Club Foot - Skew Foot Treatment Advice

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7 year old male, born with bilateral talipes equinovarus. Following birth casting was performed from 5 days old, dennis browne bar, and surgery at 6 months of age. All initial treatment successful.

However, child has presented with recent severs type pain, occasionally back pain, and mother is also concerned the club foot maybe reverting back.

The child has been undergoing physiotherapy - stretching exercises etc.

On examination:

- Significant reduction AJ DF - flexed and extended, tendon taut - muscle belly soft
- STJ restricted
- MTJ increased inv
- Met adductus - styloid prominant right more than left
- talar buldge right more than left, corrected on NCSP
- calf muscle atrophy
- Calc pos vertical to slight evr
- tib pos vertical
- forefoot to rearfoot relatively parallel
- Arch profile mildly cavus
- Supination resistance - relatively low resistance to supination
- Jacks test negative
- single leg stance - lateral instability, flexor substitution.

My opinion is the foot following all previous treatment, has now aquired a z shape or skew foot structure.

Having had little experience treating the skew foot or post talipes patients, could anyone offer some advice or direction with the treatment of this patient?

Also is it possible for the club foot to re-present, following successful surgical, casting and splinting techniques.

 

I don't do the ponsetti treatment, but a few of the physio's I work with do. I see loads of children around this age a number of years after treatment for foot problems. It is this age when they begin to present because it is when the peak age for Severs especially begins.

Talipes can return if compliance to the full Ponsetti method is poor, but it would be close to the time, not years later. Following very early casting (as close to birth as possible), Dennis browne boots and bar need to be worn 24/7 for some time (not entirely sure how long) and then night-only until 4 years of age. Speaking to their physio's would be my first port of call. A Pirani score would be useful (this is a 6 point score 3 for rearfoot and 3 for forefoot), this is how they score talipes. If he had a simple TA tenotomy (which is what it sounds like) he probably had moderate-severe talipes initially, but these kids end up with a normal looking foot. If he had multiple, bony procedures, I've seen a lot of them end up with quite a munted and skew foot. Not much you can do about that.

From my experience, the whole treatment for talipes is traumatic for mums and for everything they present with foot-wise ever after this real fear re-surfaces, do be sensitive to that. I would learn the Pirani scoring, get the physio's to show you (you can't learn it well from a book so well, they use different terminology than us) so you can confidently reassure mums. I would expect thought, that the physio's would be all over this already if he is getting treatment from them. Why not speak to them and arrange a joint assessment? If they have assessed his foot position and giving him stretching, they may not be much for you to do. If his gastrocs are small, some strengthing will not go astray. I've seen this present in post-surgical talipes children up to 15 even and they respond very well. Just think how much their gait will be affected by poor gastroc power. It is also very important aspect of TA rehab

The other thing to consider is if there is a c shaped curvature, is is flexible? They will often present with a marked C shape, but see if it corrects. If is is rigid OR unable to correct to a rectus position, refer to orthopod or physio team (depending on who does it in your area) for qeuary re: serial casting. A LOT present with a flexible met adductus, where this is the case, advise to avoid kneeling on feet as this perpetuates this position. If you can, prescribe a peroneal strengthening program. At this age, just teach it as 'penguin walking' (ie. heel walking in abduction) - that's the best you'll get at this age. A few minutes per day as a fun activity / playing will help. It sounds like he is as you describe lots of flexor activity in single limb stance.

Remember Severs is a very typical presentation for this age. Normal things can happen too! Irrespective of a history of talipes.

 

Yes, if neurological in origin. Generally though it would have returned prior to this then though.

I agree with Sally, sometimes the treatment of TEV scares the pants of parents and it becomes the blame. However if you think of the pathomechanics of even a post-treated foot, you are more likely to have lateral pressure through the heel, less pronation so possible more susceptible to impact injuries (of which Sever's can be).

 

Hello JAD - I have a large pediatric orthopedic practice and Skewfoot is not an uncommon problem following TEV treatment - surgical or non-surgical. Additionally, it sounds like this boy had a MTA component in addition to the TEV issue. So, if radiographically, Kite's angle is reduced on AP and Lat views, then we can assume the TEV release worked - but possibly overcorrected yeilding the flatfoot w/MTA. Restricted ankle DF could be talar neck/body issues vs Achilles contracture. I recommend surgical reconstruction between the ages of 7-9. All issues are addressed-rearfoot..midfoot and metatarsals. Posterior release if necessary.
If RCSP is >5 degrees, medial displacement calcaneal osteotomy. Increased calcaneal cuboid joint ankle - Evans and Metatarsal osteotomies 1-5 w/care to protect the 1st met. growth plate. Ankle joint dorsiflexion - if soft tissue, then redo posterior release (complete). If osseous, then I'll wait and stage down the road. Your are looking at talar neck osteotomy or tibial osteotomy and that is too much to do at the same time. So I wait and send to PT.

Best of Luck!

S. Jeffrey Siegel, DPM, FACFAS
heeldoc@verison.net

 

Thank you all for your thoughts. I will be considering all your thoughts for treatment of this patient.

Thank you all once again!