Residency Insight -- A PRESENT Podiatry eZine

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Jay Lieberman,
DPM, FACFAS

Case Study: Neglected Club Foot

A 16-year-old male presented to the office with a right neglected clubfoot deformity. His family immigrated to the United States two years before. Although the problem was a source of embarrassment, it did not interfere with the patient�s ability to function in normal childhood and adolescent life tasks.

Click on the images below for a larger view.

Figure 1: Preop AP		Figure 2: Preop Lateral

A recent growth spurt brought the patient to a height of 6’3”. The football coaches at his local high school greatly anticipated getting him on their defensive line. Unfortunately, once tryouts started, they noticed that he was not as mobile as they had hoped. More specifically, his ability to push off the foot was limited.

His family explored the idea of fixing the foot but their goals were unrealistic.

Upon examining his foot, I noticed a large callused area underlying the cuboid. On gait analysis, it became apparent that this area corresponded to the very limited weight bearing component of his foot.


Figure 3: Preop		Figure 4: Preop Lateral

I presented a set of realistic goals to the family. These included increasing the weight bearing potential of the foot, increasing the functionality but not completely addressing the deformity.

Not many children in the United States reach this stage in their life with such a pronounced deformity. Approximately one child out of a thousand is born with clubfoot. This disorder is a bit more prevalent in males than females. Advanced serial casting techniques outlined by Ponsetti has made it so that most clubfoot deformities can be addressed without surgery at an early age.

The classic clubfoot, or talipes, equinovarus has the following components: Forefoot adductus, hind foot varus and hind foot equinus.


Figure 5: pre op Calcaneal Axial

Most experts today agree that a germ plasma defect in the head and neck of the talus is the precipitating cause. Preoperative x-rays often reveal medial deviation of the talar head and neck, hypoplasia of the talar surface and the talocalcaneal parallelism.

Previous nominal attempts to address the deformity included three separate lengthening procedures of the Achilles tendon. The pre op CT scan ruled out coalition of the subtalar joint. Prior to surgery, subtalar joint motion was limited but there was no joint crepitation. The goal of surgical intervention is to enable the foot to evert and prevent any further limitation of subtalar joint motion. The ankle should be able to dorsiflex 90 degrees.

Intra-operatively soft tissue contractures were addressed via Steindler striping, deltoid and spring ligament release. The hind foot varus/equinus was addressed with a tri-plane Dwyer osteotomy. The heel was also repositioned laterally and superiorly to preserve and possibly improve the limited ankle and subtalar joint motion.


Figure 6: Steindler Stripping		Figure 7: Release Deltoid


Figure 8: deltoid released		Figure 9: Dwyer

Figure 10: Dwyer with Wedge

Finally the anterior tibial tendon was lengthened to address the forefoot adductus and varus deformity.


Figure 11: Identified Anterior Tib		Figure 12: Proximal Identificatoin with Lengthening

Postoperatively the cosmetic appearance of the foot improved dramatically. More importantly, the weight-bearing surface increased from approximately 10 percent to over 70 percent.


Figure 13: Post op Axial		Figure 14: Post op Lateral

I considered a dorsal wedge osteotomy to increase the weight bearing potential of the first ray. However, intra-operatively, I determined that this would limit the subtalar joint motion and chose not to perform this component of the surgery.