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

THANK YOUTHANK YOU