CTEV

Congenital Talipes Equino Varus

1. C ONGENITAL T ALIPES E QUINO V ARUS DR RITESH JAISWAL M.B.B.S D.Ortho DNB (Ortho) M.N.A.M.S M.Ch (Ortho) Fellowship in Joint Replacement ( Mumbai ) Fellow AO Trauma ( Switzerland )

2. INTRODUCTION ETIOLOGY PATHOANATOMY CLINICAL PRESENTATION INVESTIGATIONS CLASSIFICATIONS TREATMENT

3. INTRODUCTION Deformity in which foot is turned inwards to varying degrees with Equinus at ankle Varus and Internal Rotation of heel Forefoot adduction with supination Cavus of midfoot Secondary deformities Internal torsion of tibia Atrophy of calf Smaller foot

4. INCIDENCE OF IDIOPATHIC CLUB FOOT - 1 - 2 / 1000 live births - Highest prevalence in Hawaiians and Maoris population - Boys are affected more than girls ( 4:1 ) - U/L Right foot common than left ( R > L ) - B/L in approximately 50% of cases - Increased incidence with positive family history for clubfoot.

5. Associated anomalies and syndromes Arthrogryposis Hand anomalies (Streeter dysplasia) Diastrophic dysplasia Amniotic band syndrome Pierre Robin syndrome Larsen syndrome Prune-belly syndrome Absent anterior tibial artery Freeman-Sheldon syndrome Down syndrome Tibia Hemimelia

6. ETIOLOGY Clubfoot is usually an isolated finding which is IDIOPATHIC in nature. Multiple theories have been proposed to explain its etiology. The “ arrest of development ” theory by Ignacio V. Ponseti Multifactorial system of inheritance by Palmer Polygenic theory supported by Wynne Davis and showed a rapid decrease in incidence of clubfoot from first to second to third degree relatives.

7. Deficiency of a part of the long arm of chromosome 18 - Insley Primary defect in germ plasma - Sherman and Irani ( constant abnormalities were found in the anterior part of the talus) Environmental factors - External pressure in utero ( Hydroamnios or oligoamnios) - Infectious disease during pregnancy - Maternal nutrition defects - Vitamin deficiency - Toxic agents like azaserine, d-tubocurarine, aminopterin - Maternal metabolic disorders

8. PATHOANATOMY

9. ANKLE – MEDIAL VIEW

10. ANKLE – LATERAL VIEW

11. BONES

12. . METATARSALS Medial migration & Inversion of all 5 MT. Cause forefoot adduction & contributes convexity of lateral border of foot

13. MUSCLES & TENDONS

14. 2 COMPONENTS OF PATHOLOGY INTEROSSEOUS - Foot Plantar flexion at Ankle & Subtalar joint - Hindfoot inverted - Forefoot, Midfoot are adducted, inverted & in Equinus - Calcaneus & Navicular are Displaced medially and plantarward over talus and Cuboid medially over calcaneus . - Soft tissue contractures Maintain deformity

15. INTRAOSSEOUS Talus – - Medial plantar deviation of anterior end – reduced angle of declination to 115 degree & increased obliquity of neck - Short neck misshapen ant talar facet - Wider ant part may not enter ankle mortise Calcaneus – - inverted under talus – secondarily distal facet ant, medial & plantar so cuboid is medial Articular Malalignment - Tibio talar – equinus of talus exposes 1/3 rd of articular surface - Talonavicular – navicular is medial and plantar to head of talus which is uncovered - Subtalar – spin- calcaneus is rotated medially & in equinus & inverted ( moving 3 axes ) This is important to understand because total posterolateral release is needed to derotate the calcaneus

16. CLINICAL PRESENTATION HISTORY Detail enquiry to rule out any congenital defect Family history ( helpful to prognosticate about incidence in future offsprings 1 in 35 for second child )

17. EXAMINATION Fully undressed the child Examine supine , then prone Check for anomalies in Head, Neck, Chest , trunk & Spine Mobility of trunk & extremities should be evaluated

18. MEASUREMENTS Measure limb length Circumference of thigh & calf Skin creases of thigh, ankle & foot Degree of equinus of heel and forefoot adduction ROM Hip & Knee DO NOT FORGET NEUROLOGICAL EXAMINATION….

19. LOOK Morphological features Spine – dysraphism Neck- Torticollis Other limbs FEEL Skin mobility Creases Hip for click MOVE Pirani Scoring Telescopy Neck Movements Active toe movements – neuro examination Spasticity

20. CLINICAL TESTS : DORSIFLEXION TEST – Screening test SCRATCH TEST – - Detect muscle imbalance in an infant who cannot follow commands - In normal child when medial sole scratched foot everts – test peroneals - If scratched on lateral sole foot inverts – test invertors PLUMBLINE TEST – To detect tibial torsion

21. CLASSIFICATION

22. ATTENBOROUGH ( 1966 )

23. CUMMIN CLASSIFICATION SUPPLE – Foot can brought back to normal position and all joints are mobile NEGLECTED – Never receive treatment (Conservative/operative) till walking age 1 year RELAPSED – one or many or all deformities recur after successfully achieving correction of all deformities RECURRENT – one or many or all deformities recur during the course of treatment which was successfully corrected previously RESISTANT – correction is not obtained in any or all deformities by manipulation / surgical methods ( commonly due to inappropriate technique ) RIGID – After conservative treatment forefoot deformity corrected hindfoot remains uncorrected

24. The most commonly used classifications are those described by Pirani Diméglio Both classifications assign points based on the severity of the clinical findings the correctability of the deformity.

25. PIRANI SCORING

26. DIMEGLIO SCORING Based on : - Equinus deviation - Varus deviation - Derotation - Adduction

27. RADIOGRAPHS AT 3 months : Ossific centres of calcaneus , cuboid , talus, MT are seen AP view with tube placed 30 deg cranial Lateral in max. dorsiflexion , foot to be parallel to cassette Radiographs are not mandatory to diagnose or treat clubfoot. Useful in complex clubfoot or to monitor correction

28. TALOCALCANEAL ANGLE AP view for HEEL VARUS ( Kite’s Angle ): 30-55 degree ( Reduced in CTEV ) Dorsi flexion Lateral view : 25 – 50 degree TIBIOCALCANEAL ANGLE ( for Equinus ) Stress lateral view : 10-40 degree TALUS 1 st METATARSAL ANGLE ( for Forefoot Adduction )

29. TREATMENT - Every clubfoot has its own nature and personality and need to be treated as individual -We can discuss only the guidelines

30. GOAL To achieve functional, painfree, normal looking, Plantigrade foot, with good mobility , without calluses, and requiring no modified shoes A I M S To achieve concentric reduction of talocalcaneonavicular joint , tarsus & ankle joint and to maintain it to establish a balanced & mobile foot for cosmesis & function

31. OPTIONS SERIAL MANIPULATION & CAST APPLICATION SOFT TISSUE RELEASE BONY PROCEDURE EXTERNAL FIXATOR ( Instrumental Distraction )

32. Kite’s Technique Manipulation as soon as after birth 3 point pressure concept Fulcrum – Calcaneocuboid joint Forefoot grasped & distracted while other hand holds heel Applying counterpressure over calcaneocuboid joint the navicular is pushed laterally Heel is everted as the foot is abducted Followed by cast application extended below knee with foot everted with gentle external rotation Afterwards foot is pushed into DF to correct equinus once adductus & Varus are corrected LOTS OF COMPLICATIONS………

33. French Technique Daily manipulation for 2 mths by physiotherapist Peroneal ms stimulation Taping with Adhesive tape Paediatric CPM Thrice weekly session – 6 mths BRACING- 3 years Posterior release needed in 30 %

34. PONSETI METHOD Treatment starts soon after birth but may be delayed for a few weeks in a premature baby. The sequence of deformity correction is cavus, abduction, varus and finally equinus (CAVE) The forefoot is held supinated and not pronated. Lateral pressure with the thumb is over the neck of the talus and not the calcaneocuboid joint. Long leg POP (plaster-of-Paris) casts are applied with the knee in flexion. (This prevents the cast falling off and controls tibial rotation.) Casts are changed on a weekly basis, although this may be done at 5-day intervals.

35. Equinus should be corrected without causing a midfoot break and correction should start after achieving forefoot abduction of about 60° with the heel moved into the valgus position. Residual equinus is corrected by a percutaneous Achilles tenotomy using a single incision (Required in up to 90% of feet) this is followed by a last cast for 2–3 weeks.

36. After removing the last cast, a foot abduction orthosis ( Denis Browne boots and bar ) is applied and worn 23 hours a day , initially for 3 months then only at night-time for 2–4 years . This is required to facilitate remodelling of the foot and prevent relapse of the deformity. The most common cause of relapse of the deformity is poor compliance with the Denis– Browne boot and bar. Relapse is treated by further serial casting with or without an Achilles tenotomy.

37. COMPLICATIONS - of non operative treatment Rocker bottom foot Bean shaped foot Pressure sores Failure of correction Recurrence or Relapse Flat top talus

38. Indications for surgery in club foot 1) Failure of nonoperative treatment in an infant 2) Syndromic clubfoot 3) Residual deformity correction 4) Neglected clubfoot

39. SOFT TISSUE RELEASE - 6 mnths – 4 years SOFT TISSUE RELEASE + LAT. COLUMN SHORTENING – 4 – 8 years BONY PROCEDURES ARE MUST - > 9 years

40. SOFT TISSUE RELEASE – To reduce TC-N & CC joints Turco’s ( 1971 ) – Most common – Single stage PMSTR Mckay’s ( 1977 ) – Complete subtalar release – Based on concept of calcaneal rotation – Need posterolateral release to derotate calcaneum – 2 incisions – 1) Cinncinnati 2) Posterolateral & Medial plantar

41. Posteromedial release. (A) Skin incision on medial aspect of foot. (B) Neurovascular bundle (black arrow), tibialis posterior tendon (red arrow), flexor digitorum longus tendon (green arrow), and flexor hallucis longus tendon (pink arrow). (C) Z-plasty of Achilles tendon. (D) Z-plasty of posterior tibial tendon. (E) Release of subtalar joint from medial aspect (black arrow) (F) Reduction of talonavicular joint (black arrow).

42. MCKAY’s Cinncinnati incision

43. Release of lateral structure of foot in complete subtalar release. (A) Peroneus longus and peroneus brevis. (B) and (C) Calcaneocuboid joint from lateral side (black arrow). (D) Circumferential release of subtalar joint (black arrow). (E) Reduction of talonavicular joint. (F) Release of plantar fascia.

44. SUMMARY SOFT TISSUE RELEASE RULE OF 3 STRUCTURES ON MEDIAL SIDE 3 muscles – AHL, FHL,TP 3 Ligaments – Deltoid, Spring, Plantar 3 capsules – Subtalar, Tarsal, Tarsometatarsal RULE OF 2 STRUCTURES ON POSTERIOR SIDE 2 muscles – Tendoachilles, TP 2 Ligaments – Talofibular, Calcanofibular 2 Capsules – Ankle jt, Subtalar jt RULE OF 1 STRUCTURES ON ANTERIOR SIDE 1 muscle – TA if inserted abnormally 1 Ligament – Sup. Peroneal lig 1 Capsule – calcaneocuboid joint

45. THANKS FOR YOUR ATTENTION