Abstract
We present the treatment protocol of congenital clubfoot in different age groups that has been widely used in Bulovka Orthopedic Clinic since 1984. Conservative treatment begins immediately after delivery and corrects all presented deformities on the principle of subtalar derotation of the calcaneus. The correction is applied and an above-knee cast is changed every 48 hours. After five corrections and changes of casts, the casting and correction is then repeated weekly. After achieving reduction of deformities, the cast is changed at intervals of two to three weeks. Cast immobilisation should be continued for two to three months for postural clubfoot, and six to seven months for congenital clubfoot. After retention in the cast, a polypropylene above-knee splint is applied up to the age of two to three years. In addition, passive stretching exercise and stimulation of the lateral part of the foot should be provided in order to achieve muscle balance between the evertors and invertors.
Surgical treatment: When conservative treatment is unsatisfactory, the goal of operative treatment is to reduce all deformities in a one-step procedure. Posterior capsulotomy at the age of three to six months is indicated when the forefoot has been corrected by conservative treatment but the hindfoot remains fixed in the equinus and mild varus, or at the age of six to 12 months for residual hindfoot equinus.
Complete subtalar release according to McKay is required at the age of over six months to three years. Post-operative treatment is the same as for the abovementioned conservative treatment.
Treatment between the age of three and seven: The choice of surgical procedure must be individual according to the deformity, but surgical correction of severe deformity principally includes extensive subtalar release, and lateral column shortening by cuboid enucleation.
Treatment between the age of seven and ten: Individual procedures (Ilizarov method; Dwyer osteotomy of the calcaneus, or osteotomy of the mid-tarsal bones) are chosen to treat deformities. These procedures are usually combined with soft tissue release, but not with complete subtalar release.
Treatment after the age of ten (skeletal maturity of the foot): The same methods as in the previous group are used. When severe or unsatisfactory results after previous surgical treatment are obvious, a triple subtalar arthrodesis is the appropriate salvage method of correction.
Treatment of residual deformities: For treatment of dynamic deformities due to muscle imbalance after the age of four, a temporary lateral transfer of the whole tendon of the anterior tibial muscle is performed. For the same age group, forefoot adduction and supination are corrected with a ball and socket osteotomy of the base of metatarsals I-V.
This therapeutic concept was applied to 397 operated feet. 60% of the cases were primary surgical corrections, and 40% were repeated surgical corrections. 95% of primary surgical procedures and 75% of secondary surgical procedures were classified as satisfactory, indicating that the foot was sufficiently mobile, with plantigrade weight bearing.
The abstracts were prepared by David P. Davlin. Correspondence should be addressed to him at the Orthopedic Clinic Bulovka, Budínova 2, 18081 Prague 8, Czech Republic.
