CTEV presentation for seminar final.pptx

investigations and treatment

1. ctev investigations and treatment. moderator: dr Jayant jain presenter: dr atal shetty

2. Investigations: 1. Clinical Assessment: Primary tool for diagnosis Physical examination shows: Forefoot adduction Hindfoot varus Equinus at ankle Medial displacement of navicular and cuboid bones Bilateral vs Unilateral deformity

3. 2. Radiological Investigations (Usually done after 3-4 months of age when ossification centers are visible) X-rays of the foot (AP & lateral views): AP view angles: Kite’s angle (talocalcaneal angle: normally 20–40°, decreased in CTEV). Lateral view angles: Tibiocalcaneal angle and talocalcaneal angle. Assess talonavicular and calcaneocuboid alignment. Stress or dynamic views: For assessing correction. Ultrasound of foot: Useful in neonates (before ossification centers appear) to visualize cartilaginous structures.

4. 3. Ultrasound of foot: Useful in newborns (pre-ossification). Shows relationship of talus, calcaneus, and navicular. 4. Screening for Associated Anomalies Hip ultrasound (Graf’s method): To rule out DDH. Spine X-ray/USG: If spinal defects (e.g., spina bifida) are suspected.

5. Aims of treatment

6. Principles of treatment : The abnormal tarsal relationships are maintained by soft-tissue contractures. Soft Tissue Contractures should be stretched out in order to restore normal tarsal relationship. Once the tarsal relationship is attained, correction should be maintained till tarsal bones remoulds stable articular surface. Recurrent deformity results either in a failure to attain complete correction or maintain.

7. Nonoperative treatment KITE’S METHOD : Correction of each component separately Correction was done in following order

8. Outline of Ponseti regimen

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

10. Varus, inversion, and adduction correction

11. Stabilise the talus abducting the foot in supination

12. Correction of equinus

13. Percutaneous tenotomy under LA Foot held in max dorsiflexion by an assistant Tenotomy done 1.5 cm above calcaneal insertion Blade is pushed medial to tendon and rotated 90* underneath it. Tendon is cut from medial to lateral direction. "Pop" is felt additional 25-30 deg dorsiflexion obtained

14. POST TENOTOMY CAST WITH MAXIMUM DORSIFLEFION FOOT IN 60-70 DEG ABDN

15. Bracing protocol

16. Bracing protocol

17. CTEV SHOES Modified shoes for child who start walking. These shoes are used until 5 years of age. Special features: straight inner border outer shoe rise with no heel

18. Surgical management of CTEV

19. INDICATIONS RESISTANT CTEV RELAPSE AND RESIDUAL DEFORMITY ESP. AFTER PREVIOUS SURGERY NEGLECTED CLUB FOOT

20. RELAPSED VS NEGLECTED CTEV Relapsed CTEV Initial correction done and subsequent deformity, less severe Neglected CTEV Deformity severe and worsens as child starts walking

21. Surgical correction

22. SOFT TISSUE RELEASE

23. Cincinnati approach Circumferential incision : Posterio medial incision and posterio lateral incision limited exposure of the Achilles tendon.

24. TURCO’S APPROACH Posteromedial incision from base of 1 st mt to tendocalcaneum A  medial incision  is made to access the deep structures of the foot, which include: Tibialis posterior tendon Flexor digitorum longus (FDL) tendon Flexor hallucis longus (FHL) tendon Tendo Achillis Posterior vascular bundle

25. Z- plasty of Tendo Achilles:  This procedure involves lengthening the Achilles tendon using a Z-shaped incision. It helps reduce the tightness and contracture, improving the range of motion. Incision of the posterior capsule of the ankle joint : This helps to release any tight joint capsules that may be impeding normal ankle movement.

26. Subtalar joint release : The subtalar joint (between the talus and calcaneus) is released to allow for proper alignment. Division of the talofibular ligament : This ligament between the talus and fibula is divided to relieve tension and facilitate the correction. Division of the calcaneofibular ligament : This ligament between the calcaneus and fibula is also divided, which can be crucial for restoring normal foot alignment.

27. Soft tissue release 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

28. ACHILLES TENDON LENGTHENING AND POSTERIOR CAPSULOTOMY

29. Osteotomies Soft tissue release alone may not fully correct the deformity because of secondary bony deformity. The combination of this soft tissue release with midfoot osteotomy is usually required in children between approximately 4 and 12 years of age

30. DWYER OSTEOTOMY INDICATION : Persistent varus deformity of heel when soft tissue surgeries are contraindicated. Age 3-4 years Done by medial open wedge osteotomy or by lateral closed wedge osteotomy.

31. LATERAL COLUMN SHORTENING PROCEDURE INDICATION: Recurrence of clubfoot deformity after surgical release is mostly due to disparity between medial and lateral border of foot. Any attempt to correct deformity is resisted by medial contracture and excessive length of lateral column. Different procedure to shorten lateral column are : DILLWYNN EVANS PROCEDURE LICHTBLAU PROCEDURE

32. LATERAL COLUMN SHORTENING PROCEDURE DILLWYN EVANS PROCEDURE LICHTBLA U PROCEDURE

33. 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.

34. Incision and Exposure: Oblique incision : Centered over the  sinus tarsi . In line with  lateral foot skin creases . Incision is carried sharply through the  sinus tarsi  to reach the  extensor digitorum brevis (EDB) muscle .

35. Clear sinus tarsi  to expose: Subtalar joint Calcaneocuboid joint Lateral portion of the talonavicular joint Incise capsules  of: Talonavicular joint Calcaneocuboid joint Subtalar joint

36. TALECTOMY INDICATION: Reserved for severe untreated clubfoot. PROCEDURE : Complete excision of talus Derotate the foot and displace the calcaneus posteriorly into ankle mortise until navicular abuts the anterior edge of tibial plafond. COMPLICATION : Loss of limb length Limitation of ankle movement

37. Ilizarov in CTEV

38. Ilizarov 1) Correction slow enough to protect soft tissues; 2) correction at the focus of deformity, 3) simultaneous three-dimensional, multilevel correction; 4) deformity correction without shortening the foot;

39. Ilizarov Rings are fixed to the tibia connected to half rings for the calcaneus and the forefoot. Asymmetric distraction corrects the various deformities bony deformity not severe,(<8 yr): unconstrained frame Severe deformities,(>8 yrs): distraction osteogenesis through osteotomies using constrained frame with hinges

40. The construct

41. JOSHI EXTERNAL STABILISATION SYSTEM DR.B.B. JOSHI, MUMBAI.

42. JESS Fractional, differential distraction used to Sequentially correct deformities. 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

43. conclusion Proper understanding of the pathology and kinematics of clubfoot Application of therapeutic methods Laying stress on parental education to ensure compliance Surgery only as the last resort and is essential to successful therapy of this complex condition

44. Reference Campbell’s Operative Orthopaedics 14 th ed Tachdjian’s Pediatric Orthopaedics 6 th ed