CONGENITAL TALIPES EQUINOVARUS

Sriram Venkitaraman

INTRODUCTION

Most common congenital foot disorder

Males more commonly affected

Incidence : 1.2 per 1000 live births.

TYPESOsseous: tibia, fibula absent

Muscular : Arthrogryposis congenita or multiple cong. Contractures

Neuropathic: spina bifida etc.

Idiopathic (most common)

PATHOLOGYBone changesCalcaneum : varus positionTalus : medial, plantar displacementNavicular: medial displacement and rotation

Cuboid: medial displacement and articulates with non-articular surface of calcaneum (cuboid sign/locked cuboid)

Metatarsals: medial deviation at T-MT jTalocalcaneal joint: dislocatedTibia: medial torsion (rarely lateral)

Soft tissue contracturesMedial side:

MusclesLigamentsCapsules ofAbHLDeltoidSubtalarTPSpringTarsalFHLPlantarT-MT

Posterior side:

Anterior side:

MusclesLigamentsCapsules ofTPTalofibularAnkle j.Tendo-achillesCalcaneo-fibularsubtalar

MusclesligamentsCapsules ofTA inserted abnormallySup. Peroneal retcalcaneo-cuboid

CLINICAL FEATURES

Primary deformitiesEquinusVarusCavusForefoot adductionInternal tibial torsion

Secondary deformities

Foot size dec. by 50%Medial border concave, lateral-convexForefoot plantarflexed upon hindfootSkin stretched upon dorsumCallosities over dorsumStumbling gaitHypotrophic Anterior Tibial arteryAtrophied muscles of ant.and post. compartments

Late changes

Degeneration of jointsFusion of joints

CLINICAL TESTSDorsiflexion testPlumbline test

Scratch testMedial scratch testLateral scratch test

RADIOGRAPHYA-P viewTalocalcaneal (TC) angle reduced (N=30-35)Talometatarsal angle zero or ve (N=5-15)Talocalcaneal index (TCI) reducedTCI=TC angle AP view + Lat view(N is atleast 40)

Lateral viewTC angle reduced (N=25-50)Tibiocalcaneal angle ve (N=5-15)

MANAGEMENTFirst 6 weeks: serial manipulation + above knee casting weeklyUpto 6 months: repeat fortnightly

Order of correction of deformity

AD AD duction of forefoot corrected

V V arus of heel corrected

E E quinus of hindfoot corrected

RB to prevent R ocker B ottom foot

If correction achieved in 6 months:6 to 18 monthsPhelps brace dayDenis Browne splint night

18m to 4 yrsBelow-knee walking calipers

Follow-up till skeletal maturity

Surgical managementindications:No response to conservative treatment after 6m.Rigid club-foot. Relapse.Recurrent club-foot (muscle imbalance)Resistant club-foot.

Methods:A) Turcos procedure-posteromedial release:

Posteriorly:Z-plasty of tendo-achilles - lengthening

Post. Capsulotomy - ankle and subtalar j.

Release post. talofibular, calc.fibular lig.

MediallyLengthen TP, FHL and FDL muscles.

Release talonavicular, spring, superficial part of deltoid lig.

Release interosseous talocalcaneal lig.

Release naviculocuneiform, 1st metatarso-cuneiform joint capsules.

Plantar sideRelease plantar fascia

Release AbH, FDB

B) Mc-Kays procedure:For severe deformities. Posteromed. and posterolat. release

Surgeries in older children:A) Triple arthrodesis:Lateral closed wedge osteotomy thru subtalar and midtarsal joints.all 3 j. fused (subtalar, TN, CC)B) Talectomy:salvage procedure for severe clubfootin uncorrected and unsuccessful corressctionsuncorrectable CTEV

Recurrent club-foot (muscle imbalance)Garceaus method: transfer TA to middle cuneiform boneModified Garceaus: transfer TA to base of 5th metatarsal

Correction of tibial torsion: Sells criteria- > 15 degree torsionBy derotation osteotomyTo prevent recurrence

External fixators

Ilizarovs method2 types

Joshis External Stabilisation System (JESS)

Advantages of fixators:semi-invasive, bloodless, without tourniquetAvoids surgical complications and post-op scarCorrects bone and soft tissue defectsLess chance of recurrence or relapse

Retention of Correction

Denis Browne splint during nightPhelps brace during daytimeBelow-knee walking calipersCTEV shoes