Management of Clubfoot by Joshi’s External Stabilization System (JESS) BB Joshi, Ram Prabhoo, BG Kanaji, Sandhya Kaushik
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Classification and Evaluation of Clubfoot1

MC Vaishnav
Ram Prabhoo
BG Kanaji
2
 
CLASSIFICATION OF CLUBFOOT
MC Vaishnav
Several systems of evaluation and classification of the club foot are described in the literature. There are over 30 criteria for clinical function and radiographic evaluation of clubfoot.
 
Pandey's Classification
S Pandey and AK Pandey state that, “The quantification of the clubfoot deformity on a mathematical scale is impossible”. They go on to add, “However, the well planned clinical classification of the clubfoot will be a definite guideline for the surgeons to declare its prognosis”.
In their clinical evaluation of 1117 idiopathic clubfeet in 767 patients, they graded the following clinical findings on a scale of mild, moderate, severe and very severe:
  1. Skin condition
  2. Attitude of foot
  3. Stretchability of the deformity
  4. Heel
  5. Calf
  6. Feel of calf
  7. Varied
A mild or Grade I deformity has normal skin, a mild equino-varus attitude of the foot, is fully correctable on passive stretching, with an almost normal heel and calf, an almost normal feel of the calf and is treated by manipulation, massage and maintenance with orthotic devices.
A Grade II foot is treated by conservative means while a Grade III foot may require surgical release of tight structures and prolonged aftercare to prevent recurrence.3
Grade IV feet have atrophied skin with an infero-medial congenital groove and thick callosities on weight bearing areas, inverted attitude of the foot, less than 25% correction on passive stretching, a small heel with severe varus, ‘peg-like’ almost cylindrical calf with a markedly firm feel. The treatment is usually surgical and recurrence is common.
 
Carroll's Classification
Clinical evaluation consists of inspection, palpation and manipulation.
Inspect the foot for:
  1. Calf atrophy
  2. Posterior displacement of the lateral malleolus (as seen with the patient prone and the knee flexed to 90 degrees)
  3. Medial and/or posterior creases
  4. Curved lateral border
  5. Cavus
Palpate the foot to see if :
  1. The navicular is fixed to the medial malleolus
  2. The calcaneus is fixed to the fibula
Manipulate the foot to see if there is :
  1. Fixed equinus
  2. Fixed adduction
  3. Fixed forefoot supination Assign one point for each criterion present. Severely deformed feet would score 10 and a well corrected foot would score 0.
 
Dimeglio's Classification
In an assessment of 384 cases, A Dimeglio classified clubfeet in four basic categories:
  1. Stiff (irreducible)4
  2. Severe (slightly reducible)
  3. Mild (partially reducible)
  4. Postural (totally reducible) He emphasized that, “the degree of reducibility is more significant than the deformity itself”.
 
Catterall's Classification
Catterall identified three deformities.
  1. Postural or resolving type
  2. Tendon contracture type
  3. Joint contracture type
He described the dynamic concept of the foot as having a medial and a lateral ray with a link mechanism that allows movement within the limits imposed by the elasticity of the link mechanism.
 
International Clubfoot Study Group (ICFSG) Classification (Bensahel et al, 2005)
This study group was founded in 1998 to provide a uniform rating system of the outcome of various treatments for clubfoot. All the criteria used in the “Outcome Evaluation in Clubfoot” express objectivity which is the only way to compare the results of different treatments.
Rating System
Score
I. Morphology
  1. Hindfoot
  1. Varus or valgus
  2. Equinus or calcaneus
0
0
1 (10°)
1 (10°)
2 (>10°)
2 (>10°)
  1. Midfoot
  1. Supination or pronation
  2. Adduction or abduction
0
0
1 (10°)
1 (10°)
2 (>10°)
2 (>10°)
5
Score
  1. Global alignment of the foot:
  1. Rotation: Medial or lateral
    (Thigh-Knee foot angle)
0
1 (10°)
2 (>10°)
  1. Pes cavus or flat foot
    Maximum
0
12
1 (10°)
2 (>10°)
II. Functional evaluation:
  1. Passive motion:
  1. Ankle
  1. Dorsiflexion (in degrees)
  2. Plantar flexion (in degrees)
0
0
1 (0°)
1 (10°)
2 (–ve)
2 (0° or –ve)
  1. Subtalar varus-valgus:
  • Flexible
    Stiff
0
1
  1. Midtarsal joint motion:
    pronation-supination:
  • Flexible
    Stiff
0
1
  1. Muscle function:
Normal
Moderate
Severe
  • Jones' classification
(5, 4)
(3)
(2, 1, 0)
  1. Triceps surae
  2. Toe flexors
  3. Extensors
  4. Anterior tibia tendon
  5. EHL
  6. Posterior tibia tendon
  7. Peroneal tendon
  8. FHL
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
  1. Dynamic function:
  1. Gait
None
Positive
  1. Intoeing (medial rotation)
  2. Calcaneus or c) equinus
0
0
1 (10°)
1 (10°)
2 (>10°)
2 (>10°)
6
Score
  1. Dynamic supination
  2. Limping
  3. Ability to run
  4. Ability to jump
0
0
1
1
1 (10°)
1
0
0
2 (>10°)
  1. Shoe wear
Normal
0
Abnormal
1
  1. Heel walking OR
    Toe walking
Yes
0
No
1
  1. Pain:
  1. No pain
  2. Pain with activity
  3. Pain with sports
  4. Constant
    Maximum
0
1
2
3
36
III. Radiologic evaluation
  1. Standing AP views (foot in weight bearing position)
Normal
Abnormal
  1. Talocalcaneal angley
  2. Cuboid-calcaneo alignment
  3. Cubo-M5 axis
  4. Talo-M1 angle
  5. Talonavicular position
0
0
0
0
0
1
1
1
1
1
  1. Standing lateral views (foot in weight bearing position)
Normal
Abnormal
  1. Talocalcaneal angle
  2. Tibiocalcaneal angle
  3. Talo-navicular position
  4. Talo-M1 axis
  5. Calcaneo-M5 angle
  6. Flat top talus
0
0
0
0
0
0
1
1
1
1
1
1
7
 
RADIOGRAPHIC EVALUATION OF CLUBFOOT
Ram Prabhoo
The use of radiography in the evaluation of CTEV is an area of considerable controversy. Several angles are described and the relative merits of these are a subject of many debates. Some experts say that the appearance and shape of the talus and calcaneus in the lateral view is as important as the measurement of the angles between them.
The following points should be marked and studied in the radiographs:
  1. Talometatarsal angle
    zoom view
    Figures 1.1A and B: The talometatarsal angle is well demonstrated in this diagram made in the antero-posterior projection. One line is drawn through the long axis of the talus, and a second line is drawn through the long axix of the first netatarsal shaft (A) Normal foot (B) clubfoot
    8
  2. AP talocalcaneal angle
    zoom view
    Figure 1.2: AP talocalcaneal angle
    zoom view
    Figure 1.3: AP talocalcaneal angle divergence (modified from Simons)
  3. Lateral talocalcaneal angle
    zoom view
    Figure 1.4: Lateral talo-calcaneal angle (modified from Simons, 14 who uses the plantar surface rather than the long axis as one side of the angle)
    9
  4. AP navicular position
    zoom view
    Figure 1.5: AV navicular position according to Simmons
  5. Lateral navicular position
    zoom view
    Figure 1.6: Lateral navicular position according to Simons
    10
  6. Calcaneocuboid joint evaluation
    zoom view
    Figure 1.7: Grading system for calcaneocuboid deformity on the AP or PA radiograph. Normal: the midpoint of the cuboid ossification center lies on the midlongitudinal (long) axis of the calcaneus. +1: midpoint of the cuboid ossification center lies between the long axis of the calcaneus and a line along the medial border of the calcaneus (medial tangent) parallel to the long axis of the calcaneus. +2: the midpoint of the cuboid ossification center lies medial to the medial tangent. +3: the midpoint of the cuboid ossification center lies proximal to the distal end of the ossification center of the calcaneus. The measurements are essentially the same on the AP view as they are on the PA view
    zoom view
    Figure 1.8: The clinical appearance of a foot with calcaneocuboid subluxation. The lateral angulation is more prominent than that which occurs with metatarsus adductus. (The arrow indicates the level of the subluxation at the calcaneocuboid joint)
    11
    zoom view
    Figure 1.9: Several radiographic configurations that may be seen in feet with calcaneocuboid subluxation. A: The uncorrected clubfoot. t. talus: n. navicular; cu, cuboid: ca, calcaneus. B: The clubfoot, in which a complete subtalar release (CSTR) has resulted in reduction of the talonavicular subluxation but the calcaneocuboid deformity remains uncorrected. Valgus of the calcaneus is present (increased TC angle). C: “Spin out” of the calcaneus. A marked degree of valgus results when CSTR is performed along with a partial calcaneocuboid joint release in a patient with significant calcaneocuboid subluxation. Leaving the lateral capsule intact enables the capsule to act like a hinge. D: Complete release of the calcaneocuboid joint along with CSTR allows the calcaneus to be rotated back to its normal alignment and the calcaneocuboid joint to be anatomically reduced and pinned. All bones have been restored to normal alignment. E: Translation at the subtalar joint. which results following reduction of the calcaneocuboid subluxation and talonavicular subluxation when the calcaneus is not properly positioned with internal fixation across the subtalar joint. This is not unique to calcaneocuboid subluxation but also may occur without it
  7. The method of Meary
    zoom view
    Figure 1.10: The method of Meary is demonstrated by diagram A. The talometatarsal angle as illustrated provides a relatively good represen-tation of the degree of cavus of the forefoot on the hindfoot, but does not assist in determination of flexibility of either component
    For measurement of cavus deformity.
    12
    zoom view
    Figure 1.11: The technique of drawing the lateral talocalcaneal angle
    Equinus deformity
    zoom view
    Figure 1.12: The long axis of the talar body is the bisector of the angle between the medial and lateral articular margins of the trochlea. The long axis of the talar nucleus is the bisector of the angle between the medial and the lateral margins of the ossific nucleus
    Measurement of the talar neck deformation
    A: The long axis of the talar body
    B: The long axis of the nucleus of the talus
    zoom view
    Figure 1.13: The long axis of the talar body is the bisector of the angle between the medial and lateral articular margins of the trochlea. The long axis of the calcaneal nucleus is drawn parallel to its lateral border. The angle is negative if the long axis of the calcaneal nucleus is adducted to the long axis of the talar body.
    For measurement of varus/valgus of the heel
    A : The long axis of the talar body
    C : The long axis of the nucleus of the calcaneus
    13
  8. The first ray angle
    The first ray angle is the acute angle formed by the axis of the first metatarsal and the tangential line from the base of the first metatarsal to the base of the fifth metatarsal; therefore the name “first ray angle”. An anteroposterior (AP) radiograph is taken with the X-ray tube placed vertically. Special attention is given to assure that all the metatarsal heads touch the cassette at the time of exposure.
    zoom view
    Figure 1.14: The technique of measurement of the first ray angle
    14
  9. The bimalleolocalcaneal angle (BMC)
    zoom view
    Figure 1.15: The bimalleolocalcaneal (BMC) angle is the angle formed by the longitudinal line of the calcaneus and the bimalleolar line. This is an index of varus deformity of the calcaneus
  10. The metatarsotalobimalleolar angle (MTB)
    zoom view
    Figure 1.16: The metatarsotalobi-malleolar (MTB) angle is the angle formed by the metatarsotalar line and the bimalleolar line. This is an index of adduction deformity of the forefoot
    15
The lateral tibiocalcaneal angle is a more valid measure of equinus than the lateral talocalcaneal angle. The first ray angle and the MTB angle are a good measure of forefoot adduction. The BMC angle measures the varus and subtalar rotation of the calcaneum.
The normal angle ranges from 0-20 degrees and a positive talometatarsal angle (angle B in Fig. 1.1) connotes an abnormal adducted relationship between the forefoot and the hindfoot. (Simmons, G.W.: Analytical radiography of clubfeet. J. Bone Joint Surg. 59B: 487,1977.)
 
PHOTOGRAPHIC EVALUATION OF CTEV
BG Kanaji
Photographs provide a static picture in the pose which has been selected. They can show the shape and appearance of the foot which can be used for comparison after correction. They can reveal subtle changes of shape and helps in recognition of an early relapse.
The following views can be standardized as each one reveals certain deformities:
Prone plantar view: This view reveals the proximity of the posterior aspect of the heel (proximal end of calcaneum) to the lateral malleolus due to its relatively externally rotated position, compared to the tibia. The distal end of the calcaneum along with the distal end of the talus and the navicular face medially. It can also demonstrate the range of rotatory movement possible in the horizontal plane, i.e. external/internal rotation on a stabilized tibia. However, it does not show the equinus or inversion-eversion.16
zoom view
Figure 1.17: Prone plantar view
Medial view of CTEV: This view provides an excellent judgement about the degree of equinus of the hindfoot and also the drop of the forefoot (cavus deformity). It also reveals the deep posterior crease just superior to the calcaneum, as also, the deep medial crease. The flexion contractures of the toes are also noted. Atrophy of the calf muscles may be compared with the opposite side, in unilateral CTEV. However it does not show the adduction deformity. Thus, this view is good for the quantitative measurement of the equinus of the hindfoot and of the forefoot, associated contractures of the toes and the calf size.17
zoom view
Figure 1.18: Medial view of CTEV
Supine plantar view: This view reveals the varus deformity of the heel, supination and varus of the foot, convexity of the lateral border and the depth of the medial crease and also the flexion contracture of the toes. It is of value especially after correction.
zoom view
Figure 1.19: Supine plantar view
18
Frontal view of the leg and foot with the knee flexed at right angles and the foot hanging free: This view allows one to directly appreciate the degree of supination and forefoot adduction, unaltered by any external forces. It indicates the approximate extent of medial torsion of the leg. The convexity of the lateral border is also made obvious, and it allows comparison of the preoperative and postoperative status as regards the correction achieved quantitatively.
zoom view
Figures 1.20A and B: (A) Frontal view of the leg and foot hanging free (B) Frontal and hind view of leg and feet with weight bearing
19
zoom view
Figure 1.21A: Forced dorsiflexion view from medial side
Forced adduction view. Forced dorsiflexion with foot in neutral position/mild eversion position.
zoom view
Figures 1.21B and C: Forced forefoot abduction frontal view
20
zoom view
Figure 1.22: Forced dorsiflexion with foot in neutral position/mild eversion position (medial view)
zoom view
Figure 1.23: Standing frontal view
zoom view
Figure 1.24: Standing hind view
21
Squatting view: Views taken from the side, front and behind, reveal the extent of dorsiflexion in an older child. The hind view also shows the inherent varus deformity.
zoom view
Figure 1.25: Squatting view and plantar view
Standing on the toes and on the heels
zoom view
Figure 1.26: Standing on the toes frontal and hind view
22
Footprints: Features that can be noted from footprints include assessment of the convex lateral border, extent of transverse line across the sole, size of the great toe, size and shape of the heel and size of the foot. Maintenance of foot-prints before, during and after treatment form a record of correction achieved.
zoom view
Figure 1.27: Normal footprint achieved after posteromedial release in an 8-year-old-boy. This finding was exceptional in our series. The width of the plantar contact about the midfoot was measured at right angles to the 5th metatarsal at its base. This width (35 mm) was expressed in relation to the width of the midfoot measured on the same axis and limited by the medial tangential line to the footprint (64 mm). The adduction of the forefoot was measured through the angulation of the lateral border of the foot at the base of the 5th metatarsal (5th abduction)
zoom view
Figure 1.28: Marked residual adduction of the forefoot after posteromedial release in a 12-year-old boy. No reintervention was performed. Although the width of the plantar contact about the midfoot is normal, the adduction of the 5th ray measures 27 degrees. The patient is asymptomatic
23
zoom view
Figure 1.29: Bimalleolar/foot angle is the angle between the bimalleolar axis and the foot axis (according to McKay)
zoom view
Figure 1.30: Measurement of foot length and width on foot tracing
24
zoom view
Figure 1.31: Metatarsus adductus angle is the angle between the heel bisector line and the axis of the 2nd ray
zoom view
Figure 1.32: Dimeglio classification : sagittal plane evaluation of equinus.(Reprinted with permission from Ref. 17)
25
zoom view
Figure 1.33: Dimeglio classification: Sagittal plane evaluation of varus printed with permission from Ref. 17)
zoom view
Figure 1.34: Dimeglio classification: Horizontal plane evaluation of derotation of the calcaneopedal block.(Reprinted with permission from Ref. 17)
26
zoom view
Figure 1.35: Dimeglio classification: Horizontal plane evaluation of fore-foot adduction relative to the hindfoot.(Reprinted with permission from Ref. 17)
zoom view
Figure 1.36: Normal ranges of motion of ankle and hindfoot. DF, dorsiflexion; PF, plantar flexion; IN, inversion; EV, eversion
zoom view
Figure 1.37: Estimation of residual heel varus or valgus on weight bearing (according to Bleek)