04 Congenital Talipes Equino Varus
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Transcript of 04 Congenital Talipes Equino Varus
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Congenital Talipes Equino
Varus
Dr. Mohammad Imran Khan
04/01/2011
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CTEV
1 in 1000 live births.
Bilateral in 50%.
Cause (several theories)
1. Primary germ plasm defect in the talus cause continued plamterflexion and inversion followed by soft tissue changes.
1. Soft tissue abnormatilies are primary.
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CTEV is composed of;
1. Forefoot adduction.
2. Heel varus.
3. Ankle equinus
4. Midfoot cavus.
5. Intrernal tibial torsion
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Pathoanatomy
Very important to understand
TURCO in early 1970s
Medial displacement of calcaneus andnavicular around the talus.
Talus goes into equinus while its head andneck deviated medially.
Calcaneus is inverted under the talus.
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McKay
Gave awareness of three dimential aspect ofbony deformity.
Abnormal relation of calcaneus to talus in allthree planes.
A. CALCANEUM
Rotates horizontally tuberiosity movestowards fibular malleolus.
Heel goes into varus in coronal plane.
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B. TALONAVICULAR JOINT
Goes into extreme inversion.
Navicular displaces on the talus.
Cuboid displaces on the calcaneum.
C. Soft tissue contracture follows apposingcorrection of various joints.
D. BONY CHANGES
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Radiological Evaluation
Part of clinical evaluation.
Done before, during and after treatment.
Non-ambulatory child
AP & stress dorsiflexion lateral views.
Ambulatory child
Standing AP & lateral views
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Radiological Evaluation
Important angles are
On AP view
1. Talocalcaneal angle
2. Talus-first metatarsal angle
On lateral view
1. Talocalcaneal angle2. Tibiocalcaneal angle
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Talocalcaneal angle on AP view
Normal is 30-55
Decreases in clubfootdue to calcaneal
rotation in horizontalplane.
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Talus-first metatarsal angle on AP view
Normal is 5-15
Decreases in clubfootdue to forefoot
adduction
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Talocalcaneal angle on lateral view
Taken in dorsiflexion
Normal is 25-50
Decreases to 0 in clubfoot as cacaneum and
talus become parallel.
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Tibiocalcaneal angle on lateral view
Normal is 10-40
In clubfoot it becomes negative due to heelequinus.
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Classifications
Currently in use
Pirani classification.
Dimglio
Others classifications are
Harrold and Walker
Somppii
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Piranis Classification
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Dimglio
Classification
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Harrold & Walker Classification
Mild
Moderate
Fixed varus or equinus < 20 degrees
Severe
Fixed varus or equinus > 20 degrees.
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Non-operative treatment
Kite method:1. Weekly MUA & casting for
first 6 weeks of life.
2. Fortnightly MUA & casting
until foot is clinically &radiologically corrected.
3. Correction done in the orderof forefoot reduction, heelvarus & ankle equinus.
4. Rocker Bottom foot(success rate 15-80%reported)
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Ponseti Technique
Consists of treatment phase andmaintenance phase.
TREATMENT PHASE:
Should begin early.
Gentle MUA & casting on weekly basis.
Six casts required.
70% require TAL in the last cast.
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First Cast
Corrects cavus by aligning forefoot and hindfoot.
Supinating the forefoot and elevating the first
metatarsal.
Long leg cast applied (toe to groin).
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Second Cast
Gradual abduction.
Maintain supination.
Never manipulate the heel directly which isthe most common mistake, as also seen inKite method.
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3rd, 4th & 5th Casts
Gradual correction continued with even moregradual correction of pronation.
Final Cast Maximum abduction 70 degrees.
15 degrees dorsiflexion. TAL usually done to avoid Rocker Bottom
deformity.
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Sequence of correction
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Maintenance Phase
Foot placed in food abduction orthosis (FAO).
Worn 23 hours a day for 3 months and thenfor 2-3 years while asleep.
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Operative Treatment
Depends on
Age.
Severity
Deformity to be corrected.
1. Mild with no rotational deformity of calcaneum
TURCOs PMR.
2. Mild with severe rotational deformity modifiedMcKay procedure through a single Cincinnatiincision or 2 incisions of Carroll.
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3. Severe deformities Modified McKayprocedure.
Studies show better results of modifiedMcKay procedure than TURCOs procedure
for severe deformities.
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Cincinnati Incision
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RESISTANT CLUBFOOT
The appropriate procedures and combination of procedures
depend on; The age of the child.
The severity of the deformity
The pathological processes involved.
Common components of resistant clubfoot deformity are:
1. Adduction or supination, or both, of the forefoot
2. A short medial column or long lateral column of the foot3. Internal rotation and varus of the calcaneus
4. Equinus.
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Forefoot deformity:
1. Dynamic deformity tendon balancing procedure (split orcomplete transfer of tibialis anterior to middle cuneform).
2. Rigid deformity (5years): Bony procedures like domeosteotomies of metatarsal bases and cuniform-cuboidosteotomy.
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HINDFOOT
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Triple Arthrodesis
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HEEL EQUINUS
Achilles tendon lengthening plus posteriorcapsulotomy of subtalar joint, ankle joint(mild-to-moderate deformity)
Lambrinudi procedure (severe deformity,skeletal immaturity)
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Tendoachilles Lengthening
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Lambrinudi Procedure
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ALL THE THREE DEFORMITIES
Triple arthrodesis in patients age > 10years
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INTERNAL TIBIAL TORSION
Occationally occur in resistant cases
Rarely require tibial derotational osteotomies
Foot deformity should be excluded beforedoing osteotomy on the tibia
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HOWZZAT