Relapsed Club Foot

	Treatment of resistant & residual clubfoot in older children
	The appropriate procedures and combination of procedures depend on;     The age of the child. The severity of the deformity. The pathological processes involved.         Common components of resistant clubfoot deformity are:       Adduction or supination, or both, of the forefoot. A short medial column or long lateral column of the foot. Internal rotation and varus of the calcaneus. Equinus.               Forefoot deformities:       Dynamic deformities – tendon balancing procedure (split or complete transfer of tibialis anterior to lateral cuneiform or cuboid).             2. Rigid deformity (<5years): Multiple MTPJ capsulotomies.       3. Rigid deformity (>5years): – Bony procedures like dome osteotomies of metatarsal bases and cuneiform-cuboid osteotomy.         Rigid Deformity           Cunieform Cuboid Osteotomy for correcting forefoot adduction deformity     Hindfoot Deformities   <2-3 years: - modified McKay procedure               Picture showing Cincinnati incision for pantalar release                 3-10 years:     Its important to find out if hindfoot deformity is because of isolated heel varus, short medial column or long lateral column.           Isolated Heel Varus          Dwyer osteotomy is the treatment.                   Short lateral column  Dillwyn-Evans procedure is the treatment       Long lateral Column   Lichtblau procedure is the treatment         10-12 years: triple arthrodesis                     Heel Equinus               Achilles tendon lengthening plus posterior capsulotomy of subtalar joint, ankle joint (mild-to-moderate deformity)                                   Lambrinudi procedure (severe deformity, skeletal immaturity)                                 All Three Deformities           Triple Arthrodesis is done children more than 12 years. Upto 12 years one should try Ponseti treatment first.                 External Fixator     Has been used successfully in relapsed and resistant clubfoot                 Case 1     Relapsed club foot after posteromedial release in a five year old child.                           Treatment with JESS External Fixator.                           Result – Maintenance of correction 8 years later at the age of 13 years               Result at the age of 13 years           Internal Tibial Torsion           De-rotational Osteotomy of tibia is rarely required. Foot deformities should be excluded before undertaking tibial osteotomy.