MCQs-peds foot 1
– the most common cause of flat top talus in the club foot is damage secondary to over-manipulation; you can’t crank too hard on the foot to correct the equinus!
– a child who presents with recurrent clubfoot deformity that has been treated before with casting and a posterior release should probably have a repeat release. Depending on the pathology, this should include a release of the equinus contracture, then a release of the varus deformity (so a whole posteromedial release). A common cause of persistent deformity or recurrent deformity is that the initial release was insufficient, and did not lengthen the plantar fascia, release the long and short plantar ligaments, and reposition the cuboid properly. Also, the posterolateral tether needs to be addressed – the calcaneus, calcaneofibular ligament, and talofibular ligament.
– a chubby 11 month child that presents with minimal hindfoot equinus and moderate forefoot supination and adduction after repeat casting and one posterior release at age 3 months should undergo a full posteromedial and lateral release. Bony procedures should be reserved for fixed deformity in the older child (3-4 years)
– the pathology that may exist in a persistent clubfoot in a 2.5 year old would include shortening of the calcaneofibular ligament, medial and plantar inclination of the talar neck, and the persistence of that so called “posterolateral tether” – the calcaneofibular ligament, talofibular ligament, and calcaneus.
– the treatment for recurrent clubfoot deformity that is passively correctable in a young child (3 years) is controversial – If the deformity is truly correctable and primarily a dynamic supination, Carroll favors doing a split tib ant transfer to decrease the inversion/supination force of tib ant and transfer some of it into an eversion/pronation force. Ponsetti does a complete tib ant transfer. The deformity may represent dysfunction or incoordination between the tib ant and posterior tib muscles (invertors) versus the peroneals (evertors), so by transferring some of tib ant, this balance may be restored. Gartland has recommended tib post transfer through the interosseous membrane to the lateral aspect of the foot – so this is not a crazy option either.
– x-rays of a recurrent clubfoot in a 3 year old might show a flat topped talus and parallelism of the talus and calcaneus (the Kite angle) which normally is 20-40 but in the clubfoot might be closer to 0-10.
– internal tibial torsion is NOT a feature of the clubfoot deformity – this is raised in several questions.
– factors in a recurrent clubfoot deformity include persistent tib post tightness and a dynamic imbalance between muscle groups.
– in children older than 3-4, residual clubfoot deformity probably cannot be dealt with by soft-tissue releases alone. You need to start thinking about osseous techniques +/- soft tissue releases. Usually there is a short medial column, long lateral column, with fixed varus of the hindfoot, and adduction/supination of the forefoot. Options include:
– split ant tib tendon transfer
– multiple metatarsal osteotomies to move the toes out of adduction
– Dwyer calcaneal osteotomy (lateral closing wedge)
– cuboid decancellization to shorten the lateral column
– Dillwyn Evans procedure (which includes a calcaneal-cuboid fusion in addition to a posteromedial release) – not sure about this Dillwyn Evans surgery – it has traditionally been described for the flatfoot deformity, not the equinovarus deformity. It is an operation designed to lengthen a SHORTENED lateral column by inserting a tibial bone graft immediately proximal to the calcaneocuboid joint. Why you would do this for a clubfoot, I’m not sure.
– a 6 year old with recurrent clubfoot now walking on the lateral border of the foot – treat with repeat posteromedial release and shortening of the lateral column (could be done with cuboid decancellization) plus or minus a Dwyer calcaneal osteotomy.
– a residual clubfoot deformity that appears to be