Clubfoot

club foot seminar part1

1. CTEV BY –SAIKRISHNA.K

2. FOREFOOT MID FOOT HINDFOOT

3. ANATOMY-JOINTS ANKLE JOINT : TIBIA AND TALUS SUBTALAR JOINT : TALUS AND CALCANEUM TALONAVICULAR JOINT CALCANEO- CUBOID JOINTS

4. NOMENCLATURE Planus : flatfoot Cavus : highly arched foot Varus : heel going towards the midline Valgus : heel going away from the midline Adduction: forefoot going towards the midline Abduction: forefoot going away From the midline

5. CLUB FOOT

6. INTRODUCTION Ossific development of the foot begins in utero. During embryonic development the foot passes through 3 different positions. 15mm---- Foot is Straight 30mm----Foot is in equinovarus and adducted. 50mm---Foot returns to neutral slightly adducted and equinovarus position known as fetal position.

7. Growth of Foot-- The foot has its own Growth pattern, which differs from the growth rate of rest of the body. Foot grows rapidly between infancy and 5 years of age and slows to 0.9 cm per year between 5-12 years in girls and 5-14 yrs in boys and growth usually ceases . Foot Ankle.1990 Feb;10(4)211-3

8. Clubfoot-- Clubfoot is probably the most common (1-2 in 1000 live births) congenital orthopaedic condition that requires intensive treatment. It most likely represents congenital dysplasia of all musculoskeletal structures below the knee.

9. Etiology Idiopathic Clubfoot Secondary Clubfoot  Arthrogryposis Diastrophic dysplasia Streeter`s dysplasia Freeman Sheldon Syndrome Mobius syndrome etc.

10. Many theories have been proposed recently to explain the etiology of idiopathic clubfoot including vascular deficiencies , environmental factors, in utero positioning , abnormal muscle insertions , and genetic factors . While it is becoming more clear that clubfoot is multifactorial in origin , genetic factors clearly play a role as suggested by the 33% concordance of identical twins and the fact that nearly 25% of all cases are familial . J Pediatr Orthop B. 2012 Jan; 21(1): 7–9.

11. Additional evidence for a genetic etiology is provided by differences in clubfoot prevalence across ethnic populations with the lowest prevalence in Chinese (0.39 cases per 1000 live births) and the highest in Hawaiians and Maoris (seven per 1000) J Pediatr Orthop B. 2012 Jan; 21(1): 7–9.

12. Theories 1) Arrest in embryonic development. 2) MyoFibroblastic retractile tissue in the medial ligaments. 3) Primary Germ plasm defect in the cartilaginous talar anlage produces the dysmorphic neck and navicular subluxation. 4) Local Neuro myogenic imbalance especially involving the peroneals , has been proposed.

13. Environmental factors may play a role in some cases of clubfoot. Early amniocentesis (< 13 weeks gestation) was associated with an increased risk in talipes equinovarus compared to midgestational amniocentesis or chorionic villus sampling . . Increased risk of clubfoot was partially associated with amniotic fluid leakage , suggesting that oligohydramnios occurring at a critical gestational period may be detrimental to foot development . .

14. Unlike positional foot deformities, such as metatarsus adductus , that occur at increased frequency in twin pregnancies, there are little data to support an association of clubfoot with late gestational uterine compression. Environmental exposure to cigarette smoke in utero is another independent risk factor for clubfoot.

15. Finally it is safe to say that etiology of idiopathic club foot is multifactorial and modulated significantly by developmental aberrations early in the limb bud development. Club foot does cluster in families but doesn`t fit in any inheritance patterns.

16. Pathologic Anatomy A postural deformity needs to be distinguished from a true clubfoot. The cause of the postural deformity is the position in utero in contrast to the true clubfoot, which has an underlying pathology . Additionally, the postural condition usually responds to passive manipulation by the mother.

17. The anatomy was first described by Scarpa in 1800 and has been subsequently verified by other authors such as Kite and Turco . ( Turco VJ. Clubfoot. New York: Churchill Livingstone; 1981) According to Scarpa , clubfoot is a congenital talocalcaneonavicular (TCN) joint dislocation , which is the currently accepted view . In contrast, Goldstein believes that the primary abnormality is outward rotation of the talus in the ankle mortise .

18. The true clubfoot is characterized by equinus , varus , adductus and cavus . The equinus deformity is present at the ankle joint, TCN joint and the forefoot. In the varus component, the hind foot is rotated inwards and this occurs primarily at the TCN joint . The whole of the tarsus, except for the talus, is rotated inward with respect to the lower leg. Since the forefoot follows the hind foot, the medial border of the forefoot faces upward.

19. The adductus deformity takes place at the talonavicular and the anterior subtalar joints. The cavus component involves forefoot plantar flexion, which contributes to the composite equinus .

20. T alus —Medial and plantar deviation of the anterior end. Short talar neck projecting medially from a dysmorphic,small body that is poorly placed within ankle joint .

21. The talar neck-body declination angle is invariably decreased to 90 degrees from the normal 150 to 160 degrees.

22. The articular surface of the talar head is so close to the body that true neck is not present. On the inferior aspect of talus,the anterior and medial facets are absent or fused or misshapen.

23. C alcaneum —Contour is generally normal although calcaneus is often small. The sustentaculum tali is ususally under developed. Anterior articular surface is of the calcaneus is medially deviated and deformed because of the interosseus deformity of the calcaneocuboid joint.

24. Both the navicular and cuboid tend to have normal shapes and are misshapen only due to their inter osseus relation ships with talus and calcaneus. N avicular is consistently displaced medially and plantarward on the talar head and has a false articular relation ship with the medial malleolus.

25. C uboid is similarly medially displaced on the anterior end of the calcaneus. Controversy exists regarding the presence or absence of internal tibial torsion.

26. Tibio-talar plantar flexion Medially displaced navicular Adducted and inverted calcaneus Medially displaced cuboid

27. PATHO-ANATOMY MUSCLES CAPSULES AND LIGAMENTS STRCTURES CONTRACTED ON THE MEDIAL SIDE

28. PATHO-ANATOMY MUSCLES CAPSULES AND LIGAMENTS STRCTURES CONTRACTED ON THE POSTERIOR SIDE

29. PATHO-ANATOMY MUSCLES CAPSULES AND LIGAMENTS STRCTURES CONTRACTED ON THE ANTERIOR SIDE

30. PATHO-ANATOMY SKIN Adapts shortening on the medial side Deep creases on the medial side Dimples on the lateral aspect SECONDARY CHANGES Occurs when the child starts walking-exaggerates the deformity Callosities and bursae

31. Master knot of Henry  Fibrous slip that envelops the FDL and FHL tendons. Binds the plantar medial surface of the navicular . Flexor digitorum accessorius longus muscle may be identified in 7% children,deficiencies of dorsalis pedis and posterior tibial also noted.

32. CLASSIFICATIONS

33. Pirani ’ s severity scoring Six parameters : 3 of midfoot and 3 of hindfoot Each parameter is given a value as follows: 0: normal 0.5: moderately abnormal 1: severely abnormal

34. Mid foot score Curved lateral border [A] Medial crease [B] Talar head coverage [C]

35. Hind foot score Posterior crease [D] Rigid equinus [E] Empty heel [F]

36. Uses of Pirani ’ s score Assessment of progress by serial plotting of the score Predicting need for tenotomy . 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

37. International Clubfoot Study Group Score Introduced by Henri Bensahel et al in 2003 Found to have good interobserver reliability and reproducibility.** Morhological (12 pts ), functional (24 pts ) & radiological (12 pts ) parameters * * Celebi L et al J Pediatr Orthop B. 2006;15:34-36.

38. Morphological parameters

39. Functional parameters

40. Radiological parameters

41. Classification of clubfoot severity by Diméglio A.Equinus deviation B. Varus deviation C. Derotation D. Adduction. A-Sagittal plane evaluation of Equinus B-Frontal plane evaluation of varus . C-Horizontal plane evaluation of derotation of Calcanopedal block. D-Horizontal plane evaluation of Forefoot relative to Hind foot.

42. Reducibility( degrees) Score Additional parameters Score 90-45 4 Marked posterior crease 1 45-20 3 Marked mediotarsal crease 1 20-0 2 Cavus 1 0 t0 -20 1 Poor muscle condition 1

43. Grade Type Score Reducibility i Benign 1-4 >90% ii Moderate 5-9 >50%, soft-stiff, reducible, partially resistant iii Severe 10-14 >50%, stiff-soft, resistant, partially reducible iv Very severe 15-20 <10% stiff- stiff,resistant

44. IMAGING

45. Plain radiography

46. Limitations Difficult to position the foot The ossific nuclei do not represent the true shape 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

47. Plain radiograph The 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

48. AP Radiograph normal CTEV AP Talo calcaneal angle 20 -50 deg <20 deg Tarsal-1 st MT angle Upto 30 deg valgus Varus anglulation cuboid os. center w.r.t calcaneal axis medial displacement

49. AP radiograph: Talo-Calcaneal angle Normal foot: 20`-50` CTEV:<20 deg

50. AP Radiograph: convergence of base of MT

51. Lateral radiograph normal CTEV Talo calcaneal angle 25 to 50 deg <25 deg Tarsal-1 st MT angle hyperflexion

52. Lateral view: Talo-Calcaneal angle Normal foot : 25` to 50` CTEV: <25 `

53. Hindfoot equinus is plantar flexion of the anterior calcaneus (similar to a horse's hoof) such that the angle between the long axis of the tibia and the long axis of the calcaneus ( tibiocalcaneal angle) is greater than 90°

54. On the lateral view, instead of having the normal overlapped appearance, the metatarsals are arranged in a ladder like configuration , with the first being most dorsal

55. SUMMARY OF RADIOLOGICAL FINDINGS

56. Ultrasonogram

57. ANTENATAL DIAGNOSIS Ideally 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.

58. Research tool Recent study: to describe the morphological changes in a comparative study of treatment methods Used for demonstrating complete healing of TA at 3 wks foll. Percutaneous tenotomy

59. MRI

60. ROLE OF MRI NOT used in routine clinical practice Important tool in research studies

61. PIRANI ’ S MRI PROTOCOL Sagittal images perpendicular to the bimalleolar axis Oblique axial images perpendicular to the talonavicular joint Oblique axial images perpendicular to the calcaneocuboid joint Oblique coronal images perpendicular to the subtalar joint

62. SAGITTAL IMAGES Tibiotalar plantarflexion Inferior talar neck inclination, and Inferior talonavicular displacement

63. Oblique axial images perpendicular to the talonavicular joint medial talar neck inclination, medial talonavicular displacement, the wedge-shaped head of the talus, and navicular

64. Oblique axial images perpendicular to the calcaneocuboid joint the wedge-shaped distal calcaneus Medial calcaneocuboid displacement

65. Oblique coronal images perpendicular to the subtalar joint The inverted and adducted calcaneus The abnormal facets of the subtalar joint

66. Thankyou 