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CONGENITAL TALIPES
EQUINOVARUS
DR PRATIK AGARWAL
DR MADHAV KHADILKAR
OUTLINE
• WHAT IS CTEV?
• EPIDEMIOLOGY
• ETIOLOGY
• PATHOLOGICAL ANATOMY
• CLINICAL FEATURES
• CLASSIFICATION
• RADIOGRAPHIC EVALUATION
• TREATMENT
• SUMMARY
WHAT IS CTEV?
• ROTATORY SUBLUXATION OF TALOCALNOENAVICULAR JOINT (SUBTALAR)
COMPLEX WITH TALUS IN PLANTAR FLEXION AND SUBTALAR COMPLEX IN
MEDIAL ROTATION AND INVERSION.
• ALSO REFFERED AS CLUBFOOT.
• TALIPES DERIVED FROM TERM: TALUS- ANKLE &
PES - FOOT
• EQUINOVARUS DERIVED FROM WORD EQUINO - LIKE A HORSE &
VARUS - TURNED INWARD.
DEFORMITIES:
• 4 CLINICAL COMPONENTS: CAVE
• C- CAVUS- EXAGGERATED MEDIAL LONGITUDINAL ARCH AT MIDFOOT
• A- ADDUCTION- FOREFOOT IN ADDUCTION AT TARSOMETATARSAL
JUNCTION
• V- VARUS- HINDFOOT ROTATED INWARD AT TALONAVICULAR JOINT
• E- EQUINUS- FOOT FIXED IN PLANTAR FLEXION AT ANKLE JOINT
Congenital talipes equinovarus (club foot/ctev) ppt by Dr Pratik
EPIDEMIOLOGY:
• INCIDENCE- 1-2 PER 1000 LIVE BIRTH
• INCIDENCE IN FIRST DEGREE RELATION- 2%
• INCIDENCE IN SECOND DEGREE RELATION- 0.6%
• INCIDENCE IN MALE:FEMALE- 2.5:1
• LATERALITY- >50% CASES ARE BILATERAL
• IN UNILATERAL AFFLICTION- RIGHT> LEFT
ETIOLOGY:
• MOST COMMON CAUSE OF CTEV IS
IDIOPATHIC.
• OTHER THAN IDIOPATHIC IS
SECONDARY CTEV WHICH IS
ASSOCIATED WITH UNDERLYING
CAUSE.
IDIOPATHIC CTEV:
• ARRESTED FETAL DEVELOPMENT: BOHM PROPOSED ARREST OF FETAL DEVELOPMENT OF THE
LOWER LIMB IN 6-8 WKS SO CALLED CLUB FOOT EMBRYONIC STAGE. HOWEVER DYSMORPHIC
TALAR HEAD AND MEDIAL DISPLACEMENT OF NAVICULAR IS NOT SEEN IN ANY STAGE OF
NORMAL FETAL DEVELOPMENT.
• MECHANICAL FACTOR IN UTERO: OLDEST THEORY PROPOSED BY HIPPOCRATES SUGGESTING
FOOT WAS HELD IN EQUINO VARUS BY EXTERNAL UTERINE COMPRESSION. SOME INVESTIGATOR
OPINE DIMINUTION OF AMNIOTIC FLUID AS CAUSE OF CLUB FOOT.
• VASCULAR HYPOTHESIS: KEITH SUGGESTED TEMPORARY CESSATION OF CIRCULATION IN
DEVELOPING FETUS RESULTED IN CONTRACTURES OF SOFT TISSUES AND DEFECTIVE
DEVELOPMENT OF CARTILAGE.
IDIOPATHIC CTEV:
• MUSCULOLIGAMENTOUS FIBROSIS: IPPOLITO AND PONSETI FOUND CONSIDERABLE INCREASE
IN COLLEGEN FIBRES AND FIBROBLASTIC CELLS IN LIGAMENTS AND TENDONS OF CLUBFOOT.
THEY CONSIDERED TO BE PRIMARY DEFECT, CARTILAGINOUS AND BONY CHANGES BEING
SECONDARY.
• PRIMARY GERM PLASMA DEFECT: WAISBROD SUGGESTED DEFECT IN PRIMARY GERM PLASMA
OF CARTILAGINOUS TALAR ANALGE RESULTING IN DYSMORPHIC TALAR NECK AND NAVICULAR
SUBLUXATION.
• HEREDITARY: WYNNE- DAVIES SUGGESTED CLUB FOOT ARE PART OF NUMEROUS SYNDROMES
FOLLOWING MANDELIAN PATTERN OF EITHER AUTOSOMAL DOMINANT OR AUTOSOMAL
RECESSIVE INHERITANCE.
SECONDARY CTEV:
• ASSOCIATED WITH NEUROMUSCULAR OR SYNDROMIC ETIOLOGIES-
 ARTHROGRYPOSIS MULTIPLEX CONGENITA
 DIASTROPHIC DYSPLASIA
 STREETER SYNDROME (CONSTRICTION BAND SYNDROME)
 FREEMAN SHELDON SYNDROME
 MOBIUS SYNDROME
 NAIL PATELLA SYNDROME
 DIASTROPHIC DWARFISM
• ASSOCIATED WITH PARALYTIC DISORDER-
 POLIOMYELITIS
 SPINA BIFIDA
 MYELODYSPLESIA
 FREIDRICH’S ATAXIA
SECONDARY CTEV:
• GENETIC CAUSES-
N- ACETYLATION GENES NAT1 AND NAT2
XENOBIOTIC METABOLISM GENES CYP1A1
LIMB AND MUSCLE MORPHOGENESIS GENE HOXA, HOXD AND IGF BP3
GENE FOR LOWER EXTREMITY DEVELOPMENT- CAN D2 AND WNT 7A
GENE FOR CONTACTILE PROTEIN OF SKELETAL MYOFIBRES- TBX4
PATHOLOGICAL ANATOMY:
1. BONES-
• TALUS-
HEAD AND NECK DEVIATED MEDIALLY AND DOWNWARD.
MEDIAL AND PLANTAR DEVIATION OF NAVICULAR ARTICULATION.
BODY ROTATED EXTERNALLY AND IS IN EQUINUS OF NECK IN ANKLE
MORTISE.
BODY EXTRUDED ANTERIORLY
SMALLER THAN NORMAL
NECK- BODY ANGLE IS 90-110* (NORMAL- 150*)
DISLOCATION OF HEAD OF TALUS OUT OF ITS SOCKET.
PATHOLOGICAL ANATOMY:
• NAVICULAR-
MEDIALLY AND PLANTAR
DISPLACEMENT
CLOSE TO MEDIAL MALLEOLUS
ARTICULATES WITH MEDIAL SURFACFE
OF DYSMORPHIC TALUS
TALONAVICULAR JOINT SUBLUXATION
PATHOLOGICAL ANATOMY:
• CALCANEUM-
OFTEN SMALL IN SIZE
MEDIALLY ROTATED
ANTERIOR PORTION LIES BENEATH THE HEAD
OF TALUS CAUSING VARUS AND EQUINUS OF
HEEL.
SUSTENTACULUM TALI IS UNDERDEVELOPED.
• CUBOID-
MEDIALLY SUBLUXATED OVER CALCANEUM
HEAD
PATHOLOGICAL ANATOMY:
• MUSCLES AND TENDONS-
ATROPHY OF PERONEAL GROUP OF
MUSCLES
CONTRACTURE OF TRICEP SURAE,TIBIALIS
POSTERIOR,FLEXOR DIGITORUM LONGUS
AND FLEXOR HALLUCIS LUNGUS.
NUMBER OF FIBRES IN MUSCLE IS NORMAL
BUT ARE SMALLER IN SIZE.
THICKENING AND CONTRACTURE OF
TENDON SHEATHS ESPECIALLY OF TIBIALIS
POSTERIOR AND PERONEAL.
PATHOLOGICAL ANATOMY:
• LIGAMENTS-
THICKENING AND CONTRACTURES ARE SEEN
IN
 CALCANEOFIBULAR LIGAMENT
 TALOFIBULAR LIGAMENT
 DELTOID LIGAMENT
 LONG AND SHORT PLANTAR LIGAMENT
 SPRING LIGAMENT
 BIFURCATE LIGAMENT
 INTEROSSEOUS TALO CALCANEUM LIGAMENT
 MASTER KNOT OF HENRY
PATHOLOGICAL ANATOMY:
• JOINTS CAPSULE AND FASCIA-
CONTRACTURES ARE SEEN IN
POSTERIOR ANKLE CAPSULE
SUBTALAR CAPSULE
TALONAVICULAR JOINT CAPSULE
CALCANEOCUBOID JOINT CAPSULE
PLANTAR FASCIA CONTRACTURE ARE SEEN WHICH IS RESPONSIBLE CAVUS
DEFORMITY
PATHOLOGICAL ANATOMY:
• SKIN CHANGES-
DEEP CREASE ON MEDIAL SIDE
DIMPLES IN LATERAL ASPECT OF ANKLE AND MID
FOOT.
SHORTENING ON MEDIAL SIDE OF SOLE
CALLOSITIES AND BURSA ON LATERAL SIDE OF FOOT
• VASCULAR CHANGES-
HYPOPLASIA OR ABSENCE OF DORSALIS PAEDIS AND
ANTERIOR TIBIAL ARTERY
CLINICAL FEATURES:
• HEEL IS SMALL AND IN EQUINUS
• FOOT INVERTED ON END OF TIBIA
• DEEP CREASES ON MEDIAL AND POSTERIOR ASPECT
• ABNORMAL THIN CALF
• VARYING DEGREE OF RESISTANCE/ FIXED DEFORMITY WHEN
TRY TO DORSIFLEX AND EVERT THE FOOT.
• LACK OF CORRECTABILITY
• OTHER JOINT ABNORMALITY
• ASSOCIATED ANOMALIES AND NEUROMUSCULAR
CONDITION.
CLASSIFICATION:
1. IDIOPATHIC AND NON-IDIOPATHIC
2. CUMMIN CLASSIFICATION
3. PONSETI AND SMOLEY CLASSIFICATION- BASED ON EXTENT OF DEFORMITY
4. HARROLD AND WALKER CLASSIFICATION- BASED ON ABILITY TO CORRECT THE
DEFORMITY.
5. BROWNE’S CLASSIFICATION- BASED ON TYPE OF DEFORMITY
6. DIMEGLIO ET AL SCORING SYSTEM BASED ON SEVERITY OF THE DEFORMITY
7. PIRANI SCORING SYSTEM
CUMMIN CLASSIFICATION
• SUPPLE: FOOT CAN BE BROUGHT TO NORMAL POSITION AND ALL JOINTS ARE
MOBILE.
• NEGLECTED: NO TREATMENT FOR 1 YR.
• RELAPSED: CORRECTED DEFORMITIES APPEARS AGAIN.
• RECCURENT: TYPE OF RELAPSE DUE TO MUSCLE IMBALANCE
• RESISTANT: NO CORRECTION AFTER CONSERVATIVE MANAGEMENT.
• RIGID: AFTER CONSERVATIVE TREATMENT FOREFOOT DEFORMITY
CORRECTED AND HINDFOOT DEFORMITY REMAIN UNCORRECTED.
DIMEGLIO SCORING SYSTEM
Congenital talipes equinovarus (club foot/ctev) ppt by Dr Pratik
PIRANI SCORING SYSTEM:
• SIMPLE AND RELIABLE SYSTEM TO DETERMINE SEVERITY AND MONITOR PROGRESS IN THE ASSESSMENT AND
TREATMENT OF CLUBFOOT.
• SIX “SIGNS” ARE ASSESSED
• 3 SIGNS IN MIDFOOT
• 3 SIGNS IN HINDFOOT
• BASED ON 6 WELL-DESCRIBED CLINICAL SIGNS OF CONTRACTURE CHARACTERIZING A SEVERE CLUBFOOT:
• IF THE SIGN IS SEVERELY ABNORMAL IT SCORES 1
• IF IT IS PARTIALLY ABNORMAL IT SCORES 0.5
• IF IT IS NORMAL IT SCORES 0
• TOTAL SCORE (TS) VARIES FROM 0 TO 6 AND IS THE SUM OF MIDFOOT AND HINDFOOT CONTRACTURE SCORES
PIRANI SCORING SYSTEM:
RADIOGRAPHIC EVALUATION:
• FOR NON AMBULATORY CHILD-
 ANTEROPOSTERIOR
 STRESS DORSIFLEXION LATERAL VIEW
• FOR OLDER CHILD-
 STANDING ANTEROPOSTERIOR
 STANDING LATERAL
• IMPORTANT ANGLE WE MEASURE-
 TALOCALCANEAL ANGLE ON AP AND LAT VIEW
 TIBIOCALCANEAL ANGLE ON LAT VIEW
 TALUS- FIRST METATARSAL ANGLE
RADIOGRAPHIC
EVALUATION:
TALOCALCANEAL ANGLE-
• ON AP VIEW-
 1ST LINE THROUGH THE CENTRE OF LONG
AXIS OF TALUS (PARALLEL TO MEDIAL
BORDER)
 2ND LINE THROUGH LONG AXIS OF
CALCANEUM (PARALLEL TO LATERAL
BORDER)
 NORMAL 25-40*
• ON LATERAL VIEW-
 1ST LINE MIDPOINT OF HEAD AND BODY OF
TALUS
 2ND LINE ALONG BOTTOM OF CALCANEUM
 NORMAL 35-50*
RADIOGRAPHIC EVALUATION
• RADIOLOGICAL FINDING SEEN-
• ON LATERAL VIEW-
 DECREASED TALOCALCANEAL ANGLE (TALOCALCANEAL PARALLELISM)
 DISRUPTED TALAR FIRST METATARSAL ANGLE
 LONG AXIS OF TALUS AND CALCANEUM PASSES INFERIOR TO CUBOID (NORMALLY CROSSES CUBOID)
• ON ANTEROPOSTERIOR VIEW-
 INCREASED TALOCALCANEAL ANGLE
 INCREASED TALAR FIRST METATARSAL ANGLE
 LONG AXIS OF TALUS DEVIATE LATERALLY AND PASSES ALONG 3RD OR 4TH METATARSAL BONE
RADIOGRAPHIC EVALUATION
RADIOGRAPHIC EVALUATION:
TREATMENT:
• GOAL: TO ACHIEVE
PLANTIGRADE FOOT
FLEXIBILTY
COSMETICALLY ACCEPTABLE FUNCTIONAL AND PAIN FREE FOOT IN SHORTEST TREATMENT TIME
• PRINCIPLES:
SOFT TISSUE CONTRACTURE RELEASE OR STRETCHING TO RESTORE NORMAL TARSAL
RELATIONSHIP.
ONCE NORMAL TARSAL RELATIONSHIP ATTAINED, CORRECTION SHOULD BE MAINTAINED TILL
TARSAL BONES REMOULDS STABLE ARTICULAR SURFACE.
NONOPERATIVE TREATMENT:
• SEVERAL REGIME HAVE BEEN PROPOSED INCLUDING SPLINTING TAPING AND CASTING.
• KITE’S METHOD:
 CORRECTION OF EACH COMPONENT SEPARATELY
 CORRECTION WAS DONE IN FOLLOWING ORDER
 KITE’S ERRORS:
 PRONATION/ EVERSION OF 1ST METATARSAL.
 PREMATURE DORSIFLEXION OF HEEL.
 USED CALCANEOCUBOID JOINT AS FULCRUM THAT BLOCKS ABDUCTION OF CALCANEUS , THERBY PREVENTS
EVERSION OF CALCANEUS.
FOREFOOT
ADDUCTION
HEEL VARUS EQUINUS
Congenital talipes equinovarus (club foot/ctev) ppt by Dr Pratik
Congenital talipes equinovarus (club foot/ctev) ppt by Dr Pratik
NONOPERATIVE TREATMENT:
• PONSETI TECHNIQUE:
2 PHASE- TREATMENT AND MAINTENANCE PHASE
TREATMENT PHASE-
BEGINS AS EARLY AS POSSIBLE. DURING FIRST WEEK OF LIFE ONLY MANIPULATION IS CARRIED OUT
BUT CAST IS NOT APPLIED.
ORDER OF CORRECTION-
TALUS HEAD IS USED AS FULCRUM.
5-6 SERIAL CASTING WITH MANIPULATION IS GENERALLY ENOUGH TO CORRECT THE DEFORMITY.
MAXIMUM UPTO 1O CASTING CAN BE DONE.
CAVUS
ADDUCTION WITH
VARUS
EQUINUS
PONSETI TECHNIQUE:
• CORRECTION OF CAVUS DEFORMITY:
CORRECTED BY FOREFOOT SUPINATION
RELATIVE TO HINDFOOT ALONG WITH
ADDUCTION OF FOREFOOT.
TENDS TO EXAGGERATE FOOT
INVERSION.
PRONATION OF FOREFOOT SHOULD NOT
BE DONE AS IT INCREASES CAVUS
DEFORMITY BECAUSE 1ST METATARSAL IS
FURTHER PLANTAR FLEXED. E- RIGHT MANEUVER TO CORRECT CAVUS DEFORMITY
F- WRONG MANEUVER TO CORRECT CAVUS DEFORMITY
PONSETI TECHNIQUE
A: THUMB IS POSITIONED OVER LATERAL ASPECT OF HEAD OF TALUS AND FINGER CORRECT THE FOREFOOT.
B: CAVUS AND ADDUCTION ARE CORRECTED BY SLIGHT SUPINATION OF FOREFOOT IN RELATION TO HINDFOOT.
PONSETI TECHNIQUE
• CORRECTION OF VARUS AND ADDUCTION:
CORRECTION OF CAVUS BRINGS METATARSAL, CUNIEFORM, NAVICULAR, AND
CUBOID IN SAME PLANE OF SUPINATION.
NOW FOOT IS ABDUCTED AND HELD IN FLEXION AND SUPINATION TO
ACCOMMODATE THE INVERSION OF TARSAL BONES WHILE COUNTER
PRESSURE IS APPLIED WITH THUMB ON LATERAL ASPECT OF HEAD OF TALUS.
THIS MANEUVER NECESSITATES PROLONG STRETCHING OF MEDIAL TARSAL
LIGAMENTS AND TENDONS.
PRESSURE EXERTED ON METATARSAL AND COUNTERPRESSURE ON LATERAL ASPECT OF HEAD OF TALUS.
FURTHER ABDUCTION OF FOOT HELD IN FLEXION AND SUPINATION.
FOOT IS
FURTHER
ABDUCTED
AND
SUPINATION
DECREASED
BUT
WITHOUT
PRONATING
THE FOOT
PONSETI TECHNIQUE
• CORRECTION OF EQUINUS:
• SHOULD BE ATTEMPTED WHEN HINDFOOT IS IN NEUTRAL POSITION TO
SLIGHT VALGUS AND FOOT IS ABDUCTED 70* RELATIVE TO LEG.
• EQUINUS IS COORECTED BY PROGRESSIVE DORSIFLEXING THE FOOT.
• TO FACILITATE RAPID CORRECTION SUBCUTANEOUS TENOTOMY IS DONE.
• CARE SHOULD BE TAKEN WHILE DORSIFLEXING FOOT BY APPYLING
PRESSURE UNDER ENTIRE SOLE AND NOT UNDER METATARSAL HEADS.
FOOT IS FURTHER ABDUCTED UPTO 70* TO
STRETCH TO STRETCH MEDIAL TARSAL LIGAMENT.
NOTE: HEEL IS NOT GRASPED BY HAND THUS
ALLOWING CALCANEUS TO ABDUCT WITH FOOT
AND HEEL VARUS TO CORRECT
EQUINUS CORRECTED BY
SUBCUTANEOUS SECTION OF
TENDO ACHILLES
PERCUTANEOUS TENOTOMY
FOOT HELD IN DORSIFLEXION AND TENDON IS FELT
BLADE OF 11 SIZE ENTERS PARALLEL TO MEDIAL BORDER OF
TENDOACHILLES 1CM ABOVE INSERTION AT CALCANEUM.
BLADE IS PUSHED MEDIAL TO TENDON AND ROTATED 90*
UNDERNEATH IT. TENDON IS CUT FROM MEDIAL TO LATERAL
DIRECTION.
"POP" IS FELT AND CAST IS APPLIED IN MAXIMAL
DORSIFLEXION AND 70* ABDUCTION FOR 3-4 WEEKS.
PERCUTANEOUS
ACHILLES
TENOTOMY FROM
MEDIAL TO
LATERAL
Congenital talipes equinovarus (club foot/ctev) ppt by Dr Pratik
Congenital talipes equinovarus (club foot/ctev) ppt by Dr Pratik
PONSETI TECHNIQUE
• MAINTAENANCE PHASE:
• AFTER REMOVAL OF CAST INFANT IS PLACED IN FOOT ABDUCTION ORTHOSIS.
• BRACE IS WORN FOR 23HRS PER DAY FOR FIRST 3 MONTH THEN ONLY WHILE
SLEEPING FOR 3-4 YEARS.
• FREQUENT FOLLOW UP IS IMPORTANT TO DETECT EARLY RECCURENCE.
• IT PREVENT RECURRENCE OF DEFORMITY
• IT FAVORS REMODELLING OF JOINTS WITH THE BONES IN PROPER ALINGMENT AND
TO INCREASE LEG AND FOOT MUSCLE STRENGTH.
FOOT ABDUCTION
ORTHOSIS
• ALSO KNOWN AS DENIS BROWN SPLINT.
• CONSIST OF SHOES MOUNTED TO
CROSSBAR IN POSITION OF 70* EXTERNAL
ROTATION AND 15* DORSIFLEXION.
• DISTANCE BETWEEN SHOES IS SET AT
ABOUT 1INCH WIDER THAN THE WIDTH OF
INFANT’S SHOULDER.
• IN UNILATERAL CASES NORMAL FOOT
SHOULD IN 40* OUTWARD ROTATION.
CTEV SHOES
• MODIFIED SHOES FOR
CHILD WHO START
WALKING.
• THESE SHOES ARE USE
UNTILL 5 YEARS OF AGE.
• SPECIAL FEATURES:
STRAIGHT INNER BORDER
OUTER SHOE RISE
NO HEEL
NONOPERATIVE TREATMENT
• STRETCHING AND ADHESIVE STRAPPING(ROBERT JONES):
PRINCIPLE- APPLY EVERSION CORRECTION FORCE ON FOOT WITH HELP OF
ADHESIVE STRAPPING.
• FRENCH TECHNIQUE:
GOAL IS TO REDUCE TALONAVICULAR JOINT, STRETCH OUT MEDIAL TISSUES AND
THEN SEQUENTIALLY CORRECT FOREFOOT ADDUCTION, HINDFOOT VARUS AND
EQUINUS OF CALCANEUM.
COMPLICATIONS OF NONOPERATIVE TREATMENT
• ROCKER BOTTOM FOOT
• BEAN SHAPED FOOT
• FRACTURES
• PRESSURE SORES
• FLAT TOP TALUS
• FAILURE OF CORRECTION
• RECCURENCE OR RELAPSE OF DEFORMITY
SURGICAL TREATMENT
• INDICATION:
 IN CASE OF NEGLECTED CTEV, RELAPSED CTEV, RECCURENT CTEV, RESISTANT CTEV, RIGID CTEV.
• CHOICE OF SURGERY:
1-4 YEARS-
 SOFT TISSUE RELEASE
4-11 YEARS-
 SOFT TISSUE RELEASE WITH
 OSTEOTOMY PERFORMED ACCORDING TO THE DEFORMITIES
>11YRS- SALVAGE PROCEDURES
 TRIPLE ARTHRODESIS
 TALECTOMY
SOFT TISSUE RELEASE OPERATION
TURCO’S OPERATION- IT IS ONE STAGE POSTEROMEDIAL RELEASE. HE EMPHASIZED ON SUBTALAR
RELEASE ALONG WITH CALCANEOFIBULAR LIGAMENT.
CAROLL’S INCISION- CAROLL EMPHASIZED ON PLANTAR FASCIA RELEASE AND CAPSULOTOMY OF
CALCANEOCUBOID JOINT. IT INCLUDE 2 INCISIONS, MEDIAL AND POSTERO-LATERAL INCISION.
CINCINATTI INCISION- IT IS DONE FOR POSTEROMEDIAL AND POSTEROLATERAL SOFT TISSUE
RELEASE. PREFFERED TECHNIQUE FOR INITIAL SURGICAL MANAGEMENT OF CLUB FOOT.
TENDOACHILLES TENDON RELEASE WITH POSTERIOR CAPSULOTOMY- TO CORRECT RESIDUAL
HIND FOOT EQUINUS
TURCO OPERATION
• MEDIAL INCISION GIVEN
• EXPOSE TIBIALIS POSTERIOR, FDL,FHL, TENDOACHILLES AND POSTERIOR NEUROVASCULAR BUNDLE.
• DIVIDE MASTER KNOT OF HENRY.
• DIVIDE CALCANEONAVICULAR LIGAMENT AND ABDUCTOR HALLUCIS FROM TIBIALIS POSTERIOR TENDON,NAVICULAR TUBEROSITY AND
1ST METATARSAL.
• POSTERIOR RELEASE- BY DOING Z-PLASTY OF TENDO ACHILLES, INCISING POSTERIOR CAPSULE OF ANKLE JOIN, SUBTALAR JOINT AND
DIVIDING TALOFIBULAR LIGAMENT AND CALCANEOFIBULAR LIGAMENT.
• MEDIAL PLANTAR RELEASE- DIVIDE TIBIALIS POSTERIOR, SUPERFICIAL DELTOID LIGAMENT, TALONAVICULAR CAPSULE AND SPRING
LIGAMENT.
• SUTALAR RELEASE- DIVIDE MEDIAL PART OF TALOCALCANEAL INTERROSEOUS LIGAMENT AND BIFURCATION OF Y LIGAMENT.
• AFTER REDUCING NAVICULAR BONE TRANSFIX TALONAVICULAR JOINT BY K-WIRE AND SUBTALAR JOINT BY 2ND K-WIRE.
Congenital talipes equinovarus (club foot/ctev) ppt by Dr Pratik
CINCINATTI INCISION
• TRANSVERSE CIRCUMFERENTIAL INCISION
ACHILLES TENDON
LENTHENING AND
POSTERIOR CAPSULOTOMY
• TO CORRECT RESIDUAL HINDFOOT EQUINUS
• Z-PLASTY IS DONE TO LENGTHEN THE
ACHILLES TENDON.
• RELEASING MEDIAL HALF DISTALLY AND
LATERAL HALF PROXIMALLY.
• POSTERIOR CAPSULOTOMY OF ANKLE AND
SUBTALAR JOINT TO RELEASE CAPSULE
CONTRACTURE.
TENDON TRANSFER
• INDICATION- PASSIVELY CORRECTABLE
DEFORMITY RESULTING FROM MUSCLE
IMBALANCE.
• ANTERIOR TIBIALIS TENDON TRANSFER-
TENDON IS TRANSFERRED EITHER TO
MIDDLE CUNIEFORM OR TO BASE OF 5TH
METATARSAL.
• SPLATT (SPLit ANTERIOR TIBIALIS TENDON
TRANSFER)- LATERAL PART OF TENDON IS
SPLIT AND INSERTED TO CUBOID.
DWYER
OSTEOTOMY
• INDICATION- PERSISTENT VARUS
DEFORMITY OF HEEL WHEN
SOFT TISSUE SURGERIES ARE
CONTRAINDICATED.
• AGE- 3-4YRS
• DONE BY MEDIAL OPEN WEDGE
OSTEOTOMY OR BY LATERAL
CLOSED WEDGE OSTEOTOMY
LATERAL COLUMN SHORTENING PROCEDURE
• INDICATION- RECURRENCE OF CLUBFOOT DEFORMITY
AFTER SURGICAL RELEASE IS MOSTLY DUE TO
DISPARITY BETWEEN MEDIAL AND LATERAL BORDER
OF FOOT. ANY ATTEMPT TO CORRECT DEFORMITY IS
RESISTED BY MEDIAL CONTRACTURE AND EXCESSIVE
LENGTH OF LATERAL COLUMN.
• DIFFERENT PROCEDURE TO DO SHORTEN LATERAL
COLUMN ARE-
 DILLWYNN EVANS PROCEDURE
 LICHTBLAU PROCEDURE
 FOWLER PROCEDURE
LATERAL COLUMN SHORTENING PROCEDURE
DILLWYN EVANS PROCEDURE LICHTBLAU PROCEDURE
AGE- 4-8 YRS
INDICATION- MIDFOOT IN VARUS DUE TO
TALONAVICULAR AND CALCANEOCUBOID
SUBLUXATION
AGE- 3-4 YRS
INDICATION- HEEL VARUS & RESIDUAL INTERNAL
DEFORMITY OF CALCANEUS WITH LONG LATERAL
COLUMN
FOWLER
PROCEDURE
• INDICATION- SUFFICIENT SCARRING THAT
MEDIAL SOFT TISSUE AND SUBTALAR
RELEASE WOULD BE IN EFFECTIVE.
• AGE- 6-8 YEARS
• PROCEDURE- LATERAL COLUMN
SHORTENING COMBINING WITH MEDIAL
COLUMN LENGTHING BY REMOVING
WEDGE FROM CUBOID AND
TRANSFERING IT TO AN OPENING
WEDGE.
SALVAGE PROCEDURE
• INDICATION-
 UNCORRECTED CLUBFOOT OR WITH RESIDUAL DEFORMITY AFTER THE AGE OF 10 YRS.
 PAINFUL STIFF FOOT WITH POOR FUNCTION
 DIFFICULT TO ACCOMMODATE TO FOOT WEAR
• GOAL-
 CORRECT RESIDUAL DEFORMITY WHICH IS RESISTANT TO SOFT TISSUE RELEASE.
 TO ATTAIN FUNCTIONALLY AND COSMETICALLY ACCEPTABLE FOOT.
• PROCEDURE-
 TRIPLE ARTHRODESIS
 TALECTOMY
TRIPLE
ARTHRODESIS
• INDICATION-
PAINFUL STIFF FOOT WITH POOR FUNCTION
DIFFICULT TO ACCOMMODATE TO FOOT
WEAR
ALL OTHER CORRECTION FAILED
• AGE – 10 – 12 YEARS
• PROCEDURE-
 OSTEOTOMY FOLLOWED BY FUSION OF
TALONAVICULAR, TALOCALCANEUM AND
CALCANEOCUBOID JOINT.
TALECTOMY
• INDICATION-
 RESERVED FOR SEVERE UNTREATED
CLUBFOOT
• AGE - <6 YEARS
• PROCEDURE-
 COMPLETE EXCISION OF TALUS
 DEROTATE THE FOOT AND DISPLACE THE
CALCANEUS POSTERIORLY INTO ANKLE
MORTISE UNTIL NAVICULAR ABUTS THE
ANTERIOR EDGE OF TIBIAL PLAFOND.
• COMPLICATION-
 LOSS OF LIMB LENGTH
 LIMITATION OF ANKLE MOVEMENT
EXTERNAL FIXATOR
• INDICATION-
IN CASE OF NEGLECTED AND RECCURENT DEFORMITY WITH SEVERE SCARRING
• MODALITIES-
ILLIZAROV’S EXTERNAL FIXATOR
JESS (JOSHI EXTERNAL STABILIZING SYSTEM)
• ADVANTAGE-
PREVENT CRUSHING OF THE TISSUES ON CONVEX SIDE
LENGHTENS THE LIMB
EFFECTIVELY CORRECT THE DEFORMITY AT SAME TIME
ILLIZAROV’S EXTERNAL
FIXATOR
• PRINCIPLE- FRACTIONAL DISTRACTION
• INDICATION- SEVERE DEFORMITIES WITH SEVERE
SCARING OR TROPHIC ULCERS WHICH MAKE
OPERATIVE INTERVENTION CONTRAINDICATION
BECAUSE OF RISK OF TISSUE NECROSIS.
• STEPS OF CORRECTION-
ANGULAR CORRECTION
OF HINDFOOT
CORRECTION OF
FOREFOOT SUPINATION
CORRECTION OF FOOT
EQUINUS
JESS
• PRINCIPLE- DIFFERENTIAL DISTRACTION
• ADVANTAGE-
 LENTHENS ALL CONTRACTED TISSUES
PREVENTING HISTIOGENESIS AND
THUS AVOID CUTTING OF THESE
IMMINENT SCARRING.
 POSSIBLE TO CONTROL MAGNITUDE
OF CORRECTION.
 NO FURTHER SHORTHENING OF FOOT
 RESULTANT FEET IS VERY SUPPLE.
SUMMARIZING
PLAN OF TREATMENT
A. FRESH CASE OF CTEV AT BIRTH
PONSETI
METHOD
TENOTOMY
ALL DEFORMITIES LEFT: PMSTR
ONLY EQUINUS: POSTERIOR RELEASE
ONLY HEEL VARUS: DWYER’S OSTEOTOMY
FOLLOW TILL 10-
12 YEARS OF AGE
TREATMENT SUCCESSFUL
TREAT AS B
B. OLD AND NEGLECTED CASES
< 3 YEARS OLD
SOFT TISSUE
RELEASE
4-8 YEARS OLD
SOFT TISSUE
RELEASE
+
OSTEOTOMY
10-12 YEARS OLD
ALREADY OPERATED
THANK YOU
3RD JUNE

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Congenital talipes equinovarus (club foot/ctev) ppt by Dr Pratik

  • 1. CONGENITAL TALIPES EQUINOVARUS DR PRATIK AGARWAL DR MADHAV KHADILKAR
  • 2. OUTLINE • WHAT IS CTEV? • EPIDEMIOLOGY • ETIOLOGY • PATHOLOGICAL ANATOMY • CLINICAL FEATURES • CLASSIFICATION • RADIOGRAPHIC EVALUATION • TREATMENT • SUMMARY
  • 3. WHAT IS CTEV? • ROTATORY SUBLUXATION OF TALOCALNOENAVICULAR JOINT (SUBTALAR) COMPLEX WITH TALUS IN PLANTAR FLEXION AND SUBTALAR COMPLEX IN MEDIAL ROTATION AND INVERSION. • ALSO REFFERED AS CLUBFOOT. • TALIPES DERIVED FROM TERM: TALUS- ANKLE & PES - FOOT • EQUINOVARUS DERIVED FROM WORD EQUINO - LIKE A HORSE & VARUS - TURNED INWARD.
  • 4. DEFORMITIES: • 4 CLINICAL COMPONENTS: CAVE • C- CAVUS- EXAGGERATED MEDIAL LONGITUDINAL ARCH AT MIDFOOT • A- ADDUCTION- FOREFOOT IN ADDUCTION AT TARSOMETATARSAL JUNCTION • V- VARUS- HINDFOOT ROTATED INWARD AT TALONAVICULAR JOINT • E- EQUINUS- FOOT FIXED IN PLANTAR FLEXION AT ANKLE JOINT
  • 6. EPIDEMIOLOGY: • INCIDENCE- 1-2 PER 1000 LIVE BIRTH • INCIDENCE IN FIRST DEGREE RELATION- 2% • INCIDENCE IN SECOND DEGREE RELATION- 0.6% • INCIDENCE IN MALE:FEMALE- 2.5:1 • LATERALITY- >50% CASES ARE BILATERAL • IN UNILATERAL AFFLICTION- RIGHT> LEFT
  • 7. ETIOLOGY: • MOST COMMON CAUSE OF CTEV IS IDIOPATHIC. • OTHER THAN IDIOPATHIC IS SECONDARY CTEV WHICH IS ASSOCIATED WITH UNDERLYING CAUSE.
  • 8. IDIOPATHIC CTEV: • ARRESTED FETAL DEVELOPMENT: BOHM PROPOSED ARREST OF FETAL DEVELOPMENT OF THE LOWER LIMB IN 6-8 WKS SO CALLED CLUB FOOT EMBRYONIC STAGE. HOWEVER DYSMORPHIC TALAR HEAD AND MEDIAL DISPLACEMENT OF NAVICULAR IS NOT SEEN IN ANY STAGE OF NORMAL FETAL DEVELOPMENT. • MECHANICAL FACTOR IN UTERO: OLDEST THEORY PROPOSED BY HIPPOCRATES SUGGESTING FOOT WAS HELD IN EQUINO VARUS BY EXTERNAL UTERINE COMPRESSION. SOME INVESTIGATOR OPINE DIMINUTION OF AMNIOTIC FLUID AS CAUSE OF CLUB FOOT. • VASCULAR HYPOTHESIS: KEITH SUGGESTED TEMPORARY CESSATION OF CIRCULATION IN DEVELOPING FETUS RESULTED IN CONTRACTURES OF SOFT TISSUES AND DEFECTIVE DEVELOPMENT OF CARTILAGE.
  • 9. IDIOPATHIC CTEV: • MUSCULOLIGAMENTOUS FIBROSIS: IPPOLITO AND PONSETI FOUND CONSIDERABLE INCREASE IN COLLEGEN FIBRES AND FIBROBLASTIC CELLS IN LIGAMENTS AND TENDONS OF CLUBFOOT. THEY CONSIDERED TO BE PRIMARY DEFECT, CARTILAGINOUS AND BONY CHANGES BEING SECONDARY. • PRIMARY GERM PLASMA DEFECT: WAISBROD SUGGESTED DEFECT IN PRIMARY GERM PLASMA OF CARTILAGINOUS TALAR ANALGE RESULTING IN DYSMORPHIC TALAR NECK AND NAVICULAR SUBLUXATION. • HEREDITARY: WYNNE- DAVIES SUGGESTED CLUB FOOT ARE PART OF NUMEROUS SYNDROMES FOLLOWING MANDELIAN PATTERN OF EITHER AUTOSOMAL DOMINANT OR AUTOSOMAL RECESSIVE INHERITANCE.
  • 10. SECONDARY CTEV: • ASSOCIATED WITH NEUROMUSCULAR OR SYNDROMIC ETIOLOGIES-  ARTHROGRYPOSIS MULTIPLEX CONGENITA  DIASTROPHIC DYSPLASIA  STREETER SYNDROME (CONSTRICTION BAND SYNDROME)  FREEMAN SHELDON SYNDROME  MOBIUS SYNDROME  NAIL PATELLA SYNDROME  DIASTROPHIC DWARFISM • ASSOCIATED WITH PARALYTIC DISORDER-  POLIOMYELITIS  SPINA BIFIDA  MYELODYSPLESIA  FREIDRICH’S ATAXIA
  • 11. SECONDARY CTEV: • GENETIC CAUSES- N- ACETYLATION GENES NAT1 AND NAT2 XENOBIOTIC METABOLISM GENES CYP1A1 LIMB AND MUSCLE MORPHOGENESIS GENE HOXA, HOXD AND IGF BP3 GENE FOR LOWER EXTREMITY DEVELOPMENT- CAN D2 AND WNT 7A GENE FOR CONTACTILE PROTEIN OF SKELETAL MYOFIBRES- TBX4
  • 12. PATHOLOGICAL ANATOMY: 1. BONES- • TALUS- HEAD AND NECK DEVIATED MEDIALLY AND DOWNWARD. MEDIAL AND PLANTAR DEVIATION OF NAVICULAR ARTICULATION. BODY ROTATED EXTERNALLY AND IS IN EQUINUS OF NECK IN ANKLE MORTISE. BODY EXTRUDED ANTERIORLY SMALLER THAN NORMAL NECK- BODY ANGLE IS 90-110* (NORMAL- 150*) DISLOCATION OF HEAD OF TALUS OUT OF ITS SOCKET.
  • 13. PATHOLOGICAL ANATOMY: • NAVICULAR- MEDIALLY AND PLANTAR DISPLACEMENT CLOSE TO MEDIAL MALLEOLUS ARTICULATES WITH MEDIAL SURFACFE OF DYSMORPHIC TALUS TALONAVICULAR JOINT SUBLUXATION
  • 14. PATHOLOGICAL ANATOMY: • CALCANEUM- OFTEN SMALL IN SIZE MEDIALLY ROTATED ANTERIOR PORTION LIES BENEATH THE HEAD OF TALUS CAUSING VARUS AND EQUINUS OF HEEL. SUSTENTACULUM TALI IS UNDERDEVELOPED. • CUBOID- MEDIALLY SUBLUXATED OVER CALCANEUM HEAD
  • 15. PATHOLOGICAL ANATOMY: • MUSCLES AND TENDONS- ATROPHY OF PERONEAL GROUP OF MUSCLES CONTRACTURE OF TRICEP SURAE,TIBIALIS POSTERIOR,FLEXOR DIGITORUM LONGUS AND FLEXOR HALLUCIS LUNGUS. NUMBER OF FIBRES IN MUSCLE IS NORMAL BUT ARE SMALLER IN SIZE. THICKENING AND CONTRACTURE OF TENDON SHEATHS ESPECIALLY OF TIBIALIS POSTERIOR AND PERONEAL.
  • 16. PATHOLOGICAL ANATOMY: • LIGAMENTS- THICKENING AND CONTRACTURES ARE SEEN IN  CALCANEOFIBULAR LIGAMENT  TALOFIBULAR LIGAMENT  DELTOID LIGAMENT  LONG AND SHORT PLANTAR LIGAMENT  SPRING LIGAMENT  BIFURCATE LIGAMENT  INTEROSSEOUS TALO CALCANEUM LIGAMENT  MASTER KNOT OF HENRY
  • 17. PATHOLOGICAL ANATOMY: • JOINTS CAPSULE AND FASCIA- CONTRACTURES ARE SEEN IN POSTERIOR ANKLE CAPSULE SUBTALAR CAPSULE TALONAVICULAR JOINT CAPSULE CALCANEOCUBOID JOINT CAPSULE PLANTAR FASCIA CONTRACTURE ARE SEEN WHICH IS RESPONSIBLE CAVUS DEFORMITY
  • 18. PATHOLOGICAL ANATOMY: • SKIN CHANGES- DEEP CREASE ON MEDIAL SIDE DIMPLES IN LATERAL ASPECT OF ANKLE AND MID FOOT. SHORTENING ON MEDIAL SIDE OF SOLE CALLOSITIES AND BURSA ON LATERAL SIDE OF FOOT • VASCULAR CHANGES- HYPOPLASIA OR ABSENCE OF DORSALIS PAEDIS AND ANTERIOR TIBIAL ARTERY
  • 19. CLINICAL FEATURES: • HEEL IS SMALL AND IN EQUINUS • FOOT INVERTED ON END OF TIBIA • DEEP CREASES ON MEDIAL AND POSTERIOR ASPECT • ABNORMAL THIN CALF • VARYING DEGREE OF RESISTANCE/ FIXED DEFORMITY WHEN TRY TO DORSIFLEX AND EVERT THE FOOT. • LACK OF CORRECTABILITY • OTHER JOINT ABNORMALITY • ASSOCIATED ANOMALIES AND NEUROMUSCULAR CONDITION.
  • 20. CLASSIFICATION: 1. IDIOPATHIC AND NON-IDIOPATHIC 2. CUMMIN CLASSIFICATION 3. PONSETI AND SMOLEY CLASSIFICATION- BASED ON EXTENT OF DEFORMITY 4. HARROLD AND WALKER CLASSIFICATION- BASED ON ABILITY TO CORRECT THE DEFORMITY. 5. BROWNE’S CLASSIFICATION- BASED ON TYPE OF DEFORMITY 6. DIMEGLIO ET AL SCORING SYSTEM BASED ON SEVERITY OF THE DEFORMITY 7. PIRANI SCORING SYSTEM
  • 21. CUMMIN CLASSIFICATION • SUPPLE: FOOT CAN BE BROUGHT TO NORMAL POSITION AND ALL JOINTS ARE MOBILE. • NEGLECTED: NO TREATMENT FOR 1 YR. • RELAPSED: CORRECTED DEFORMITIES APPEARS AGAIN. • RECCURENT: TYPE OF RELAPSE DUE TO MUSCLE IMBALANCE • RESISTANT: NO CORRECTION AFTER CONSERVATIVE MANAGEMENT. • RIGID: AFTER CONSERVATIVE TREATMENT FOREFOOT DEFORMITY CORRECTED AND HINDFOOT DEFORMITY REMAIN UNCORRECTED.
  • 24. PIRANI SCORING SYSTEM: • SIMPLE AND RELIABLE SYSTEM TO DETERMINE SEVERITY AND MONITOR PROGRESS IN THE ASSESSMENT AND TREATMENT OF CLUBFOOT. • SIX “SIGNS” ARE ASSESSED • 3 SIGNS IN MIDFOOT • 3 SIGNS IN HINDFOOT • BASED ON 6 WELL-DESCRIBED CLINICAL SIGNS OF CONTRACTURE CHARACTERIZING A SEVERE CLUBFOOT: • IF THE SIGN IS SEVERELY ABNORMAL IT SCORES 1 • IF IT IS PARTIALLY ABNORMAL IT SCORES 0.5 • IF IT IS NORMAL IT SCORES 0 • TOTAL SCORE (TS) VARIES FROM 0 TO 6 AND IS THE SUM OF MIDFOOT AND HINDFOOT CONTRACTURE SCORES
  • 26. RADIOGRAPHIC EVALUATION: • FOR NON AMBULATORY CHILD-  ANTEROPOSTERIOR  STRESS DORSIFLEXION LATERAL VIEW • FOR OLDER CHILD-  STANDING ANTEROPOSTERIOR  STANDING LATERAL • IMPORTANT ANGLE WE MEASURE-  TALOCALCANEAL ANGLE ON AP AND LAT VIEW  TIBIOCALCANEAL ANGLE ON LAT VIEW  TALUS- FIRST METATARSAL ANGLE
  • 27. RADIOGRAPHIC EVALUATION: TALOCALCANEAL ANGLE- • ON AP VIEW-  1ST LINE THROUGH THE CENTRE OF LONG AXIS OF TALUS (PARALLEL TO MEDIAL BORDER)  2ND LINE THROUGH LONG AXIS OF CALCANEUM (PARALLEL TO LATERAL BORDER)  NORMAL 25-40* • ON LATERAL VIEW-  1ST LINE MIDPOINT OF HEAD AND BODY OF TALUS  2ND LINE ALONG BOTTOM OF CALCANEUM  NORMAL 35-50*
  • 28. RADIOGRAPHIC EVALUATION • RADIOLOGICAL FINDING SEEN- • ON LATERAL VIEW-  DECREASED TALOCALCANEAL ANGLE (TALOCALCANEAL PARALLELISM)  DISRUPTED TALAR FIRST METATARSAL ANGLE  LONG AXIS OF TALUS AND CALCANEUM PASSES INFERIOR TO CUBOID (NORMALLY CROSSES CUBOID) • ON ANTEROPOSTERIOR VIEW-  INCREASED TALOCALCANEAL ANGLE  INCREASED TALAR FIRST METATARSAL ANGLE  LONG AXIS OF TALUS DEVIATE LATERALLY AND PASSES ALONG 3RD OR 4TH METATARSAL BONE
  • 31. TREATMENT: • GOAL: TO ACHIEVE PLANTIGRADE FOOT FLEXIBILTY COSMETICALLY ACCEPTABLE FUNCTIONAL AND PAIN FREE FOOT IN SHORTEST TREATMENT TIME • PRINCIPLES: SOFT TISSUE CONTRACTURE RELEASE OR STRETCHING TO RESTORE NORMAL TARSAL RELATIONSHIP. ONCE NORMAL TARSAL RELATIONSHIP ATTAINED, CORRECTION SHOULD BE MAINTAINED TILL TARSAL BONES REMOULDS STABLE ARTICULAR SURFACE.
  • 32. NONOPERATIVE TREATMENT: • SEVERAL REGIME HAVE BEEN PROPOSED INCLUDING SPLINTING TAPING AND CASTING. • KITE’S METHOD:  CORRECTION OF EACH COMPONENT SEPARATELY  CORRECTION WAS DONE IN FOLLOWING ORDER  KITE’S ERRORS:  PRONATION/ EVERSION OF 1ST METATARSAL.  PREMATURE DORSIFLEXION OF HEEL.  USED CALCANEOCUBOID JOINT AS FULCRUM THAT BLOCKS ABDUCTION OF CALCANEUS , THERBY PREVENTS EVERSION OF CALCANEUS. FOREFOOT ADDUCTION HEEL VARUS EQUINUS
  • 35. NONOPERATIVE TREATMENT: • PONSETI TECHNIQUE: 2 PHASE- TREATMENT AND MAINTENANCE PHASE TREATMENT PHASE- BEGINS AS EARLY AS POSSIBLE. DURING FIRST WEEK OF LIFE ONLY MANIPULATION IS CARRIED OUT BUT CAST IS NOT APPLIED. ORDER OF CORRECTION- TALUS HEAD IS USED AS FULCRUM. 5-6 SERIAL CASTING WITH MANIPULATION IS GENERALLY ENOUGH TO CORRECT THE DEFORMITY. MAXIMUM UPTO 1O CASTING CAN BE DONE. CAVUS ADDUCTION WITH VARUS EQUINUS
  • 36. PONSETI TECHNIQUE: • CORRECTION OF CAVUS DEFORMITY: CORRECTED BY FOREFOOT SUPINATION RELATIVE TO HINDFOOT ALONG WITH ADDUCTION OF FOREFOOT. TENDS TO EXAGGERATE FOOT INVERSION. PRONATION OF FOREFOOT SHOULD NOT BE DONE AS IT INCREASES CAVUS DEFORMITY BECAUSE 1ST METATARSAL IS FURTHER PLANTAR FLEXED. E- RIGHT MANEUVER TO CORRECT CAVUS DEFORMITY F- WRONG MANEUVER TO CORRECT CAVUS DEFORMITY
  • 37. PONSETI TECHNIQUE A: THUMB IS POSITIONED OVER LATERAL ASPECT OF HEAD OF TALUS AND FINGER CORRECT THE FOREFOOT. B: CAVUS AND ADDUCTION ARE CORRECTED BY SLIGHT SUPINATION OF FOREFOOT IN RELATION TO HINDFOOT.
  • 38. PONSETI TECHNIQUE • CORRECTION OF VARUS AND ADDUCTION: CORRECTION OF CAVUS BRINGS METATARSAL, CUNIEFORM, NAVICULAR, AND CUBOID IN SAME PLANE OF SUPINATION. NOW FOOT IS ABDUCTED AND HELD IN FLEXION AND SUPINATION TO ACCOMMODATE THE INVERSION OF TARSAL BONES WHILE COUNTER PRESSURE IS APPLIED WITH THUMB ON LATERAL ASPECT OF HEAD OF TALUS. THIS MANEUVER NECESSITATES PROLONG STRETCHING OF MEDIAL TARSAL LIGAMENTS AND TENDONS.
  • 39. PRESSURE EXERTED ON METATARSAL AND COUNTERPRESSURE ON LATERAL ASPECT OF HEAD OF TALUS. FURTHER ABDUCTION OF FOOT HELD IN FLEXION AND SUPINATION.
  • 41. PONSETI TECHNIQUE • CORRECTION OF EQUINUS: • SHOULD BE ATTEMPTED WHEN HINDFOOT IS IN NEUTRAL POSITION TO SLIGHT VALGUS AND FOOT IS ABDUCTED 70* RELATIVE TO LEG. • EQUINUS IS COORECTED BY PROGRESSIVE DORSIFLEXING THE FOOT. • TO FACILITATE RAPID CORRECTION SUBCUTANEOUS TENOTOMY IS DONE. • CARE SHOULD BE TAKEN WHILE DORSIFLEXING FOOT BY APPYLING PRESSURE UNDER ENTIRE SOLE AND NOT UNDER METATARSAL HEADS.
  • 42. FOOT IS FURTHER ABDUCTED UPTO 70* TO STRETCH TO STRETCH MEDIAL TARSAL LIGAMENT. NOTE: HEEL IS NOT GRASPED BY HAND THUS ALLOWING CALCANEUS TO ABDUCT WITH FOOT AND HEEL VARUS TO CORRECT
  • 43. EQUINUS CORRECTED BY SUBCUTANEOUS SECTION OF TENDO ACHILLES
  • 44. PERCUTANEOUS TENOTOMY FOOT HELD IN DORSIFLEXION AND TENDON IS FELT BLADE OF 11 SIZE ENTERS PARALLEL TO MEDIAL BORDER OF TENDOACHILLES 1CM ABOVE INSERTION AT CALCANEUM. BLADE IS PUSHED MEDIAL TO TENDON AND ROTATED 90* UNDERNEATH IT. TENDON IS CUT FROM MEDIAL TO LATERAL DIRECTION. "POP" IS FELT AND CAST IS APPLIED IN MAXIMAL DORSIFLEXION AND 70* ABDUCTION FOR 3-4 WEEKS.
  • 48. PONSETI TECHNIQUE • MAINTAENANCE PHASE: • AFTER REMOVAL OF CAST INFANT IS PLACED IN FOOT ABDUCTION ORTHOSIS. • BRACE IS WORN FOR 23HRS PER DAY FOR FIRST 3 MONTH THEN ONLY WHILE SLEEPING FOR 3-4 YEARS. • FREQUENT FOLLOW UP IS IMPORTANT TO DETECT EARLY RECCURENCE. • IT PREVENT RECURRENCE OF DEFORMITY • IT FAVORS REMODELLING OF JOINTS WITH THE BONES IN PROPER ALINGMENT AND TO INCREASE LEG AND FOOT MUSCLE STRENGTH.
  • 49. FOOT ABDUCTION ORTHOSIS • ALSO KNOWN AS DENIS BROWN SPLINT. • CONSIST OF SHOES MOUNTED TO CROSSBAR IN POSITION OF 70* EXTERNAL ROTATION AND 15* DORSIFLEXION. • DISTANCE BETWEEN SHOES IS SET AT ABOUT 1INCH WIDER THAN THE WIDTH OF INFANT’S SHOULDER. • IN UNILATERAL CASES NORMAL FOOT SHOULD IN 40* OUTWARD ROTATION.
  • 50. CTEV SHOES • MODIFIED SHOES FOR CHILD WHO START WALKING. • THESE SHOES ARE USE UNTILL 5 YEARS OF AGE. • SPECIAL FEATURES: STRAIGHT INNER BORDER OUTER SHOE RISE NO HEEL
  • 51. NONOPERATIVE TREATMENT • STRETCHING AND ADHESIVE STRAPPING(ROBERT JONES): PRINCIPLE- APPLY EVERSION CORRECTION FORCE ON FOOT WITH HELP OF ADHESIVE STRAPPING. • FRENCH TECHNIQUE: GOAL IS TO REDUCE TALONAVICULAR JOINT, STRETCH OUT MEDIAL TISSUES AND THEN SEQUENTIALLY CORRECT FOREFOOT ADDUCTION, HINDFOOT VARUS AND EQUINUS OF CALCANEUM.
  • 52. COMPLICATIONS OF NONOPERATIVE TREATMENT • ROCKER BOTTOM FOOT • BEAN SHAPED FOOT • FRACTURES • PRESSURE SORES • FLAT TOP TALUS • FAILURE OF CORRECTION • RECCURENCE OR RELAPSE OF DEFORMITY
  • 53. SURGICAL TREATMENT • INDICATION:  IN CASE OF NEGLECTED CTEV, RELAPSED CTEV, RECCURENT CTEV, RESISTANT CTEV, RIGID CTEV. • CHOICE OF SURGERY: 1-4 YEARS-  SOFT TISSUE RELEASE 4-11 YEARS-  SOFT TISSUE RELEASE WITH  OSTEOTOMY PERFORMED ACCORDING TO THE DEFORMITIES >11YRS- SALVAGE PROCEDURES  TRIPLE ARTHRODESIS  TALECTOMY
  • 54. SOFT TISSUE RELEASE OPERATION TURCO’S OPERATION- IT IS ONE STAGE POSTEROMEDIAL RELEASE. HE EMPHASIZED ON SUBTALAR RELEASE ALONG WITH CALCANEOFIBULAR LIGAMENT. CAROLL’S INCISION- CAROLL EMPHASIZED ON PLANTAR FASCIA RELEASE AND CAPSULOTOMY OF CALCANEOCUBOID JOINT. IT INCLUDE 2 INCISIONS, MEDIAL AND POSTERO-LATERAL INCISION. CINCINATTI INCISION- IT IS DONE FOR POSTEROMEDIAL AND POSTEROLATERAL SOFT TISSUE RELEASE. PREFFERED TECHNIQUE FOR INITIAL SURGICAL MANAGEMENT OF CLUB FOOT. TENDOACHILLES TENDON RELEASE WITH POSTERIOR CAPSULOTOMY- TO CORRECT RESIDUAL HIND FOOT EQUINUS
  • 55. TURCO OPERATION • MEDIAL INCISION GIVEN • EXPOSE TIBIALIS POSTERIOR, FDL,FHL, TENDOACHILLES AND POSTERIOR NEUROVASCULAR BUNDLE. • DIVIDE MASTER KNOT OF HENRY. • DIVIDE CALCANEONAVICULAR LIGAMENT AND ABDUCTOR HALLUCIS FROM TIBIALIS POSTERIOR TENDON,NAVICULAR TUBEROSITY AND 1ST METATARSAL. • POSTERIOR RELEASE- BY DOING Z-PLASTY OF TENDO ACHILLES, INCISING POSTERIOR CAPSULE OF ANKLE JOIN, SUBTALAR JOINT AND DIVIDING TALOFIBULAR LIGAMENT AND CALCANEOFIBULAR LIGAMENT. • MEDIAL PLANTAR RELEASE- DIVIDE TIBIALIS POSTERIOR, SUPERFICIAL DELTOID LIGAMENT, TALONAVICULAR CAPSULE AND SPRING LIGAMENT. • SUTALAR RELEASE- DIVIDE MEDIAL PART OF TALOCALCANEAL INTERROSEOUS LIGAMENT AND BIFURCATION OF Y LIGAMENT. • AFTER REDUCING NAVICULAR BONE TRANSFIX TALONAVICULAR JOINT BY K-WIRE AND SUBTALAR JOINT BY 2ND K-WIRE.
  • 57. CINCINATTI INCISION • TRANSVERSE CIRCUMFERENTIAL INCISION
  • 58. ACHILLES TENDON LENTHENING AND POSTERIOR CAPSULOTOMY • TO CORRECT RESIDUAL HINDFOOT EQUINUS • Z-PLASTY IS DONE TO LENGTHEN THE ACHILLES TENDON. • RELEASING MEDIAL HALF DISTALLY AND LATERAL HALF PROXIMALLY. • POSTERIOR CAPSULOTOMY OF ANKLE AND SUBTALAR JOINT TO RELEASE CAPSULE CONTRACTURE.
  • 59. TENDON TRANSFER • INDICATION- PASSIVELY CORRECTABLE DEFORMITY RESULTING FROM MUSCLE IMBALANCE. • ANTERIOR TIBIALIS TENDON TRANSFER- TENDON IS TRANSFERRED EITHER TO MIDDLE CUNIEFORM OR TO BASE OF 5TH METATARSAL. • SPLATT (SPLit ANTERIOR TIBIALIS TENDON TRANSFER)- LATERAL PART OF TENDON IS SPLIT AND INSERTED TO CUBOID.
  • 60. DWYER OSTEOTOMY • INDICATION- PERSISTENT VARUS DEFORMITY OF HEEL WHEN SOFT TISSUE SURGERIES ARE CONTRAINDICATED. • AGE- 3-4YRS • DONE BY MEDIAL OPEN WEDGE OSTEOTOMY OR BY LATERAL CLOSED WEDGE OSTEOTOMY
  • 61. LATERAL COLUMN SHORTENING PROCEDURE • INDICATION- RECURRENCE OF CLUBFOOT DEFORMITY AFTER SURGICAL RELEASE IS MOSTLY DUE TO DISPARITY BETWEEN MEDIAL AND LATERAL BORDER OF FOOT. ANY ATTEMPT TO CORRECT DEFORMITY IS RESISTED BY MEDIAL CONTRACTURE AND EXCESSIVE LENGTH OF LATERAL COLUMN. • DIFFERENT PROCEDURE TO DO SHORTEN LATERAL COLUMN ARE-  DILLWYNN EVANS PROCEDURE  LICHTBLAU PROCEDURE  FOWLER PROCEDURE
  • 62. LATERAL COLUMN SHORTENING PROCEDURE DILLWYN EVANS PROCEDURE LICHTBLAU PROCEDURE AGE- 4-8 YRS INDICATION- MIDFOOT IN VARUS DUE TO TALONAVICULAR AND CALCANEOCUBOID SUBLUXATION AGE- 3-4 YRS INDICATION- HEEL VARUS & RESIDUAL INTERNAL DEFORMITY OF CALCANEUS WITH LONG LATERAL COLUMN
  • 63. FOWLER PROCEDURE • INDICATION- SUFFICIENT SCARRING THAT MEDIAL SOFT TISSUE AND SUBTALAR RELEASE WOULD BE IN EFFECTIVE. • AGE- 6-8 YEARS • PROCEDURE- LATERAL COLUMN SHORTENING COMBINING WITH MEDIAL COLUMN LENGTHING BY REMOVING WEDGE FROM CUBOID AND TRANSFERING IT TO AN OPENING WEDGE.
  • 64. SALVAGE PROCEDURE • INDICATION-  UNCORRECTED CLUBFOOT OR WITH RESIDUAL DEFORMITY AFTER THE AGE OF 10 YRS.  PAINFUL STIFF FOOT WITH POOR FUNCTION  DIFFICULT TO ACCOMMODATE TO FOOT WEAR • GOAL-  CORRECT RESIDUAL DEFORMITY WHICH IS RESISTANT TO SOFT TISSUE RELEASE.  TO ATTAIN FUNCTIONALLY AND COSMETICALLY ACCEPTABLE FOOT. • PROCEDURE-  TRIPLE ARTHRODESIS  TALECTOMY
  • 65. TRIPLE ARTHRODESIS • INDICATION- PAINFUL STIFF FOOT WITH POOR FUNCTION DIFFICULT TO ACCOMMODATE TO FOOT WEAR ALL OTHER CORRECTION FAILED • AGE – 10 – 12 YEARS • PROCEDURE-  OSTEOTOMY FOLLOWED BY FUSION OF TALONAVICULAR, TALOCALCANEUM AND CALCANEOCUBOID JOINT.
  • 66. TALECTOMY • INDICATION-  RESERVED FOR SEVERE UNTREATED CLUBFOOT • AGE - <6 YEARS • PROCEDURE-  COMPLETE EXCISION OF TALUS  DEROTATE THE FOOT AND DISPLACE THE CALCANEUS POSTERIORLY INTO ANKLE MORTISE UNTIL NAVICULAR ABUTS THE ANTERIOR EDGE OF TIBIAL PLAFOND. • COMPLICATION-  LOSS OF LIMB LENGTH  LIMITATION OF ANKLE MOVEMENT
  • 67. EXTERNAL FIXATOR • INDICATION- IN CASE OF NEGLECTED AND RECCURENT DEFORMITY WITH SEVERE SCARRING • MODALITIES- ILLIZAROV’S EXTERNAL FIXATOR JESS (JOSHI EXTERNAL STABILIZING SYSTEM) • ADVANTAGE- PREVENT CRUSHING OF THE TISSUES ON CONVEX SIDE LENGHTENS THE LIMB EFFECTIVELY CORRECT THE DEFORMITY AT SAME TIME
  • 68. ILLIZAROV’S EXTERNAL FIXATOR • PRINCIPLE- FRACTIONAL DISTRACTION • INDICATION- SEVERE DEFORMITIES WITH SEVERE SCARING OR TROPHIC ULCERS WHICH MAKE OPERATIVE INTERVENTION CONTRAINDICATION BECAUSE OF RISK OF TISSUE NECROSIS. • STEPS OF CORRECTION- ANGULAR CORRECTION OF HINDFOOT CORRECTION OF FOREFOOT SUPINATION CORRECTION OF FOOT EQUINUS
  • 69. JESS • PRINCIPLE- DIFFERENTIAL DISTRACTION • ADVANTAGE-  LENTHENS ALL CONTRACTED TISSUES PREVENTING HISTIOGENESIS AND THUS AVOID CUTTING OF THESE IMMINENT SCARRING.  POSSIBLE TO CONTROL MAGNITUDE OF CORRECTION.  NO FURTHER SHORTHENING OF FOOT  RESULTANT FEET IS VERY SUPPLE.
  • 71. A. FRESH CASE OF CTEV AT BIRTH PONSETI METHOD TENOTOMY ALL DEFORMITIES LEFT: PMSTR ONLY EQUINUS: POSTERIOR RELEASE ONLY HEEL VARUS: DWYER’S OSTEOTOMY FOLLOW TILL 10- 12 YEARS OF AGE TREATMENT SUCCESSFUL TREAT AS B
  • 72. B. OLD AND NEGLECTED CASES < 3 YEARS OLD SOFT TISSUE RELEASE 4-8 YEARS OLD SOFT TISSUE RELEASE + OSTEOTOMY 10-12 YEARS OLD ALREADY OPERATED

Notes de l'éditeur

  1. TRANSFORMING GROWTH FACTOR – BETA AND PLATELET DERIVED GROWTH FACTOR ARE INCREASED IN THESE CONTRACTED TISSUES.
  2. NAVICULAR BONE SHOULD BE BOUGHT DOWNWARD UNDER MEDIAL MALLEOLUS FROM VERTICAL POSITION AND THEN DISPLACE IT LATERALLY, ABDUCT AND LASTLY EVERT IT COBOID IS LESS DISPLACED STILL BRING LATERALLY, ABDUCT AND THEN EVERT SAME FOR CALCANEUM, ABDUCTED IN FLEXION UNDER TALUS THEN EVERTED.
  3. > 10 CASTING CAN DAMAGE OF OSTEOPOROTIC BONE.