ctev.ppt by krr

CLUBFOOT

DR.SANJEEV REDDY HEAD OF DEPARTMENT DEPT OF ORTHOPAEDICS MRMC GULBARGA

PRESENTER :DR.RAMACHANDRA

INTRODUCTION

• Clubfoot is also known as CTEV which means Congenital Talipes Equino Varus.

• Congenital - Present at birth • Talipes - Latin word for ankle & foot • Equino - Heel is elevated • Varus - Foot is turned inwards

• Incidence is about 1 in 1000 live births.• It is developmental deformation.• A normally developing foot turns into a

clubfoot during 2nd trimester of pregnancy.

• Rarely detected with USG before 16th week.

• CTEV is a complex deformity with four clinical components:

• 1.Hind foot equinus • 2.Hind foot varus• 3.Mid/forefoot adductus• 4.Cavus

PATHOLOGICAL ANATOMY:

• The deformity has the following features:Equinus:• Severe tibio-talar & talocalcaneal plantar

flexion.Adductus:• Medial talar neck inclined • Medial displacement of navicular & cuboid• Calcaneus adducted• Distal calcaneous articulating surface

adducted• Forefoot adducted in relation to hindfoot

Varus:• Adducted, plantar flexed & inverted

calcaneus.

Cavus: Plantar flexed 1st metatarsal.

• In clubfoot, the ligaments of posterior & medial aspect of ankle & tarsal joints are very thick & taut

foot in equinus navicular & calcaneus in adduction &

inversion.

• The size of leg muscles correlates inversely with severity of deformity.

• There is excessive pull of tibialis posterior abetted by gastrosoleus & long toe flexors.

• These muscles are shorter than normal foot.In distal end of gastrosoleus, there is an increase of connective tissue rich in collagen, which tends to spread into tendo achilis & deep fasciae.

CLASSIFICATION

Classified in two ways

• Relation to cause of deformity

Relation to treatment stage

Idiopathic clubfootSecondary clubfootPostural clubfootMetatarsus adductus

Untreated clubfootTreated clubfootResistant clubfootRecurrent clubfootNeglected clubfootComplex clubfoot

PIRANI SCORE

• A reliable methord for assessing amount of deformity in clubfoot

• Formulated by Dr Shafique Pirani• A child's total score is between 0 & 6• 6 signs are assessed & each is scored

0,0.5 & 1 depending on severity. • Total score of 0 - no deformity• Total score of 6 - severe deformity

Total score comprised of :Hind Foot Contracture Score betn 0 & 3• Posterior crease• Empty Heel• Rigid Equinus

Mid Foot Contracture Score betn 0 & 3• Medial Crease• Lateral Head of Talus• Curved Lateral Border

RADIOGRAPHIC EVALUATION

• In a nonambulatory child, standard radiographs include anteroposterior & stress dorsiflexion lateral radiographs of both feet.

• AP & Lateral standing radiographs may be obtained for older child.

• Important angles to consider in evaluation of clubfoot are:

• Talocalcaneal angle on AP view &

• Talocalcaneal angle on lateral view & the Talus-first metatarsal angle.

• In clubfoot: • On AP view Talocalcaneal angle is

progressively decreases with increase in heel varus.

• On lateral view Talocalcaneal angle is progressively decreases with severity of deformity to an angle of zero degrees.

• Tibiocalcaneal angle in a normal foot is 10 to 40 degrees on stress lateral view.

• In clubfoot this angle is generally negative, indicating equinus of calcaneus in relation to tibia.

• Talus-first metatarsal angle measures forefoot adduction.

• In clubfoot it is negative, indicating adduction of forefoot.

TREATMENT

• Nonoperative Treatment• Operative Treatment

Nonoperative Treatment

• Most widely accepted technique is described by Ignacio Ponseti.

• Consists of weekly serial manipulation & casting during first weeks of life.

Ponseti Method of Casting

• Consists of two Phases:• Treatment Phase• Maintainance Phase

• Treatment Phase should begin as early as possible, optimally within first week of life.

• Gentle manipulation & casting done weekly.

• The order of correction by serial manipulation & casting should be as follows:

• 1)Correction of Cavus• 2)Correction of Adduction• 3)Correction of heel Varus• 4)Correction of hindfoot Equinus• Each cast holds foot in corrected position

allowing it to reshape gradually.• Generally 5-6 casts required for correction.

• First cast applied by extend first metatarsal & supinate foreoot.

• This elevates the first ray & puts the forefoot in proper alignement with hindfoot.

• Cast should be applied in two stages:• First, a short leg cast of below knee & then

extend till above knee when plaster sets.• Long leg casts are essential to maintain a strong

external rotation force of foot beneath the talus,to allow stretching of medial structures, & to prevent cast slippage.

Correction of Cavus

• Corrction of Abduction & Varus

• The whole foot is abducted under talus.• Thumb should be on the head of talus.• The Navicular moves away from medial

malleolus & covers head of talus.• The foot should never be corrected, & heel

should not be touched.• Do not dorsiflex until you have reached

60-70 degrees of Abduction.

Correction of Equinus

• When heel is in Valgus, talar head is covered & the foot is in atleast 60 degree abduction.

• Equinus can be corrected by dorsiflexing foot.

• When tendon is tight, this is facilitated by percutaneous Tenotomy of Tendo Achilis.

• Tenotomy should occur in around 90% of cases.

Tenotomy

• Timing of Tenotomy:• Pirani score indicates MFCS is one or

less.• Score for LHT is zero.• Heel is in Valgus.• Foot is in Abduction.

Maintenance Phase

• When final cast is removed, infant is placed in a brace that maintains foot in its corrected position.

• This brace is FOOT ABDUCTION BRACE.• It consists of shoes mounted to a bar in a

position of 70 degrees of external rotation & 15 degrees of dorsiflexion.

• The distace between shoes is set at about one inch wider than width of infant's shoulder.

• This brace is worn 23hrs each day for first 3months after casting & then while sleeping for 2 to 3yrs.

• Without proper bracing, recurrence will occur in 90% of cases.

Complications of Casting

• Pressure Ulcers• Skin allergy • Swelling• Cast slip• Circulation problems• Rocker bottom foot• Muscle atrophy

Operative Treatment

• Surgery in clubfoot is indicated for deformities that do not respond to conservative treatment by serial manipulation & casting.

• In planning surgical correction it is essential to recognize the mechanics & pathologic contractures preventing reduction.

• General principles for any one stage extensile clubfoott release includes:

• Release of tourniquet at the completion of procedure, obtaining hemostasis by electrocautery.

• Careful subcutaneous & skin closure with foot in plantar flexion.

• Foot can beplaced in a fully corrected position 2wks after surgery at first post op cast change.

• The following three types of contractures are seen:

POSTERIOR:• Posterior capsule, Achiles tendon, Posterior

talofibular & calcaneofibular ligmt.MEDIAL:• Deltoid & Spring ligmts, Talonavicular

capsule, Posterior tibial tendon, tendons of FDL & FHL.

SUBTALAR:• Anterior interosseos ligmt, bifurcated ligmt.

• Extensive release include the posterolateral ligmnt complex most often is required for severe deformity.

• The procedure is described by McKay.• Takes consideration into 3-dimensional

deformity of subtalar joint & allows correction of IR deformity of calcaneus & release of contractures of posterolateral & posteromedial foot.

• A Modified McKay procedure through a transverse circumferential(Cincinnati) incision is preferred technique for initial operative management of most clubfoot.

• TRANSVERSE CINCINNATTI INCISION:

• This incision provides exposure of subtalar jt & is useful in pts with a severe IR deformity of calcaneus.

• Problem of this incision is tension on suture line.

• To avoid this foot can be placed in plantar flexion in immediate post op cast & then in dorsiflexion when wound has healed at 2wks.

• EXTENSILE POSTEROMEDIAL & POSTEROLATERAL RELEASE:

• By Modified Mckay• When equinus & varus deformity coexist,

both must be overcome, either seperately or at same time.

• Posterior release alone will not correct hindfoot equinus, because anterior end of calcaneus is locked beneath talus.

• Both ends of calcaneus & navicular must be freed so that anterior end moves outward & upward with navicular as posterior tuberosity of calcaneus moves downward.

• This is achieved by modified Mckay procedure which includes posteriorly Achiles tendon lengthening by z plasty.

• Medially by releasing posterior tibial tendon, superficial deltoid ligmnt from calcaneus, capsule of talonavicular jt & spring ligmnt.

• The deep deltoid ligmnt which inserts into talus must be preserved.

• If this is divided, a flatfoot deformity with tilting of talus may develop.

• The deformity can now reduced by replacing navicular in front of head of talus.

• Anterior end of calcaneus moves laterally & everts while its posterior end moves downward & away from ankle jt.

• Talonavicular jt is transfixed with k wire.

• Achiles tendon is repaired with interrupted sutures.

• Post operative care:• A long leg cast is applied with foot in

plantar flexion. • At 2wks cast is changed, & foot is placed

in corrected position.• At 6wks cast is changed again & pins are

removed.• All casts are discontinued at 10 - 12wks

after surgery.

• ACHILLES TENDON LENGTHENING & POSTERIOR CAPSULOTOMY:

• When there is residual hindfoot equinus in children 6 to 12 months old who have obtained adequate correction of forefoot adduction & hindfoot varus.

• This is corrected by ACHILLES TENDON LENGTHENING & POSTERIOR CAPSULOTOMY of Ankle & subtalar jt.

• In case of dynamic metatarsus adductus caused by overpull of anterior tibial tendon in older children who have had correction of clubfoot.

• In these cases treatment of choice is, either as a split transfer or as a transfer of entire tendon to middle cuneiform.

RESISTANT CLUBFOOT

• Treatment of residual or resistant clubfoot in an older child is most difficult problems in paediatric orthopaedics.

• Residual forefoot deformity should be determined to be either dynamic(with a flexible forefoot) or rigid.

• The amount of inversion & eversion of calcaneus & dorsiflexion & plantar flexion of ankle jt should be noted.

• Any prior surgical procedures causing significant scarring around foot or loss of motion shold be noted.

• Standing AP & Lateral radiographs taken to assess anatomical measurements.

• Allpossible causes of persistent deformity, like underlying neuropathy, abnormal growth of bones, or muscle imbalance should be investigated.

• The basic surgical correction of resistant clubfoot includes

• SOFT TISSUE RELEASE • BONY OSTEOTOMIES• These procedures done based on :• Age of child• Severity of deformity • Pathological process involved.

In general Childrens 2-3yrs old may be candidates for modified Mckay procedure.

If previous soft tissue release caused stiffness, osteonecrosis talus

should undergo Osteotomies

• Common components of resistant clubfoot deformity includes:

• Adduction or Supination • Both, of forefoot, a short medial column or

long lateral column of the foot • IR & Varus of calcaneus• Equinus.

Correction of forefoot with residual adduction or supination or both

by multiple metatarsal osteotomies or by combined medial cuneiform & lateral cuboid osteotomies .

• In hind foot heel varus, a long lateral column of foot or a short medial column

• Children younger than 2 or 3yrs who had no previous surgery

• Corrected by extensive subtalar release

• Children 3 to 10yrs who have residual soft tissue & bony deformities

• Need combined procedures.

For symptomatic ankle Valgus

Percutaneous malleolar ephiphysiodesis using a 4.5mm cortical screws has been recommended.

Isolated heel varus with mild supination of forefoot

Dwyer Osteotomy with lateral closing wedge osteotomy of calcaneus done.

Hindfoot deformity includes heel varus & residual IR of calcaneus with a long lateral column of foot

Lichtblau procedure done

Corrects long lateral column of foot by a closing wedge osteotomy of lateral aspect of calcaneus or by cuboid enucleation

Complication includes z foot or skew foot deformity.

Residual heel Equinus

In younger child corrected by Achiles tendon lengthening & Posterior ankle & subtalar capsulotomies

In older childrens a Lambrinudi Arthrodesis done

Residual midfoot deformities

Talonavicular Arthrodesis done.

If all three defomities present in a child older than 10yrs

TRIPLE ARTHRODESIS performed

Rigid Cavus or Cavovarus deformity

Stepwise correction of deformity with closing wedge osteotomy of 1st metatarsal

Open wedge osteotomy of medial cuneiform

Close wedge osteotomy of cuboid & 2nd & 3rd metatarsals

Sliding osteotomy of calcaneus, plantar

fasciotomy & peroneus to brevis transfer.

• TRIPLE ARTHRODESIS & TALECTOMY • These two procedures are generally are

salvage operation for uncorrected clubfoot in old & adolescents.

• Tripple arthrodesis corrects deformed foot by a lateral closing wedge osteotomy through subtalar & midtarsal jts.

• Talectomy performed:

• for severe untreated clubfoot• previously treated clubfoot that is

uncorrectable by any other procedures • neuromuscular clubfoot.

DHANYAVAAD