Ctev assessment & ponseti technique

Congenital Talipes Equinovarus (CTEV) deformity and Ponseti management.

1. CTEV : ASSESSMENT & PONSETi TECHNIQUE DR. SOUVIK BHATTACHARJEE JUNIOR RESIDENT (ACADEMIC) DEPARTMENT OF PHYSICAL MEDICINE & REHABILITATION AIIMS, BHUBANESWAR

2. introduction Clubfoot or congenital talipes equino varus (CTEV) is a set of foot deformities of varying severity, consisting of equinus (plantar flexion of the talocalcaneal joint), hindfoot varus (subtalar inversion), forefoot supination (adduction of talo -navicular) & cavus of midfoot . Etiology : Heredity : According to Wynne-Davis, the idiopathic clubfoot is inherited by polygenic pattern. Germ-plasm defect : Clubfoot is caused by the defect in the cartilaginous structure and developmental anomaly of tarsal bones in early embryonic life. Neurogenic cause : Abnormal distribution of type 1 and type II muscle fibres and ultrastructural abnormalities due to abnormal pattern of innervations. Developmental arrest Intrauterine mechanical factors EPIDEMIOLOGY INCIDENCE 1 IN 1000 LIVE BIRTHS M : F 2.5 : 1 BILATERAL 50% 1 parent is affected 1-4% Both parents affected 15-20% Dizygotic twins 3 % Monozygotic twins 32 %

3. Associated conditions Spina bifida Trisomy 18 Ehler -Danlos Larsen’s syndrome 22q11 deletion syndrome Arthrogryposis multiplex congenita Streeter’s dysplasia Secondary to cerebral palsy Secondary to polio

4. Pathophysiological anatomy The clubfoot deformity is due to the abnormal relationship of the tarsal bones. Correction of the abnormal tarsal relationship is resisted by pathological contracture of the associated softer parts. Severity of the deformity depends upon degree of displacement . Resistance to treatment is determined by the rigidity of soft tissue structures . Wolf’s Law : Every change in the use of the static function of the bone causes a change in the internal form as well as the architecture and also the external form and function according to mathematic law. Davis’ law : When then ligaments and soft tissues are in lax state they will shorten.

5. KINEMATICS Clubfoot deformity occurs mostly in the tarsus. Talus – severe plantar flexion, its neck is medially and plantarly deflected & head is wedge shaped. Navicular – severely medially displaced and articulates with the medial surface of the talus. Calcaneus – adducted and inverted under the talus. Cuboid – medially displaced & adducted Cuneiforms – downwards and medially displaced The calcaneo -cuboid joint is directed postero -medially. Tendons of tibialis anterior, extensor hallucis longus & extensor digitorum longus are medially displaced . COMPONENTS : Cavus of midfoot Adductus of forefoot Varus of midfoot Equinus of hindfoot

6. Soft tissue pathology POSTERIOR CONTRACTURE : Achilles tendon, Tibio -talar capsule, Talo -calcaneal capsule, Posterior talo -fibular ligament, Calcaneo -fibular ligament. These structures resist equinus correction. MEDIAL CONTRACTURE : Most important & most resistant structures. Tibialis posterior, deltoid ligament, Talo -navicular capsule, and spring ligament. SUBTALAR : Talo -calcaneal interosseous ligament, bifurcated Y ligament PLANTAR CONTRACTURE : Abductor hallucis, Intrinsic flexors, Quadratus plantae & plantar aponeurosis.

7. pathoanatomy Calf is smaller : Shorter and smaller muscle tendon unit of Triceps surae . Hindfoot equinus : severe plantar flexion , high calcaneus, severe flexion of talus Heel varus : Supination and adduction of the calcaneus. Calcaneus locked under talus

8. pathoanatomy Inversion of midfoot : Plantar flexion, adduction & supination Cavus : Increase height of medial arch of the foot. Plantar flexion of 1 st metatarsal Affected foot is smaller

9. TYPICAL CLUBFOOT Classic clubfoot without any anomaly of other systems Generally corrects in 5 casts and long term outcome is good or excellent Types Positional clubfoot – Deformity is flexible and is due to intrauterine crowding . Correction achieved by one or two casts. Delayed treated clubfoot – Beyond 6 months of age. Recurrent typical clubfoot – Recurrence after management. Relapse is due to premature discontinuation of bracing . Recurrence is most often supination and equinus . Alternatively treated typical clubfoot – Feet treated by surgery or non- ponseti casting.

10. ATYPICAL CLUBFOOT Associated with other problems. Correction more difficult. Types Rigid or resistant atypical clubfoot – Short, stiff, chubby feet with a deep crease in the sole of the foot and behind the ankle and have shortened 1 st metatarsal with hyperextension of metatarso -phalangeal joint. Syndromic clubfoot – congenital anomalies are present. Ponseti management is the standard management but is more difficult to treat. Teratologic clubfoot – Congenital tarsal synchondrosis Neurogenic clubfoot – associated with meningomyelocele Acquired clubfoot – Streeter dysplasia

11. assessment HISTORY : Comprehensive history focusing on signs & symptoms of associated conditions. Birth history, developmental history relevant family history and overall health status. PHYSICAL EXAMINATION : Neuromuscular disorder & genetic disorder should be ruled out Complete Musculo-skeletal examination – Active & passive range of motion of foot & ankle Assessment of hip and spine abnormality Other joint involvement, cutaneous manifestations and limb anomalies should be checked for

12. Clinical examination Smaller stubby feet with shortened 1 st metatarsal ray ( metatarsal 1 & phalanges of 1 st toe ) Equinus deformity with inversion of heel, adduction and varus of the forefoot Medial border of the foot is concave and elevated, plantar surface face upwards. Lateral border of the foot is convex and depressed down. The posterior tuberosity of the heel is upwards Callosity on the dorsal aspect of the 5 th metatarsal. Bony prominence visible and palpable over the dorsolateral aspect of the foot represents the head and neck of talus, partially uncovered by navicular

13. assessment FUNCTIONAL ASSESSMENT : Screening for developmental delay Assessment of mobility Evaluate effects on mood & behavior ELECTRODIAGNOSTIC STUDY : Helps to diagnose associated neurological conditions. CLINICAL ASSESSMENT & GRADING : Mac Evan assessed the clubfoot by degree of dorsiflexion, heel varus, forefoot adduction, calf atrophy and graded the results as excellent, good, fair & poor. Chacko described a preoperative grading of clubfoot depending on – components of deformity present, flexibility of the foot & amount of correction possible. Douglas Mckay developed a scoring system which include- ankle motion, bimalleolar angle, strength of the triceps surae , hee , forefoot, FHL, painful gait, subtalar pain, shoe wear & sports.

14. Dimeglio classification system Major components are graded from I to IV Equinus Heel varus Medial rotation of calcaneo -pedal block Forefoot adduction Additional points are added for Deep posterior crease Deep medial crease Cavus Poor muscle condition

15. Pirani severity scoring USEFULLNESS: To assess severity of the clubfoot To monitor treatment progress Indicates the timing for tenotomy To indicate the timing for bracing . PRINCIPLES OF SCORING : 6 clinical signs of clubfoot are compared with the normal foot 3 sign to evaluate the Hind foot contractures  Posterior crease, Empty heel & Rigid equinus 3 signs to evaluate midfoot contracture  Medial crease, Lateral part of the head of talus & curvature of the lateral border of the foot. Each sign is scored with: 0 = No abnormality, 0.5 = moderate abnormality & 1 = severe abnormality

16. Posterior crease of the ankle

17. empty heel

18. Rigid equinus

19. Medial crease of the sole of the foot

20. Lateral part of the head of talus

21. Curvature of the lateral border of the foot

22. Radiological assessment INDICATIONS : To assess the degree of subluxation of the TALOCALCANEONAVICULAR joint & the severity of deformity To provide a guide to progress during the course of closed non-operative treatment To ascertain whether reduction of the dislocation & normal alignment is achieved To analyze the composite deformities preoperatively and to plan operative treatment accordingly. Standard views are Dorso -plantar view and Lateral view Kites angle : AP view with foot flexed 30° and tube angles 30° anterior to sagittal plane. Angle between mid-talar line & mid-calcaneal line Talocalcaneal index : Kite’s angles from AP & lateral views are added together to form Talocalcaneal Index. In corrected foot this index should be > 40°

23. Normal foot vs clubfoot MEASUREMENT NORMAL FOOT CLUBFOOT PICTURE TIBIOCALCANEAL ANGLE 60-90° ON LATERAL VIEW > 90° ON LATERAL VIEW TALOCALCANEAL ANGLE 25-45° ON LATERAL VIEW 15-40° ON DP VIEW < 25° ON LATERAL VIEW <15° ON DP VIEW METATARSAL CONVERGENCE SLIGHT ON LATERAL VIEW & DP VIEW NO CONVERGENCE ON LATERAL VIEW INCREASE IN DP VIEW

24. ANGLES IN RADIOLOGICAL VIEW

25. Ponseti cast correction SETUP – calming the child with bottle or breastfeeding. Trained assistant. Assistance of the parents. Assistant holds the foot & the manipulator performs the correction MANIPULATION & CASTING - as soon after as possible. Within 7 to 10 days LOCATE THE HEAD OF TALUS – Palpate the malleoli with thumb and index finger of one hand and toes and mtatarsals are held with the other hand Slide the thumb and the index finger downward to palpate the head of the talus ,navicular and anterior tuberosity of calcaneus.

26. CONT.. MOTION OF TALO-CALCANEO-NAVICULAR JOINT : Abduction of forefoot will cause Movement of navicular in front of the head of talus Movement of anterior calcaneal tuberosity towards lateral side under the head of talus. MANIPULATION : It consists of abduction of the foot beneath the stabilized talar head. All components of clubfoot deformity is corrected simultaneously except the equinus deformity. Stabilization of Talus: Place thumb over the talar head. This provides a pivot point for abduction of the foot. Manipulation of foot by supination followed by abduction Hold the correction with gentle pressure, then release and repeat. Never pronate, never touch the heel and never use force . Younger child (not walked) Older child ( walked ) Hold correction for 30-40 seconds, release Hold correction for 1-2 minutes, release Repeat 1-2 times Repeat 3-4 times 2 minutes per clubfoot 5-10 minutes per clubfoot.

27. Younger child Cast the knees in 90 ° flexion Change casts every 5 – 7 days Abduction 50-60° After tenotomy last cast will remain for 3 weeks Abduction 60-70° Dorsiflexion 15-30° Cast knees in 70° flexion Change cast every 7-10 days Abduction 30-50° After tenotomy last cast will remain for 4 weeks Abduction 30-60° Dorsiflexion 10-20° Older child Cast after manipulation The cast is applied after the manipulation and immobilizes the foot in order to stretch the tight ligaments, joint capsule and tendons. Main focus of the 1 st cast is correction of cavus . Mid foot inversion and heel varus are corrected in subsequent casts. Long casts up to the groin to keep the talus in abduction and prevent its rotation in the ankle mortise.

28. Steps in cast application After preliminary manipulation cast is applied. APPLYING THE PADDING : thin layer of cast padding for molding of the foot. Maintain the foot in the maximum corrected position by holding the toes with counterpressure applied against the head of the talus . APPLYING THE CAST : First apply the cast below knee and then extend the cast to the upper thigh Two to four turns around toes and then work proximally up to the knee. Add a little tension to the turns of plaster above the heel . The foot should be held by the toes and plaster wrapped over the holder’s fingers to provide ample space for the toes.

29. Molding the cast Do not try to force correction with the plaster, use light pressure Do not apply constant pressure with the thumb over the head of talus; press and release immediately Mould the plaster over the head of talus while holding the foot in correct position. Arch is well moulded to avoid flatfoot or rocker-bottom foot deformity Heel and malleoli are well moulded. Calcaneus is never touched during manipulation or casting. It is a dynamic process, constantly move the finger to avoid pressure over any single site Continue moulding until plaster hardens.

30. Cont.. Extend the cast up to thigh. Use much padding to avoid skin irritation around the thigh. Plaster can be layered back and forth around the knee for strength and avoiding a large amount of plaster in the popliteal fossa. Leave the plantar cast to support the toes and trim the cast dorsally to the metatarsal-phalangeal joint. Leave the dorsum of all the toes free for full extension . The foot is in equinus and the forefoot is supinated .

31. First cast Correction of cavus and mild correction of midfoot inversion and heel varus

32. Following casts Correction of mid foot inversion and heel varus and continue correction of the cavus (if needed). In each cast aim for more abduction while supination automatically decreases. Younger child- 50-60° of abduction , Older child- 30-50° of abduction

33. The final outcome At the completion of the casting the foot appears to be over-corrected into abduction with respect to the normal foot while walking. It is actually a full correction of the foot into maximum normal abduction. Helps to prevent recurrence Does not create an over-corrected or pronated foot.

34. Characteristics of adequate abduction Confirm that the foot is sufficiently abducted to safely bring the foot into 0-5° of dorsiflexion before performing tenotomy. BEST SIGN : ability to palpate the anterior process of the calcaneus as it abducts out from beneath the talus ABDUCTION of 60° in relationship to the frontal plane of the tibia is possible . Neutral or slight valgus of os calcis is present. Determined by palpating posterior os calcis .

35. Complications of casting Rocker-bottom deformity : Due to dorsiflexion of the foot too early against a tight Achilles tendon. Crowded toes : Due to tight casting over the toes. Flat heel pad : Due to application of pressure over the heel. Superficial sores Pressure sores : Common sites  head of talus, over heel, under the 1 st metatarsal head, popliteal region and groin region. Deep sores.

36. Cast removal Remove the cast in clinic just before the new cast is applied because considerable correction can be lost from the time the cast is removed until the new one is placed. OPTIONS : CAST KNIFE REMOVAL : soak the cast in water for 20 minutes  wrap the casts with wet clothes before removal. Use plaster knife and cut obliquely to avoid cutting to the skin. Remove the above knee portion of the cast first, then the below knee portion . SOAKING AND UNWRAPING : Effective method but need more time. Soak cast thoroughly in water , then unwrap the plaster. Leave the end of the plaster free for identification .

37. Common management errors Pronation or eversion of the foot : Worsens deformity by increasing cavus External rotation of foot to correct adduction while calcaneus remains in varus Kite’s method of manipulation Casting errors : Failure to manipulate Short-leg cast. Premature equinus correction Failure to use appropriate night bracing Attempts to obtain perfect anatomical correction.

38. tenotomy Indication : To correct equinus when other abnormalities are corrected but ankle dorsiflexion < 10° above neutral . Preparation : Preparing the family by explaining the procedure Tenotomy blade # 11 or #15 Skin preparation  from midcalf to midfoot Small amount of local anaesthesia SETUP FOR TENOTOMY : Assistant holds the foot in maximum dorsiflexion Site – 1.5 cm above the calcaneus Neurovascular bundle is antero-medial to the heel cord .

39. tenotomy PROCEDURE :

40. Post tenotomy cast Correction of rigid equinus in the ankle and improvement of mid foot abduction and heel varus. In severe cases after tenotomy a second cast may be required Aim : To achieve neutral position to 5° of dorsiflexion. Apply the 2 nd cast after 4-5 days , but the last cast will stay for 3 – 4 weeks. After cast is removed, foot is in hyperabducted position. Younger child Older child Dorsiflexion 15-30° Dorsiflexion 10-20° Abduction 60-70° Abduction 30-60° Duration 3 weeks Duration 4 weeks

41. Premature equinus correction Attempts to correct equinus deformity before correcting the heel varus and foot supination deformity will result in rocker-bottom foot deformity. Repeat tenotomy should be planned. Failure to perform complete tenotomy Errors during tenotomy

42. bracing After clubfoot is corrected the brace is applied to maintain the foot is abduction and dorsiflexion. The degree of abduction is required to maintain the abduction of the calcaneus and forefoot and prevent relapse. The dorsiflexion helps to maintain the stretch on the gastrocnemius and heel-cord tendon. PROTOCOL : 3 or 4 weeks after tenotomy cast is removed & brace is applied immediately. For unilateral cases – External rotation 60-70° at clubfoot side , 30-40° at normal side . For bilateral cases – External rotation 70° in both sides . The bar should be bent 5-10° with convexity away from the child . Dennis-Browne splint

43. bracing IMPORTANCE OF BRACING : Without follow-up bracing program relapse occurs in 80% of cases Ponseti management + tenotomy + bracing , relapse occurs only in 6 % of cases TIME : All feet should be braced for 3 to 4 years , unless noncompliance. Child should be monitored closely for relapse Brace should be promptly started again.

44. Bracing

45. Types of braces STEENBEEK BRACE : Made from simple and easily available materials. Effective in maintaining the correction and is ideally suited for widespread use MITCHELL BRACE : This brace consists of shoes made of a very soft leather and plastic sole that is molded to the shape of the child’s foot. Very comfortable & easy to use DOBBS BRACE : New dynamic brace for clubfoot to move while maintaining the required rotation of the foot. An ankle foot orthosis is required as part of this brace to prevent ankle plantar flexion. Developed by Washington University School of Medicine, USA.

46. Types of braces MARKEL BRACE : The shoes are first placed on the infant and then attach them to the bar KESSLER BRACE : Flexible and inexpensive. Developed by Kaiser Hospital in Los Angeles, USA. Bar is made of 1/8” thick polypropelene . Has increased compliance. ROMANUS BRACE: Developed in Sweden. Shoes are made of malleable plastic that is molded to the shape of the child’s foot. Shoes are fixed to the bar with screws.

47. BRACES METHOD : Skin is cleaned properly and dried before putting the brace The heel should be properly placed, inspection holes are used to ensure correct position. ORDERING THE BRACE : Measure the length of the soles of both feet. Length of the bar should be about the width of the shoulders .

48. PROBLEMS WITH BRACING The feet cannot be placed properly in the brace and/or the foot is easily slips out. Dorsiflexion may not be sufficient and should be treated with a series of casts. Atypical clubfeet. Foot has a sore or blister. Bar is bent wrongly : Child should not stand on the brace. Child fights the brace and cries without apparent reason : Parents should be counselled not to remove the brace in response to child’s crying and must never allow intermittent usage of braces.

49. FOLLOW-UP AFTER BRACING

50. CTEV SHOES Modified shoes for children who start walking These shoes are used up to 5 years of age. Features : Straight inner border – to prevent forefoot adduction Outer border raise – to prevent inversion No heel – to prevent equinus

51. recurrences REASONS : Failure to wear the brace Failure in the treatment : Not enough abduction has achieved , navicular displacement was not fully corrected. Not enough dorsiflexion achieved Severe fibrosis in muscles, fasciae, ligaments and tendons in the posterior and medial aspect of the foot Associated defects : Arthrogryposis, Myelomeningocele etc. PREVENTION : Correction of 70° hyperabduction in younger child Strict bracing Stretching of gastrocnemius for 2 minutes before putting the brace. Stretching of tibialis posterior , squatting for 2 minutes before putting the brace Therapeutic exercises : To facilitate active movements of the foot.

52. Types of recurrences & management VARUS recurrence : Manipulation + casts  Bracing + stretching + Therapeutic exercises EQUINUS recurrence : Manipulation + casts Possibly tenotomy  Bracing + stretching + Therapeutic exercises DYNAMIC SUPINATION : Overactive tibialis anterior. Manipulation + casts Possibly tenotomy Tibialis Anterior Transfer Bracing + stretching + Therapeutic exercises

53. Atypical clubfoot CHARACTERISTICS : Short, stubby foot with soft skin and fluffy subcutaneous tissue Deep transverse crease in the sole of the foot. Deep posterior crease above the heel. Navicular severe medially displaced Anterior tuberosity of calcaneus bulges in front of lateral malleolus. Stiff subtalar joint 1 st toe is short and hyperextended Calf muscles are short Achilles tendon is very wide, long.

54. Modification of treatment MODIFIED MANIPULATION TO CORRECT THE MID FOOT INVERSION AND HEEL VARUS : Foot should be abducted within 30-40° CORRECTION OF HYPERFLEXED METATARSAL AND RIGID EQUINUIS: PREVENT SLIPAGE OF THE PLASTER CAST: plaster cast with knee 110-120° knee flexion

55. Modification of treatment PERCUTANEOUS TENOTOMY OF ACHILLES TENDON : Always cut tendon 1.5 cm above posterior skin crease of the heel. ( to avoid damage to the posterior tuberosity of calcaneus) Change the post tenotomy cast every 4-5 days till 5° of dorsiflexion & 40° of abduction is achieved BRACING & STRETCHING : At the beginning abduction 30-40° but when foot appears to be normal abduction can be 50° Stretching of gastrocnemius and tibialis posterior to improve dorsiflexion.

56. references Clubfoot management, 3 rd edition – Dr. Ignacio Ponseti Clubfoot (CTEV) – A Review : Dr. Jagannatha Sahoo Congenital clubfoot : Dr. Sanjay Meena, Dr. Pankaj Sharma, Dr. Sreesh kumar Gangary , Dr. Lalit Kumar Lohia Congenita Clubfoot – Dr. Henrik M. Wallander Treatment of clubfoot by Ponseti Method : Iris Lohan

57. THANK YOU