PRESENTER-DR.RAGHAVENDRA RAJUMODERATOR-DR.SAMEER WOOLY

CTEV

INTRODUCTION

TALUS-ANKLEPES-FOOTEQUINO-LIKE A HORSEVARUS- TURNED INWARDS

HISTORICAL ASPECTS

- EARLIEST EVIDENCE IN EGYPTIAN PERIOD.- YAJURVEDA ADVISED TO MASSAGE TO

CORRECT DEFORMITY.- HIPPOCRATES FIRST DESCRIBED CLUB FOOT.- SCARPA(1803) FIRST DESCRIBED PATHOLOGIC

ANATOMY.- KITE (1930) DESCRIBED NON OPERATIVE

TREATMENT WITH SEVERAL MANIPULATION AND PLASTER CAST APPLICATION.

- DENNIS BROWN (1934) DEVISED SPLINT FOR MAINTENANCE OF CLUBFOOT CORRECTION.

- IGNACIO PONSETI (1950) DEVELOPED METHOD CORRECTION.

DEFINITION

CONGENITAL DYSPLASIA OFMUSCULOSKELETAL TISSUES DISTAL TO

KNEE JOINT IN THE FORM OF DEFORMITY OF

FOOT AND ANKLE.

IT IS A DEVELOPMENTAL DISORDER.

ETIOLOGY-IDIOPATHIC

1.MECHANICAL FACTORS- HIPPOCRATES Oligohydramnios Abnormal fetal positioning Unstretched uterus Placental insufficiencyConstriction bands.2.PRIMARY GERM PLASM DEFECT3.ARRESTED FOETAL DEVELOPMENT4.HEREDITARY- AD5.MUSCULOLIGAMENTOUS FIBROSIS

6. VASCULAR HYPOTHESIS- 90% of CTEV limbs showed hypoplasia / absence of anterior tibial artery.

SECONDARY CLUBFOOT

1.PARALYTIC DISORDERS - evertors and dorsiflexors are weak.

Ex- polio , spina bifida, myelodysplasia, friedrichs ataxia.

2.SYNDROMES -arthogryposis multiplex congenita, downs syndrome, larsen syndrome.

INCIDENCE- 1 to 2 in 1000 livebirths.SEX – MALE >FEMALELATERALITY- BILATERAL IN MORE THAN 50

% .FAMILY HISTORY- 5-50% POSITIVE.

COMPONENTS OF CTEV

BONY CHANGES

Talus: most deformed and least displaced. Head & neck deviated medially & plantarward Body rotated externally in the ankle mortise, superior articular

surface escapes from mortice. Talar neck is short and medially deviated. Smaller than normal, disturbance of vascular supply, ossification

centre eccentrically placed

Navicular: Medially displaced Close to medial

malleolus Articulates with medial

surface of head of talus

Calcaneus Anterior portion lies

beneath the head of talus causing varus and equinus of heel

In equinus Rotated medially

Cuboid Displaced medially on

the dysmorphic distal end of the calcaneus

Tibio-talar plantar flexion

Medially displaced navicular

Adducted and inverted calcaneus

Medially displaced cuboid

Soft tissue changes

Posterior structures :

Tendo achilles Post. capsule of ankle

joint & subtalar joint Post. talo fibular Calcaneo-fibular

ligaments

MEDIAL- Tibialis posterior FHL,FDL, Master Knot of

Henry Talonavicular ligament Calcaneo-navicular

ligament Deltoid ligament Interossseus talo calcaneal

ligaments Capsules of naviculo

cuneiform & cuneiform first metatarsal

Plantar wards : Plantar fascia Plantar ligaments Flexor digitorum brevis & abductor hallucis Laterally Calcaneofibular ligament Bifurcated ligament Calcaneocuboid joint capsule

EXAMINATION

1.DORSIFLEXION TEST-2. PLUMB LINE TEST-

CLASSIFICATION

1. IDIOPATHIC AND NON IDIOPATHIC-2. CUMMIN CLASSIFICATION3. a. supple –foot can be brought to normal position. b. rigid - forefoot can be corrected but not the

hind foot by conservative management. c. neglected- not received treatment for one year. d. relapsed- deformity reappear after correction. e.recurrent- type of relapse, due to muscle

imbalance. f. resistant- cannot be corrected by conservative

treatment.

3. Browne s classification- a. first degree- only forefoot adduction

present. b. second degree- inversion and equinus is

present along adduction.c. Third degree- toes pointing upwards, sole is

in contact with medial surface of tibia. Equinus component is not present.

Radiology

Plain radiograph: Can be assessed prior to treatment with A-P & Lateral of foot

Foot held in position of best correction, with weight-bearing, or simulated weight-bearing

AP view: Taken with foot in 30° of plantar flexion and tube at 30° from vertical

Lat. View: Transmalleolar with the fibula overlapping the posterior half of the tibia; foot in 30° of plantar flexion

Anteroposterior view

Talocalcaneal angle

Calcaneal-second metatarsal angle

Talus –first metatarsal angle

Lines drawn through center of the long axis of talus (parallel to medial border) and through the long axis of calcaneum (parallel to lateral border), and they usually subtend an angle of 25-40°.

Any angle less than 20° considered abnormal

AP radiograph: Talo-Calcaneal angle

Lateral view Talocalcaneal view Calcaneal-first

metatarsal view Tibiocalcaneal Talus-first metatarsal

angle Talocalcaneal index

(Kite's angles from AP and Lateral views added)         

Pirani’s severity scoring

Six parameters : 3 of midfoot and 3 of hindfoot

Each parameter is given a value as follows:0: normal0.5: moderately abnormal1: severely abnormal

Pirani s et al. A method of evaluating virgin clubfoot with substantial interobserver reliability. Annual meeting of Pediatric orthopaedic society of North America 1995

Mid foot score

Curved lateral border [A]

Medial crease [B]

Talar head coverage [C]

Hind foot score

Posterior crease [D]

Rigid equinus [E]

Empty heel [F]

Uses of Pirani’s score

Assessment of progress by serial plotting of the score

Predicting need for tenotomy

Estimation of probable no. of casts reqd*

Very good interobserver reliability and reproducibility**

* J. Dyer et al Journal of Bone and Joint Surgery - British Volume, Vol 88-B, Issue 8, 1082-1084P.

** Flynn JM, Donohoe M, Mackenzie WG. J Pediatr Orthop 1999;18:323-7

Classification of clubfoot severity by Diméglio A.Equinus deviation B. Varus deviation C. Derotation D. Adduction.

Reducibility( degrees)

Score Additional parameters

Score

90-45 4 Marked posterior crease

1

45-20 3 Marked mediotarsal crease

1

20-0 2 Cavus 10 t0 -20 1 Poor muscle

condition1

Grade Type Score Reducibilityi Benign 1-4 >90%ii Moderate 5-9 >50%, soft-stiff,

reducible, partially resistant

iii Severe 10-14 >50%, stiff-soft, resistant, partially reducible

iv Very severe 15-20 <10% stiff-stiff,resistant

Aims of treatment

Achieve a plantigrade , pliable, cosmetically accepted foot in shortest possible time and with least disruption of family and child life.

PRINCIPLES OF TREATMENT

Soft tissue contractures should be stretched out in order to restore normal tarsal relationship.

Once achieved correction should be maintained in till tarsal bones remoulds stable articular surfaces.

TWO OPTIONS –1. NON OPERATIVE- immediately after birth2. OPERATIVE

KITES METHOD

Correction of each component separately and in order.

Avg time 6 months Fulcrum –

calcaneocuboid joint. Order 1.adduction 2.varus 3.equinus

Kite method

Believed heel varus would correct simply by everting calcaneus

Did not realize calcaneus can evert only when it is abducted (i.e., laterally rotated) under the talus

Forefoot overcorrected into mild flatfootCalcaneus is rolled out of inversion by placing

plantar surface of a slipper cast on glass plate to flatten the sole

Dorsiflexion of foot with wedging casts

Outline of Ponseti regimenSerial casting of lower

limb using a strictly defined technique and weekly change of casts

Percutaneous tenotomy of tendo achilles for “hind foot stall”

Once foot corrected, an abduction foot orthosis worn full time for 12 weeks, and then at nights and naps, up to age of four.

Reasons for poor results in kites method1. FULCRUM- prevents abduction of

calcaneum and thereby eversion of calcaneum.

2. Pronation of forefoot worsens cavus.

Manipulation and cast application

1.Manipulation Manipulation: start as soon after

birth as possible

Setup for casting includes calming the child with a bottle or breast feeding

Assistant holds the foot while the manipulator performs the correction

.

Order- cavus adduction varus equinus

2. Correction of cavus Cavus results from

pronation of the forefoot in relation to hindfoot “ THE PRONATION TWIST “

Attempting to correct the supination of hindfoot before correction of varus results in an iatrogenic increase in cavus

Corrected by supinating the forefoot to place it in proper alignment with the hindfoot.

Cast application Manipulation Padding

Plaster at toes Below knee pop

Molding Extension upto the thigh

Plantar support to toes Final appearance

Casts and foot Adequate abductionBest sign of sufficient

abduction: ability to palpate the anterior process of the calcaneus as it abducts out from beneath talus

Abduction of approx.70 degrees in relationship to the frontal plane of the tibia possible

Complications of casting

Tight castRocker bottom deformityCrowded toesFlat heel padSuperficial soresDeep soresPressure soresInjury to distal tibial physis

Common errors(Kite errors)

No manipulationPronation/eversion

of 1st metatarsalPremature

dorsiflexion of heelCounterpressure at

calcaneocuboid jointBelow knee castsShort splints

Rocker bottom deformity

Dorsiflexion via midfoot before correction of hindfoot varus

Dorsal dislocation of navicular on talus

Fixed equinus of calcaneus

Correction of equinus and tenotomy

No direct attempt at equinus correction is made until heel varus is corrected

Equinus deformity gradually improves with correction of adductus and varus- calcaneus dorsiflexes as it abducts under talus

Residual equinus- manipulation and casting +/- percutaneous tenotomy

Tenotomy : Indicated to correct equinus when cavus, adductus, and varus fully corrected but ankle dorsiflexion remains less than 10 degrees above neutral

Percutaneous tenotomy under LA

Foot held in max dorsiflexion by an assistant.

Tenotomy done 1.5 cm above calcaneal insertion Additional 25-30 deg dorsiflexion obtained.

Cast with the foot abducted 60 to 70 degrees with respect to the frontal plane of the ankle, and 15 degrees dorsiflexion for 3 weeks

Foot Abduction braces

Shoes mounted to bar in position of 70° of ER and 15° of dorsiflexion in B/L cases and incase of U/L cases 30 to 40° of ER in normal side, distance between shoes set at about 1˝ wider than width of shoulders

Knees left free, so the child can kick them “straight” to stretch gastrosoleus tendon

Bracing protocol

Worn 24 hours each day for first 3 months. For 12 hours at night and 2 to 4 hours in middle of

day for a total of 14 to 16 hours during each 24-hour period.

Continued until the child is 3 to 4 years of age.

Noncompliance with bracing protocol – the most common cause of recurrence in children on Ponseti regimen

.

Mitchell brace Dobbs dynamic brace

Dennis brown Romanus

CTEV Splint

Straight inner border to prevent forefoot adduction

Outer shoe raise to prevent fooot inversion

No heel to prevent equinus Slight(1/8”) lateral sole

raise Inner iron bar Outer t trap Walking age to 5 yrs of age

The French method

Bensahel/Dimeglio regime Daily manipulations by a skilled physiotherapist

and temporary immobilisation with elastic and non-elastic adhesive taping .

GOAL- reduce talonavicular joint, stretch out medial tissues, correct deformities squentially.

Mobilisation during the hours of sleep with CPM machine.

Successful in 51% of cases ( of which 9% req TA tenotomy) ; 49% Reqd extensive soft tissue release -29% post release and 20% comprehensive posteromedial release**.

Follow up protocol

2 weeks: to troubleshoot compliance issues

3 months: to graduate to the nights and naps protocol

Every 4 months: until age 3 years to monitor compliance and check for relapses

Every 6 months: until age 4 years.

Every 1 to 2 years: until skeletal maturity

RESULTS OF NON OPERATIVE TREATMENT

OVERALL – 19% TO 95%.KITES METHD- 80%.PONSETI – 95%

Surgery in clubfootINDICATIONS

Resistant clubfoot( non-responsive to serial casting and manipulation)

Persistently deformed clubfoot(non-operative correction inadequately done with/without compliant bracing)

Relapsed clubfoot( initially satisfactorily corrected that recurs in part or whole)

Neglected clubfoot( no treatment given till age of 2 yrs)

General Principles

Goal: address all pathoantomic structures.

Type of surgery depend on age and deformity.

ApproachesTurco (postero medial

incision)Cincinnati (postero medial

and postero lateral )

Caroll’s two incision techniqueMedial incision - straight oblique incision from first metatarsal, across medial malleolus to Achilles tendon

Straight lateral incision along the lateral subtalar joint antr to distal fibula

AGE 9- 12 MONTHS

RELEASING OF MEDIAL, PLANTAR,

AND POSTERIOR ASPECTS

OF FOOT.

TURCOS ONE STAGE RELEASE

IDENTIFY AND MOBILISE-1.TIBIALIS

POSTERIOR2.FDL3.FHL4.NV BUNDLE5.ACHILLES

TENDON

Medial tibial navicular ligament, dorsal talonavicular ligamnet, and plantar calcaneonavicular ligament cut

Capsule of T-N cut all the way around

Bifurcated ligament cut Complete release of

talocalcaneal joint ligaments except interosseous ligaments

Detach origin of quadratus plantae muscle from calcaneus

Roll talus back into ankle koint, if not incise post. talofibular ligament, post. Portion of deep deltoid ligament

Line up medial side of head and neck of talus with medial side of cuneiforms, medially push calcaneus post. to ankle joint

K wire through talonavicular ,talocalcaneal joints

Check for proper position of foot

Longitudinal plane of foot 85-90° to bimalleolar ankle plane, heel under tibia in slight valgus

Suture all tendons with foot in 20° dorsiflexion

Wound closure

Follow up : Wound inspection done under sedation at 1 week Foot held in neutral, plantigrade position and cast

applied – above knee Cast kept for 4 – 6 weeks Cast removed along with any K wires, if applied

during surgery for stabilisation AFO given for 6 months

Residual deformities

Residual hindfoot equinus : Achilles tendon lengthening and posterior capsulotomy of ankle and subtalar joints

Dynamic metatarsus adductus : Transfer of anterior tibial tendon, either as split transfer or entire tendon

Resistant clubfoot

Metatarsus adductus : >5 yrs metatarsal osteototomy Hindfoor varus : <2-3 yrs modified Mckay procedure 3- 10 yrs Dwyer osteotomy ( isolated heel varus) Dilwyn Evans procedure (short medial

column) Lichtblau procedure( long lateral column) 10-12 yrs triple arthrodesis Equinus : Achilles tendon lengthening and posterior

capsulotomy of subtalar joint, ankle joint / Lambrinudi procedure

All three deformities >10 yrs triple arthrodesis

TENDON TRANSFERS

INDICATION –PASSIVELY CORRECTABLE FOOT RESULTING FROM MUSCLE IMBALANCE.

NEVER A PRIMARY PROCEDURETHREE TYPES-1.TIBIALIS ANTERIOR2.TIBIALIS POSTERIOR3.SPLIT ANTERIOR TIBIALIS TENDON

TRANSFER

AGE 3- 6 YEARS

Weakness of muscle(peroneus).Garceaus- middleCuneiform.Mod gerceaus- 5 thmetatarsl base.

TIBIALIS ANTERIOR TRANSFER

SPLATT

Indicated for dynamic foot deformity.

Lateral part on to cuboid

TIBIALIS POSTERIOR TRANSFER

AGE- 8 YEARS.PRINCIPLE- eliminate the deforming force of

tibialis posterior and use it corrective force when

there is toe in gait, cavus ,weak peroneals, forefoot

equinus.Through interroseous membrane to lateral

cuneiform.

Bony proceduresDwyer calcaneal

osteotomyAge 3-4 years

IND- persistent varus deformity. Opening wedge medialosteotomy to increase thelength and height of

calcaneus Osteotomy held open by

a wedge of bone taken from tibia with k wire.

Cast for 3 months.

Litchblau procedure

IND – hind foot includes varus and residual internal deformity of calcaneum with long lateral column.

AGE – min 3 years.Lateral closing wedge

osteotomy of calcaneus along with medial soft tissue release .

• Shortens the lateral column.

• Complication- skew foot.

Dilwyn Evans Osteotomy

Posteromedial releaseCalcaneocuboid

wedge resection and arthrodesis of the joint

Shortens lateral column

Stiffness at subtalar and midfoot joints

Preferred in older children (4-8 yrs)

Dilwyn Evans Osteotomy

PRINCIPLE- basic deformity is at mid tarsal joint and all other deformities are adaptive.

Age – 4 years- 8 years. Staged procedure.Lateral foot shortened by closed wedge

osteotomy.Medial soft tissue release and closed

tenotomy of plantar fascia.Posterior capsulotomy and soft tissue release.Calcaneo – cuboid fusion.

Salvage procedures

Triple arthrodesisSalvage procedure for painful stiff foot.Correction of large degrees of deformity in

neglected clubfeet.Not performed before advanced skeletal

maturity, at age 10 to 12 years.3 Joints fused 1. subtalar joint. 2. talonavicular joint. 3. calcaneo cuboid joint.

Talectomy

Originally done for syndromic clubfoot.

Now done for severe untreated club foot.

Age – 6years. Complete excision of

talus . Derotate foot and

displace calcaneum into ankle mortise untill navicular abuts anterior edge of tibial plafond.

Complications- limb length discrepancy. limitation of ankle

movements.

Ilizarov

Correction slow enough to protect soft tissue

Correction at the focus of deformity

Simultaneous three-dimensional, multilevel correction

Deformity correction without shortening the foot

JOSHI EXTERNAL STABILISATION SYSTEM

DR.B.B. JOSHI, MUMBAI.

Principle –tension stress applied in physiological doses by mechanical device have shown to stimulate histiogenesis.

JOSHI EXTERNAL STABILISATION SYSTEM

DR.B.B. JOSHI, MUMBAI

2 to 4 transfixing wires in prox tibia

Metatarsal Transfixing wire

through I &V MT; Medial half

pin through I, II, III MT; Lat half pin thro’ IV, V MT

2 transfixing and 1 axial wire through calcaneum

JESS

Distraction used to Sequentially correct deformities (Medial- 0.25 mm every 6 hours ,Lateral- 0.25 mm every 12 hours).

Distraction continued until approximately 20 degrees of dorsiflexion and overcorrection of the forefoot deformities was achieved .

Maintained in this overcorrected position for twice as long as the distraction phase by casts/braces.

ADVANTAGES OF JESS

1. Causes lengthening of all contracted tissues and prevent further scarring by surgery.

2. Magnitude of correction can be controlled by distraction.

3. Resultant foot are supple in contrast to foot in surgery.

Results with JESS

Good or excellent results reported by Joshi in 84% of his patients

Recommended in all who have not responded to serial plaster casting methods.

Complications of surgery

Neurovascular injury Loss of foot (10% have atrophic dorsalis pedis artery bundle) Skin dehiscence Wound infection AVN talus Dislocation of the navicular Flattening and breaking of the talar head Undercorrection/ Overcorrection. Forefoot adductus Hindfoot varus Severe scarring Stiff joints Weakness of the plantar flexors of the ankle

Conclusion

Proper understanding of the patho-anatomy a must

Ponseti method is now the standard treatment method

Indications of surgery limited but well defined

Turco’s posteromedial soft tissue release remains the treatment of choice in most cases amenable to surgical treatment

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