Common Errors

The common errors in the treatment of the clubfoot and how to avoid them are:

  1. Having the parents remove the plaster cast at home the day before the cast change. Much correction is lost while the foot is out of the cast. The cast should not be removed more than an hour before the new cast is applied.
  2. Pronation or eversion of the foot (Figure 12 and Figure 13 ). The wrong assumption is made that the severe supination in the clubfoot will correct by pronating or everting the foot. Pronation of the foot will make the deformity worse by increasing the cavus and locking the adducted calcaneus under the talus, while the midfoot and forefoot are twisted into eversion [12]. Supination of the foot and heal varus are corrected by abducting the supinated foot under the talus(Figure 15 ).
  3. External rotation of the foot to correct adduction while the calcaneus is in varus (Figure 14 ). This causes a posterior displacement of the lateral malleolus by externally rotating the talus in the ankle mortice. The posteriorly displaced lateral malleolus, seen in poorly treated clubfoot, is an iatrogenic deformity [ 12]. It does not occur when the foot is abducted in flexion and slight supination to stretch the medial tarsal ligaments, with counter pressure applied on the lateral aspect of the head of the talus,thus allowing the calcaneus to abduct under the talus with correction of the heel varus (F igure 15 ).
  4. Abducting the foot at the midtarsal joints with the thumb pressing on the lateral side of the foot near the calcaneocuboid joint, arching the foot as if straightening a bent wire. This was taught by Kite and is a major error [8]. By abducting the foot against pressure at the calcaneocuboid joint the abduction of the calcaneus is blocked, thereby interfering with correction of the heel varus (Figure 11 ). Kite wrongly believed that the heel varus would correct simply by everting the calcaneus. He did not realize that the calcaneus can evert only when it is abducted, i. e. laterally rotated, under the talus. This error in the Kite technique had a major negative impact on the manipulative treatment of clubfoot. Kite was able to correct the deformity after many manipulations and changes of cast. His less patient followers, with some notable exceptions, have resorted to surgery.
  5. Frequent manipulations not followed by immobilization. The foot should be immobilized with the contracted ligaments at the maximum stretch obtained after each manipulation. Plaster casts applied between manipulations serve to keep the ligaments stretched, and to loosen them sufficiently to facilitate further stretching in the manipulations following at intervals of five to seven days [11]. The tarsal joints and bones remodel due to the changes in the direction of mechanical loading of fast growing tissues.
  6. Application of below knee instead of toe to groin casts. The longer plasters are needed to prevent the ankle and talus from rotating. Since the foot must be held in abduction under the talus, the talus must not rotate, otherwise the correction obtained by manipulation is lost.
  7. Attempts to correct the equinus before the heel varus and foot supination are corrected will result in a rocker bottom deformity.
  8. Failure to use shoes or molded orthotics attached to a bar in external rotation for three months full-time and at night for two to four years. These splints are necessary to counter the tendency of the ligaments to tighten, causing relapses. The ankles and knees are free to move and the leg and thigh muscles gain strength [11].
  9. Attempts to obtain a perfect anatomical correction. It is wrong to assume that early alignment of the displaced skeletal elements results in a normal anatomy and good long term function of the clubfoot. We found no correlation between the radiographic appearance of the foot and long- term function [3]. In severe clubfoot, complete reduction of the extreme medial displacement of the navicular may not be possible by manipulation. The medial tarsal ligaments cannot be stretched sufficiently to properly position the navicular in front of the head of the talus. Since the joint capsules and ligaments play a crucial role in the kinematics of the tarsal joints [7], they cannot be stripped away with impunity. In infants, the medial ligaments should be gradually stretched as much as they will yield rather than cut, regardless of whether a perfect anatomical reduction is obtained or not [11].

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