CTEV basics

CTEV: RELAVANT ANATOMY, PATHOMECHANICS, CLINICAL EVALUATION AND MANEGMENT

1. DR. D. P. SWAMI Club Foot Congenital Talipes Equinus Varus DPS

2. Tali – Talus ( Ankle in Latin ) Pes – Foot A ny deformity of foot and ankle Club foot– heavy tapering stick with knobby end. Incidence – 1: 1000 live birth  M: F – 2:1 Bilateral – 50% U nilateral cases = Rt side = M/c DPS

3. Introduction One of the most common congenital deformities. The congenital clubfoot is a complex three-dimensional deformity having four components: equinus varus adductus cavus DPS

4. adduction = movement of a tarsal bone in which the distal part of this bone moves towards the median body plane; abduction = movement in the opposite direction; flexion = movement of a tarsal bone in which the distal part of that bone moves in the plantar direction; extension = movement in the opposite direction; DPS

5. inversion = movement of a tarsal bone in which the undersurface of the bone moves towards the median body plane; eversion = movement in the opposite direction. Equinus = increased degree of plantar flexion of the foot. Cavus = increased height of the vault of the foot. varus = inversion and adduction of the calcaneus valgus = eversion and abduction of the calcaneus. DPS

6. Definitions of movements for a tarsal (calcaneal) bone with respect to the body planes. (From Van Langelaan 1983.) DPS

7. Causes Idiopathic Several theories have been proposed . Otogenic Theory Arrest of fetal development Fetal Theory Mechanical block to development of fetal foot Embryonic Theory Primary Germ Plasm defect Neurogenic Theory Primary defect in neurogenic tissue or Neuromuscular defect Myogenic Theory Primary defect in muscles Primary soft tissue defect Abnormal TP tendon & contracted deltoid ligaments Chromosomal Theory Defect in unfertilised germ cells DPS

8. Intrauterine causes– Intrauterine pressure abnormality Amniotic fluid tension abnormality DPS

9. The four basic components of clubfoot are– C = cavus , A = adduction, V = varus, and E = equinus . DPS

10. Congenital clubfoot in newborn. Posterior view—inversion, plantar flexion, and internal rotation of calcaneus and cavus deformity with transverse plantar crease. DPS

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13. Equinus Ankle joint Inversion Subtalar joint Forefoot Adduction Midtarsal joint Midfoot Cavus Excessive Arching of foot DPS

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17. CLINICAL FEATURES High and small heel Abnormal crease in middle of foot Callosities at abnormal pressure areas Internal torsion of leg Calf muscles wasting DPS

18. Clinical History and Examination DPS

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20. family history …….. include a detailed inquiry into congenital defects of the locomotor system. The baby should be fully undressed for inspect ion , first in the supine and t hen in the prone positions in order to detect possible anomalies in the head, neck, chest, trunk, and spine. neurological examination M obility of trunk and extremities should be evaluated. DPS

21. The length of the legs and the circumference of the thighs and calves should be measured. The skin creases in the thighs, the ankle, and the foot should be recorded as well as the degree of equinus , heel and forefoot adduction, cavus , and foot supination. DPS

22. The position of the malleoli in relation to the tibial crest and tuberosity, the head of the talus, and the calcaneal tuberosity should be noted. The degree of the following anomalies should be recorded: heel equinus , heel cord tightness, calf circumference proximal retraction of the gastrosoleus muscle, adduction and inversion of the calcaneus, extent to which the talar head is subcutaneus in front of the lateral malleolus. DPS

23. The toes and metatarsals are grasped with one hand while the malleoli are felt from the front with the thu m b and the index finger of the other hand. DPS

24. The index finger and thumb slide downwards to reach the head of the talus and feel the navicular. With the hand holding the toes and metatarsals, the foot is abducted and sol e motion is felt in the navicular. The distance between the medial malleolus and the navicular tuberosity indicates the degree of displacement of the navicular. The degree of displacement of the anterior tuberosity of the calcaneus under the head of the talus correlates with the changes in the talocalcaneal angle and with the varus of the heel. DPS

25. Normal Range of Radiographic Angles for Comparison to Clubfoot Talocalcaneal angle Anteroposterior view: 30-55 degrees Dorsiflexion lateral view: 25-50 degrees Tibiocalcaneal angle Stress lateral view: 10-40 degrees Talus–first metatarsal angle Anteroposterior view: 5-15 degrees DPS

26. Radiographic evaluation of clubfoot. A,Anteroposterior view of right clubfoot with decrease in talocalcaneal angle and negative talus-first metatarsal angle. B,Talocalcaneal angle on anteroposterior view of normal left foot . C DPS

27. C,Talocalcaneal angle of degrees and negative tibiocalcaneal angle on dorsiflexion lateral view of right clubfoot. D,Talocalcaneal and tibiocalcaneal angles on dorsiflexion lateral view of normal left foot. DPS

28. Pirani’s system is composed of 10 different physical examination findings , each scored for no abnormality, 0.5 for moderate abnormality, or 01 for severe abnormality. A reliable method for assessing amount of deformity in clubfoot Formulated by Dr Shafique Pirani Child’s total score = 0 to 6 6 signs are assessed & each is scored 0,0.5 & 1 depending on severity Total score = 0 …….. No deformity Total score = 6 ……… Severe deformity SCORING SYSTEM FOR CTEV DPS

29. In the system of Dimeglio et al ., four parameters are assessed on the basis of their red with a handheld goniometer: equinus deviation in the sagittal plane varus deviation in the frontal plane, derotation of the calcaneopedal block in the horizontal plane, and adduction of the forefoot relative to the hindfoot in the horizontal planeucibility with gentle manipulation as measured DPS

30. PARAMETERS SCORE - 0 SCORE 0.5 SCORE 1 HIND FOOT SCORE Severity of PC Multiple fine creases One or two deep creases Deep creases change contour of arch EH Tuberosity of calcaneus easily palpable Tuberosity of calcaneus more difficult to palpate Tuberosity of calcaneus not palpable RE Normal ankle Dorsiflexion Ankle dorsiflexes beyond neutral, but not fully Can’t dorsiflex ankle to neutral MID FOOT SCORE Severity of MC Multiple fine creases One or two deep creases Deep creases change contour of arch CLB of foot Straight Mild distal curve Curve at calcaneocuboid joint Palpation of LHT Navicular completely reduces, Lateral talar head can’t be felt Navicular partially reduces, Lateral head less palpable Navicular doesn’t reduce, Lateral talar head easily felt Pirani scoring system DPS

31. Treatment goal - reduce or eliminate all the components of the congenital clubfoot deformity so that the patient has a functional, pain-free, normal- looking, plantigrade foot, with good mobility, without calluses, and requiring no modified shoes The initial treatment of clubfoot is nonoperative. Ponseti technique- described by Ignacio Ponseti and consists of weekly serial manipulation and casting during the first weeks of life. Bansahel/ Dimeglio Modified French technique. Kites technique. DPS

32. Ponseti Method Consists of two phases: T reatment maintenance. The treatment phase should begin as early as possible, optimally within the first week of life. Ponseti method is ideally used in newborns . Recurrence rates after Ponseti casting range from 10% to 30% most important factor in avoiding recurrent deformity is patient compliance with the postoperative brace wear regimen. DPS

33. The order of correction by seria l manipulation and casting should be as follows: first, correction of cavus next, correction of adductus and heel varus; and, finally, correction of hindfoot equinus . Generally five to six casts are required to correct the alignment of the foot and ankle fully. Before application of the final cast, most infants require percutaneous Achilles tenotomy to gain adequate lengthening of the Achilles tendon and prevent a rocker-bottom deformity. DPS

34. C a vus The cavus or high arch is a very common component of the clubfoot deformity. This deformity is, therefore, the result of the first metatarsal being in more plantar flexion than the last three metatarsals. DPS

35. After gentle manipulation of the forefoot into supination and abduction , the cavus deformity usually corrects with the first plaster cast. The sole of the foot should be molded so as to maintain the height of a normal arch. By abducting the foot with counter-pressure applied on the head of the talus, not only is the adduction of the forefoot partially corrected by the first cast but, to a lesser degree, also the hindfoot adduction. DPS

36. Relapsed clubfoot of a 3-year-old boy.The foot is supinated, but the forefoot is pronated in relation with the heel.The first metatarsal is severely plantarflexed while the fifth is in proper alignment with the cuboid and calcaneus.This abnormal relationship between the forefoot and the hindfoot causes the cavus deformity DPS

37. The main errors in the correction of the clubfoot are the pronation of the whole foot (A), and the pronation of the forefoot (B). DPS

38. Varus and adduction Occur primarily in the hindfoot. The correction of the cavus brings the metatarsals, cuneiforms, navicular, and cuboid onto the same plane of supination. All these structures form the lever arm necessary to laterally and slightly downwardly displace the navicular and the cuboid. This manipulation abducts the foot held in flexion and supination so as to accommodate the inversion of the tarsal bones while counter-pressure is applied with the thumb on the lateral aspect of the head of the talus. DPS

39. (Kite's error). By abducting the forefoot against pressure at the calcaneocuboid joint the abduction of the calcaneous is blocked thereby interfering with the correction of the heel varus. Grasping the heel with the hand will prevent the calcaneus from abducting DPS

40. In the fifth plaster cast to correct the clubfoot of this baby the feet are abducted 50 degrees. DPS

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42. Equinus The equinus is corrected by dorsiflexing (extending) the foot with the heel in neutral position after the varus and adduction of the foot have been corrected. While the foot is extended, with one hand placed flat under the entire sole, the heel is grasped with the thumb and fingers of the other hand and pulled downwards Two or three plaster casts applied after manipulations, carefully molding the heel, are usually needed to correct the equinus deformity. DPS

43. Plaster Cast Application The plaster cast is applied to maintain the correction obtained by manipulation. During plaster cast application an assistant holds the thigh with one hand and the toes with the thumb and index finger of the other hand, maintaining the knee in 90 degrees of flexion. A 2-inch-wide rolled bandage of soft cotton is wrapped by the orthopedist overlapping by half the width, starting at the toes and proceeding upwards to the upper thigh. plaster cast is extended to the upper thigh, just below the groin, with the knee at 90 degrees of flexion and the leg in a slight external rotation The plaster cast covering the toes should be trimmed to allow the toes to extend freely, but a platform of plaster should be left underneath the toes to prevent them from flexing. Otherwise, the tight toe flexors would remain unstretched. DPS

44. An assistant holds the thigh with one hand and the toes with the thumb and index finger of the other hand maintaining the knee at 90 degrees of flexion.A 2-inch soft roll is wrapped from the toes to the upper thigh. In the second cast the foot is in some supination. The sole of the foot is well molded and the forefoot is not everted. DPS

45. C The heel prominence is emphasized by molding around it instead of pressing on it. D In the third plaster cast the foot is only slightly supinated and the adduction is corrected to a neutral position. DPS

46. E In the fifth plaster cast the foot is markedly abducted without pronation. F In the sixth plaster cast applied after subcutaneous section of the tendo Achilles the foot is held in 70 degrees of abduction and 25 degrees of dorsiflexion without pronation. DPS

47. Maintenance Very important to prevent recurrence. a splint is needed to maintain the foot in the same degree of abduction as it was in the last plaster cast. DPS

48. Foot abduction brace and sandals with a well-molded plastic sole and three straps of soft leather to firmly hold the food down in the sandal.The sandals are attached to the splint in 60° to 70° of external rotation. DPS

49. The brace (foot abduction orthosis) consists of shoes mounted to a bar in a position of 70 degrees of external rotation and 15 degrees of dorsiflexion.The distance between the shoes is set at about 1 inch wider than the width of the infant’s shoulders.This brace is worn 23 hours each day for the first 3 months after casting and then while sleeping for 2 to 3 years. DPS

50. Surgery in clubfoot Resistant clubfoot( non-responsive to serial casting and manipulation) Relapsed clubfoot( initially satisfactorily corrected that recurs in part or whole) Neglected clubfoot( no treatment given till age of 2 yrs) DPS

51. General Principles Goal: address all pathoantomic structures Decision regarding timing, extent Index surgery, the most important Turco’s ‘one size fits all’ approach Posteromedial-plantar-lateral release: all deformities present Posterior release: straight lateral border, flexible forefoot and hindfoot, and palpable gap between medial malleolus and navicular tuberosity DPS

52. Approaches Turco Cincinnati DPS

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

54. Extensile posteromedial and posterolateral release Modified McKay procedure Cincinnati incision Posterolateral release Z lengthening of the TA Posterior capsulotomy of Ankle joint &Subtalar joint DPS

55. Incise superior peroneal retinaculum C u t off calc a n e ofi b ular 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 DPS

56. 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 DPS

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

58.  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 DPS

59. 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 DPS

60. Follow up : Wound inspection done under sedation at 1- 2 week Foot held in neutral, plantigrade position and above knee Cast applied for 4 – 6 weeks Cast removed along with any K wires, if applied during surgery for stabilisation, another 6 wks above knee cast given DPS

61. Resistant clubfoot Metatarsus adductus with age>5 yrs - metatarsal osteotomy 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 DPS

62. Neglected clubfoot No / incomplete initial treatment till the age of 2 years Moderately flexible, moderately stiff, and rigid Modified Ponseti*: manipulation for 5-10 mins, two weekly cast change, correction of foot to 30-40° abduction, and AFO for 1 year Extensive soft tissue release upto 4 yrs Dilwyn-Evans, Lichtblau procedure Triple arthrodesis Ilizarov/ JESS Lourenco et al . Correction of neglected club foot by ponseti method. JBJS Br. 2007 DPS

63. Bony procedures Dwyer osteotomy Osteotomy of calcaneus Opening wedge medial osteotomy to increase the length and height of calcaneus For isolated heel varus Modified method uses lateral incisions DPS

64. Litchblau procedure Medial soft tissue release Lateral closing wedge osteotomy of calcaneus Prevents long term stiffness of hindfoot Shortens the lateral column DPS

65. 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) DPS

66. Salvage procedures Triple arthrodesis Salvage procedure for pain after previous surgical correction. Correction of large degrees of deformity in neglected clubfeet. Not performed before advanced skeletal maturity, at age 10 to 12 Lateral closing wedge osteotomy through subtalar and midtarsal joints DPS

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68. Triple arthrodesis Dunn arthrodesis Hoke and kite DPS

69. T al e cto m y Severe, untreated clubfoot Previously treated clubfoot that is uncorrectable by any other surgical procedures Resistant neuromuscular or syndromic clubfoot DPS

70. Iliza r o v Correction slow enough to protect soft tissue Correction at the focus of deformity Simultaneous three- dimensional, multilevel correction Deformity correction without shortening the foot DPS

71. JOSHI EXTERNAL STABILISATION SYSTEM DR.B.B. JOSHI, MUMBAI 2 to 4 transfixing wires in prox tibia Metatarsal Transfixing wire through I &V MT; Medial half pin through I, II, III MT; Lat half pin thro’ IV,V MT  2 transfixing and 1 axial wire through calcaneum DPS

72. JESS Fractional, differential distraction used to Sequentially correct deformities (Medial- 0.25 mm every 6 hours ,Lateral- 0.25 mm every 12 hours) Distraction continued until approximately 20 degrees of dorsiflexion and overcorrection of the forefoot deformities was achieved Maintained in this overcorrected position for twice as long as the distraction phase by casts/braces DPS

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74. Complications of surgery Neurovascular injury Loss of foot (10% have atrophic dorsalis pedis artery bundle) Skin dehiscence Wound infection AVN talus Dislocation of the navicular Flattening and breaking of the talar head Undercorrection/ Overcorrection (esp with Cincinatti) Forefoot adductus Hindfoot varus Severe scarring Stiff joints Weakness of the plantar flexors of the ankle DPS

75. Conclusion Proper understanding of the patho- anatomy a must Ponseti method is now the standard treatment method Indications of surgery limited but well defined Turco’s posteromedial soft tissue release remains the treatment of choice in most cases amenable to surgical treatment DPS

76. THANK YOU DPS

77. Classification in 2 ways Relation to cause of deformity Idiopathic Secondary Postural Metatarsus Adductus Relation to Treatment Stage Untreated Treated Resistant Recurrent Neglected Complex DPS

78. Classification of Clubfoot according to etiology DPS

79. Child presents with apparent deformity. The foot is assessed using Pirani Score Child scores in both hind and mid foot categories Child has mid but no hind foot contracture scores Child has flexible foot with near full range and low pirani scores POSTURAL CLUBFOOT METATARSUS ADDUCTUS Child id given a general physical assessment; parents asked if they’ve noticed any other problems Physical assessment = Abnormal Physical assessment = N SECONDARY CLUBFOOT IDOIOPATHIC CLUBFOOT SYNDROMIC CLUBFOOT NEUROPATHIC CLUBFOOT Child has symptoms indicative of Syndromic condition Child has symptoms indicative of Neurological condition DPS

80. Classification of Clubfoot according to treatment DPS

81. Child presents with apparent clubfoot. Parents are asked about child’s treatment history Child has had Non – Ponseti treatment Child has had Ponseti treatment COMPLEX CLUBFOOT Foot has corrected Foot has not corrected RESISTANT CLUBFOOT TREATED CLUBFOOT Deformity occurs UNTREATED CLUBFOOT >2 years <2 years Child has never had treatment NEGLECTED CLUBFOOT RECURRENT CLUBFOOT DPS

82. Complications of casting Pressure ulcers Skin allergy Swelling Cast slip Circulation problems Rocker Bottom foot Muscle atrophy DPS

83. Tenotomy Timing of tenotomy Pirani score indicates MFCS is one or less Score for LHT is zero Heel is in valgus Foot is in abduction DPS

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