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