Pie bot: conceptos actuales / Clubfoot: current concepts

El pie bot es la deformidad congénita más frecuente de las extremidades inferiores del ser humano, afectando a 1 de cada 1000 recién nacidos vivos. Consiste en la presencia de cuatro deformidades estructurales en el pie y el tobillo: cavo del medio pie, aducto del antepié, varo del retropié y pie en equino.Su registro en la humanidad data del siglo XII A.C. en momias del antiguo Egipto.La fisiopatología de esta deformidad aún no está aclarada. El diagnóstico puede ser prenatal mediante visualización ecográfica, pero la forma más común de diagnóstico es postnatal. La evaluación de estos pacientes se basa en la exploración clínica. Entre las clasificaciones más utilizadas se encuentran: Diméglio, que enfatiza lo reductible ante maniobras manuales de la deformidad; Pirani, que evalúa la gravedad inicial y el progreso del tratamiento; y Ponseti International Association (PIA), que clasifica según etiología.Durante el siglo pasado se describieron numerosos procedimientos quirúrgicos, muchos de los cuales fueron quedando en desuso ante sus resultados insatisfactorios, pies rígidos y dolorosos, con función limitada. Actualmente el método Ponseti es el Gold estándar para su tratamiento, consistiendo en una manipulación y enyesado seriado buscando la corrección sistemática del pie, basado en los fundamentos de la cinemática y la fisiopatología de la deformidad.

Clubfoot is the most frequent congenital deformity of the lower extremities of humans, affecting 1 out of 1000 live newborns. It consists of the presence of four structural deformities in the foot and ankle: midfoot cavus, forefoot adductus, hindfoot varus, and equinus foot.Its records in humanity date from the 12th century B.C., in ancient Egyptian mummies.The pathophysiology of this deformity is still unclear. Prenatal diagnosis by ultrasound imaging is feasible, but most common diagnosis is postnatal. The evaluation of these patients is based on clinical examination. Among the most used classifications are: Diméglio, which emphasizes the reductibility with manual maneuvers; Pirani, who assesses initial severity and progress of treatment; and Ponseti International Association (PIA), which classifies according to etiology.During the last century, numerous surgical procedures were described, many of which were disused due to their unsatisfactory results, stiffness and painful feet, with limited functionality. Currently the Ponseti method is the gold standard for its treatment. It consists of serial manipulation and casting, looking for a systematic correction of the deformity, based on the fundamentals of kinematics and pathophysiology of the deformity.

Arthrogrypotic club foot

Arthrogryposis Multiplex congenita is a rare disorder, characterized by multiple joint deformities i.e. multiple congenital contractures, with shapelessly cylindrical limbs and absent skin creases. Club foot can be the only obvious deformity of this widespread disorder. To assess the most frequent recurrent deformity after extensive soft-tissue release operations for arthrogrypotic club foot and its appropriate treatment regarding combined tendon transfer and bony operations. A retrospective study of 14 patients with arthrogrypotic club foot [28 feet], had been operated on by multiple soft tissue and bony operations and followed in a period between January [1993] till February [1999]. Both clinical assessment including goniometer use to measure the recurrent deformity, and radiological assessment, was used in this study. In this series, 4 patients [7 feet] had recurrent deformity, 3 patients [5 feet] out of these 4 had recurrent forefoot adduction, 2 of them had bilateral affection. The 4[th] patient had bilateral recurrent varus heel. The main problem in arthrogrypotic club foot is the liability for recurrence. The most frequent recurrent deformity was forefoot adduction. Combined tendon transfer and bony operations can correct the deformity once performed at the same session forefoot adduction. All required 2[nd] operation, in the 1[st] 3 patient combined Evan's [calcaneocuboid wedge-excision] and tibialis anterior transfer operations were performed. Talectomy was performed on one foot in the 4[th] patient, combined with capsulectomy of the calcaneocuboid joint, while triple arthrodesis done on the other foot

Antenatal Diagnosis of Iniencephaly: Sonographic and MR Correlation: A Case Report

Iniencephaly is an uncommon and fatal neural tube defect involving the occiput and inion, this occurs together with rachischisis of the cervical and thoracic spine, and retroflexion of the head. We report the ultrasound (US) and magnetic resonance (MR) imaging findings of a case of iniencephaly with clubfeet and arthrogryposis. The diagnosis of iniencephaly is easy to make on ultrasound due to the typical star-gazing fetus. However, the details of the fetal brain and spinal cord may not be adequately delineated on US. We found MR imaging to be superior for depicting central nervous system abnormalities. MR imaging has evolved as an imaging modality and it is complementary to fetal US, yet US remains the screening modality of choice.

[Nonoperative treatment of clubfoot] 814 cases

814 feet which have congenital talipes equinovarus of 537 children were followed at the surgical and Pediatric orthopedic clinic of the Casablanca children's hosp ital during the period February 1976 to September1990. 64,2% of the feet were examined during the first three months after birth and 70,4% of the children were masculin. The bilateraly was noted in 51,6% of the cases and 42,3 of the feet were irreducible [classified type III]. 15 cases of congenital dislocation of the hip were associated to clubfoot as well as to other malformations. The functional [orthopedic] treatment was applied at the service since 1980, in the form of manipulations with the utilization of posture splints. 131 feet of 81 children benefited from a series of plasters before hand. The aim of manipulations is to correct the various and the supination at first; the peroneus muscles stimulated by a toothbruch during the second phase. At the end, the equins is corrected in pulling the heel downwards. The Denis Brown splints are borne continuously, and are removed only during their-education sessions or in case of complications. Bearing this equipment needs surveyance on the part of the physiotherapist and the mother. Cutaneous ulceration may appear following the placement of the splints; they decreased markedly during our study thanks to artifices applied by the physiotherapist of the favorable shoes evolution, wearing reversed ankle shoes is permitted during the daytime. For the evolution of results, criteria of a morphological and radiological as well as of a functional nature were assessed. Only 495 feet of 318 children were able to be judged with sufficient retreat: the average period being 5 years. In this way, appraisals were done at birth, and on the third, sixth and tenth month of the functional treatment. The x-rays of the tenth month were particularly decisive; they permitted follow-up on the treatment or else they indicated the necessity for conducting surgery. The global results of the treatment were good in 31,1% of cases. Reviewing the literature allowed a comparative study with our works; thus our results were close to those obtained by Turco [35%] and Seringe [38,7%]; Knowing that all the feet were examined by most of the authors before the 30 th day afterbirth. results obtained were even better [36,5%] when the treatment started during the first three months after birth instead of afterwards [13,7%]; this was the case when the foot was initially reducible [classified type I] [39,7%]. 83,8% the feet classified type II [partially reducible] and treated as type I, responded badly to the treatment. Stiff feet, made flexible by using series of plasters, obtained poor results in 57,3% of the cases. All the feet of group III [with bad results] were proposed for surgery, only 197 were operated of which.56,8% had 8 to 12 months of age. 83,7% of these feet underwent minor surgery of the posteromedial release type

Evaluating the results of conservative and operative methods of treatment in congenital talipes equinovarus

The purpose of the study was to evaluate the results of treatment, both conservative and operative, of Congenital Talipes Equinovarus [CTEV] with the aim of evolving a simple, objective follow-up procedure for uniform comparison of results. Fifty three patients of CTEV reporting to Orthopaedics Department. Sheikh Zayed Hospital Lahore, between September 1986 and June 1988, were studied. Out of them 43.4% patients were treated conservatively while the rest [56.6%] were operated upon. The system of follow-up assessment evolved, was based on grading of function, appearance and growth. The system has the advantage of being practical objective and easily reproducible