A male child of Caucasian origin was brought to our hospital at the age of 5 days with circumferential congenital constriction rings just above the ankle joint, and severe clubfeet. The pediatric examination revealed no other abnormality in the upper extremities or other organs. Pregnancy was uneventful, but during a routine ultrasound examination at 18 weeks of gestation, the gynecologist noticed bilateral clubfoot deformities and informed the parents (Fig.1). The child was born by normal vaginal delivery at full term with cephalic presentation. There was no family history of congenital anomalies. The karyotype test was done and revealed no abonormality. Further genetic testing were not done.
On inspection, both feet had inversion at the subtalar joint, equinus and varus in the ankle joint, adduction of the forefoot, pronation of the forefoot in relation to the ankle joint, cavus (excavatum), internal rotation of the crural region. (Fig.2) The right foot: a constriction circumferential ring, type II in Patterson classification, was located about 4.0 cm above ankle joint without neurologic deficit, but with dorsal lymphedema. The toes of the right foot were hypoplastic. There was also a severe clubfoot deformity grade 4 according to Dimeglio classification with a marked medio-tarsal crease. The left foot: a circumferential constriction band, type II in Patterson classification, was located above 3.8 cm on the ankle but without lymphedema. The clubfoot deformity was grade 4 according to Dimeglio. There wasn’t noticed any limb-length discrepancy.Fig. 2. Severe bilateral clubfoot in a newborn at the day of birth and at the age of 5 days with constriction rings. Constriction rings in the calf above to the ankle joint are circumferential and responsible for foot and ankle lymphedema on the right side .
Clubfeet were corrected with Ponseti method as a safe and effective procedure. During treatment of clubfoot 3 phases were essential: reduction of deformation (2 months), consolidation of obtained results (4 months), and manage the risk for relapse(3 months). A long-leg-cast was applied with knee flexed 90⁰. The cast was changed every week with gradual correction of the deformity according to Ponseti protocol. Cavus, adductus, and varus were fully corrected but dorsiflexion was limited for 20 degrees bilaterally so the tenotomy of the Achilles tendon was indicated. Because of lymphedema from amniotic band syndrome on the right foot, we decided to cut the constriction bands to release the tourniquet-like effect. Percutaneous Achilles tenotomy was performed bilaterally and three longitudinal incisions were made through the constriction band, on the right foot.
Of course, a later reconstruction procedure was necessary. There were no bleeding complications following percutaneous Achilles tenotomy (Fig. 3B). The post-tenotomy casting remained for 3 weeks with changing the cast casts every 10 days. After Ponseti procedure the foot abduction brace (FAB) protocol was applied to maintain the correction: the bracing protocol included 23 hours a day at 700 of external rotation for three months, then reduced to 18 hours a day and then removed gradually, one hour a day until use of 12 hours a day. After walking age, the brace was worn at night (Fig. 3C). The patient was followed until 2 years old, and there was no relapse of the deformity. A two-stage circumference excising of the congenital constriction band was done by plastic surgeons, with a three months interval between stages (Fig. 5). The first stage of surgery was done at age of 13 months and 3 weeks, and the second stage three months later. There was no wound complication. The lymphedema was withdrawn.