of the foot and shin bones, pronounced torso of the shin bones and neurogenic form of deformation.
• The recurrent form is clubfoot, which develops after treatment with a heavily weighed or strongly clubfooted degree.

The present typical form of congenital clubfoot should be differentiated from atypical ones with arthrogryposis, amniotic constriction of the tibia, spina bifida aperta in myelodysplasia.

• With arthrogryposis, along with deformity of the foot according to the clubfoot type, contractures and deformations of the knee, hip joints, often with a hip dislocation, flexion contractures of the upper limb, are noted from birth. More often wrist joint.
• Amniotic constrictions are formed when the amnion fuses with different parts of the fetus, often causing spontaneous amputation of the extremities or forming, for example, in the shin region, deep circular entrails and deformations of the distal part (with the clubfoot type legs) with functional and trophic disturbances.
• With spina bifida aperta, accompanied by spinal hernia and myelodysplasia. Deformation by the type of clubfoot is formed as a result of flaccid paralysis or paresis of the lower limb. Neurological symptoms are revealed (hyporeflexia, hypotonia with limb muscles hypotrophy), impaired pelvic organs.

How to fix a congenital clubfoot?

Non-drug treatment

Congenital clubfoot should be eliminated from the first days of the child's life conservative methods. Basics of conservative treatment - manual correction of deformation and retention of the achieved correction. Manual correction of deformation is as follows:

• dressing gymnastics, club foot massage;
• sequential correction of the components of deformation of the foot: adduction, supination and equinus.

With an easy degree of deformation, corrective gymnastics is performed before the baby's feeding for 3-5 minutes, ending with a shin and foot massage, repeating 3-4 times a day. Stop after gymnastics is held in a corrected position with a soft bandage made of flannel fabric (length of bandage 1.5-2 m, width 5-6 cm) according to the Finck-Oettingen method. Occurring sometimes cyanosis of fingers in 5-7 minutes should disappear. Otherwise, the limb should be bandaged again, loosening the bandage tours.

At moderate and severe degrees of deformity, the above exercise therapy for clubfoot should be used as a preparatory stage for treatment by gradual corrective gypsum dressings. Treatment clubfoot performed by a doctor-orthopedist polyclinic, starting with a two-week-old child. The first gypsum bandage-boot is applied from the fingertips to the knee joint without correction of deformation. In the following, with each change of the cast bandage, after 7-10 days, the supination and adduction elimination is consistently followed, followed by the plantar flexion of the foot.

To correct clubfoot, the child is placed on the abdomen, the leg is bent at the knee joint and hand is fixed to the heel and lower third of the shin. With the other hand, an easy non-violent movement, slowly, gradually stretching the soft tissues and ligaments, carry out correction. Gypsum bandage is applied to the leg with a cotton-gauze pad. Gypsum bandage tours are conducted freely, in circular strokes against the direction of deformation, from the outside of the foot to the rear surface inwards with careful modeling of the bandage. It is important to monitor the condition of your fingers. Elimination of deformation is achieved in 10-15 stages, depending on the degree of clubfoot. Then, in the position of hypercorrection of the foot, a gypsum boot is applied for 3-4 months. Changing it monthly. After removing the plaster boot recommended massage, medical gymnastics, physiotherapy (warm baths, paraffin or ozocerite applications). Shoes with clubfoot look like a pierced on the entire surface of the sole by a pronator. To keep the foot in a corrected position, put on a plaster of gypsum or polymeric materials (for example, a polyvik) for the night.

Immediately upon discharge from the maternity hospital, the child must be sent to a specialized institution where gradual gypsum corrections will be performed to eliminate deformities of the foot.

Treatment started as early as possible has a much better chance of achieving full foot correction conservatively than delayed.

Surgery

Indications

In case of failure of conservative treatment in children older than 6 months, as well as late treatment, surgical treatment is indicated - tenoligamen-tokalsulotomy according to the method of TS Zatsepin.

Technique of operation

Apply bleeding and hemostatic tourniquets to the lower third of the thigh. The operation is performed from four sections:

• a skin incision 2-3 cm long along the sole-medial surface of the foot. Palpation is determined by the plantar aponeurosis, for which the assistant pulls it, pressing on the head of metatarsal bone and heel. Under the plantar aponeurosis lead gullet probe, a scalpel perform fasciotomy. On the skin there are nodal catgut stitches;
• a skin incision length of 4 cm along the medial surface of the foot above the head I metatarsal bone. Mobilize and Z-shaped lengthen the tendon of the muscle that removes the finger. Apply nodal catgut stitches to the skin:
• a skin incision extending from the middle of the medial-plantar surface of the foot through the middle of the inner ankle to the middle third of the shin. Mobilize the skin. The lacunar ligament is dissected, the tendon of the vagina of the posterior tibialis muscle and the long flexor of the fingers is opened on the gaunt probe. Produce a Z-shaped lengthening of the tendons of these muscles. The medial, posterior (carefully - the neurovascular bundle) and the anterior ligaments of the supratenal and subtalar joints are cut with a scalpel. The wound is not sutured.
• cut skin length of 6-8 cm to the outside of the calcaneal tendon (carefully - to the saphena parvel). Mobilize the skin. The probe opens the tendon sheath and produces the Z-shaped extension of the Achilles tendon in the sagittal plane, leaving the outer half of the tendon at the heel. The dissected tendon is removed, a deep leaf of the fascia of the shin is revealed in the depth of the wound along the middle line. Mobilize the tendon of the long flexor of the 1st finger.

Following distally along the tendon (carefully - inside the neurovascular bundle), dissect the posterior ligaments of the supratenal and subtalar joints. The foot is taken to the middle position when the limb is straightened in the knee joint and is held in this position. Impose nodal sutures on elongated tendons. Take off the tourniquet. Impose nodal catgut stitches on the vagina of the tendons, subcutaneous fatty tissue and skin.

Complications

It is necessary to strive to leave a wider "cutaneous bridge" between the third and fourth cuts, since with a narrow flap and extended mobilization, necrosis is possible in the postoperative period.

In some clinics, a modified procedure is used. The operation is performed from one section. Begin it over the head I metatarsal bone, pass along the border with the plantar surface of the foot to the projection of the calcaneus and further up the projection of the neurovascular bundle (the middle between the inner ankle and the calcaneal tendon). Mobilize the skin and the neurovascular bundle. The latter is taken on rubber holders.

Further, lengthen the above tendons of the muscles and open up the overturned and burnt joints. Eliminate deformation. The operation is terminated as described above. The proposed method of operation makes it possible to widely open the operating field and avoid damage to the vascular-neural formations on the foot and shin. In the postoperative period, the danger of necrosis of the "cutaneous bridge" between the ankle and the calcaneal tendon disappears.

Make an aseptic gauze sticker. Apply a circular gypsum dressing from the foot to the middle third of the thigh. The dressing is cut on the front surface. After removing the joints for 12-14 days impose a blind plaster bandage. In 1 month after the operation, the bandage is changed to a plaster boot, which allows movement in the knee joint. The total period of immobilization in gypsum is 4 months. In the future, the child makes tutors and conducts restorative treatment (massage, exercise therapy, physiotherapy).

Early conservative treatment allows up to 90% of favorable outcomes. To judge about full cure of such pathology, as a congenital clubfoot can be no earlier than in 5 years. It is necessary to follow up for 7-14 years.

[12], [13], [14], [15], [16], [17], [18], [19]