Ctev

CONGENITAL TALIPUS EQIUNO VARUS

1. PRESENTER- Dr.RAGHAVENDRA RAJU MODERATOR- Dr.SAMEER WOOLY CTEV

2. INTRODUCTION TALUS-ANKLE PES-FOOT EQUINO-LIKE A HORSE VARUS- TURNED INWARDS

3. HISTORICAL ASPECTS - EARLIEST EVIDENCE IN EGYPTIAN PERIOD. - YAJURVEDA ADVISED TO MASSAGE TO CORRECT DEFORMITY. - HIPPOCRATES FIRST DESCRIBED CLUB FOOT. - SCARPA(1803) FIRST DESCRIBED PATHOLOGIC ANATOMY. - KITE (1930) DESCRIBED NON OPERATIVE TREATMENT WITH SEVERAL MANIPULATION AND PLASTER CAST APPLICATION.

4. DENNIS BROWN (1934) DEVISED SPLINT FOR MAINTENANCE OF CLUBFOOT CORRECTION. IGNACIO PONSETI (1950) DEVELOPED METHOD CORRECTION.

5. DEFINITION CONGENITAL DYSPLASIA OF MUSCULOSKELETAL TISSUES DISTAL TO KNEE JOINT IN THE FORM OF DEFORMITY OF FOOT AND ANKLE. IT IS A DEVELOPMENTAL DISORDER.

6. ETIOLOGY-IDIOPATHIC 1.MECHANICAL FACTORS- HIPPOCRATES Oligohydramnios Abnormal fetal positioning Unstretched uterus Placental insufficiency Constriction bands. 2.PRIMARY GERM PLASM DEFECT 3.ARRESTED FOETAL DEVELOPMENT 4.HEREDITARY- AD 5.MUSCULOLIGAMENTOUS FIBROSIS

7. 6. VASCULAR HYPOTHESIS- 90% of CTEV limbs showed hypoplasia / absence of anterior tibial artery.

8. SECONDARY CLUBFOOT 1.PARALYTIC DISORDERS - evertors and dorsiflexors are weak. Ex- polio , spina bifida, myelodysplasia , friedrichs ataxia. 2.SYNDROMES -arthogryposis multiplex congenita , downs syndrome, larsen syndrome.

9. INCIDENCE- 1 to 2 in 1000 livebirths . SEX – MALE >FEMALE LATERALITY- BILATERAL IN MORE THAN 50 % . FAMILY HISTORY- 5-50% POSITIVE.

10. COMPONENTS EQUINUS- FOOT IN PLANTAR FEXION VARUS-HIND FOOT INWARD ROTATION FOREFOOT ADDUCTION CAVUS- MEDIAL BORDER OF FOOT MORE ARCHED TIBIAL TORSION-CONTROVERSIAL, MEDIAL TORSION OF LOWER END OF TIBIA

11. COMPONENTS OF CTEV

12. BONY CHANGES Talus: most deformed and least displaced. Head & neck deviated medially & plantarward Body rotated externally in the ankle mortise, superior articular surface escapes from mortice . Talar neck is short and medially deviated. Smaller than normal, disturbance of vascular supply, ossification centre eccentrically placed

13. Navicular : Medially displaced Close to medial malleolus Articulates with medial surface of head of talus Calcaneus Anterior portion lies beneath the head of talus causing varus and equinus of heel In equinus Rotated medially

14. Cuboid Displaced medially on the dysmorphic distal end of the calcaneus

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

16. Soft tissue changes Posterior structures : Tendo achilles Post. capsule of ankle joint & subtalar joint Post. talo fibular Calcaneo-fibular ligaments

17. MEDIAL- Tibialis posterior FHL,FDL, Master Knot of Henry Talonavicular ligament Calcaneo-navicular ligament Deltoid ligament Interossseus talo calcaneal ligaments Capsules of naviculo cuneiform & cuneiform first metatarsal

18. Plantar wards : Plantar fascia Plantar ligaments Flexor digitorum brevis & abductor hallucis Laterally Calcaneofibular ligament Bifurcated ligament Calcaneocuboid joint capsule

19. EXAMINATION 1.DORSIFLEXION TEST- 2. PLUMB LINE TEST-

20. CLASSIFICATION IDIOPATHIC AND NON IDIOPATHIC- CUMMIN CLASSIFICATION a. supple –foot can be brought to normal position. b. rigid - forefoot can be corrected but not the hind foot by conservative management. c. neglected- not received treatment for one year. d. relapsed- deformity reappear after correction. e.recurrent - type of relapse, due to muscle imbalance. f. resistant- cannot be corrected by conservative treatment.

21. 3. Browne s classification- a. first degree- only forefoot adduction present. b. second degree- inversion and equinus is present along adduction. c. Third degree- toes pointing upwards, sole is in contact with medial surface of tibia. Equinus component is not present.

22. Radiology Plain radiograph : Can be assessed prior to treatment with A-P & Lateral of foot Foot held in position of best correction, with weight-bearing, or simulated weight-bearing AP view: Taken with foot in 30° of plantar flexion and tube at 30° from vertical Lat. View: Transmalleolar with the fibula overlapping the posterior half of the tibia; foot in 30° of plantar flexion

23. Anteroposterior view Talocalcaneal angle Calcaneal -second metatarsal angle Talus –first metatarsal angle

24. Lines drawn through center of the long axis of talus (parallel to medial border) and through the long axis of calcaneum (parallel to lateral border), and they usually subtend an angle of 25-40°. Any angle less than 20° considered abnormal AP radiograph: Talo-Calcaneal angle

25. Lateral view Talocalcaneal view Calcaneal -first metatarsal view Tibiocalcaneal Talus-first metatarsal angle Talocalcaneal index (Kite's angles from AP and Lateral views added)          

26. 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 Pirani s et al. A method of evaluating virgin clubfoot with substantial interobserver reliability. Annual meeting of Pediatric orthopaedic society of North America 1995

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

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

29. 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

30. Classification of clubfoot severity by Diméglio A.Equinus deviation B. Varus deviation C. Derotation D. Adduction.

31. 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

32. 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

33. Aims of treatment Achieve a plantigrade , pliable, cosmetically accepted foot in shortest possible time and with least disruption of family and child life.

34. PRINCIPLES OF TREATMENT Soft tissue contractures should be stretched out in order to restore normal tarsal relationship. Once achieved correction should be maintained in till tarsal bones remoulds stable articular surfaces. TWO OPTIONS – 1. NON OPERATIVE- immediately after birth 2. OPERATIVE

35. KITES METHOD Correction of each component separately and in order. Avg time 6 months Fulcrum – calcaneocuboid joint. Order 1.adduction 2.varus 3.equinus

36. Kite method Believed heel varus would correct simply by everting calcaneus Did not realize calcaneus can evert only when it is abducted (i.e., laterally rotated) under the talus Forefoot overcorrected into mild flatfoot Calcaneus is rolled out of inversion by placing plantar surface of a slipper cast on glass plate to flatten the sole Dorsiflexion of foot with wedging casts

37. Outline of Ponseti regimen Serial casting of lower limb using a strictly defined technique and weekly change of casts Percutaneous tenotomy of tendo achilles for “hind foot stall” Once foot corrected, an abduction foot orthosis worn full time for 12 weeks, and then at nights and naps, up to age of four.

38. Reasons for poor results in kites method FULCRUM- prevents abduction of calcaneum and thereby eversion of calcaneum . Pronation of forefoot worsens cavus .

39. Manipulation and cast application 1.Manipulation Manipulation: start as soon after birth as possible Setup for casting includes calming the child with a bottle or breast feeding Assistant holds the foot while the manipulator performs the correction .

40. Order- cavus adduction varus equinus

41. 2. Correction of cavus Cavus results from pronation of the forefoot in relation to hindfoot “ THE PRONATION TWIST “ Attempting to correct the supination of hindfoot before correction of varus results in an iatrogenic increase in cavus Corrected by supinating the forefoot to place it in proper alignment with the hindfoot.

42. Cast application Manipulation Padding

43. Plaster at toes Below knee pop

44. Molding Extension upto the thigh

45. Plantar support to toes Final appearance

46. Casts and foot Adequate abduction Best sign of sufficient abduction: ability to palpate the anterior process of the calcaneus as it abducts out from beneath talus Abduction of approx.70 degrees in relationship to the frontal plane of the tibia possible

47. Complications of casting Tight cast Rocker bottom deformity Crowded toes Flat heel pad Superficial sores Deep sores Pressure sores Injury to distal tibial physis

48. Common errors(Kite errors) No manipulation Pronation / eversion of 1 st metatarsal Premature dorsiflexion of heel Counterpressure at calcaneocuboid joint Below knee casts Short splints

49. Rocker bottom deformity Dorsiflexion via midfoot before correction of hindfoot varus Dorsal dislocation of navicular on talus Fixed equinus of calcaneus

50. Correction of equinus and tenotomy No direct attempt at equinus correction is made until heel varus is corrected Equinus deformity gradually improves with correction of adductus and varus- calcaneus dorsiflexes as it abducts under talus Residual equinus- manipulation and casting +/- percutaneous tenotomy Tenotomy : Indicated to correct equinus when cavus, adductus, and varus fully corrected but ankle dorsiflexion remains less than 10 degrees above neutral

51. 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.

52. Cast with the foot abducted 60 to 70 degrees with respect to the frontal plane of the ankle, and 15 degrees dorsiflexion for 3 weeks

53. Foot Abduction braces Shoes mounted to bar in position of 70° of ER and 15° of dorsiflexion in B/L cases and incase of U/L cases 30 to 40° of ER in normal side, distance between shoes set at about 1˝ wider than width of shoulders Knees left free, so the child can kick them “straight” to stretch gastrosoleus tendon

54. Bracing protocol Worn 24 hours each day for first 3 months. For 12 hours at night and 2 to 4 hours in middle of day for a total of 14 to 16 hours during each 24-hour period. Continued until the child is 3 to 4 years of age. Noncompliance with bracing protocol – the most common cause of recurrence in children on Ponseti regimen .

55. Mitchell brace Dobbs dynamic brace

56. Dennis brown Romanus

57. CTEV Splint Straight inner border to prevent forefoot adduction Outer shoe raise to prevent fooot inversion No heel to prevent equinus Slight(1/8”) lateral sole raise Inner iron bar Outer t trap Walking age to 5 yrs of age

58. Results of Ponseti method 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 Results 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 same Radiographs showed :feet not completely corrected, but functioned well despite this Cooper DM, Dietz FR. J Bone Joint Surg [Am] 1995;77-A:1477-89 .

59. Results of Ponseti’s method .. Study from Iowa (2004) : 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%. 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.

60. The French method Bensahel / Dimeglio regime Daily manipulations by a skilled physiotherapist and temporary immobilisation with elastic and non-elastic adhesive taping . GOAL- reduce talonavicular joint, stretch out medial tissues, correct deformities squentially . 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**.

61. Atypical clubfoot 2-3% Feet highly resistant to correction Severe plantarflexion of all metatarsals, a deep crease just above heel and across the sole of the midfoot , short hyperextended big toe, fibrotic muscles Treatment by manipulation and Ponseti method

62. When manipulating,index finger should rest over posterior aspect of lateral malleolus while thumb of same hand applies counter pressure over the lateral aspect of the talar head Do not abduct more than 30 degrees After 30 degrees abduction is achieved, change emphasis to correction of the cavus and equinus. All metatarsals are extended simultaneously with both thumbs Above-knee cast in 110 degrees flexion

63. 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

64. RESULTS OF NON OPERATIVE TREATMENT OVERALL – 19% TO 95%. KITES METHD- 80%. PONSETI – 95%

65. Surgery in clubfoot INDICATIONS Resistant clubfoot( non-responsive to serial casting and manipulation) Persistently deformed clubfoot(non-operative correction inadequately done with/without compliant bracing) Relapsed clubfoot( initially satisfactorily corrected that recurs in part or whole) Neglected clubfoot( no treatment given till age of 2 yrs)

66. General Principles Goal: address all pathoantomic structures. Type of surgery depend on age and deformity.

67. Approaches Turco ( postero medial incision) Cincinnati ( postero medial and postero lateral )

68. Caroll’s two incision technique Medial incision - straight oblique incision from first metatarsal, across medial malleolus to Achilles tendon Straight lateral incision along the lateral subtalar joint antr to distal fibula

69. AGE 9- 12 MONTHS RELEASING OF MEDIAL, PLANTAR, AND POSTERIOR ASPECTS OF FOOT. TURCOS ONE STAGE RELEASE IDENTIFY AND MOBILISE- 1.TIBIALIS POSTERIOR 2.FDL 3.FHL 4.NV BUNDLE 5.ACHILLES TENDON

70. Incise superior peroneal retinaculum Cut off calcaneofibular and talofibular ligament Incise talocalcaneal ligament and lateral capsule of talocalcaneal joint EDB, inferior extensor retinaculum and dorsal calcaneocuboid ligamner cut incase of severe clubfoot

71. Medial release Dissect and protect N-V bundle Master knot of Henry Z-lengthening of the Tibialis Posterior & release of sheath Follow to navicular insertion Capsule of T-N joint released

72. Medial tibial navicular ligament, dorsal talonavicular ligamnet, and plantar calcaneonavicular ligament cut Capsule of T-N cut all the way around

73. Bifurcated ligament cut Complete release of talocalcaneal joint ligaments except interosseous ligaments Detach origin of quadratus plantae muscle from calcaneus Roll talus back into ankle koint, if not incise post. talofibular ligament, post. Portion of deep deltoid ligament

74. Line up medial side of head and neck of talus with medial side of cuneiforms, medially push calcaneus post. to ankle joint K wire through talonavicular ,talocalcaneal joints

75. Check for proper position of foot Longitudinal plane of foot 85-90° to bimalleolar ankle plane, heel under tibia in slight valgus Suture all tendons with foot in 20° dorsiflexion Wound closure

76. Follow 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 weeks Cast removed along with any K wires, if applied during surgery for stabilisation AFO given for 6 months

77. Residual deformities Residual hindfoot equinus : Achilles tendon lengthening and posterior capsulotomy of ankle and subtalar joints Dynamic metatarsus adductus : Transfer of anterior tibial tendon, either as split transfer or entire tendon

78. Resistant clubfoot Metatarsus adductus : >5 yrs metatarsal osteototomy Hindfoor varus : <2-3 yrs modified Mckay procedure 3- 10 yrs Dwyer osteotomy ( isolated heel varus) Dilwyn Evans procedure (short medial column) Lichtblau procedure( long lateral column) 10-12 yrs triple arthrodesis Equinus : Achilles tendon lengthening and posterior capsulotomy of subtalar joint, ankle joint / Lambrinudi procedure All three deformities >10 yrs triple arthrodesis

79. TENDON TRANSFERS INDICATION –PASSIVELY CORRECTABLE FOOT RESULTING FROM MUSCLE IMBALANCE. NEVER A PRIMARY PROCEDURE THREE TYPES- 1.TIBIALIS ANTERIOR 2.TIBIALIS POSTERIOR 3.SPLIT ANTERIOR TIBIALIS TENDON TRANSFER

80. AGE 3- 6 YEARS Weakness of muscle( peroneus ). Garceaus - middle Cuneiform. Mod gerceaus - 5 th metatarsl base. TIBIALIS ANTERIOR TRANSFER

81. SPLATT Indicated for dynamic foot deformity. Lateral part on to cuboid

82. TIBIALIS POSTERIOR TRANSFER AGE- 8 YEARS. PRINCIPLE- eliminate the deforming force of tibialis posterior and use it corrective force when there is toe in gait, cavus ,weak peroneals , forefoot equinus . Through interroseous membrane to lateral cuneiform.

83. Bony procedures Dwyer calcaneal osteotomy A ge 3-4 years IND- persistent varus deformity. Opening wedge medial osteotomy to increase the length and height of calcaneus Osteotomy held open by a wedge of bone taken from tibia with k wire. Cast for 3 months.

84. Litchblau procedure IND – hind foot includes varus and residual internal deformity of calcaneum with long lateral column. AGE – min 3 years. Lateral closing wedge osteotomy of calcaneus along with medial soft tissue release . Shortens the lateral column. Complication- skew foot.

85. Dilwyn Evans Osteotomy Posteromedial release Calcaneocuboid wedge resection and arthrodesis of the joint Shortens lateral column Stiffness at subtalar and midfoot joints Preferred in older children (4-8 yrs)

86. Dilwyn Evans Osteotomy PRINCIPLE- basic deformity is at mid tarsal joint and all other deformities are adaptive. Age – 4 years- 8 years. Staged procedure. Lateral foot shortened by closed wedge osteotomy . Medial soft tissue release and closed tenotomy of plantar fascia. Posterior capsulotomy and soft tissue release. Calcaneo – cuboid fusion.

87. Salvage procedures Triple arthrodesis Salvage procedure for painful stiff foot. Correction of large degrees of deformity in neglected clubfeet. Not performed before advanced skeletal maturity, at age 10 to 12 years. 3 Joints fused 1. subtalar joint. 2. talonavicular joint. 3. calcaneo cuboid joint.

88. Triple arthrodesis Dunn arthrodesis Hoke and kite

89. Talectomy Originally done for syndromic clubfoot. Now done for severe untreated club foot. Age – 6years. Complete excision of talus . Derotate foot and displace calcaneum into ankle mortise untill navicular abuts anterior edge of tibial plafond.

90. Complications- limb length discrepancy. limitation of ankle movements.

91. Ilizarov Correction slow enough to protect soft tissue Correction at the focus of deformity Simultaneous three-dimensional, multilevel correction Deformity correction without shortening the foot

92. Results with Ilizarov Good 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