Congenital clubfoot is a kind of ankle deformity with clear manifestations at birth, which mainly includes ankle flexion (Figure 1A), forefoot adduction (Figure 1B), hind foot varus (Figure 1C) and high arch foot (Figure 1D).
2. What are the types of congenital clubfoot?
I) Idiopathic type: the cause is unknown; II) Postural type: soft and unfixed deformity; III) Neuromuscular type: ankle deformity related to neuromuscular diseases, such as meningocele or spina bifida with clubfoot deformity; IV) Syndrome type: Foot and ankle deformity accompanied by known syndrome, such as multi-joint contracture with clubfoot deformity.
3. How to diagnose congenital clubfoot?
The diagnosis of congenital clubfoot can be roughly divided into two stages: I) prenatal diagnosis: the existence of fetal clubfoot deformity can be found by three-dimensional or four-dimensional ultrasound as early as 12- 16 weeks of pregnancy; II) Postnatal diagnosis: The diagnosis can be confirmed by clinical examination after birth.
4. How to deal with clubfoot deformity found by prenatal ultrasound examination?
First of all, the accuracy of prenatal ultrasound diagnosis of clubfoot is not 100%, which needs to be based on the diagnosis after birth. That is to say, ultrasonic examination during pregnancy found clubfoot deformity, which may not exist after birth; No clubfoot was found during pregnancy, but this deformity may exist after birth. Secondly, even if there is clubfoot deformity that needs to be treated, we have clear treatment methods and procedures at present, and good treatment results can be achieved through systematic treatment after birth.
5. Does clubfoot need treatment?
Except postural clubfoot, the other three types of clubfoot need treatment to avoid disability.
6. When will the treatment start?
According to the current research results, congenital clubfoot can be treated after birth (usually 4-5 days after birth).
7. What methods are used for treatment?
At present, almost all orthopedic surgeons believe that the initial treatment should be non-surgical treatment for neonatal clubfoot. At present, the most widely used non-surgical treatment methods include Ponseti method and French Functional Method.
8. Which method is more widely used in China?
Ponseti method was invented by Ignacio Ponseti, a professor from Iowa University in the United States, and it has been widely popularized in Chinese mainland since 2005. Because of the excellent treatment results in the short-term and long-term follow-up, Ponseti method has been widely accepted in the world in the past few decades, and has become the first choice for the treatment of clubfoot in newborns in many countries and regions. This method can be summarized as follows: early continuous manipulation, long leg cast fixation and percutaneous Achilles tendon amputation to correct clubfoot deformity, and then assisted by abduction brace with connecting rod between feet to maintain the correction and prevent the recurrence of deformity. French functional therapy was put forward by Professor Henri Bensahel from France in 1970s, and its success rate is close to Ponseti's method. However, this method is widely used in Europe, but only in some medical institutions in China. It should be noted that this method needs to strengthen the treatment stage, occupy more medical resources, and also need more participation and cooperation from parents of children. Judging from the acceptance of treatment methods, Ponseti method is more widely used in Chinese mainland at present.
9. What is the treatment process of Ponseti method?
This is the part that needs to be introduced emphatically. * * * includes the following contents: I) Manipulation and plaster cast: the doctor fixed the distance from the bone with his thumb and raised the first metatarsal bone to correct the high arch deformity (Figure 2a&; C& D& E）；
Then continue to fix the talus and abduct the supinated forefoot (Figure 2b&; F), under this coherent technique, all deformity components of clubfoot will be corrected step by step at the same time (Figure 3).
When the baby is tolerant, abduct the foot as far as possible, keep the position with proper force and fix it with long leg cast. With the abduction of forefoot, the deformity of calcaneus varus will be corrected gradually (Figure 2g&; H）。 Generally, all deformities except plantar flexion can be completely corrected by 4~5 manipulative orthopedic operations and long leg cast fixation in knee flexion position. Plaster molding technology is particularly emphasized in Ponseti method. Plaster molding should be kept in the corrected position, and the plaster should be fixed as far as the toe below the knee, and then extended upward to the thigh root (Figure 4). Gypsum should be uniform and flat, and gypsum molding is dynamic. Before the plaster is set, you always use your fingers to shape it. Every time manual correction and plaster fixation correct some deformities, it can be seen from the plaster shape of each fixation that the deformity of the foot has been gradually corrected (Figure 5).
With the correction of the deformity, the plantar flexion deformity has been gradually improved. In most cases, the plantar flexion deformity cannot be completely corrected by manual manipulation. When the abducent forefoot and tibia are rotated about 70 degrees in the coronal plane, there is still a residual plantar flexion deformity. At this time, it is the indication to correct the plantar flexion deformity by percutaneous Achilles tendon amputation. After percutaneous achilles tendon amputation, all deformity components of clubfoot have been corrected. In order to make the achilles tendon heal well, keep it at an appropriate length and reduce scar tissue, it is necessary to perform the last three-week long-leg cast fixation. Most congenital clubfoot can be corrected by manual correction and plaster fixation for 4-5 times, but according to the current clinical practice, more than 90% cases need percutaneous achilles tendon amputation; II) Brace: After the last plaster cast is removed, it is the only effective method to prevent the recurrence of deformity by Ponseti method to maintain the orthotics obtained after the last plaster cast (Figure 6).
Brace wearing scheme: braces should be worn day and night for the first three months (no less than 23 hours per day), and then the wearing time can be shortened to 12 hours at night and 2-4 hours during the day, totaling 14~ 16 hours per day, which lasts until the child is 3-4 years old. Remember: the brace used in Ponseti method is to maintain the obtained orthopedics and prevent recurrence, not to correct deformity; III) Recurrence: No matter what treatment is adopted, clubfoot has a stubborn tendency of recurrence. After treatment with Ponseti method, it is the most fundamental reason for the recurrence of clubfoot deformity that the abduction brace cannot be worn as required by the doctor or the required wearing time cannot be reached. The recurrence of clubfoot deformity is the recurrence of any part of clubfoot deformity. If the child can't wear braces as required, it should be checked frequently, or parents should see a doctor immediately if they suspect that the child's foot shape is abnormal. For the treatment of deformity recurrence, according to the requirements of Ponseti method: the same manipulative orthopedic and plaster fixation methods are used again, and if ankle dorsiflexion is limited, percutaneous achilles tendon amputation is needed again; For recurrent clubfoot over 2 years old, on the basis of correcting the fixed deformity by manual correction and plaster fixation, if there is a dynamic supination of the forefoot in the swing TATT of the child, it is necessary to transfer tibialis anterior to the third wedge bone to establish muscle strength balance, so as to prevent the recurrence of deformity. Usually, the proportion of children who need to undergo tibialis anterior muscle transfer is less than10.
10. What should parents pay attention to in order to ensure the smooth progress of treatment at all stages of Ponseti treatment?
(The following issues need to be emphasized) The treatment process of Ponseti method requires not only doctors to operate strictly according to the requirements of the method, but also parents' active and effective cooperation: I) Manipulation and plaster: This process is completed by doctors in the plaster room of the hospital outpatient department. For newborns, within 3 hours before each manipulation and plaster fixation, it is generally recommended not to feed the children, but to prepare a bottle (about one foot needs to be prepared 1 bottle of milk) before the doctor starts the treatment, and start feeding when the manipulation treatment begins, which can ensure the children to remain quiet during the treatment and is conducive to the effective treatment; II) Brace (this stage is extremely critical): In the stage of preventing the recurrence of deformity, the doctor usually instructs the wearing method and time of the brace, but the children in this stage finish wearing the brace under the care of their parents, so parents must realize the important role of good brace wearing in preventing the recurrence of deformity, and must wear the brace according to the doctor's requirements, which is the key to successful treatment; III) Recurrence: Failure to wear the abduction brace according to the doctor's requirements or the required wearing time is the most fundamental reason for the recurrence of clubfoot deformity after Ponseti treatment. The recurrence of any part of clubfoot deformity is clubfoot deformity. If children can't wear braces well as required, they should see a doctor frequently, or parents should see a doctor immediately if they suspect that their feet are abnormal.
1 1. What kind of abduction brace should I choose?
No matter what brand and manufacturer of foot abduction brace, in the case of unilateral horseshoe foot, as long as it can maintain the abduction of the affected foot at 60-70 degrees and the healthy foot at 30-40 degrees; In the case of bilateral horseshoe feet, both feet are abduction 70 degrees. The cross bar of the brace is shoulder width, and the convex surface of the cross bar should be bent outward by 5- 10 degrees, so that the foot can be fixed in the dorsiflexion position to play the role of maintaining orthopedics and preventing recurrence (Figure 7).
12. Which hospitals in China carry out Ponseti method for the treatment of neonatal clubfoot?
The following are some hospitals and medical institutions that have been trained by Ponseti International Association (PIA): Xinhua Hospital affiliated to Shanghai Jiaotong University School of Medicine, beijing jishuitan hospital, Beijing Children's Hospital, Tianjin Orthopedic Hospital, Department of Orthopaedics, Xijing Hospital of the Fourth Military Medical University. Pediatric Hospital affiliated to Fudan University, Shanghai Children's Medical Center, Union Hospital of Huazhong University of Science and Technology, Third Affiliated Hospital of Guangzhou Southern Medical University, Shandong Provincial Hospital, Qilu Children's Hospital of Shandong University, Children's Hospital affiliated to Suzhou University, Zhengzhou Children's Hospital, Children's Hospital affiliated to Chongqing Medical University, Children's Hospital of Hunan Province, Children's Hospital of Jiangxi Province, Fifth Hospital of Harbin, Guilin People's Hospital, Qinghai Maternal and Child Health Hospital, Guangzhou Women and Children's Medical Center, Yinchuan Guolong Hospital of Ningxia.
13. What methods should be used to treat older children with clubfoot and children with neuromuscular or syndromic clubfoot?
For this kind of clubfoot, Ponseti method can still be tried first. If the effect is not obvious after long-term treatment, try other methods, such as four-dimensional orthopedic treatment with Ilizarov external fixation technology. We suggest that the surgical treatment of extensive soft tissue release to correct deformity should be minimized, especially those with intra-articular operation.
14. How to treat children with rigid clubfoot whose deformity recurs or remains after irregular massage or extensive soft tissue release surgery?
For this kind of clubfoot, Ponseti method can still be tried first. If the effect is not obvious after long-term treatment, try other methods, such as four-dimensional orthopedic treatment with Ilizarov external fixation technology.
15. what effect can be achieved by using Ponseti method in neonatal period?
The systematic Ponseti method has been used since the neonatal period, and the wearing compliance of braces is good. Children who have not experienced recurrence can get a foot that can tread flat, has good function, is painless and has good mobility, and does not need to wear orthopedic shoes.
16. Is there any hope to get a good treatment result for the children who were treated with Ponseti method in the neonatal period, but the deformity recurred due to poor compliance of wearing braces?
Ponseti method is used to treat clubfoot. Even if the deformity recurs, after systematic treatment with this method again, good treatment results can still be obtained from a simple treatment point of view, but after all, the treatment cycle is increased and the burden of patients, families and society is increased.