congenital talipes equinovarus
DESCRIPTION
Detailed description with recent advancesTRANSCRIPT
CONGENITAL TALIPES EQUINOVARUS
Definition Developmental deformation of the foot
characterized by rotational subluxation of the talocalcaneonavicular joint complex with Talus in plantar flexion and Subtalar complex in medial rotation and inversion
Extrinsic (intrauterine) factorsIntrinsic (genetic) factors
Etiological factors
Multifactorial causationEstablished by genetic epidemiologic
research by Idelberger32.5% concordance rate among
monozygotic twins as compared to 2.9% among dizygotic twins
genetic heritability of 80% .
Idelberger K. et al 1939; 33:272–276.
GENETIC FACTORSA major gene effect (inherited in recessive
manner) with additional polygenes and environmental factors
complex segregation analyses of idiopathic clubfoot populations. (de Andrade M ,1998)
deletion on Chromosome 2 (2q31-33) related to the CASP10 gene.
Heck AL et al. J Pediatr Orthop 2005;25:598-602
Extrinsic factors (intrauterine environment)
Pressure theories: Oligohydramnios
Abnormal fetal positioning Unstrctched uterusPlacental insufficiencyConstriction bandsToxinsTemperatureInfective pathogens (enteroviruses)Drugs (including abortifacients)Electromagnetic radiation
Pressure theory
Conclusively disproved by Wynne-Davies concordance between dizygotic twins was
identical to the non-twin sibling rate Dizygotic twins “crowded” into a single
uterus did not demonstrate a higher concordance with respect to non-twin siblings.
Infective pathogens (enteroviruses)Seasonal variation with significant
increase in CTEV incidence was seen in the winter (December–March ) in some studies*
Infective pathogens exhibiting seasonal activity postulated as potential causes
Conflicting evidence –Carney et al (2005)**
* Barker SL. J Pediatr Orthop B 2002; 11:129–133.** Carney BT. J Pediatr Orthop 2005;25:351-2.
Toxins and electromagnetic radiation Maternal
alcohol consumption
(Halmesmaki et al. 1985)
Maternal smoking (Alderman et al.)
Paternal smoking (HONEIN M ,2000)
High-power radio transmitters
The results are preliminary, and further work is required
Irgens LM, et al.Teratology
1998; 57:34.
Drugs:
Salicylate use in first trimester
Prenatal exposure to barbiturates.
Chung C et al. Hum Hered.
1969;19:321-42
Maternal disorders
Maternal anaemia
Maternal hyperemesis
Thyroid disorders
Byron-Scott R, et al. Paediatr Perinat Epidemiol 2005;19:227-37.
Neuromuscular theoryGray et al (1981) : increase in % of type I
fibres in the soleus muscle; suggested defective neural influence.
Recent study**: no evidence of type I fiber grouping
** Milan B MD et al. Journal of Pediatric Orthopedics. 26(1):91-
93, January/February 2006.
Vascular theory
hypoplasia or absence of the anterior tibial artery in majority of CTEV patients*
absence of the dorsalis pedis pulse in the parents of children with clubfoot**
*Sodre H et al. J Pediatr Orthop. 1990;10:101-4.
**Muir L et al. J Bone Joint Surg Br. 1995;77:114-6.
Generalized disorder of development of the limb Lower limb in unilateral CTEV
- Redn in calf and thigh girth
- Significant shortening, most prominent
at ankle and least at femur
Shimode K, Myagi N, Majima T, Yasuda K, Minami A. J Pediatr Orthop [B] 2005;14:280-4.
Conditions associated with CTEV
THE BASIS OF PONSTEI’S METHOD
BIOLOGY OF CTEV
Pathoanatomy of soft tissues1. The plantar calcaneonavicular
ligament.2. The tibionavicular ligament3. The superior, medial and
plantar parts of the talonavicular capsule
4. The posterior tibial tendon 5. The master knot of Henry
6. The calcaneofibular ligament7. The superior
peroneal(calcaneofibular) retinaculum
8. The posterior talocalcanel ligament
9. The posterior capsule of the tibiotalarjoint
10. The tendo Achillis11.The interosseous ligament12.The long toe flexors
Micro architecture
increase of collagen fibers and cells in the ligaments.
The bundles of collagen fibers display a wavy appearance known as crimp.
crimp allows the ligaments to be stretched.
The crimp reappears a few days later, allowing for further stretching
TA : non-stretchable, thick, tight collagen bundles with few cells
Bony abnormalities
The tarsal bones, which are mostly made of cartilage, are in the most extreme positions of flexion, adduction, and inversion at birth
The talus: severe plantar flexion, neck medially and plantarly deflected, and head wedge shaped.
Navicular: severely medially displaced, close to the medial malleolus, and articulates with the medial surface of the head of the talus.
The Calcaneus adducted and inverted. anterior portion of the Calcaneus lies beneath the head of the Talus.
BIOMECHANICAL FACTORSTarsal joints are functionally
interdependent. The movement of each tarsal bone involves simultaneous shifts in the adjacent bones.
No single axis of rotation
Necessiates SIMULTANEOUS correction of adduction, varus and inversion.
Clinical features
A standardized examination initially and after each interval of treatment
reference posn, usually the knee in 90° of flexion, chosen.
All deformities assessed in relation to the next most proximal segment
Exmn of the entire child to look for associated anomalies, esp the spine.
Foot shorter and wider than normal.
Transverse plantar creases or clefts at the midfoot and posterior part of the ankle.
Atrophy of the calf
Assessment of equinus
posterior aspect of the calcaneus must be palpated carefully when the equinus is measured
Equinus assessed with the knee both in extension and in flexion.
equinus with knee extended -The true contractureof the gastro-soleus muscle complex.
The difference between the equinus in knee flex and extn indicates the amount of stiffness in the ankle joint.
heel is in varus but the forefoot is well aligned with the heel. There is no supination of the forefoot on the hindfoot.
The varus of the heel at rest and in the position of best correction
Posn of forefoot in relation to midfoot
Palpation of the lateral column with the foot in dorsiflexion
Tibial torsion
Awkward gait
Congenital vs Acquired
Congenital Congenital Acquired Acquired
History History Since birthSince birth Appears laterAppears later
Bilateral Bilateral In >50%In >50% Usually unilateralUsually unilateral
Deformity Deformity EquinovarusEquinovarusForefoot adductionForefoot adductionCavus Cavus
Equinovarus Equinovarus
Congenital grooveCongenital groove Present Present Not presentNot present
Heel Heel Smaller Smaller Usually maintains Usually maintains shapeshape
Calf Calf Cylindrical and toughCylindrical and tough Normal Normal
Classification Systems
Type Type I(Extrinsic)I(Extrinsic)
Non RigidNon Rigid
Type Type II(Intrinsic)II(Intrinsic)
RigidRigid
Foot sizeFoot size Normal Normal Smaller Smaller
Heel Heel Normal sizeNormal sizeCan be brought Can be brought down with easedown with easeMinimal varusMinimal varus
Small , elevatedSmall , elevatedCannot be brought Cannot be brought down with easedown with easeMarked varusMarked varus
Creases Creases More or less normalMore or less normal Deep medial, Deep medial, posterior and lateral posterior and lateral creasescreases
Reduced creases Reduced creases laterallylaterally
Telescoping Telescoping Negative Negative Positive Positive
Differential diagnosisClub foot like appearance in cong. absence
or hypoplasia of tibia and in cong. dislocation of ankle
Careful palpation of Anatomical relationship and Radiograph will establish the diagnosis
IMAGING
Plain radiography
Limitations1. Difficult to position the foot2. The ossific nuclei do not represent the
true shape3. In the first year of life, only the talus,
calcaneus, and metatarsals may be ossified
4. Failure to hold the foot in the position of
best correction makes the foot look worse than it is
Plain radiographThe foot should be held in the position of
best correction, with weight-bearing, or, if an infant is being examined, with simulated weight-bearing
Focused on the hindfoot (about 30° from the vertical for AP view)
Lat. View: transmalleolar with the fibula overlapping the posterior half of the tibia
AP Radiograph
normalnormal CTEVCTEV
AP Talo AP Talo calcaneal calcaneal angleangle
20 -50 deg20 -50 deg <20 deg<20 deg
Tarsal-1Tarsal-1stst MT MT angleangle
Upto 30 deg Upto 30 deg valgusvalgus
Varus Varus anglulationanglulation
cuboid os. cuboid os. center w.r.t center w.r.t calcaneal axiscalcaneal axis
medialmedial
displacement displacement
AP radiograph: Talo-Calcaneal angle
Normal foot: 20`-50` CTEV:<20 deg
AP Radiograph: convergence of base of MT
Lateral radiograph
normalnormal CTEVCTEV
Talo Talo calcaneal calcaneal angleangle
25 to 50 25 to 50 degdeg
<25 deg<25 deg
Tarsal-1Tarsal-1stst MT angleMT angle
hyperflexiohyperflexionn
Lateral view: Talo-Calcaneal Lateral view: Talo-Calcaneal angleangle
Normal foot : 25` Normal foot : 25` to 50`to 50`
CTEV: <25 `CTEV: <25 `
Ultrasonogram
ANTENATAL DIAGNOSISIdeally done at 20 to 24 weeks
Recent reports*: positive predictive value of 83% with a false positive rate of 17%.
26% no Rx reqd; 61% reqd Sx
* Baron E, Mashiach R, Inbar O, et al. J Bone Joint Surg [Br] 2005;87-B:990-3.
Research tool
1.Recent study: to describe the morphological changes in a comparative study of treatment methods
2.Used for demonstrating complete healing of TA at 3 wks foll. Percutaneous tenotomy
MRI
ROLE OF MRI
NOT used in routine clinical practice
Important tool in research studies
PIRANI’S MRI PROTOCOLSagittal images perpendicular to the
bimalleolar axisOblique axial images perpendicular to the
talonavicular jointOblique axial images perpendicular to the
calcaneocuboid jointOblique coronal images perpendicular to
the subtalar joint
SAGITTAL IMAGES
Tibiotalar plantarflexionInferior talar neck inclination, and Inferior talonavicular displacement
Oblique axial images perpendicular to the talonavicular jointmedial talar neck
inclination, medial
talonavicular displacement,
the wedge-shaped head of the talus, and navicular
Oblique axial images perpendicular to the calcaneocuboid joint
the wedge-shaped distal calcaneus Medial calcaneocuboid displacement
Oblique coronal images perpendicular to the subtalar joint
The inverted and adducted calcaneusThe abnormal facets of the subtalar joint
EVALUATION SYSTEMS
Pirani’s severity scoringSix parameters 3 of midfoot and 3 of
hindfoot taken into accountEach parameter is given a value as foll:
0 normal
0.5 moderately abnormal
1 severely abnormal
Mid foot score
Curved lateral border [A]
Medial crease [B]
Talar head coverage [C]
Hind foot scorePosterior crease
[D]
Rigid equinus [E]
Empty heel [F]
Uses of Pirani’s scoreAssessment of progress by serial
plotting of the scorePredicting need for tenotomy (hs>1&
ms<1)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
International Clubfoot Study Group (ICFSG)
score.
ICFSGIntroduced by Bensahel et al in 2003Found to have good interobserver
reliability and reproducibility**Morhological (12 pts), functional (24 pts) &
radiological (12 pts) parametersMaximum of 60 for most deformed and 0
for normal feet**Celebi L et al J Pediatr Orthop B. 2006;15:34-36.
MORPHOLOGICAL PARAMETERS
FUNCTIONAL PARAMETERS
RADIOLOGICAL PARAMETERS
Treatment
Aims of treatmentStrong, painless, plantigrade and supple
foot by conservative managementPlantigrade, painless foot that can wear
shoes by surgical means if conservative regimen fails
PONSETI’S METHOD
DR. IGNACIO PONSETI
Introduction of Ponseti’s method and its wide spread use over the last decade following the publication of long-term results has been the most significant event in the history of CTEV
Outline of Ponseti regimenSerial casting of the lower limb using a
strictly defined technique and weekly change of casts
Percutaneous tenotomy of the tendo achilles for “hind foot stall”
Once the foot is corrected, an abduction foot orthosis worn full time for 12 weeks, and then at nights and naps, up to the age of four.
Transfer of the tibialis anterior tendon for dynamic supination deformity
Cavus correctionCavus results from pronation of the
forefoot in relation to the hind foot –“ THE PRONATION TWIST “
Attempting to correct the supination of hindfoot before correction of varus results in an iatrogenic increase in cavus
cavus corrected first by supinating the forefoot to place it in proper alignment with the hindfoot.
Varus, inversion, and adduction correctionvarus, inversion, and adduction of the
hindfoot are corrected after correction of cavus
Correction of all three components done simultaneously as the tarsal joints are in a strict mechanical interdependence
Stabilise the talus
abducting the foot in supination
Correction of equinus
No direct attempt at equinus correction is made until the heel varus is corrected
The equinus deformity gradually improves with correction of adductus and varus- calcaneus dorsiflexes as it abducts under the talus
Residual equinus- manipulation and casting +/- percutaneous tenotomy
Percutaneous TA tenotomy
Tenotomy of the tendo Achillis is an integral step in the Ponseti technique
Tenotomy is indicated when HS > 1, MS < 1(Pirani’s hindfoot and midfoot scores resp.), and the head of the talus is covered
The best sign of sufficient abduction is the ability to palpate the anterior process of the calcaneus as it abducts out from beneath the talus .
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
POST TENOTOMY CAST WITH FOOT IN 60-70 DEG ABDN
Complications of tenotomy
Healing of ruptured tendon:
. Barker et al* used USG studies to demonstrate complete healing of TA BY 3 weeks
. Bleeding: Dobbs MB et al ** reported a 2% incidence
of serious bleeding following tenotomy
* Barker SL et al. J Bone Joint Surg [Br] 2006;88-B:377-9.
** Dobbs MB et al. J Pediatr Orthop 2004;24:353-7.
Bracing protocol
Applied immediately after the last cast is removed, 3 weeks after tenotomy
The brace consists of open toe high-top straight last shoes attached to a bar
5 to 10 deg
Bracing protocolworn full time (day and night) for the first 3
months after the last cast is removed.After that, for 12 hours at night and 2 to 4
hours in the middle of the day for a total of 14 to16 hours during each 24-hour period.
continued until the child is 3 to 4 years of age.
Significance of bracingHaft et al**: noncompliance with bracing
protocol – the most common cause of recurrence in children on Ponseti regimen
**Haft, Geoffrey F. MD; Walker, Cameron G. PhD; Crawford,Haemish A. FRACS.J Bone Joint Surg Am, Volume 89-A(3).March 1, 2007.487–493
Atypical clubfoot2-3% Feet highly resistant to correctionDeep skin creases, rigid and severe
deformities, fibrotic muscles60 deg supination in 1st cast.AK casts with knee in 120 deg flexnTenotomy after correction of
hyperflexion of metatarsalsPost tenotomy casts changed every5
days
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
Examine the toddler walking
Look for supinationLook for heel varus
Treatment of relapse
Equinus relapse: corrective casting +/- percutaneous tenotomy in child < 2 yrs;
TA lengthening in older childrenVarus relapse: recasting and restitution of
bracing
Dynamic supination deformity
persistent varus and supination during walking
thickening of lateral plantar skin. Will require anterior tibialis
tendon transfer fixed deformity corrected by casts
before transfer. best performed when the child is
between 3 and 5 years of age. delayed till radiographs show
ossification of lateral cuneiform. No bracing is necessary after the
procedure.
Results of Ponseti’s method The key paper by Cooper and Dietz in 1995. reviewed a group of 45 adults, with 71 clubfeet, who
had been managed with the Ponseti method, 30 years after treatment.
The results were compared with NORMAL CONTROLS. Based on structured examination, radiographs,
electrogoniometry and measurements using a pedobarography.
Using the Laaveg and Ponseti score, the results in the normal controls and in those with treated clubfeet were the same.
Radiographs showed that the feet were not completely corrected, but functioned well despite this.
Cooper DM, Dietz FR. J Bone Joint Surg [Am] 1995;77-A:1477-89.
Results of Ponseti’s method..study from Iowa (2004) described the short-term
results of a more recent series of 256 feet.Correction obtained in 98% with one to seven
casts. 2.5% required extensive corrective surgery. Percutaneous tenotomy in 86%. The mean angle of dorsiflexion : 20° (0° to 35°). Minor cast complications in 8% Rate of relapse: 10%.
Morcuende JA, Dolan LA, Dietz FR, Ponseti IV. Radical reduction in the rate of extensive correctivesurgery for clubfoot using the Ponseti method. Pediatrics 2004;113:376-80.
OUTCOME AFTER CORRECTIVE SURGERY – A STARK CONTRAST
Laaveg and Ponseti scores: 0% excellent, 33% good, 20% fair and 47% poor results.
significantly reduced scores in physical functioning, role physical, general health, vitality, social functioning and physical components
similar to those with pain in the cervical spine with radiculopathy,Parkinson‘s,haemodialysis, CHF and those awaiting CABG
Dobbs MB, Nunley R, Schoenecker PL. Long term follow up of patients with clubfeet treated with extensive soft-tissue release. J Bone Joint Surg [Am] 2006;88-A:986- [on 73 feet in 45 patients after a minimum follow-up of 25 years ]
Ponseti regime Vs surgical correctionCT at skeletal maturity
manipulation and serial casting, followed by posteromedial release for the resisting feet vs modified Ponseti regime [open z-lengthening of TA]
Ponseti group: better correction of cavus, supination and adduction
Ippolito et al. J Bone Joint Surg [Br] 2004;86-B:574-80
Ponseti Vs Kite technique
Ponseti Ponseti Kite Kite
Mean follow Mean follow upup
(months)(months)
2929 5454
Residual Residual deformitydeformity
6%6% 44%44%
Need for Need for surgerysurgery
6%6% 57%57%
Segev E, Keret D, Lokiec F, et al. Early experience with the Ponseti method for the treatment of congenital idiopathic clubfoot. Isr Med Assoc J 2005;7:307-10.
Modifications of Ponseti’s methodACCELERATED PONSETI PROTOCOL
Morcuende et al , (2005) 7 day Vs 5 day interval
Average time to tenotomy: 16 days in 5 day group and 24 days in 7 day group
Morcuende JA, Abbasi D, Dolan LA, Ponseti IV. Results of an accelerated Ponseti protocol for clubfoot. J Pediatr Orthop 2005;25:623-6
Botulinum toxin injection into the gastrocsoleus Alvarez et al (2005)*: alternative to Achilles
tenotomy producing satisfactory results with less skin scarring and deep tissue fibrosis
prospective RCT(Cummings et al,2005)**:NO significant difference between injections of a placebo or Botulinum toxin.
* Alvarez CM, Tredwell SJ, Keenan SP, et al. J Pediatr Orthop 2005;25:229-35.
** Cummings RJ, Shanks DE. POSNA Annual Meeting,
Paramedical staff-delivered Ponseti service Good results can be achieved by trained
physiotherapists and orthopedic clinical officers
enables many families in rural and remote areas to receive treatment which would otherwise have been inaccessible and unaffordable.
Shack N, Eastwood DM.. J Bone Joint Surg [Br] 2006;88-B:1085-9. Tindall AJ et al.J Pediatr Orthop 2005;25:627
Application in neglected club footLourenco et al,2007: retrospective study on
17 children (24 feet) presenting after walking age (mean age 3.9 years)
Correction in 66.67% with ponseti’s method alone.
A. F. Lourenço, MD et al. Journal of Bone and Joint Surgery - British
Volume,2007. Vol 89-B, Issue 3, 378-381.
The French methodBensahel/Dimeglio regime daily manipulations by a skilled physiotherapist
and temporary immobilisation with elastic and non-elastic adhesive taping
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**.
** Richards BS, Johnston CE, Wilson H. Nonoperative clubfoot treatment using
the French physical therapy method. J Pediatr Orthop 2005;25:98-102.
Custom AFO’sManipulation and
appln of adjustable hinged orthosis
Dyanmic splintingCorrection reported
in 76% of cases with mild to severe CTEV **
**Adnan A. Faraj et al. Foot and Ankle Surgery.Volume 10, Issue 2, 2004,
Pages 57-58
Dennis Browne splint The child’s ‘physiological
motions’ are used to correct the deformity
Application of corrective shoes attached to a bar allowing progressive external rotation of the foot
Constant kicking by the infant stretches the contracted tissues correcting the deformity
. .
Surgical management of CTEV
INDICATIONS
RESISTANT CTEV
RELAPSE AND RESIDUAL DEFORMITY ESP. AFTER PREVIOUS SURGERY
NEGLECTED CLUB FOOT
RELAPSED VS NEGLECTED CTEVRelapsed CTEVInitial correction
done and susequent deformity less severe
Post surgical: extensive scarring and stiff foot
Neglected CTEVDeformity severe
and worsens as child starts walking
Lateral skin callosities and fissures- prone to infection
Surgical correction2-4 years :
Soft tissue release4 – 11 years :
Soft tissue release withOsteotomy performed according to the
deformities>11 years :Salvage procedures:
Triple arthrodesisTalectomy (astragalectomy)
SOFT TISSUE RELEASE
EXTENT OF RELEASE"À LA CARTE" approach [Bensahel] -Full posteromedial plantar lateral release
only if All components of deformity present -postr release: persistent isolated equinusTurco’s ‘one size fits all’ approach
TIMING OF SURGERY
3-6 months: high remodelling potential in 1st yr of life
9-12 months: pathoanatomy clearer and surgery easier to perform
Simons: size of foot >8 cm.
Incisions TURCO’S APPROACH hockey-stick
posteromedial type of incision
Crosses the skin creases on the medial side of the foot and ankle.
more difficult to reach
the posterolateral structures, origin of plantar fascia
Cincinnati approachCircumferential
incision
problems with the skin edges.
limited exposure of the Achilles tendon.
Caroll’s two incision technique
medial incision - straight oblique incision from the first metatarsal, across the medial malleolus to the Achilles tendon
A second short, straight lateral incision made along the lateral subtalar joint antr to distal fibula
Medial Plantar Releaseposterior and medial subtalar joint
capsule (leaving the interosseous ligaments intact),
talonavicular joint capsulotomy (including the spring ligament and bifurcate Y ligament),
medial calcaneocuboid joint capsulotomy,
knot of Henry, the abductor hallucis, lengthening of posterior tibial tendonThe plantar fascia, if cavus is present
Structures preservedThe dorsal
structures-tibialis anterior and extensor tendons,
neurovascular bundle,
the deep deltoid ligament
Posterior releaserelease of the posterior capsule of the
ankle and subtalar joint
open Achilles tendon lengthening.
The posterior talofibular ligament
Lateral release
lateral subtalar joint capsule,
peroneal tendon sheath, and
calcaneofibular ligament
Talonavicular joint fixn
The talonavicular joint, often with the subtalar joint, is routinely pinned with a K-wire
Soft tissue releaseFollow 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 weeksCast removed along with any K wires, if
applied during surgery for stabilisationAFO given for 6 months
AFO
OsteotomiesSoft tissue release alone may not fully
correct the deformity because of secondary bony deformity.
The combination of this soft tissue release with midfoot osteotomy is usually required in children between approximately 4 and 12 years of age
Correction of Adductusbony lateral column is longer than the
medial column,relative lengthening of the lateral portion of
the anterior process of the calcaneusobliquity of the calcaneocuboid joint Shortening through the distal calcaneus to
make the calcaneocuboid joint transverse.
Litchblau procedureexcision of the
anterior process of calcaneus
Calcaneocuboid Pseudoarthrosis
Stiffness minimizedPreferred in
younger children
Dilwyn Evans Osteotomycalcaneocuboid wedge resection Arthrodesis of the jointReduced risk of relapseStiffness at subtalar and midfoot jointsPreferred in older children
TRANS-MIDTARSAL OSTEOTOMY
Köse et al., in 1999, described trans-midtarsal osteotomy for>6yr olds
opening-wedge osteotomy of the medial cuneiform and
dorsal, truncated wedge osteotomies of the middle and lateral cuneiforms
Better correction of rotational and cavus deformities
Correction of Equinusadequacy of release of the lateral tetherlateral column shorteningexcision of a portion of the head of the
talus or naviculectomy.final resort is to consider adding a distal
tibial dorsiflexion osteotomy.
Correction of Calcaneal VarusCalcaneal varus
corrects as the foot abducts after medial soft tissue release.
Persistent calcaneal varus: a lateral slide osteotomy of the calcaneus is performed
Alternative: Dwyer lateral closing wedge osteotomy
Correction of CAVUS
Steindler’s release of plantar fasciaJapas ’V’ osteotomy
Patients >6 years Rigid cavusAllows midfoot correction without foot shortening
Akron midtarsal Osteotomy :Correction at midfootA dome shaped osteotomy for dorsoplantar and
varus / valgus control
Salvage proceduresTRIPLE ARTHRODESIS Salvage procedure for pain after previous
surgical correction.Correction of large degrees of deformity in
neglected clubfeet.Not performed before advanced skeletal
maturity, at age 10 to 12.
TRIPLE ARTHRODESIS Modification of the
classic lambrinudi triple arthrodeses
Resection through the talus should be minimized because of its tenuous blood supply and
Most of the correction made through the calcaneus.
Recent study in Uganda: 92% patients happy with the procedure
TRIPLE ARTHRODESISTWO STAGE :extensive
posteromedial release + triple arthrodesis
minimizes bone rescection
risk of AVN talus
SINGLE STAGE ARTHRODESIS:
less time consuming
reduced risk of AVN
Penny, John Norgrove
2005.Uganda
Ilizarov in CTEV
Ilizarov
1) Correction slow enough to protect soft tissues;
2) correction at the focus of deformity,
3) simultaneous three-dimensional, multilevel correction;
4) deformity correction without shortening the foot;
IlizarovRings are fixed to the tibia connected to
half rings for the calcaneus and the forefoot.
Asymmetric distraction corrects the various deformities
bony deformity not severe,(<8 yr): unconstrained frame
Severe deformities,(>8 yrs): distraction osteogenesis through osteotomies using constrained frame with hinges
The construct
Correction of adductus
Correction of Equinus
Results with Ilizarovgood to excellent results reported by various
surgeons( Grill et al, Huerta et al, Bradish et al, Heymann et al, Hosny et al) over the last 15 years
Recent long term follow-up study** by Hari et al (2007):74% good/excellent
result**Prem: J. pediatr. orthop., Volume 27(2).March 2007.220-224
DR.B.B. JOSHI, MUMBAI.
JOSHI EXTERNAL STABILISATION SYSTEM
JESS2 to 4 transfixing
wires in prox tibiaMetatarsal segt: Transfixing wire thro’ I &V MT; Medial half
pin thro’I, II, III MT; Lat half pin thro’ IV, V MT
2 transfixing and 1 axial wire thro calcaneum
JESSFractional, differential distraction used
to Sequentially correct deformities. 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
Results with JESSGood or excellent results reported by Joshi
in 84% of his patients Recommended in all who have not
responded to serial plaster casting methods.
Similar good results have been reported by other authors**
**Suresh et al,2003. Journal of Orthopaedic Surgery 2003: 11(2): 194–201
Advantages over Ilizarov The wires are not tensionedstability depends on the placement of the
wires, the use of half pins and pre-tensioning.
Hinges are not used in this method. Thus the corrective forces are not directed along a single axis, instead, the soft tissue envelope in conjunction with the shape of the articulating surfaces guide the correction.
frame is less bulky, is less expensive, and more simple to apply
Complications of surgeryWound infectionSkin dehiscenceSevere scarringStiff jointsOver/under correctionDislocation of the navicularFlattening and breaking of the talar headAVN of the talusWeakness of the plantar flexors of the ankle
Skin dehiscenceCincinnati incision, neglected clubfeetleft in partly corrected posn in post op cast
& remanipulation done at 1 to 2 weeks .Local rotation flap from the dorsum of the
foot (Mittal,1987)Posterior V-Y advancement flap.
Rotation flapFlap taken
superficial to venous plexus
Large proximal base ensures adequate blood supply
conclusionProper understanding of the pathology and
kinematics of clubfoot, meticulous application of therapeutic methods, laying stress on parental education to ensure compliance and resorting to surgery only as the last resort, and is essential to successful therapy of this complex condition