Congenital Talipes Equinovarus_Group 4..pptx

A slide presentation about congenital Talipes Equinovarus and Ponseti measurement.

1. Congenital talipes equinovarus &
Ponseti management/ pirani scoring GROUP 4 PRESENTATION PHT 404 PHYSIOTHERAPY IN ORTHOPEADIC CONDITIONS (PEADIATRICS)

2. group members BADMUS RASHEED - 19/46PT020 DAN-OCHIE BEULAH UGOCHI - 19/46PT023 BELLO ABDULWAHAB OLASHILE - 19/46PT021 DANIEL OLOLADE HELEN - 19/46PT024 EDET GODSWILL BASSEY - 19/46PTO25 EGBINOLA BADIRAH WURAOLA - 19/46PT026 BABALOLA OLUWANIFEMI PRECIOUS - 20/46PT080

3. Outline Introduction Epidemiology Aetiology Pathophysiology Patho-anatomy Clinical presentation Diagnosis Prognosis Management (Medical, surgical, physiotherapy) Ponsetti management/ pirani scoring

4. Introduction Congenital Talipes Equinovarus , also known as “ clubfoot ”, Is a complex, congenital deformity of the foot, that left untreated can limit a person’s mobility by making it difficult and painful to walk. It is defined as a deformity characterized by complex, malalignment of the foot involving soft and bony structures in the hindfoot , midfoot and forefoot.

5. INTRODUCTION The deformity affects the structure and position of the foot, presenting as an adductus and cavus (an inward turning) of the midfoot and a varus hindfoot . At the subtalar joint, the foot is held in a fixed equinus , or downward pointing position. The foot affected by clubfoot is shorter, and the calf circumference is less than a normal, unaffected foot. On presentation, the clubfoot deformity is not passively correctable and presents with varying degrees of rigidity. On presentation, the clubfoot deformity is not passively correctable and presents with varying degrees of rigidity.

6. Epidemiology Clubfoot is more common in males with a 2.5 to 2.8:1 Male:Female ratio. Various incidences have been noted between countries and regions ranging from 1-1.50 per 1000 live births, rising up to 3 per 1000 live birthsIt is estimated that 80% of cases of clubfoot occur in Low and Middle Income Countries. Lack of resources and medical services in these countries mean that there are high levels of disability from potentially treatable congenital anomalies such as clubfoot (Kushner et al, 2010; WHO, 2007). Many children born with clubfoot in Low and Middle Income Countries do not receive any treatment. There is a 10% chance of a subsequent child being affected if the parents already have a child with a clubfoot.

7. Aetiology Genetic Factors: There is evidence suggesting a genetic predisposition to clubfoot, with familial occurrences observed in some cases. However, the exact genetic basis remains incompletely understood, and further research is ongoing to identify specific genes involved. Environmental Factors: Several environmental factors during fetal development can contribute to the development of clubfoot. These may include intrauterine constraint, which occurs when the fetus is confined in a cramped intrauterine space, leading to abnormal positioning of the foot. Other factors such as maternal smoking, maternal nutrition, and certain medications have also been implicated.

8. Aetiology Neuromuscular Factors : Some cases of clubfoot may be associated with underlying neuromuscular conditions or abnormalities, such as spina bifida or cerebral palsy. These conditions can affect muscle tone and lead to muscle imbalances, contributing to the development of clubfoot. Mechanical Factors: Abnormal forces exerted on the developing foot during fetal development can also play a role in the etiology of clubfoot. These forces may result from factors such as abnormal positioning of the fetus in utero or mechanical compression of the foot during critical stages of development.

9. pahophysiology Various theories of the pathogenesis of clubfeet have been advanced, including the following: Arrest of fetal development in the fibular stage Defective cartilaginous anlage of the talus Neurogenic factors: This is postulated to be due to innervation changes in intrauterine life secondary to a neurologic event, such as a stroke leading to mild hemiparesis or paraparesis. This is further supported by a 35% incidence of varus and equinovarus deformity in spina bifida. Retracting fibrosis (may occur secondary to increased fibrous tissue in muscles and ligaments). Anomalous tendon insertions Seasonal variations

10. patho-anatomy The patho-anatomy of congenital talipes equinovarus can be divided into Soft tissues problem Deficiency Bone displacement SOFT TISSUE PROBLEM This can be subdivided into Imbalance Fibrosis and Atrophy

11. patho-anatomy Imbalance The problem is not the structure of the bones and their arrangement, although that is what it manifests itself. The problem is in the soft tissues. tion of the tarsal bones around the talus bone. Soft structures in the medial part of the foot become shorter, those in the lateral part – become stretched. Due to these unequal forces of the ligaments, tendons, and muscles acting on the foot, it becomes inverted, which causes the calcaneus bone to become varus.

12. patho-anatomy By shortening the plantar and medial parts of the muscles, the abduction of the forefoot (MTA – Metatarsus Abductus) takes place – the calcaneus bone locks under the talus bone and the remaining bones slide relative to each other. Too short Achilles tendon positions the foot in plantar flexion.

13. patho-anatomy Fibrosis And Atrophy Fibrosis Is an excessive amount of the regular dense connective tissue in a given structure. In the case of muscles, connective tissue – which has a fibrous structure – is densely intertwined with muscles’ fibres, but its amount is much greater than in the standard structure of the muscles. Atrophy is a decline. This is a gradual decrease in the volume of a cell, tissue, organ, or body part. Muscle atrophy in clubfoot affects especially the posterior and medial muscles of the calf. The calf triceps and the posterior tibial muscles are fibrotic, have a smaller volume, are shorter, and smaller.

14. patho-anatomy BONE DISPLACEMENT The calcaneus bone (green) is blocked under the talus. A shortened Achilles tendon pulls the back of the locked bone upwards causing the equinus position of the heel. This makes the calcaneus very difficult to feel under the fat pad. This position of the calcaneus gives a strong plantar flexion in the ankle mortice. The inclination of the calcaneus bone around the talus bone (red) gives the heel a varus alignment with the vertical axis of the talus and its blocade under the talus causes it to be adducted.

The talus (red) is also in the plantar flexion. In addition it is turned towards the middle and its side part is not covered with the navicular bone – you can feel the head of the talus bone and its exposed edge on the lateral side of the foot.

15. patho-anatomy The talus is smaller than in a healthy foot and its head is wedge-shaped. Sometimes the entire talus bone is a little flattened. Just below the head of the talus bone is the calcaneus – you can often mistake one for the other. A child’s head of the talus is only 0,5 cm in size. Foot adduction is caused by the shifting of the navicular (yellow) to the medial surface of the talus head. The navicular then forms a joint only with the medial part of the head of talus so that the navicular often touches the medial malleolus. It happens that the bone is a little flattened and is wedge-shaped from the lateral side. The cuboid (orange) moves medially relative to the anterior tuberosity of the calcaneus and lowers. The 3 cuneiforms (blue) move downwards, positioning medially to the navicular. The metatarsal bones are in plantar flexion and adducted, which looks as if the foot was ‘broken’ halfway through.

16. patho-anatomy

17. CLINICAL PRESENTATION The underlying deformity of clubfoot can be most easily understood if it is divided into four components, whose first letters make up the word CAVE . These components are: Cavus, Adductus, Varus and Equinus. The Cavus and Adductus deformities occur in the midfoot, while the Varus and Equinus deformities occur in the hindfoot.

18. CLINICAL PRESENTATION Cavus in the midfoot is the first part of the deformity of clubfoot. The arch of the foot is higher than normal.as a result of the first metatarsal being plantarflexed in relation to the calcaneum and hindfoot. Adductus is movement towards the midline. It is the second part of the clubfoot deformity. The forefoot is adducted towards the midline. This is the second part of the deformity of clubfoot. The navicular moves medially and starts to dislocate off the talus. The calcaneum also rotates medially under the talus as part of the adductus deformity.

19. CLINICAL PRESENTATION Varus means movement towards the midline. Varus of the hindfoot is the third part of the deformity of clubfoot. The heel is in varus in relation to the tibia. Equinus means an increase in the plantarflexion of the foot. The entire foot points downwards in relation to the tibia. Equinus of the hindfoot is therefore the fourth part of the clubfoot deformity.

20. CLINICAL PRESENTATION Clubfoot can be described as “congenital dislocation of the Talo-Calcaneal-Navicular (TCN) Joint”. The navicular moves medially on the talus in clubfoot while the calcaneum rotates under the talus in clubfoot The foot is held in adduction and inversion by ligaments and muscles. Muscles that are contracted are triceps surae, tibialis posterior, flexor digitorum longus and flexor hallucis longus. Further there is an imbalance between the inverter-plantarflexor muscles and the everter-dorsiflexor muscles. The calf and peroneal muscles are usually poorly developed. Weak peroneal muscles allow the foot to be inverted. The ligaments of the posterior and medial aspect of the ankle are thick and taut.

21. diagnosis Prenatal Diagnosis : Clubfoot deformity may be discovered during prenatal ultrasonography. Clubfoot can be detected at 13 weeks’ gestation using transvaginal ultrasonography15,16 and at 16 weeks’ gestation using transabdominal ultrasonography. A prenatal diagnosis cannot always be made, even by high-quality ultrasonography, particularly if the deformity is mild or moderate.

22. diagnosis Newborn Evaluation: The evaluation of a newborn with a clubfoot deformity involves a thorough general examination to determine overall health and development, exclude syndromes and neurologic conditions (eg, spina bifida, arthrogryposis e.t.c), and provide a focused examination of the foot and limb. Examination of all joints for range of motion and stability, including the hips, is important, as is examination of lower extremities for equal length and symmetry. The severity of a newborn foot deformity is determined more by the foot’s flexibility than by its appearance.Newborn foot deformities that can be easily manipulated into an overcorrected position are considered positional rather than true clubfoot deformities. These resolve with minimal or no treatment. Unless a limb deficiency such as fibular hemimelia, tibial hemimelia, or congenital short femur is noted, radiography is not necessary.

23. prognosis Prognosis can be dependant on when treatment begins. When treatment is started before the child begins weight bearing, the chances of successful treatment and relatively ‘normal’ foot function are high. Persistence in wearing the Foot Abduction Brace also contributes to a good prognosis, by preventing relapse. In older children, some may achieve partial, or even full correction with the Ponseti treatment. In others, a period of casting following the Ponseti principles may need to be supplemented with surgery to gain full correction of the foot position.

24. management Nonsurgical Treatment The initial treatment of clubfoot is nonsurgical, regardless of how severe the deformity is. Ponseti method: The most widely used technique in North America and throughout the world is the Ponseti method, which uses gentle stretching and casting to gradually correct the deformity. Treatment should ideally begin shortly after birth, but older babies have also been treated successfully with the Ponseti method. French method: Another nonsurgical method to correct clubfoot uses stretching, mobilization, and taping. The French method , also called the functional or physical therapy method, is typically directed by a physical therapist who has specialized training and experience.Like the Ponseti method, the French method is begun soon after birth and requires family involvement. Each day, the baby's foot must be stretched and manipulated, then taped to maintain the range of motion gained by the manipulation. After taping, a plastic splint is put on over the tape to maintain the improved range of motion.

25. management Surgical Treatment Although many cases of clubfoot are successfully corrected with nonsurgical methods, sometimes the deformity cannot be fully corrected or it returns, often because families have difficulty following the treatment program. In addition, some infants have very severe deformities that do not respond to stretching. When this happens, surgery may be needed to adjust the tendons, ligaments, and joints in the foot and ankle. Because surgery typically results in a stiffer foot, particularly as a child grows, every effort is made to correct the deformity as much as possible through nonsurgical methods.

26. management PHYSIOTHERAPY INTERNENTION Physiotherapists play a vital role in the education and management of Clubfoot. Along with other healthcare professionals, physiotherapists provide treatment and support to children and their families. Physiotherapy is recommended to start immediately upon a diagnosis of club foot as the outcome tends to be better the earlier treatment starts. For positional talipes physiotherapy will include; gentle stretches, exercise advise, handling / positioning techniques, and advice and education for the parents.

27. MANAGEMENT For babies with fixed talipes additional treatment may be required such as; strapping, splints, plaster casts or special boots, all of which help maintain the position of the foot. Some children with more severe talipes may require referral onto orthopaedic surgeons as surgery may be required on the tendons and muscles of the foot to correct their length and loosen them. If a child has undertaken surgery to lengthen tension from the Achilles tendon, physiotherapy treatment will be required post-surgery to ensure the foot maintains range of movement around the joint during the healing process. The physiotherapist will use passive movements to encourage normal movement and prevent any stiffening.

28. Ponsetti management & pirani scoring

29. Introduction The Ponseti Method is a conservative and manipulative method that is utilised worldwide to correct clubfoot or Congenital Talpes Equino Varus (CTEV). The Ponseti method is endorsed by the World Health Organization, the American Academy of Pediatrics, the American Academy of Orthopedic Surgeons, the Pediatric Orthopedic Society of North America, the European Pediatric Orthopedic Society, as well as more than 35 national and regional orthopedic societies globally.

30. History Until the past decade, most children born with clubfoot in low- and middle-income countries were not treated due to the complexity of surgery and limited access to safe services. Surgery became the popular option in the 1950-70’s but caused considerable health issues later in life; the feet tend to become stiff, weak and painful, often resulting in the need for additional surgeries. Ponseti method was developed by Dr. Ignacio.V.Ponseti (1914-2009) of the University of Iowa hospital and clinics. This method was developed in response to the complications and poor outcomes which came with surgical management of clubfoot. Dr. Ponseti was convinced there was a more efficient and effective way of treating clubfoot, this resulted in him studying extensively functional and patho-anatomy of the normal foot and the one which presented with clubfoot. When the non-surgical Ponseti method became the orthopedic standard for treating clubfoot around 2005, a global movement was born.

31. Goals of Ponseti management The goal is to reduce if not eliminate all elements of the clubfoot deformity, hence leaving a functional / pain- free, normal-looking, plantigrade, mobile foot. Functional, Pain-free Feet Wear Normal Shoes Avoid Permanent Disability The Ponseti method results in complete correction and full functionality in 95% of cases. When treatment is initiated during infancy, correction is usually achieved within six to eight weeks.

32. Goals of Ponseti management When should the Ponseti method start? It is best to begin within the first few weeks of life in order to correct clubfoot without the need for major reconstructive surgery. The pliable tissues of a newborn’s foot, including tendons, ligaments, joint capsules, and certain bones, will yield to gentle manipulation and casting of the feet at weekly intervals. How long does the Ponseti method take? The initial casting period takes about 6 to 8 weeks, followed by a period of 3 months during which the baby wears a removable orthotic 23 hours a day. After that, the child continues orthotic treatment for sleep (naps and night time) until 5 years of age.

33. Phases of Ponseti management Treatment phase The treatment is based on a sound understanding of the functional anatomy of the foot and of the biological response of muscles, ligaments and bone to corrective position changes gradually obtained by manipulation and casting This phase consists of Manipulation Casting Tenotomy.

34. Phases of Ponseti management Manipulation and casting : The baby's foot is gently stretched and manipulated into a corrected position and held in place with a long-leg cast (toes to thigh). Each week this process of stretching, re-positioning, and casting is repeated until the foot is largely improved. For most infants, this improvement takes about 6 to 8 weeks. Achilles tenotomy: After the manipulation and casting period, approximately 90% of babies will require a minor procedure to release continued tightness in the Achilles tendon (heel cord). During this quick procedure (called a tenotomy), the child's doctor will use a very thin instrument to cut the tendon. The cut is very small and does not require stitches. A new cast will be applied to the leg to protect the tendon as it heals. This usually takes about 3 weeks. By the time the cast is removed, the Achilles tendon has regrown to a proper, longer length, and the clubfoot has been fully corrected.

35. CASTING Achilles tenotomy

36. Phases of Ponseti management Bracing: Even after successful correction with casting, clubfeet have a natural tendency to recur (come back). To ensure that the foot will permanently stay in the correct position, your baby will need to wear a brace (commonly called "boots and bar") for several years. The brace keeps the foot at the proper angle to maintain the correction.

37. Phases of Ponseti management Maintenance phase This phase is for the prevention of clubfoot recurrence. Upon removal of the final cast, the infant is placed into foot abduction orthosis (FAO) also known as a Ponseti brace. The FAO consists of Ponseti shoes (also called Ponseti boots) in about 70 degrees of External Rotation, mounted to a bar (the length of which is the distance between the baby’s shoulders) .This maintains the feet in a corrected position, with the forefeet set apart and pointed upward. The brace is worn 23 hours per day for the first 3 months following casting. The child will then continue to wear it at night while sleeping until 5 years old. Multiple studies have demonstrated the high risk for recurrence of clubfoot if the brace is not worn according to these guidelines. It is not known why. Regardless of the cause, recurrence of clubfoot appears to be close to zero when the bracing regimen is followed stringently.

38. PIRANI SCORING INTRODUCTION The Pirani Score is a simple and reliable system to determine severity and monitor progress in the Assessment and Treatment of Clubfoot. This Scoring System uses the different views of the foot to help visualize the issues in the underling soft tissue and bony anatomy. It is an outcome measures used both as a means to assess the severity of the Clubfoot at initial presentation and for ongoing monitoring of the patients’ progress. The Pirani Clubfoot Score documents the severity of the deformity and sequential scores are an excellent way to monitor progress. An increase in the Pirani Score between visits may be an indication that a relapse in the Clubfoot Deformity is occurring.

39. PIRANI SCORING SCORING The Pirani score should be recorded at each visit the patient makes. If the Pirani score increases from one visit to the next it may indicate that a relapse of deformity is occurring. Scoring the foot at each visit during treatment enables the health care worker treating the child to document how the foot is responding to manipulation and casting.Many degrees of severity and rigidity of Clubfoot are found at birth. Failures in treatment are related more often to faulty technique of manipulation and casting rather than severity of deformity.

40. PIRANI SCORING METHOD OF USE The Pirani Scoring System is based on 6 well-described Clinical Signs of Contracture characterizing a severe clubfoot. These signs include - 3 Signs in Midfoot - 3 Signs in Hindfoot Each sign is assigned a score of 0,0.5 or 1 If the sign is severely abnormal it scores 1 If it is partially abnormal it scores 0.5 If it is normal it scores 0 Total Score (TS) varies from 0 to 6 and is the sum of Midfoot and Hindfoot Contracture Scores.

41. references Robert Cady, Theresa A. Hennessey, Richard M. Schwend; SECTION ON ORTHOPEDICS, Diagnosis and Treatment of Idiopathic Congenital Clubfoot. Pediatrics February 2022; 149 (2): e2021055555. 10.1542/peds.2021-055555 emedicine.medscape.com/article/1237077-clinical?form=fpf Physoipedia https://www.physio-pedia.com/Ponseti_method https://www.hss.edu/conditions_the-ponseti-method-for-clubfoot-correction.asp Physoipedia https://www.physio-pedia.com/Pirani_Score

42. REFERENCES https://www.manchesterneurophysio.co.uk/paediatrics/conditions-we-treat/orthopaedic-msk-conditions/talipes/physiotherapy-treatment-for-talipers.php Dobbs MB. Update on Clubfoot: Etiology and Treatment. Clin Orthop Relat Res. 2009;467(5):1146-1153. doi:10.1007/s11999-008-0596-7 Ponseti IV. Congenital Clubfoot: Fundamentals of Treatment. Oxford University Press; 1996.

43. THANK YOU!