CLUBFOOT (pes equinovarus) — the difficult combined deformation of foot, at a cut the following changes of its form and situation are observed:
1) foot is turned inside — supinated by hl. obr. calcaneal area and a tarsus — - internal To., pes varus, talipes;
2) foot is in the provision of bottom bending — pes equinus; the sum of these changes is called pes equinovarus, talipes equinovarus;
3) reduction — adduction of front department of foot — pes adductus. To. happens inborn and acquired.
Inborn clubfoot (inborn internal horse and clumsy foot, pes equinovarus congenitus) — one of the most often found deformations. On a nek-eye to data, among inborn deformations To. wins first place. At boys inborn To. it is observed by 1,5 — 2 times more often than at girls.
Under the name «inborn clubfoot» combine different types of inborn deformations of feet which are divided into two groups: typiforms — apprx. 80% and atypical forms — apprx. 20%.
There are several typiforms inborn To. 1. Varus contractures Osten-Sakena at which changes in muscles, sheaves and bones of foot happen insignificant. Correction of provision of foot is carried out rather easily. 2. The Myagkotkanny copular forms which are found most often. Changes from bones are insignificant. At correction of provision of foot the springing resistance is felt; completely it is in one step impossible to eliminate deformation. 3. Bone forms K., meeting less often. Along with changes from ligaments and muscles more expressed changes of a form of an astragalus and its anteposition and knaruzh are observed. The lateral anklebone reaches the considerable sizes and prevents correction of deformation. In attempt to korrigirovat deformation, even at small children, an impression of a bone obstacle is at once made.
Treats atypical forms To., arising owing to amniotic banners, an arthrogryposis, inborn defects of bones, hl. obr. tibial bone, inborn spastic paralyzes.
The etiology and a pathogeny
Exist the theories explaining emergence inborn To. defect of primary bookmark, the mechanical theories connecting emergence To. with the wrong provision of a fruit in a uterus, neurogenic theories.
Inborn To. it is caused by various factors: the abnormal size of a lateral anklebone or a peculiar shape and an unusual arrangement of a medial anklebone, but these types of deformation meet seldom. Patients at whom the explicit thickening of sheaves, an atypical arrangement of muscles and sinews, and also quite often additional, normal not existing muscles supinating foot is observed meet more often. Disturbance funkts, balances between instep supports and pronators can be most often the cause of development inborn To.
The pathological anatomy
the Astragalus is almost always displaced and its considerable part is given knaruzh and forward, at the same time the neck is turned inside and down. The corner sometimes reaches it 50 ° and more whereas normal at the adult this corner is equal 12,3 °, and at an embryo — 35,7 °. The long axis of an astragalus is located with an inclination forward and inside. The semi-circle of an upper joint surface of an astragalus is not in the sagittal plane as is normal, and in frontal, i.e. bottom and the dorsiflexion of foot is replaced with pronation and its supination. Rotation of bones of a shin and other changes is observed.
The clinical picture
Foot (especially its average department and area of a heel) is turned inside, the front department of foot is given therefore on its inner surface in the area I of wedge-shaped and carinate bones often there is a deep fold — Adams's furrow. All foot is in the provision of bottom bending. Extent of deformation fluctuates in very wide limits: from scarcely noticeable and easily removable to sharp. These deformations sharply break basic function of the lower extremity.
Treatment of patients with inborn To. still Hippocrates made. In 18 and 19 centuries a wide spread occurance at treatment To. received various devices and cars offered A. S by carat sing, G. Stromeyer, etc. by means of which violently improved a form and situation of foot.
In the second half of 19 century a number of surgeons — X. Delore, P. Tillaux, etc. made the forced manual redressment under anesthetic then fixed foot a plaster bandage.
At inborn To. it is necessary to consider that the shortened sheaves on an inner surface of an ankle joint hold bones in the wrong situation statically, and the shortened and reinforced muscles (instep supports and sgibatel) — dynamically.
Treatment inborn To. at children of chest age begin on 7 — the 10th day after the birth of the child. Only at the most mild cases it is possible to achieve treatment by means of an immobilization flannel bandage, corrective gymnastics and massage. Usually apply stage plaster bandages which at first change in 7 days, and after 3 — 5 months of treatment, after removal of foot in average situation, in 9 — 12 days. During the imposing of a bandage of the child stack on a stomach, bend a leg in a knee joint, pulling together points of an attachment of a gastrocnemius muscle (fig. 1). Some orthopedists apply a plaster bandage foot and a shin, others — take a knee joint and the lower third of a hip. To 6 — to 7-month age, and sometimes by the time of when the child starts walking, it is possible to eliminate deformation completely at most of patients. When treatment is finished, the child needs to be supplied with the plaster tire, to-ruyu in mild cases To. it is necessary to impose only for the night, and at danger of a recurrence the child shall reside in it. The special gymnastics for correction of deformation and strengthening of muscles of a shin (fig. 1) surely enters treatment. V. Ya. Vilensky offered during the imposing of a plaster bandage on a dorsum of foot to impose wedge-shaped laying from the made foam polymer. Removal of this laying gives the chance to carry out corrective aktivnopassivny gymnastics of foot. Splints for deduction of foot in the correct situation do of thermoplastic material (polivik), monolithic polyethylene etc.
At unsuccessfulness of conservative treatment, a recurrence of deformation at the age of 2 — 14 years apply operation on the tendinous and copular device by Zatsepin's method (1940). Operation is done under anesthetic or under intra bone anesthesia. During operation of the patient lies on a stomach.
1. Make hypodermic crossing of a bottom fascia if it is tense. 2. Do a vertical section through the middle of a medial anklebone (fig. 2, a) from the place of transition of skin to bottom covers and anklebones, depending on age are 2 — 5 cm higher. Sinews of a back tibial muscle and a long sgibatel of fingers of Z-obrazno cut for lengthening. Cross the deltoid sheaf fixing foot in the provision of supination (fig. 2, b). A sharp-pointed scalpel cut the copular device between a medial anklebone and an astragalus, and then from a medial surface between an astragalus and calcaneal. 3. Do a slit of skin on posterointernal edge of heelstring (Achilles tendon), a cut Z-shapedly cut in the sagittal plane (fig. 2, c). Open a back fascia of a shin under an ankle joint, Z-shapedly cut a long sgibatel of a thumb. Cut the capsule of a joint and sheaf on a back and posterointernal surface between tibial and collision and between collision and calcaneal bones. Do trial manual correction of foot, and the crash owing to a rupture of a collision and calcaneal sheaf and incompleteness of the crossed other sheaves usually is distributed. After that foot is easily established in the provision of small hyper correction. Recover sinews. Wounds sew up, without putting stitches on the crossed sheaves and the capsule of joints.
For elimination of reduction of front department of foot bare and Z-shapedly extend a sinew of the muscle which is taking away a thumb, on a sole cross a short sgibatel of a thumb and the joint capsule on an inner surface of the I klinoplusnevy joint. The leg is fixed a plaster bandage in the provision of correction, but not hyper correction, for prevention of a necrosis of skin of a medial surface of foot between two cuts. After operation the plaster bandage is applied 6 months. During this time there is a transformation of bones of foot. At strict execution of all specified inclusion in 95% of cases of stop gets a normal form and function. 5% are made by those patients, the Crimea because of considerable deformation operations on bones of foot are shown.
B. V. Rubenstein and K. N. Kornilov at deformation of an astragalus recommend to make its reconstruction, generally surgical modeling of the block. At patients happens to sharp deformation of bones of foot it is necessary to make a wedge-shaped resection of foot. Wedge turned by the basis of a knaruzha shall be excised so that its back surface was perpendicular a calcaneus, and a lobby — a tarsus. Nek-rym the patient with the wrong provision of a calcaneus make an osteotomy on Gomanna.
If for any reason to operate on foot it is impossible, then make a wedge-shaped resection of bones of a shin in the lower third for elimination of its supination. Their osteotomy can be made for elimination of sharp rotation of bones of a shin.
The principles of treatment of patients with atypical forms inborn To. because of amniotic banners, an arthrogryposis and bone anomalies same, as well as at a typiform. However at severe forms the reliable result turns out after operation of an astragalektomiya — removal of an astragalus according to Vogt (1884). Sometimes it is necessary to make an osteotomy or a resection of an outside anklebone, cubical bone, a three-joint artificial ankylosis of foot or other bone operations.
At conservative and operational treatment To. widely apply physical therapy (thermal procedures, ultrasound, electrostimulation of muscles, etc.) for increase in elasticity of soft tissues, strengthening of muscles etc.
the Acquired clubfoot
the Paralytic clubfoot is observed after the postponed poliomyelitis when the peroneal group of muscles is paralyzed, and function of the muscles supinating foot remains; after the isolated injuries of a fibular nerve. Principles of treatment of these forms K. are identical. It is begun with elimination To. stage plaster bandages, at disturbance of an integrity of a fibular nerve make its sewing together; if it is impossible to sew a nerve, make change of sinews of healthy muscles from an inner edge of foot on outside.
At paralytic pes varus, but in the presence of active back extension it is possible to make a three-joint artificial ankylosis: in collision and calcaneal, collision and carinate and calcaneocuboid joints. At pes equinovarus paralyticus along with tendon grafting of an instep support on the outer edge of foot it is necessary to make Z-shaped lengthening of heelstring in the sagittal plane, crossing below a medial part of a sinew.
To. meets also after incorrectly treated changes of an astragalus or several bones of foot, at a fracture of anklebones an incomplete dislocation of foot in talocrural or collision and calcaneal joints. Apply operational repositions, a wedge-shaped resection of bones of foot, a shin, artificial ankyloses to treatment.
To. can be a consequence of various inflammatory processes of an ankle joint. At cicatricial forms K. after deep burns, inflammatory processes apply or excision of cicatricial fabrics with the subsequent plastics a bucket-handle graft, or bone operations. To. it can be formed after an ischemic necrosis of muscles of a shin.
Bibliography: Baume G. S. Clinical forms of an inborn clubfoot, Ortop, and travmat., book 5, page 55, 1937, bibliogr.; M. V. and Dedov V. D wolves. Danish orthopedics, page 90, M., 1972; R. R Is harmful. Practical guidance on orthopedics, page 156, L., 1936; Zatsepin T. S. An inborn clubfoot and its treatment at children's age, M., 1947, bibliogr.; M about in sh about in and the p I. And. and Vilen with to and y In, I. Polymers in traumatology and orthopedics, page 279, M., 1978; M a shouting about z P. F. Surgical treatment of an inborn clubfoot at children, Chisinau, 1976, bibliogr.; Osten-Sakene. BB. Amniotic forms of a clubfoot, Ortop. and travmat., book 1-2, page 29, 1929, bibliogr.; Early conservative treatment of an inborn clubfoot by means of products from polymeric materials, sost. V. Ya. Vilensky, etc., M., 1973; Campbell W. Page of Operative orthopedics, St Louis, 1949; Henkel H. L. Die Behand-lung des angeborenen Klumpfusses im Sauglings-und Kindesalter, Stuttgart, 1974.
S. T. Zatsepin.