congenital talipes equino varus
DESCRIPTION
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CONGENITAL TALIPES CONGENITAL TALIPES EQUINO VARUSEQUINO VARUS
Children with physical Children with physical disabilities are often disabilities are often socially and socially and economically economically disadvantageddisadvantaged
Importance of Clubfoot Importance of Clubfoot – easily diagnosed – easily diagnosed - -easily treatedeasily treated
CTEV – CTEV – congenital congenital talipes equino-varustalipes equino-varus
Talipes - The term talipes Talipes - The term talipes is derived from a is derived from a contraction of the Latin contraction of the Latin words for words for ankleankle, , talus,talus, and and foot, foot, pespes. The term . The term refers to the gait of refers to the gait of severely affected severely affected patients, who walked on patients, who walked on their ankles their ankles
DefinitionDefinition
Club foot is a Club foot is a congenital deformity congenital deformity of the foot and ankle of the foot and ankle characterized by characterized by equinus deformity at equinus deformity at the ankle, inversion at the ankle, inversion at the the subtalar ,adduction at subtalar ,adduction at the midtarsal the midtarsal joint,cavus and joint,cavus and internal tibial torsioninternal tibial torsion
INCIDENCEINCIDENCE
About 1 in 1000 live About 1 in 1000 live birthsbirths
Most cases sporadicMost cases sporadic Sometimes Sometimes
Autosomal dominant Autosomal dominant trait with incomplete trait with incomplete penetrancepenetrance
More common in boys than girlsMore common in boys than girls50 % cases are bilateral50 % cases are bilateral In unilateral cases right side is more often In unilateral cases right side is more often
involvedinvolved
Types According To CauseTypes According To Cause
1) Idiopathic1) Idiopathic 2) Secondary2) Secondary 3) Postural / Positional3) Postural / Positional
IdiopathicIdiopathic
Diagnosed when child has normal upper Diagnosed when child has normal upper and lower extremities spine and and lower extremities spine and neurological status apart from club footneurological status apart from club foot
Can be detected by USG by 16 wks Can be detected by USG by 16 wks gestationgestation
Combination of genetic and environmental Combination of genetic and environmental factors are involved factors are involved
Theories regarding causeTheories regarding cause
Primary germ plasm Primary germ plasm defect of talusdefect of talus
Contractile Contractile myofibroblastic tissue myofibroblastic tissue in the in the musculotendinous musculotendinous unitsunits
Secondary ClubfootSecondary Clubfoot
Diagnosed when deformity forms part of Diagnosed when deformity forms part of another health conditionanother health condition
a)a) Neuropathic Neuropathic – deformity in – deformity in association with neurological abnormalities association with neurological abnormalities or spina bifidaor spina bifida
b) b) SyndromicSyndromic – clubfoot in association – clubfoot in association with other syndromeswith other syndromes
Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEV
Spina Bifida = Paralytic TEVSpina Bifida = Paralytic TEV
Syndromes Producing CTEVSyndromes Producing CTEV
Streeters dysplasiaStreeters dysplasiaArthrogryposisArthrogryposisEdwards syndrome – trisomy 18Edwards syndrome – trisomy 18
PosturalPostural
Due to abnormal intrauterine positionDue to abnormal intrauterine positionEasily corrected by massage by mother or Easily corrected by massage by mother or
by 1 or 2 castsby 1 or 2 casts
Types of Clubfoot According to Types of Clubfoot According to Treatment StageTreatment Stage
Untreated Untreated Treated Treated Resistant Resistant RecurrentRecurrentNeglectedNeglectedComplex Complex
Untreated –Untreated – affected child is under 2 yrs of affected child is under 2 yrs of age and had no or very little treatmentage and had no or very little treatment
Treated –Treated – affected childs feet have affected childs feet have corrected with ponseti mehod and they corrected with ponseti mehod and they have completed the casting phasehave completed the casting phase
ResistantResistant – child has previously untreated – child has previously untreated clubfoot and that does not correct with clubfoot and that does not correct with Ponseti method. This is usually syndromic Ponseti method. This is usually syndromic and surgery may be necessaryand surgery may be necessary
Recurrent clubfootRecurrent clubfoot – children who show – children who show signs of deformity in previously treated signs of deformity in previously treated clubfootclubfoot
supination of foot – tib antsupination of foot – tib ant
hindfoot equinus – tendoachilleshindfoot equinus – tendoachilles
usually due to failure to wear FAOusually due to failure to wear FAO
treated by casting or surgerytreated by casting or surgery
Neglected clubfootNeglected clubfoot – child older than two – child older than two years who had little or no treatmentyears who had little or no treatment
usually severe soft tissue contractures usually severe soft tissue contractures and bony deformitiesand bony deformities
Ponseti treatment has some success Ponseti treatment has some success but many require surgerybut many require surgery
Complex clubfootComplex clubfoot – clubfoot treated by any – clubfoot treated by any method other than ponseti techniquemethod other than ponseti technique
- complicated by additional pathology or - complicated by additional pathology or scarringscarring
Pathological ChangesPathological Changes
Four basic Four basic components are components are
midfoot midfoot CCavus (tight avus (tight intrinsics, FHL, FDL) intrinsics, FHL, FDL)
forefoot forefoot AAdductus dductus (tight tibialis posterior) (tight tibialis posterior)
hindfoot hindfoot VVarus (tight arus (tight tendoachilles, tibialis tendoachilles, tibialis posterior) posterior)
hindfoot hindfoot EEquinus quinus (tight tendoachilles )(tight tendoachilles )
The ankle, subtalar and midtarsal joints The ankle, subtalar and midtarsal joints are involvedare involved
The severity of deformity varies and is The severity of deformity varies and is graded by the pirani scoregraded by the pirani score
McKay’s Description of McKay’s Description of Pathological AnatomyPathological Anatomy
calcaneus rotates horizontally and the calcaneus rotates horizontally and the tuberosity moves towards the lat malleolustuberosity moves towards the lat malleolus
The taolonavicular joint is in extreme The taolonavicular joint is in extreme inversioninversion
Cuboid is displaced medially on the Cuboid is displaced medially on the calcaneuscalcaneus
Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEV
Associated findings- hypotrophic anterior Associated findings- hypotrophic anterior tibial artery tibial artery
-atrophy of muscles -atrophy of muscles around the calf around the calf
-abnormal foot is -abnormal foot is smaller smaller
Soft Tissue AbnormalitiesSoft Tissue Abnormalities
Talocalcaneal (subtalar) joint realignment Talocalcaneal (subtalar) joint realignment is opposed by-is opposed by-
- calcaneo fibular ligament- calcaneo fibular ligament
- peroneal tendon sheath- peroneal tendon sheath
- posterior talo calcaneal ligament- posterior talo calcaneal ligament
Talo navicular joint realignment is opposed Talo navicular joint realignment is opposed by- posterior tibial tendonby- posterior tibial tendon
- deltoid ligament- deltoid ligament
- spring ligament - spring ligament
- joint capsule- joint capsule
- dorsal talonavicular ligament- dorsal talonavicular ligament
- bifurcated Y ligamant- bifurcated Y ligamant
Calcaneo cuboid joint realignment is Calcaneo cuboid joint realignment is opposed by-bifurcated Y ligament opposed by-bifurcated Y ligament
- long plantar ligament- long plantar ligament
- plantar calcaneo cuboid - plantar calcaneo cuboid ligamentligament
If the deformity is left untreated late If the deformity is left untreated late adaptive changes occur in the bones.adaptive changes occur in the bones.
These depend on the severity of soft These depend on the severity of soft tissue contracture and effect of walkingtissue contracture and effect of walking
Radiological EvaluationRadiological Evaluation Talocalcaneal angle Talocalcaneal angle
- - Anteroposterior Anteroposterior view: 30-55 degreesview: 30-55 degrees
Talocalcaneal angle - Talocalcaneal angle - Dorsiflexion lateral Dorsiflexion lateral view: 25-50 degreesview: 25-50 degrees
Tibiocalcaneal Tibiocalcaneal angle angle Stress lateral view: Stress lateral view: 60-90 degrees60-90 degrees
Talus–first metatarsal Talus–first metatarsal angle Anteroposterior angle Anteroposterior view: 5-15 degreesview: 5-15 degrees
Treatment Treatment
Non operative – Ponseti techniqueNon operative – Ponseti technique Kite techniqueKite technique French techniqueFrench technique
Surgical–Posteromedial soft tissue releaseSurgical–Posteromedial soft tissue release OsteotomiesOsteotomies
Triple arthrodesisTriple arthrodesis Achilles tendon lengtheningAchilles tendon lengthening
Ilizarov / JESSIlizarov / JESS
Ponseti techniquePonseti technique
Weekly Serial manipulation and Weekly Serial manipulation and casting (long leg cast)casting (long leg cast)
goal is to rotate foot lateraly around a fixed goal is to rotate foot lateraly around a fixed talus talus
order of correction (order of correction (cavecave) ) midfoot midfoot ccavus avus forefoot forefoot aadductus dductus hindfoot hindfoot vvarus arus hindfoot hindfoot eequinus (TAL)quinus (TAL)
After the last cast TA After the last cast TA lengthening lengthening
FAB for 23 hrs a day FAB for 23 hrs a day for 3 months and for 3 months and night splint till 2-3 yrs night splint till 2-3 yrs of ageof age
Chance of recurrence Chance of recurrence up to 4 or 5 yrs of ageup to 4 or 5 yrs of age
Kite’s techniqueKite’s technique
Foot manipulated with calcaneo cuboid Foot manipulated with calcaneo cuboid joint as fulcrumjoint as fulcrum
Casting done after manipulationCasting done after manipulationAfter correction Denis Browne splint After correction Denis Browne splint
appliedapplied
French TechniqueFrench Technique
Daily manipulation by physical therapist for Daily manipulation by physical therapist for 30 mts 30 mts
Electrical stimulation of peroneal muscles Electrical stimulation of peroneal muscles donedone
Reduction maintained by adhesive tapingReduction maintained by adhesive taping
PMRPMR
Done at age 1 yrDone at age 1 yr Tight structures in Tight structures in
posterior and medial posterior and medial aspect of the foot is aspect of the foot is released or released or lengthenedlengthened
Osteotomies – for Osteotomies – for residual hind foot residual hind foot varusvarus
Triple arthrodesis – in Triple arthrodesis – in children more than 12 children more than 12 yrs oldyrs old
TA lengthening – for TA lengthening – for residual equinusresidual equinus
Ilizarov and JESS are Ilizarov and JESS are for older children with for older children with recurrence or residual recurrence or residual deformitydeformity
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