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Treatment of Club Foot

- Non Operative Treatment:

- Operative Considerations:
    - surgical indications:
             - when deformity has not been treated successfully w/ proper manipulation & serial application of casts, supported by limited  
                    operative intervention;
    - operative timing:
    - surgical goals:
             - goal for surgical procedures is concentric reduction of the talonavicular and calcaneocuboid joints;
                   - deformities of the bones and joints are rarely, if ever, corrected completely;
                   - some persistent medial displacement of navicular bone & talocalcaneal index that is outside of the normal range are compatible 
                          with a fully functional, normal-looking, pain-free, plantigrade foot;
             - soft tissue releases:
                   - achilles tendon: z lengthening
                   - calcaneal fibular ligament: release
                   - post talofibular ligament: release
                   - tibialis posterior tendon: z-lengthening
                   - ankle and subtalar capsule:
                          - posterior capsulotomy of ankle & subtalar joint is avoided in some cases, because the small gain in correction may be later 
                                 offset by the retraction of the scar tissue;
                   - superficial deltoid: release
                   - talonavicular and tibionavicular: release
                   - plantar fascia release
                          - failure to release the plantar fascia may lead to persistant cavus deformity;

- Treatment Options:
    - circumferential release: "cincinati incision"
    - Goldner four quadrant approach:
    - medial release
    - posterior release
    - posteromedial release
    - tendon transfers
    - posteroplantar release:
         - 133 resistant congenital clubfeet in 93 patients between 3 and 10 months of age were operated on using a standardized 
               posteroplantar release;
               - mean followup of 7 years 4 months (range, 3-12 years);
               - 79.7% of the surgically treated clubfeet were classified as having a good or excellent result;
               - 3 patients had relapse of their clubfoot that required additional surgery;
               - 17 feet in 15 patients had residual forefoot adduction at the time of followup;
               - radiographs showed that the early posteroplantar release led to sufficient hindfoot correction in all but the three patients who had 
                      relapse of the clubfoot;
               - in patients with persistent talonavicular subluxation after conservative treatment, an additional talonavicular release combined with 
                      the posteroplantar release is recommended.
               - Posteroplantar Release for Congenital Clubfoot in Children Younger Than 1 Year 
    - salvage procedures:
          - procedures that involve bone are usually done in older children (may be regarded as salvage procedure);
          - combined soft-tissue and bone procedures;
          - arthrodesis / osteotomy: (triple arthrodesis)
                - in older pts (3-10 yo), medial opening or lateral column shortening osteotomies or cubital decancelization is recommended;
                - for children who present w/ refactory clubfoot late (8-10 yo), triple arthrodesis is only procedure possible to eliminate 
                      associated pain;
                - note that triple arthrodesis is contraindicated in patients with insensate feet (such as the myelomeningocele club foot) because it 
                       causes a rigid foot that may lead to ulceration;
                       - talectomy may be a better procedure in these patients;

- Post Op Care:
    - long plaster cast is used for the first six weeks and a short cast, for the second six weeks;
    - transfixion pins are removed 6 weeks after first surgical procedure;
    - following surgery: the foot and ankle are immobilized in a well padded cast above the knee cast;
    - casts are changed 1 week and 2 weeks after surgery to allow inspection of the wound and verification of the correction;
    - in especially stiff club foot deformities, AFO may be considered after the casts come off (after post op week 12)
    - all pts must be followed throughout their growth period to assess and ensure that the correction is maintained 

- References for Club Foot:

Long-Term Comparative Results in Patients with Congenital Clubfoot Treated with Two Different Protocols.

Correction of equinus in clubfoot: the contribution of arthrography.

Dynamic Foot-Pressure Measurement in the Assessment of Operatively Treated Clubfeet