Congenital tallipes equinovarus

ctev

1. CONGENITAL TALLIPES EQUINOVARUS Dr. Pratik Dhabalia Resident in Orthopedics Dr DY Patil Hospital, Navi Mumbai

2. INTRODUCTION AKA CLUBFOOT One of the commonest congenital orthopedic deformities Four basic components: 1. C -> Cavus 2. A -> Adduction 3. V -> Varus 4. E -> Equinus

3. EPIDEMIOLOGY Incidence: 1-2 cases every 1000 live births Gender predilection: More common in boys Laterality: Approximately 50% cases are bilateral Side: If unilateral, Right is more commonly affected than left Inheritance: Most cases are sporadic, but if familial, they are inherited through autosomal dominant pattern with incomplete penetrance First degree relative - 2% Second degree relative – 0.6%

4. ETIOLOGY Exact cause is still controversial. Most cases are idiopathic in nature Presently, it is said that it is multifactorial. Several theories have been put forward

5. I. GENETIC FACTORS: Incidence of clubfoot increases with increase in number of affected relatives Siblings – 30 fold increase in risk Monozygotic twins – 32.5% Dizygotic twins – 2.9% Common in patients with family history

6. II. HISTOLOGICAL FACTORS: Irani and Sherman – Primary germ plasm defect of bone resulted in clubfoot Ippolito and Ponseti – Retraction fibrosis of distal muscles of calf and supporting connective tissue with medial angulation and tilting of talus Zimny et al. – increased myofibroblasts on medial side fascia leading to contractures IHC – in clubfoot patients showed contractile proteins and myofibroblasts

7. III. Vascular Anomalies: It was observed that majority of cases had either hypoplastic or total absence of anterior tibial artery IV. Anomalous muscles: In about 15% of cases, abnormal distribution of type I and II muscle fibers and they might be smaller in size

8. V. Intrauterine factors: Hippocrates – position of equinus due to external uterine compression or due to oligohydromnios Associated with amniocentesis – if done early in gestation Developemental defect

9. PATHOANATOMY Four basic components – CAVE Varies in severity from passively correctable to rigid clubfoot Involves bony components (ankle joint, subtalar joint, midtarsal joint) along with soft tissues and musculotendon complex

10. Bony components TALUS is deflected into equinus and rotated medially CALCANEUM rotates horizontally such that its anterior process lies beneath the talar head and tuberosity near lateral malleolus leading to varus NAVICULAR is medially displaced and inverted causing adduction Forefoot is pronated in relation to hindfoot causing cavus Internal tibia torsion maybe present

11. Soft tissues TA and posterior tibial tendon are thickened TC joint is kept in varus by calcneofibular ligament and peroneal retinaculum TN joint is resisted by deltoid ligament CC joint rotation causes contracture of peroneal sheath Muscle contractures and finally atrophy Anterior tibial tendon and toe extensors are medially displaced

12. CLINICAL FEATURES Visible deformity from birth Family history shape of the leg, foot and the degree of atrophy of the calf Degree of medial skin creases Skin crease at the back of the heel Size of the heel and great toe Number of rays in the foot and size of the foot in unilateral case weight bearing causing callosities of the skin on the outer side of the foot

13. Palpation of normal presence and relation of lower part of tibia and fibula (both malleolus) Empty heel sign (gives idea of severe equinus ) Palpation of lateral side for head of talus. Rigidity of the foot-resistance to manual correction Whether the skin is inelastic and adherent to the subcutaneous tissues, or there is adequate subcutaneous fat with free mobility of the skin Neurological examination is must before planning for the treatment. Ipsilateral hip and knee examination and spine examination are must to rule out secondary causes of clubfoot

14. Classification and Evaluation Two clubfoot grading systems described by Pirani et al . and by Dimeglio et al. They found very good reliability

15. DIMEGLIO Classification Divided clubfeet into four groups with use of a 20-point scale. Points were given according to motion 4 points each for equinus , varus of the heel, internal torsion and adduction. In addition, 1 point each may be added for the presence of a posterior crease, a medial crease, cavus and poor muscle condition. The points were then converted into four grades, each with implications for the success of treatment. Grade I: Indicated that the clubfoot was mild or postural, not requiring surgery Grade II: That there was considerable reducibility Grade III: That the clubfoot was resistant but partially reducible Grade IV: That it was teratologic

16. PIRANI Severity Score It is a reliable and valid clinical assessment of severity of deformity under 2 years of age. It is based on six clinical signs (three signs of hind foot and three signs of mid-foot). Each sign is scored 0 (normal), 0.5 (mildly abnormal) or 1 (severely abnormal). The amount of deformity is “scored” at every visit and recorded as “Hindfoot Score”, “Midfoot Score” and as a summed “Total Score”

17. MIDFOOT CONTRACTURE SCORE = CLS + MC + PC Curved lateral border

18. 2. Medial Crease

19. 3. Posterior crease

20. HINDFOOT CONTRACTURE SCORE = LHT + EH + RE 1. Lateral head of talus

21. 2. Empty heel

22. 3. Rigid Equinus

23. Pirani severity score = Midfoot contracture score + Hindfoot contracture score Midfoot contracture score = curved lateral border + medial crease + posterior crease Hindfoot contracture score = Lateral head of talus + empty heel + rigid equinus

24. RADIOGRAPHIC ASSESSMENT Routine xrays are not necessary Indicated in resistant, non idiopathic and atypical clubfoot Problems: Difficult to position the foot Ossific nuclei are do not represent the true shape of tarsal Rotation can distort the measured angles For optimum results, foot held in best corrected position with weight bearing

25. Anteroposterior and lateral talocalaneal angles (KITE’s Angle) Heel varus increases with decrease in angle (<20 in ctev )

26. Talar – 1 st metatarsal angle Talocalcaneal angle

27. MANAGEMENT The aim of clubfoot management is to achieve painless, plantigrade, supple foot without complications

28. NON-OPERATIVE Basis of nonoperative techniques is the correction of deformity through the production of plastic (permanent) deformation (lengthening) of the shortened ligaments and tendons in the involved foot. Serial manipulation and cast immobilization rely on the viscoelastic nature of connective tissue to produce plastic deformation through a process known as stress relaxation KITE’s technique and PONSETI technique

29. KITE’s Technique Starts with stretching of the foot through longitudinal traction applied to the foot. A thumb is placed laterally in the sinus tarsi over the head of the talus. Navicular is gently pushed onto the head of the talus with the index finger. Slipper cast is applied after the talonavicular joint is reduced Pushing of the heel out of varus and flattening of the foot to prevent cavus Correction of forefoot adduction is achieved by abducting the forefoot on the hindfoot as the slipper cast dries. The cast is then extended to the thigh while the foot is held in external rotation. No effort is made to correct equinus until forefoot adduction and heel varus are corrected because an attempt to correct equinus before correction of the other deformities leads to a rocker-bottom deformity

30. PONSETI’s Technique Usually for <2 years old Begin as early as possible for better results Order of correction – cavus , adduction, varus then equinus It has two phases of correction TREATMENT PHASE: 1 st cast corrects cavus by aligning forefoot with hindfoot by supinating forefoot to bring it in line with heel Cast is applied in two stages, first a short leg cast then it is extended above knee to maintain external rotation for allowing medial structures to stretch and prevent cast slippage

31. After 1 week, first cast is removed and manipulation is done for 1-2 minutes. Reduction of talonavicular joint is done (felt) Forefoot is maintained in supination to avoid ROCKER BOTTOM Deformity and the cast is extended above knee Final cast is applied 2-3 weeks after manipulation in maximum abduction and maximum dorsiflexion. TA tenotomy may be required to avoid rocker bottom deformity

32. MAINTAINANCE PHASE: Final cast is removed Infant is place in brace that maintains 70* abduction and 15* dorsiflexion Distance between both shoes should be > 1 inch of shoulder width Worn for 23 hours for 3 months and then while sleeping for 3-4 years

33. CTEV SHOES MODIFIED SHOES FOR CHILD WHO START WALKING. THESE SHOES ARE USE UNTILL 5 YEARS OF AGE. SPECIAL FEATURES: STRAIGHT INNER BORDER OUTER SHOE RISE NO HEEL

34. NONOPERATIVE TREATMENT STRETCHING AND ADHESIVE STRAPPING(ROBERT JONES): PRINCIPLE- APPLY EVERSION CORRECTION FORCE ON FOOT WITH HELP OF ADHESIVE STRAPPING. FRENCH TECHNIQUE: GOAL IS TO REDUCE TALONAVICULAR JOINT, STRETCH OUT MEDIAL TISSUES AND THEN SEQUENTIALLY CORRECT FOREFOOT ADDUCTION, HINDFOOT VARUS AND EQUINUS OF CALCANEUM.

35. COMPLICATIONS OF NONOPERATIVE TREATMENT ROCKER BOTTOM FOOT BEAN SHAPED FOOT FRACTURES PRESSURE SORES FLAT TOP TALUS FAILURE OF CORRECTION RECCURENCE OR RELAPSE OF DEFORMITY

36. SURGICAL TREATMENT INDICATION : IN CASE OF NEGLECTED CTEV, RELAPSED CTEV, RECCURENT CTEV, RESISTANT CTEV, RIGID CTEV. CHOICE OF SURGERY : 1-4 YEARS- SOFT TISSUE RELEASE 4-11 YEARS- SOFT TISSUE RELEASE WITH OSTEOTOMY PERFORMED ACCORDING TO THE DEFORMITIES >11YRS- SALVAGE PROCEDURES TRIPLE ARTHRODESIS TALECTOMY

37. SOFT TISSUE RELEASE OPERATION TURCO’S OPERATION- IT IS ONE STAGE POSTEROMEDIAL RELEASE. HE EMPHASIZED ON SUBTALAR RELEASE ALONG WITH CALCANEOFIBULAR LIGAMENT. CAROLL’S INCISION- CAROLL EMPHASIZED ON PLANTAR FASCIA RELEASE AND CAPSULOTOMY OF CALCANEOCUBOID JOINT. IT INCLUDE 2 INCISIONS, MEDIAL AND POSTERO-LATERAL INCISION. CINCINATTI INCISION- IT IS DONE FOR POSTEROMEDIAL AND POSTEROLATERAL SOFT TISSUE RELEASE. PREFFERED TECHNIQUE FOR INITIAL SURGICAL MANAGEMENT OF CLUB FOOT. TENDOACHILLES TENDON RELEASE WITH POSTERIOR CAPSULOTOMY- TO CORRECT RESIDUAL HIND FOOT EQUINUS

38. TURCO OPERATION MEDIAL INCISION GIVEN EXPOSE TIBIALIS POSTERIOR, FDL,FHL, TENDOACHILLES AND POSTERIOR NEUROVASCULAR BUNDLE. DIVIDE MASTER KNOT OF HENRY. DIVIDE CALCANEONAVICULAR LIGAMENT AND ABDUCTOR HALLUCIS FROM TIBIALIS POSTERIOR TENDON,NAVICULAR TUBEROSITY AND 1 ST METATARSAL. POSTERIOR RELEASE- BY DOING Z-PLASTY OF TENDO ACHILLES, INCISING POSTERIOR CAPSULE OF ANKLE JOIN, SUBTALAR JOINT AND DIVIDING TALOFIBULAR LIGAMENT AND CALCANEOFIBULAR LIGAMENT. MEDIAL PLANTAR RELEASE- DIVIDE TIBIALIS POSTERIOR, SUPERFICIAL DELTOID LIGAMENT, TALONAVICULAR CAPSULE AND SPRING LIGAMENT. SUTALAR RELEASE- DIVIDE MEDIAL PART OF TALOCALCANEAL INTERROSEOUS LIGAMENT AND BIFURCATION OF Y LIGAMENT. AFTER REDUCING NAVICULAR BONE TRANSFIX TALONAVICULAR JOINT BY K-WIRE AND SUBTALAR JOINT BY 2 ND K-WIRE.

39. CINCINATTI INCISION TRANSVERSE CIRCUMFERENTIAL INCISION

40. ACHILLES TENDON LENTHENING AND POSTERIOR CAPSULOTOMY TO CORRECT RESIDUAL HINDFOOT EQUINUS Z-PLASTY IS DONE TO LENGTHEN THE ACHILLES TENDON. RELEASING MEDIAL HALF DISTALLY AND LATERAL HALF PROXIMALLY. POSTERIOR CAPSULOTOMY OF ANKLE AND SUBTALAR JOINT TO RELEASE CAPSULE CONTRACTURE.

41. TENDON TRANSFER INDICATION - PASSIVELY CORRECTABLE DEFORMITY RESULTING FROM MUSCLE IMBALANCE. ANTERIOR TIBIALIS TENDON TRANSFER- TENDON IS TRANSFERRED EITHER TO MIDDLE CUNIEFORM OR TO BASE OF 5 TH METATARSAL. SPLATT (SPLit ANTERIOR TIBIALIS TENDON TRANSFER)- LATERAL PART OF TENDON IS SPLIT AND INSERTED TO CUBOID.

42. DWYER O S T E OT O M Y INDICATION- PERSISTENT VARUS DEFORMITY OF HEEL WHEN SOFT TISSUE SURGERIES ARE CONTRAINDICATED. AGE- 3-4YRS DONE BY MEDIAL OPEN WEDGE OSTEOTOMY OR BY LATERAL CLOSED WEDGE OSTEOTOMY

43. LATERAL COLUMN SHORTENING PROCEDURE INDICATION - RECURRENCE OF CLUBFOOT DEFORMITY AFTER SURGICAL RELEASE IS MOSTLY DUE TO DISPARITY BETWEEN MEDIAL AND LATERAL BORDER OF FOOT. ANY ATTEMPT TO CORRECT DEFORMITY IS RESISTED BY MEDIAL CONTRACTURE AND EXCESSIVE LENGTH OF LATERAL COLUMN. DIFFERENT PROCEDURE TO DO SHORTEN LATERAL COLUMN ARE- DILLWYNN EVANS PROCEDURE LICHTBLAU PROCEDURE FOWLER PROCEDURE

44. LATERAL COLUMN SHORTENING PROCEDURE DILLWYN EVANS PROCEDURE LICHTBLAU PROCEDURE AGE- 4-8 YRS INDICATION- MIDFOOT IN VARUS DUE TO TALONAVICULAR AND CALCANEOCUBOID SUBLUXATION AGE- 3-4 YRS INDICATION- HEEL VARUS & RESIDUAL INTERNAL DEFORMITY OF CALCANEUS WITH LONG LATERAL COLUMN

45. FOWLER P R O C E D U R E INDICATION - SUFFICIENT SCARRING THAT MEDIAL SOFT TISSUE AND SUBTALAR RELEASE WOULD BE IN EFFECTIVE. AGE- 6-8 YEARS PROCEDURE - LATERAL COLUMN SHORTENING COMBINING WITH MEDIAL COLUMN LENGTHING BY REMOVING WEDGE FROM CUBO I D AN AND O P ENI N G T R ANS F E R I N G IT TO WEDGE.

46. SALVAGE PROCEDURE INDICATION- UNCORRECTED CLUBFOOT OR WITH RESIDUAL DEFORMITY AFTER THE AGE OF 10 YRS. PAINFUL STIFF FOOT WITH POOR FUNCTION DIFFICULT TO ACCOMMODATE TO FOOT WEAR GOAL- CORRECT RESIDUAL DEFORMITY WHICH IS RESISTANT TO SOFT TISSUE RELEASE. TO ATTAIN FUNCTIONALLY AND COSMETICALLY ACCEPTABLE FOOT. PROCEDURE- TRIPLE ARTHRODESIS TALECTOMY

47. TRIPLE A R T H R O D E S I S INDICATION- PAINFUL STIFF FOOT WITH POOR FUNCTION D I FFI CU L T T O A C C O MM O D A T E T O F O O T WEAR ALL OTHER CORRECTION FAILED AGE – 10 – 12 YEARS PROCEDURE - OSTEOTOMY FOLLOWED BY FUSION OF TALONAVICULAR, TALOCALCANEUM AND CALCANEOCUBOID JOINT.

48. T A L E C T O M Y UN T R E A TED INDICATION- RES E R V E D F O R S E V E RE CLUBFOOT AGE - <6 YEARS PROCEDURE- COMPLETE EXCISION OF TALUS DEROTATE THE FOOT AND DISPLACE THE CALCANEUS POSTERIORLY INTO ANKLE MORTISE UNTIL NAVICULAR ABUTS THE ANTERIOR EDGE OF TIBIAL PLAFOND. COMPLICATION- LOSS OF LIMB LENGTH LIMITATION OF ANKLE MOVEMENT

49. EXTERNAL FIXATOR INDICATION- IN CASE OF NEGLECTED AND RECCURENT DEFORMITY WITH SEVERE SCARRING MODALITIES- ILLIZAROV’S EXTERNAL FIXATOR JESS (JOSHI EXTERNAL STABILIZING SYSTEM) ADVANTAGE- PREVENT CRUSHING OF THE TISSUES ON CONVEX SIDE LENGHTENS THE LIMB EFFECTIVELY CORRECT THE DEFORMITY AT SAME TIME

50. ILLIZAROV’S EXTERNAL FIXATOR PRINCIPLE - FRACTIONAL DISTRACTION INDICATION - SEVERE DEFORMITIES WITH SEVERE SCARING OR TROPHIC ULCERS WHICH MAKE OPERATIVE INTERVENTION CONTRAINDICATION BECAUSE OF RISK OF TISSUE NECROSIS. STEPS OF CORRECTION- ANGULAR CORRECTION OF HINDFOOT CORRECTION OF FOREFOOT SUPINATION CORRECTION OF FOOT EQUINUS

51. J E S S PRINCIPLE- DIFFERENTIAL DISTRACTION ADVANTAGE- LENTHENS ALL CONTRACTED TISSUES PREVENTING HISTIOGENESIS AND THUS AVOID CUTTING OF THESE IMMINENT SCARRING. POSSIBLE TO CONTROL MAGNITUDE OF CORRECTION. NO FURTHER SHORTHENING OF FOOT RESULTANT FEET IS VERY SUPPLE.