CONGENITAL TALIPES EQUINO VARUS

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1. CONGENITAL TALIPES CONGENITAL TALIPES
EQUINO VARUSEQUINO VARUS

2. Children with physical Children with physical
disabilities are often disabilities are often
socially and socially and
economically economically
disadvantageddisadvantaged
Importance of Importance of
Clubfoot – easily Clubfoot – easily
diagnosed diagnosed
-easily -easily
treatedtreated

3. CTEV – CTEV – congenital congenital
talipes equino-varustalipes equino-varus
Talipes - The term Talipes - The term
talipes is derived from talipes is derived from
a contraction of the a contraction of the
Latin words for Latin words for ankleankle, ,
talus,talus, and and foot, foot, pespes. .
The term refers to the The term refers to the
gait of severely gait of severely
affected patients, who affected patients, who
walked on their walked on their
ankles ankles

4. 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 subtalar the subtalar
,adduction at the ,adduction at the
midtarsal joint,cavus midtarsal joint,cavus
and internal tibial and internal tibial
torsiontorsion

6. 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

7. More common in boys than girlsMore common in boys than girls
50 % cases are bilateral50 % cases are bilateral
In unilateral cases right side is more often In unilateral cases right side is more often
involvedinvolved

8. Types According To CauseTypes According To Cause
 1) Idiopathic1) Idiopathic
 2) Secondary2) Secondary
 3) Postural / Positional3) Postural / Positional

9. 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

10. 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

11. 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 association with neurological
abnormalities or spina bifidaabnormalities or spina bifida
b) b) SyndromicSyndromic – clubfoot in association – clubfoot in association
with other syndromeswith other syndromes

12. Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEV
Spina Bifida = Paralytic TEVSpina Bifida = Paralytic TEV

13. Syndromes Producing CTEVSyndromes Producing CTEV
Streeters dysplasiaStreeters dysplasia
ArthrogryposisArthrogryposis
Edwards syndrome – trisomy 18Edwards syndrome – trisomy 18

14. PosturalPostural
Due to abnormal intrauterine positionDue to abnormal intrauterine position
Easily corrected by massage by mother or Easily corrected by massage by mother or
by 1 or 2 castsby 1 or 2 casts

15. Types of Clubfoot According to Types of Clubfoot According to
Treatment StageTreatment Stage
Untreated Untreated
Treated Treated
Resistant Resistant
RecurrentRecurrent
NeglectedNeglected
Complex Complex

16. 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

17. 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

18. 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

19. 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

20. Complex clubfootComplex clubfoot – clubfoot treated by – clubfoot treated by
any method other than ponseti techniqueany method other than ponseti technique
- complicated by additional pathology or - complicated by additional pathology or
scarringscarring

21. Pathological ChangesPathological Changes
Four basic Four basic
components are components are
midfoot midfoot CCavus (tight avus (tight
intrinsics, FHL, FDL) intrinsics, FHL, FDL)

22. forefoot forefoot AAdductus dductus
(tight tibialis posterior) (tight tibialis posterior)

23. hindfoot hindfoot VVarus (tight arus (tight
tendoachilles, tibialis tendoachilles, tibialis
posterior) posterior)

24. hindfoot hindfoot EEquinus quinus
(tight tendoachilles )(tight tendoachilles )

25. 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

26. 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

27. Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEV

29. 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

30. 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

31. Talo navicular joint realignment is Talo navicular joint realignment is
opposed by- posterior tibial tendonopposed by- 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

32. 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

33. 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

34. Radiological EvaluationRadiological Evaluation
Talocalcaneal angle Talocalcaneal angle
- - Anteroposterior Anteroposterior
view: 30-55 degreesview: 30-55 degrees

35. Talocalcaneal angle - Talocalcaneal angle -
Dorsiflexion lateral Dorsiflexion lateral
view: 25-50 degreesview: 25-50 degrees

36. Tibiocalcaneal Tibiocalcaneal angle angle
Stress lateral view: Stress lateral view:
60-90 degrees60-90 degrees

37. Talus–first metatarsal Talus–first metatarsal
angle Anteroposterior angle Anteroposterior
view: 5-15 degreesview: 5-15 degrees

38. Treatment Treatment
Non operative – Ponseti techniqueNon operative – Ponseti technique
Kite techniqueKite technique
French techniqueFrench technique
Surgical–Posteromedial soft tissue Surgical–Posteromedial soft tissue
releaserelease
OsteotomiesOsteotomies
Triple arthrodesisTriple arthrodesis
Achilles tendon lengtheningAchilles tendon lengthening
Ilizarov / JESSIlizarov / JESS

39. 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)

40. 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

41. 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 manipulation
After correction Denis Browne splint After correction Denis Browne splint
appliedapplied

42. French TechniqueFrench Technique
Daily manipulation by physical therapist Daily manipulation by physical therapist
for 30 mts for 30 mts
Electrical stimulation of peroneal muscles Electrical stimulation of peroneal muscles
donedone
Reduction maintained by adhesive tapingReduction maintained by adhesive taping

43. 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

45. 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

46. Ilizarov and JESS are Ilizarov and JESS are
for older children with for older children with
recurrence or residual recurrence or residual
deformitydeformity

48. THANK YOUTHANK YOU