CTEV presentation for medical graduates.

Congenital talipes

1. Dr Ankit Bhalerao JR2 Dept of orthopaedic Dr. Deepak Agrawal Prof and HOD Dept of ortho DUPMC & H Dr. Pramod sarkelwad Ass. Prof and HOU Dept of ortho DUPMC & H

2. CTEV Congenital talpis equino varus

3. INTRODUCTION The word " talipes " is a portmanteau of two Latin words referring to ankle ( talus ) and foot ( pes ). The vernacular term" clubfoot " should be restricted to congenital variety of talipes equino varus deformity only and not the paralytic forms. The clubfoot was defined as congenital subluxation of talocalcaneonavicular (TCN) joint by Scarpa . Brockman defined it as congenital atresia of the astragalo-calcaneal scaphoid joint ( TCN joint). CTEV is a nonembryonal deformity i n which foot is turned inward to varying degrees.

4. Nonembryonal in the sense that the deformity develops during second trimester of pregnancy and is not possibly genetic at least always, so it can safely be classified to the best of current knowledge as a developmental deformity similar to congenital scoliosis or dysplastic development of hip. Clubfoot is one of the most common musculoskeletal birth defects and around 1 newborn is affected in every 1,000 live births

5. though the incidence varies (0.5-5%) in different geographic locations and among ethnicities (more common in Hawaii, Middle East, and Mediterranean Coast of North Africa). Up to half of the cases are bilateral and males are more commonly affected than females with a ratio of 2.5:1. Though less common in females they have a greater proportion of relatives with clubfoot abnormality compared to males. The incidence in first-degree relatives is around 2%. The incidence of occurrence of CTEV in second monozygotic twin if the first one has deformity is 32%, this supports multifactorial inheritance rather than a purely genetic one.

6. Pathoanatomically , it is defined as rotatory subluxation of TCN joint complex ( subtalar complex) with talus in plantar flexion and subtalar complex in medial rotation and inversion. In its most characteristic forms, the deformities are a combination of the following components Equinus at ankle  Varus and internal rotation of heel ( varus of heel is equivalent to inversion at subtalar joint) Adduction + Supination of forefoot ( varus of forefoot ) Cavus of midfoot  Internal tibial torsion

7. Equinus is composite of ankle joint plantar flexion, inversion of TCN joint, and plantar flexion of forefoot. Varus primarily occurs at TCN joint when the whole tarsus is rotated inward except talus. Adduction occurs when the foot is rotated inward. It occurs at talonavicular , anterior subtalar joint, and tarsometatarsal area. Cavus occurs due to relative pronation of the forefoot as compared to hindfoot which is supinated. This causes plantar flexion of the first metatarsal resulting in cavus. There is no differential diagnosis to CTEV-it is a classical presentation.

8. Various theories have been proposed for pathogenesis of clubfoot and are as follows: Hereditary Germ plasm defect Defective cartilage anlage of talus Intrauterine packaging defect Seasonal variations Neuromuscular defect (AMC) Fetal developmental arrest in fibular stage Congenital atresia of talonavicular joint Retracting fibrosis Three dimensional developmental bony deformity of Subramanian complex Infective pathogens Anomalous tendon insertion Vascular theory

9. BIOLOGY OF DEVELOPING CLUBFOOT As described by Ponseti in detail the deformities are a combination of soft-tissue contractures and possibly secondary bony changes. There is excessive pull of the tibialis posterior reinforced by the gastrosoleus , the tibialis anterior (TA), and the long toe flexors. These muscles are also smaller and shorter than the normal foot. The size of the leg muscles is inversely proportional to the severity of deformity. The "crimp collagen" arises from gastrosoleus and spreads to whole tendo-Achilles and the deep fascia tightening the structure. The bundles of collagen fibers display a wavy appearance known as crimp .

10. The ligaments of the posterior and medial aspect of the ankle and tarsal joints are very thick and taut, thereby severely restraining the foot in equinus and the navicular and calcaneus in adduction and inversion. The tautness is partially related to excess disorganized collagen synthesis. Excessive collagen synthesis (and crimp) may persist until the child is 3 or 4 years of age and can cause relapses. This crimp allows the ligaments to be stretched and, hence, explains the utility of manipulative maneuvers for treatment. The crimp reappears a few days of stretching, allowing for further stretching.

11. CLINICAL EXAMINATION AND CHARACTERISTIC FINDINGS Pathognomonic signs of idiopathic clubfoot include absence of dorsiflexion even on application of strong pressure ( dorsi-flexion test!). Normal foot of newborn will usually touch or reach out anterior aspect of leg. On clinical examination: The characteristic CTEV deformity will have an equinus that is accompanied by inversion of heel, adduction and varus of foot. The medial border is concave, elevated, and its plantar surface faces upward. The lateral border is convex and depressed downward. The posterior tuberosity of heel is pulled upward, difficult to palpate, and less visible.

12. An older child in addition may have callous on the dorsal aspect of fifth metatarsal. Bony prominence over dorsolateral aspect of foot represents head and neck of talus which are partially uncovered. Skin on the dorsolateral aspect the foot is usually stretched out and atrophied. In clubfoot, the skin over posterior tuberosity of calcaneum is smooth and lacks usual wrinkles. Skin over dorsolateral aspect of foot is atrophied, stretched, and thin. There is a deep cleft over medial plantar surface (usually accompanied with severe cavus with a forefoot flexion contracture). Some feet with severe cavus and equinus may have cleft on medial plantar surface and a cleft above heel

13. The knee shows hyperextension deformity due to fixed equinus of foot Genu valgum and external rotation at ankle joint may result on child's attempt to walk on a plantigrade foot. Increased external rotations of ankle mortise occur due to repeated attempts to dorsiflex and evert the deformed foot to compensate varus adduction deformity of foot by rotating the leg externally on weight bearing. The underdeveloped medial malleolus is slightly anterior to its normal position while lateral malleolus is palpable slightly posterior. The overall limb length is decreased. The atrophy of lower leg becomes prominent after child grows.

14. Plumb-line test (to detect tibial torsion): A line drawn from center of patella to tibial tubercle, when extended down, will pass normally through first web space. In CTEV due to medial rotation of tibia, it passes through third web space. Scars and callosities are features of patient walking on the deformity and are seen in neglected clubfoot. Pain in clubfeet, if present, may be caused by peroneal spasm, trauma, and callosities. Patients with severe deformities have a "stumbling" gait. Patients should be examined for movements at knee and hip that may be restricted in AMC. Significant number has developmental dysplasia of the hip (DDH)

15. CHARACTERISTIC BONY CHANGES AND RADIOLOGICAL EXAMINATION The detailed bony and soft-tissue changes are described below. Talus This bone is in severe plantar flexion with its head displaced medially and deflected plantarward . Due to persistent equinus, the anterior wider part of body never enters the ankle joint, therefore, this part may become relatively broad. There may be outward flaring of the facet which articulates with fibula. This prevents full dorsiflexion and causes persistent equinus. Normal angle between long axis of neck and head with body is 150° . But, in clubfoot, the medial deviation is increased so that angle (angle of declination) is between 115° and 135° (i.e., more acute).

16. Hence, neck is medially deviated and foreshortened. Normal constriction at neck which accommodates anterior lip of tibial plafond on dorsiflexion is absent, which decreases the dorsiflexion. Head and facet for navicular face medially instead of facing forward. It is broader with varying degree of flattening. In severe cases, it may be wedge-shaped. Posterior facet on the inferior surface of talus is underdeveloped and shallow. The three plantar facets on head appear as a single surface.Medial borders of talus and calcaneus are congruent and underdeveloped.

17. Calcaneum The calcaneus is involved in all three components of the deformity, i.e., (1) equinus, (2) varus , and (3) adduction. Its posterior tuberosity is displaced upward and laterally. The anterior end is displaced downward, medially, and is inverted. Sustentaculum tali is medially displaced, underdeveloped and fails to provide usual pulley for flexor hallucis longus (FHL) tendon.

18. Navicular The navicular is usually medially displaced. Its articular surface faces laterally to articulate with medially deviated head and neck of talus. In severe deformities, dorsomedial subluxation of navicular is present. Normal concavity of the proximal articular process is flattened. The navicular tuberosity is elongated and in close proximity to medial malleolus. Metatarsals Medial migration and inversion of all five metatarsals cause forefoot adduction which contributes to the convexity of the lateral border

19. Cuboid Bone Cuboid bridges the midtarsal and tarsometatarsal joint and as it occupies a position in both rows of tarsal bones, hence, significant medial displacement of cuboid is obstructed by navicular. Minimal changes occur in calcaneocuboid joint.

20. Soft-tissue Contractures This involves muscles, tendons, tendon sheaths, ligaments, joint capsule, and skin. Posterior tibial neurovascular bundle may also be shortened. The prime contractures which are common to all patients are tendo-Achilles , tibialis posterior, deltoid ligament, spring ligament, and talonavicular capsule. Contractures may be divided into posterior, medial, plantar, and subtalar . Posterior contractures ( tendo-Achilles , tibiotalar capsule, talocalcaneus capsule, post-talofibular ligament, calcaneofibular ligament) resist equinus deformity and correction of calcaneus and ankle joint.

21. Medial plantar contractures tibialis posterior (TP) tendon and sheath, tendon of FHL and flexor digitorum longus (FDL), deltoid ligament, talonavicular capsule, and spring ligament] Subtalar contractures comprise talocalcaneal interosse-ous ligament and bifurcate Y-ligament. These are usually seen in older children. Plantar contractures consist of abductor hallucis , intrinsic toe flexors, quadratus plantae , and plantar aponeurosis.

22. RADIOLOGY The ossification center for calcaneus and talus appear at 5-6th month and 8th month respectively in the intrauterine period. The ossification centers for the metatarsals appear between 9th and 10th week of gestation. The ossification center for cuboid appears at birth , and those for medial, intermediate lateral cuneiforms appear hat second, third, and the first year, respectively. As a rule, navicular is the last to appear among tarsus at 3-4 years of age. The skeletal maturity of foot appears at 12 years of age . There is delayed appearance of ossification centers for tarsal bones in CTEV

23. Normal Foot Radiology In a normal foot on an AP view, long axes of talus and calcaneus have a divergent angle (30-55°). The talo-first metatarsal angle is measured by drawing lines through the long axis of the talus and along the long axis of the first metatarsal . The normal range is 0-20°. On a stress limit lateral view, long axis of talus looks downward and that of calcaneus upward. The talocalcaneal angle in lateral view increases with dorsiflexion and decreases with plantar flexion, (normal 25-50°)

24. Radiology of Congenital Talipes Equinovarus Foot On an AP view, the divergent angle between talus and calcaneus decreases because calcaneus is inverted and its anterior end is adducted under talus . Angle of <20° indicates hindfoot varus . The continuation of long axis of talus falls lateral to the first metatarsal due to inversion-adduction of heel and forefoot adduction making talo-first metatarsal angle positive. This is well-appreciated in Kite's view (foot plantarflexed 30° and X-ray tube angled 30° anteriorly in sagittal plane). Navicular is medially displaced ( talonavicular subluxation).

25. Lateral view shows talonavicular parallelism. The talocalcaneal angle is markedly reduced and the lines may become parallel in severe cases. On a lateral view with foot in maximum dorsiflexion three signs of persistent equinovarus deformity include: No dorsiflexion of heel in relation to ankle joint Parallelism of talus and calcaneus (decrease in talocalcaneal angle)No overlap of anterior ends of calcaneus and talus (open sinus tarsi) The tibiocalcaneal angle (normal 10-40°) assessment is considered most reliable method for evaluating correction.

26. Talocalcaneal index = Combined talocalcaneal angle on
AP and lateral views. This should be >40° normally but is less in CTEV foot. Flat top talus is an apparent deformity when talus is deformed due to forcible correction in CTEV. Longer duration of casts treatment (>3 months) is also associated with flat-top talus deformity.

27. CLASSIFICATION OF CONGENITALTALIPES EQUINOVARUS Harrold Walker classified the CTEV based on ability to correct the deformity at first examination with firm pressure insufficient to cause pain.

28. Catterall described the system based on evolution of deformity based on several clinical parameters

29. The system of Dimeglio is based on four parameters with intrinsic details. These include equinus in sagittal plane, varus deviation in frontal plane, derotation around the talus, and adduction of forefoot on hindfoot .

30. The Ponseti and Smoley system is based on assessment of deformity correction following treatment and classifies them into good acceptable and poor

31. The Pirani system of scoring foot has been widely accepted and applied for assessment of the progress of deformity correction with the Ponseti method of manipulative correction of CTEV deformities. The system is based on clinical assessment of deformities and grading them from mild (or normal)—0, moderate—0.5, severe—1. The scores are added for midfoot (MFCS) and hindfoot (HFCS) individually.

32. TREATMENT The goal of treatment is to achieve: A plantigrade, pliable, functional, and cosmetically acceptable foot in the shortest treatment time with least disruption of the family life.A lasting correction. The objectives are: To obtain concentric reduction of TCN joint and ankle joint-the forefoot deformity should be corrected so that it points outward 20° then the keystone hindfoot deformity should be addressed to realign vertically with the leg instead of inversion.

33. Lastly, the equinus is corrected.
To maintain the reduction.To establish balanced muscular activity.To produce normal function and movements. On first visit, parents should be reassured and explained that they are not responsible for deformity. They should also be told about nature of deformity, course of treatment, unpredictability of response to the treatment, and propensity for recurrence.

34. Nonsurgical Treatment The initial management of clubfoot is nonsurgical treatment that should be started as soon as possible. A common saying is that "given a clubfoot deformity an orthopedician will apply cast to the foot before the child is born if it is breech delivery". As such the first 3 months of life are best for manipulative correction of foot. Different methods of non-operative treatment include manipulation of serial plaster casts, stretching and adhesive strapping and continuous passive motion (CPM).

35. History of non surgical treatment The first casts used for manipulative correction were made from egg-white and flour ( Cheselden,1740 ). The use of plaster of Paris (POP) for bandaging the clubfeet was described by Mathijsen in 1854. Thomas Wrench (1834-1891): This involved forceful correction of the deformity using device developed by HO Thomas.This often led to iatrogenic introduction of complex deformities and incomplete corrections. The acute corrections often lead to uncontrolled failure of important structures that often healed with stiffness. The "French method" of treatment by adhesive strapping + CPM ( Bensahel /Dimeglio regime): It works on a principle to apply an eversion corrective force (eversion tug) on feet by knee's motion. Daily manipulation is done by a physiotherapist and maintenance is done by elastic or nonelastic adhesive taping. CPM machine is used in sleep hours. The improvement is seen by first 3 months and if successful the regime is continued till the child starts walking. Irritation of skin and blister formation are its limiting factors.

36. Manipulative Treatment The manipulative treatment is based on the inherent properties of the young connective tissue, cartilage, and bone which respond to the appropriate mechanical stimuli created by the gradual reduction of the deformity. The ligaments, joint capsules, and tendons gradually stretch to accommodate reduction of the TCN joint. The displaced bones are gradually brought into normal relationship with serial casts. The casts must be applied with "eversion tug" principle, i.e., with each application of the layer of the cast an eversion force is gently applied to the foot.

37. Kite's Method of Manipulation and Kite’s Error Kite's method of manipulation 1939) for sequential correction of deformities (as opposed to simultaneous correction done in Ponseti: The classical method described by Kite included correction of adduction and varus components first (adduction → inversion → varus → equinus). However, the results were not very encouraging with this method as there were The primary "error" (commonly now called as "Kite's error") with this method is premature or initial correction attempted by direct abduction of forefoot that actually locks the calcaneum beneath the talus (the subtalar joint is rendered immobile).

38. The second error was choosing the lateral prominence ( calcaneocuboid joint or the cuboido-fifth metatarsal joint instead of talar head for counter pressure ) Thus, the method often leads to prolonged cast treatment up to 2 years and often had to be surgically corrected.

39. Ponseti Method of Simultaneous Correction of Congenital Talipes Equinovarus Deformities (1948) The results with this method have been consistently satisfactory and produce very low rates of relapse. The rate of surgery has also reduced significantly. The "principle" of the method is based on relative and interdependent intertarsal motion. There are three stages to Ponseti method of correction: The first stage It is manipulative correction to stretch out the tendons and straightening of the foot. This is gradually achieved as follows: The first deformity to be corrected is cavus . The varus and adduction deformity are corrected next. Then the equinus is corrected by stretching the tight posterior structures.

40. The second stage comprises quickened correction of equinus by percutaneous TA tenotomy and casting: The correction of the equines can be hastened by percutaneous tenotomy of the tendo-Achilles . The last plaster after tenotomy is generally applied for 3 weeks following which foot abduction brace (FAB) is given.

41. The third stage involves bracing of the feet. The FAB consists of comfortable sandals with a molded sole with a bar attached in between. The width of the bar matches the width of the shoulders and the feet are maintained in approximately 70° of abduction and 10-15° of dorsiflexion (bilateral deformity). For unilateral deformity, the normal foot is kept in 30-50° of abduction and neutral dorsiflexion. The FAB is applied 23 hours a day initially for the first 3 months. The 1 hour out of the brace is used for hygiene and toilet.

42. After 3 months weaning is begun by reducing wearing time @2 hours/month until FAB is applied only during sleeping time for a minimum of 4 years. Noncompliance with the FAB is the most common reason of recurrence especially the equinus deformity.

43. Bracing for Congenital Talipes Equinovarus Bracing the foot is an important part of clubfoot management specifically the maintenance of correction and improving the modeling of foot. Importantly, this part should be emphasized by the treating physician else parents often consider casting as the end of treatment and land up with recurrent deformities and loss of correction. Currently, three major groups of braces are available: Ankle foot orthosis Wheaton brace or Wheaton's type brace Foot abduction brace

44. Ankle Foot Orthosis It is similar to historically used tin rectangular night shoe covering the ankle and foot fully with neutral position at ankle. There is correction of plantar flexion only, while abduction is not provided by the brace so metatarsus adductus may not be corrected. Its use is also associated with calf-muscle atrophy. In cases of arthrogryposis or peroneal nerve palsy, this brace may be used as an adjunct to the abduction orthosis. Phelps brace is used for children between 6 and 18 months of age. This is fitted with an inside bar and outside T-strap on a high top shoe. Simple ankle foot orthoses can also be used for holding correction after soft-tissue release.

45. Wheaton's Type Braces (Knee-ankle-foot Orthosis) They provide reasonable abduction to the foot and medial stretching force pushing the forefoot in abduction if applied properly. Velcro strap is tightened against the apex of deformity to provide direct force for correction of deformity. The brace comes in two forms one in plantigrade position (foot in 15° dorsiflexion and the other with ankle in neutral position (0° plantar flexion). The brace being tied to the thigh may produce thigh muscle atrophy also along with the calf atrophy.

46. Adjustable Length Foot Abduction Brace Ponseti advised abduction and dorsiflexion of the foot for proper maintenance of the correction. Both these are optimally met with the use of foot abduction brace (also called though wrongly Denis-Browne shoe/bar/splint or"wobbly shoes", it is a brace not a splint/shoe.). The brace comprises two shoes connected by an abduction bar, the length of bar being guided by the distance between shoulders and changed with the growth of child. Feet are typically placed in 60-70° of external rotation/abduction or in case of unilateral deformity the normal foot is placed in 30-50° of external rotation.

47. Steenbeeck braces- developed in Uganda by Michiel Steenbeek and David Okello) have been developed that can be made from locally available cheap material while following the recommendations of Dr Ponseti. Kessler brace - Flexible connecting bar this facilitatesthe dorsiflexion twist provided by child's kicking action. Horton's click brace- here the shoe can be easily changed by just attaching the shoe through a clicking mechanism.
The shoe size changes fast in a growing infant and needs frequent changes. This is facilitated by the brace.

48. Dobb's dynamic clubfoot brace- to improve compliance this brace allows independent movement of the legs and thus allows movements at knee and hips. ALFA-Flex shoe - produced in Europe has nontoxic biocompatible materials and has "intelligent' foam (having both viscous and elastic components) allowing close fit to the child's foot and equidistribution of pressure.

49. Commonly followed bracing protocol: After correction, wear brace for 22-23 hours a day for first 3 months. Weaning schedule involves reducing the wearing time of brace by 2 hours every month for next 4 months. Maintain night-time bracing for 12-14 hours as child grows along with using CTEV shoe for during day till the age of 4-5 years.

50. MODIFIED PONSETI MANIPULATION FOR ATYPICAL CONGENITAL TALIPES EQUINOVARUS there is a small subset of clubfoot which does not correct or shows resistance to correction by standard Ponseti method. Over the course of treatment of idiopathic clubfoot by Ponseti technique, some feet show resistance to treatment. The common clinical features of these resistant (to manipulation)/atypical clubfeet are: Short and stubby feet Deep medial crease present over sole of foot Deep crease above the heel Severe equinus and supination 
Forefoot in adduction and plantarflexion of all metatarsals except great toe which is short and hyperextended

51. This type of clubfoot is difficult to treat and requires modification of standard Ponseti technique. Adduction of forefeet should not be corrected beyond 40° to prevent hyperabduction at tarso-metatarsal joint. Adduction should be corrected by keeping thumb on lateral aspect of talar head and index finger of same hand behind lateral malleolus . This also corrects heel varus .Once the heel varus is corrected, the plantarflexed forefoot and the equinus are corrected simultaneously by forcefully dorsiflexing the metatarsals with both thumbs while keeping index fingers of both hands on dorsal aspect of talar head

52. The cast is re-enforced by applying a posterior slab behind the ankle. To prevent the cast from slipping, knee is immobilized at 110° of flexion and it is re-enforced with a slab applied anteriorly over the knee. A tenotomy is performed before applying the last plaster cast to facilitate correction of a non-yielding equinus. Following cast removal Dennis-Brown brace is applied. Feet are kept at 40° abduction on both normal and affected sides. unlike standard Ponseti protocol, where feet are kept at 70° abduction on affected side and 30-50° abduction on normal side.

53. During the hour when the brace was removed, two exercises were performed. One, the child is made to squat for 10 minutes. Second, the parents passively dorsiflex the affected foot for 10 minutes.

54. SURGICAL MANAGEMENT OF CLUBFOOT When proper treatment of clubfeet is started shortly after birth a good clinical correction is a rule. After advent of the Ponseti's treatment, there has been a worldwide decline in the surgical intervention. The classical operations like posteromedial release and complete subtalar release are no longer required where Ponseti's method is being practiced correctly. Still surgery might be mainstay in rigid, relapsed, and neglected clubfeet in developing countries where Ponseti method is not practiced.

55. The kind of surgeries done for a clubfoot may be classified as: Soft-tissue surgery Bony surgery Combined soft tissue and bony surgery Correction of deformities by external fixation application

56. Soft-tissue Surgery Percutaneous tenotomy of the tendo-Achilles : It is an OPD procedure done under local anesthesia it should be known that tenotomy was first used and described by Delpech in 1816 and Stromeyer in 1836 A 15-number blade is introduced on the medial side of the tendon about 2 cm above its calcaneum insertion . The blade is introduced in the front of the tendon which is severed from front to back. The angle of dorsiflexion increases suddenly to about 10-15°, following which the final cast is given in about 70° of abduction and 10° of dorsiflexion for 3 weeks. A preliminary tendo-Achilles lengthening can also be done before manipulation to allow talus to enter ankle mortice.

57. Open Z-lengthening of the tendo-Achilles : It may still be rarely indicated in an older child. Percutaneous tenotomy has been done even in an older child with complete regeneration of the tendon thereby precluding use of Z-lengthening. Tendon transfers: Tibialis anterior transfer of Peabody: It is usually indicated after relapse in a child older than 3 years of age where the tendon has significant supination pull or in patients with a relative " evertor insufficiency". In both the conditions, the patients walk on lateral border of foot. TA transferred to lateral aspect prevents further relapses, corrects the AP talocalcanean angle, and reduces the need for medial release operations.

58. The transfer can be done as split anterior tibialis transfer (SPLATT) or whole tendon transfer. In SPLATT, the tendon is exposed by 4-5 cm long incision from just below ankle to medial cuneiform. Another incision is made over the lateral cuneiform. The split half of tendon is now anchored subcutaneously in a drill hole in the lateral cuneiform with a pull-out suture. To prevent bow stringing, the tendon is left under the superior retinaculum .

59. Peroneus transfer: Sometimes excessive lengthening of tendo-Achilles is done for aggressive correction of equinus deformity. This produces weakness of the gastro-soleus complex due to lengthened tendon. Most commonly the peroneus brevis is used to provide plantar flexion power by rerouting it into calcaneal tuberosity. Eversion insufficiency is prevented by tenodesing the distal cut stump to peroneus longus .

60. Tibialis posterior transfer is usually done in older children (>8 years of age) where the muscle is transferred anteriorly through the interosseous space on middle cuneiform. It is indicated in children with severe in-toeing, weak peroneals , cavus, and forefoot equinus. The principle is to eliminate the deforming force and use it as a corrective force.

61. Soft-tissue releases: The following surgical operations are of more or less academic interest only as their utility for the management of clubfoot is no longer or rarely required Simon recommended a foot size of at least 8 cm for doing the PMSTR. Turco favored doing PMSTR, after 1 year but within 2 years, One-stage posteromedial release (PMR) ( Turco ): The technique involves a release of posterior, medial plantar, and subtalar soft-tissue contractures in one stage. The following structures are released:

62. Medial release: Posterior and medial subtalar joint capsule (preserve interosseous ligament) Talonavicular joint capsule Spring ligament Y-ligament: Knot of henry Medial c alcan eocuboid joint capsule Abductor hallucis Lengthening of posterior tibial tendon, FHL, FDL Plantar fascia, quadrates plantae origin

63. Posterior release: Ankle joint capsule  Subtalar joint capsule Achilles tendon Z-lengthening Posterior talofibular ligament Lateral release: Lateral subtalar joint capsule Peroneal tendon sheath Calcaneofibular ligament Lateral talocalcaneal ligament Extensor digitorum brevis origin, calcaneocuboid ligament, inferior extensor retinaculum ,

64. Structures that should be preserved include dorsal structures, medial neurovascular bundle, deep deltoid ligament, and interosseous ligament. After the contractures are released, the navicular and calcaneus are restored to their normal relationship with talus and the surgical correction is temporarily stabilized by temporarily transfixing the talonavicular and talocalcaneal joints with K-wires.

65. Bony Procedures Dwyer’s osteotomy Osteotomy of calcaneus medial opening wedge osteotomy Disadvantages-high rate of wound dehiscence, development of equinus deformity, and problems of bone healing. Modified Dwyer osteotomy The present practice of lateral closing wedge osteotomy is well-accepted for improved union rates and avoiding complications. Dillwyn Evans procedure Resection and arthrodesis of calcaneocuboid is preferred for so-called short medial column CTEV

66. Lichtblau's osteotomy Medial release and osteotomy of distal calcaneus is used for persistent varus deformity of the hindfoot . This is done for the "long lateral column" CTEV. The lateral column is shortened by resecting the anterior process of calcaneum or a shortening osteotomy.Enucleation of the cuboid, anterior part of the calcaneus and head of the talus may be used for more resistant and syndromic feet in older children. Supramalleolar osteotomy (for persistent intoeing gait) and osteotomies of the bases of metatarsals are used to correct residual deformities.

67. External Distraction Devices for Clubfoot They have been popular for short periods when there was a shift from Kite to Ponseti method of manipulation and also previously when a lot of cases of resistant and recurrent deformities were found due to unsuccessful manipulation. Three types of external fixators have been used in clubfoot: Joshi's device Ilizarov apparatus Wagner's device

68. Controlled differential distraction, Joshi's external stabilization system (JESS) A dvantages like minimal surgery avoidance of surgical scar, and correction of all deformities either simultaneously (commonly) or sequentially (correction of forefoot adduction then correction of equinus). Foot length can also be gained. Correction of deformity by manipulation takes 3-6 weeks that has to be further maintained in POP cast for further 6 weeks. The procedure involves two major steps: Insertion of K-wires Formation of hold and connection between the hold

69. Insertion of K-wires: These include: Two tibial K-wires are placed one finger breadth distal to tibial tuberosity parallel to each other and to the knee joint line. Two parallel calcaneal K-wires are passed into the tuberosity of calcaneum from medial to lateral side around 1-1.5 cm apart protecting the neurovascular structures. One additional half K-wire is passed from the posterior aspect of the calcaneum axially .Metatarsal K-wire placement: One transfixing K-wire is passed through the necks of first and fifth metatarsal from lateral to medial side. Additional wires are passed parallel to and 10-12 mm apart from either side engaging three metatarsals each. The third metatarsal will have engaging pins from either side.

70. Creation of Holds and Connecting between the Holds: Two"Z" bars are attached to the tibial pins one on either side. Distraction schedule : Fractional calcaneo-metatarsal distraction is begun from third postoperative day to correct forefoot adduction at tarsometatarsal joint, reducing talus and calcaneocuboid joint. Differential distraction on medial side is performed twice as fast as on the lateral side (0.25 mm every 6 hours medially and 0.25 mm every 12 hours laterally). The tibiocalcaneal distraction is first carried out parallel to the leg and just posterior to the transfixing calcaneal wires at the rate of 0.25 mm every 6 hours medially and 0.25 mm every 12 hours laterally to correct varus of the hindfoot and equinus. The distractors are then shifted posteriorly to stretch posterior structures and correct hindfood equinus at the ankle and subtalar joints @0.25 mm every 6 hours.

71. The advantages of JESS methods are: Semi-invasive nature Bony procedures often not required Bloodless surgery Controlled correction of deformity Avoids fibrous tissue formation Actual lengthening and neohistiogenesis avoiding pressure on growing epiphysis

72. Correction with Ilizarov's apparatus The correction is based on two principles elucidated by Ilizarov himself: Tension-stress principle-Gradual traction on living tissue stimulates the genesis of tissue and growth throughout the distraction period. Shape-forming process acting upon bone tissue depending on the magnitude of applied load and vascularity. Increased load with accompanied adequate blood supply will lead to increased bone tissue while without good supply same load leads to reduction in bone volume.

73. TREATMENT OF RESISTANT DEFORMITY AND RELAPSED CONGENITAL TALIPES EQUINOVARUS Common components of a resistant deformity are: Adduction of forefoot Short medial column or long lateral column  Varus of calcaneum Equinus of the ankle Correction of forefoot adduction deformity is preferably done by metatarsal osteotomies.

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