CTEV- Zuhra Ayu Ayu Ayu Ayu Ayu Ayu Ayu.pptx

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1. CONGENITAL TALIPES EQUINOVARUS Zuhra Ayu Ramdhani C014222097

2. OUTLINE WHAT IS CTEV? EPIDEMIOLOGY ETIOLOGY PATHOLOGICAL ANATOMY CLINICAL FEATURES CLASSIFICATION RADIOGRAPHIC EVALUATION TREATMENT SUMMARY

3. WHAT IS CTEV? ROTATORY SUBLUXATION OF TALOCALNOENAVICULAR JOINT (SUBTALAR) COMPLEX WITH TALUS IN PLANTAR FLEXION AND SUBTALAR COMPLEX IN MEDIAL ROTATION AND INVERSION. ALSO REFFERED AS CLUBFOOT . TALIPES DERIVED FROM TERM: TALUS- ANKLE & PES - FOOT EQUINOVARUS DERIVED FROM WORD EQUINO - LIKE A HORSE & VARUS - TURNED INWARD .

4. DEFORMITIES: 4 CLINICAL COMPONENTS: CAVE C - CAVUS - EXAGGERATED MEDIAL LONGITUDINAL ARCH AT MIDFOOT A - ADDUCTION - FOREFOOT IN ADDUCTION AT TARSOMETATARSAL JUNCTION V - VARUS - HINDFOOT ROTATED INWARD AT TALONAVICULAR JOINT E - EQUINUS - FOOT FIXED IN PLANTAR FLEXION AT ANKLE JOINT

5. EPIDEMIOLOGY: INCIDENCE- 1-2 PER 1000 LIVE BIRTH INCIDENCE IN FIRST DEGREE RELATION- 2% INCIDENCE IN SECOND DEGREE RELATION- 0.6% INCIDENCE IN MALE:FEMALE- 2.5:1 LATERALITY- >50% CASES ARE BILATERAL IN UNILATERAL AFFLICTION- RIGHT> LEFT

6. ETIOLOGY: MOST COMMON CAUSE OF CTEV IS IDIOPATHIC. OTHER THAN IDIOPATHIC IS SECONDARY CTEV WHICH IS ASSOCIATED WITH UNDERLYING CAUSE.

7. IDIOPATHIC CTEV: ARRESTED FETAL DEVELOPMENT : BOHM PROPOSED ARREST OF FETAL DEVELOPMENT OF THE LOWER LIMB IN 6-8 WKS SO CALLED CLUB FOOT EMBRYONIC STAGE. HOWEVER DYSMORPHIC TALAR HEAD AND MEDIAL DISPLACEMENT OF NAVICULAR IS NOT SEEN IN ANY STAGE OF NORMAL FETAL DEVELOPMENT. MECHANICAL FACTOR IN UTERO : OLDEST THEORY PROPOSED BY HIPPOCRATES SUGGESTING FOOT WAS HELD IN EQUINO VARUS BY EXTERNAL UTERINE COMPRESSION. SOME INVESTIGATOR OPINE DIMINUTION OF AMNIOTIC FLUID AS CAUSE OF CLUB FOOT. VASCULAR HYPOTHESIS : KEITH SUGGESTED TEMPORARY CESSATION OF CIRCULATION IN DEVELOPING FETUS RESULTED IN CONTRACTURES OF SOFT TISSUES AND DEFECTIVE DEVELOPMENT OF CARTILAGE.

8. IDIOPATHIC CTEV: MUSCULOLIGAMENTOUS FIBROSIS : IPPOLITO AND PONSETI FOUND CONSIDERABLE INCREASE IN COLLEGEN FIBRES AND FIBROBLASTIC CELLS IN LIGAMENTS AND TENDONS OF CLUBFOOT. THEY CONSIDERED TO BE PRIMARY DEFECT, CARTILAGINOUS AND BONY CHANGES BEING SECONDARY. PRIMARY GERM PLASMA DEFECT : WAISBROD SUGGESTED DEFECT IN PRIMARY GERM PLASMA OF CARTILAGINOUS TALAR ANALGE RESULTING IN DYSMORPHIC TALAR NECK AND NAVICULAR SUBLUXATION. HEREDITARY : WYNNE- DAVIES SUGGESTED CLUB FOOT ARE PART OF NUMEROUS SYNDROMES FOLLOWING MANDELIAN PATTERN OF EITHER AUTOSOMAL DOMINANT OR AUTOSOMAL RECESSIVE INHERITANCE.

9. SECONDARY CTEV: ASSOCIATED WITH NEUROMUSCULAR OR SYNDROMIC ETIOLOGIES- ARTHROGRYPOSIS MULTIPLEX CONGENITA DIASTROPHIC DYSPLASIA STREETER SYNDROME (CONSTRICTION BAND SYNDROME) FREEMAN SHELDON SYNDROME MOBIUS SYNDROME NAIL PATELLA SYNDROME DIASTROPHIC DWARFISM ASSOCIATED WITH PARALYTIC DISORDER- POLIOMYELITIS SPINA BIFIDA MYELODYSPLESIA FREIDRICH’S ATAXIA

10. SECONDARY CTEV: GENETIC CAUSES- N- ACETYLATION GENES NAT1 AND NAT2 XENOBIOTIC METABOLISM GENES CYP1A1 LIMB AND MUSCLE MORPHOGENESIS GENE HOXA, HOXD AND IGF BP3 GENE FOR LOWER EXTREMITY DEVELOPMENT- CAN D2 AND WNT 7A GENE FOR CONTACTILE PROTEIN OF SKELETAL MYOFIBRES- TBX4

11. PATHOLOGICAL ANATOMY: BONES - TALUS - HEAD AND NECK DEVIATED MEDIALLY AND DOWNWARD. MEDIAL AND PLANTAR DEVIATION OF NAVICULAR ARTICULATION. BODY ROTATED EXTERNALLY AND IS IN EQUINUS OF NECK IN ANKLE MORTISE. BODY EXTRUDED ANTERIORLY SMALLER THAN NORMAL NECK- BODY ANGLE IS 90-110* (NORMAL- 150*) DISLOCATION OF HEAD OF TALUS OUT OF ITS SOCKET.

12. PATHOLOGICAL ANATOMY: NAVICULAR - MEDIALLY AND PLANTAR DISPLACEMENT CLOSE TO MEDIAL MALLEOLUS ARTICULATES WITH MEDIAL SURFACFE OF DYSMORPHIC TALUS TALONAVICULAR JOINT SUBLUXATION

13. PATHOLOGICAL ANATOMY: CALCANEUM - OFTEN SMALL IN SIZE MEDIALLY ROTATED ANTERIOR PORTION LIES BENEATH THE HEAD OF TALUS CAUSING VARUS AND EQUINUS OF HEEL. SUSTENTACULUM TALI IS UNDERDEVELOPED. CUBOID - MEDIALLY SUBLUXATED OVER CALCANEUM HEAD

14. PATHOLOGICAL ANATOMY: MUSCLES AND TENDONS - ATROPHY OF PERONEAL GROUP OF MUSCLES CONTRACTURE OF TRICEP SURAE,TIBIALIS POSTERIOR,FLEXOR DIGITORUM LONGUS AND FLEXOR HALLUCIS LUNGUS. NUMBER OF FIBRES IN MUSCLE IS NORMAL BUT ARE SMALLER IN SIZE. THICKENING AND CONTRACTURE OF TENDON SHEATHS ESPECIALLY OF TIBIALIS POSTERIOR AND PERONEAL.

15. PATHOLOGICAL ANATOMY: LIGAMENTS - THICKENING AND CONTRACTURES ARE SEEN IN CALCANEOFIBULAR LIGAMENT TALOFIBULAR LIGAMENT DELTOID LIGAMENT LONG AND SHORT PLANTAR LIGAMENT SPRING LIGAMENT BIFURCATE LIGAMENT INTEROSSEOUS TALO CALCANEUM LIGAMENT MASTER KNOT OF HENRY

16. PATHOLOGICAL ANATOMY: JOINTS CAPSULE AND FASCIA- CONTRACTURES ARE SEEN IN POSTERIOR ANKLE CAPSULE SUBTALAR CAPSULE TALONAVICULAR JOINT CAPSULE CALCANEOCUBOID JOINT CAPSULE PLANTAR FASCIA CONTRACTURE ARE SEEN WHICH IS RESPONSIBLE CAVUS DEFORMITY

17. PATHOLOGICAL ANATOMY: SKIN CHANGES- DEEP CREASE ON MEDIAL SIDE DIMPLES IN LATERAL ASPECT OF ANKLE AND MID FOOT. SHORTENING ON MEDIAL SIDE OF SOLE CALLOSITIES AND BURSA ON LATERAL SIDE OF FOOT VASCULAR CHANGES- HYPOPLASIA OR ABSENCE OF DORSALIS PAEDIS AND ANTERIOR TIBIAL ARTERY

18. CLINICAL FEATURES: HEEL IS SMALL AND IN EQUINUS FOOT INVERTED ON END OF TIBIA DEEP CREASES ON MEDIAL AND POSTERIOR ASPECT ABNORMAL THIN CALF VARYING DEGREE OF RESISTANCE/ FIXED DEFORMITY WHEN TRY TO DORSIFLEX AND EVERT THE FOOT. LACK OF CORRECTABILITY OTHER JOINT ABNORMALITY ASSOCIATED ANOMALIES AND NEUROMUSCULAR CONDITION.

19. CLASSIFICATION: IDIOPATHIC AND NON-IDIOPATHIC CUMMIN CLASSIFICATION PONSETI AND SMOLEY CLASSIFICATION- BASED ON EXTENT OF DEFORMITY HARROLD AND WALKER CLASSIFICATION- BASED ON ABILITY TO CORRECT THE DEFORMITY. BROWNE’S CLASSIFICATION- BASED ON TYPE OF DEFORMITY DIMEGLIO ET AL SCORING SYSTEM BASED ON SEVERITY OF THE DEFORMITY PIRANI SCORING SYSTEM

20. CUMMIN CLASSIFICATION SUPPLE : FOOT CAN BE BROUGHT TO NORMAL POSITION AND ALL JOINTS ARE MOBILE. NEGLECTED : NO TREATMENT FOR 1 YR. RELAPSED : CORRECTED DEFORMITIES APPEARS AGAIN. RECCURENT : TYPE OF RELAPSE DUE TO MUSCLE IMBALANCE RESISTANT : NO CORRECTION AFTER CONSERVATIVE MANAGEMENT. RIGID : AFTER CONSERVATIVE TREATMENT FOREFOOT DEFORMITY CORRECTED AND HINDFOOT DEFORMITY REMAIN UNCORRECTED.

21. DIMEGLIO SCORING SYSTEM

22. PIRANI SCORING SYSTEM: SIMPLE AND RELIABLE SYSTEM TO DETERMINE SEVERITY AND MONITOR PROGRESS IN THE ASSESSMENT AND TREATMENT OF CLUBFOOT. SIX “SIGNS” ARE ASSESSED 3 SIGNS IN MIDFOOT 3 SIGNS IN HINDFOOT BASED ON 6 WELL-DESCRIBED CLINICAL SIGNS OF CONTRACTURE CHARACTERIZING A SEVERE CLUBFOOT: IF THE SIGN IS SEVERELY ABNORMAL IT SCORES 1 IF IT IS PARTIALLY ABNORMAL IT SCORES 0.5 IF IT IS NORMAL IT SCORES 0 TOTAL SCORE (TS) VARIES FROM 0 TO 6 AND IS THE SUM OF MIDFOOT AND HINDFOOT CONTRACTURE SCORES

23. PIRANI SCORING SYSTEM:

24. RADIOGRAPHIC EVALUATION: FOR NON AMBULATORY CHILD- ANTEROPOSTERIOR STRESS DORSIFLEXION LATERAL VIEW FOR OLDER CHILD- STANDING ANTEROPOSTERIOR STANDING LATERAL IMPORTANT ANGLE WE MEASURE- TALOCALCANEAL ANGLE ON AP AND LAT VIEW TIBIOCALCANEAL ANGLE ON LAT VIEW TALUS- FIRST METATARSAL ANGLE

25. RADIOGRAPHIC EVALUATION: TALOCALCANEAL ANGLE- ON AP VIEW- 1 ST LINE THROUGH THE CENTRE OF LONG AXIS OF TALUS (PARALLEL TO MEDIAL BORDER) 2 ND LINE THROUGH LONG AXIS OF CALCANEUM (PARALLEL TO LATERAL BORDER) NORMAL 25-40* ON LATERAL VIEW- 1 ST LINE MIDPOINT OF HEAD AND BODY OF TALUS 2 ND LINE ALONG BOTTOM OF CALCANEUM NORMAL 35-50*

26. RADIOGRAPHIC EVALUATION RADIOLOGICAL FINDING SEEN- ON LATERAL VIEW- DECREASED TALOCALCANEAL ANGLE ( TALOCALCANEAL PARALLELISM ) DISRUPTED TALAR FIRST METATARSAL ANGLE LONG AXIS OF TALUS AND CALCANEUM PASSES INFERIOR TO CUBOID (NORMALLY CROSSES CUBOID) ON ANTEROPOSTERIOR VIEW- INCREASED TALOCALCANEAL ANGLE INCREASED TALAR FIRST METATARSAL ANGLE LONG AXIS OF TALUS DEVIATE LATERALLY AND PASSES ALONG 3 RD OR 4 TH METATARSAL BONE

27. RADIOGRAPHIC EVALUATION

28. RADIOGRAPHIC EVALUATION:

29. TREATMENT: GOAL : TO ACHIEVE PLANTIGRADE FOOT FLEXIBILTY COSMETICALLY ACCEPTABLE FUNCTIONAL AND PAIN FREE FOOT IN SHORTEST TREATMENT TIME PRINCIPLES : SOFT TISSUE CONTRACTURE RELEASE OR STRETCHING TO RESTORE NORMAL TARSAL RELATIONSHIP. ONCE NORMAL TARSAL RELATIONSHIP ATTAINED, CORRECTION SHOULD BE MAINTAINED TILL TARSAL BONES REMOULDS STABLE ARTICULAR SURFACE.

30. NONOPERATIVE TREATMENT: SEVERAL REGIME HAVE BEEN PROPOSED INCLUDING SPLINTING TAPING AND CASTING. KITE’S METHOD : CORRECTION OF EACH COMPONENT SEPARATELY CORRECTION WAS DONE IN FOLLOWING ORDER KITE’S ERRORS : PRONATION/ EVERSION OF 1 ST METATARSAL. PREMATURE DORSIFLEXION OF HEEL. USED CALCANEOCUBOID JOINT AS FULCRUM THAT BLOCKS ABDUCTION OF CALCANEUS , THERBY PREVENTS EVERSION OF CALCANEUS.

31. NONOPERATIVE TREATMENT: PONSETI TECHNIQUE : 2 PHASE- TREATMENT AND MAINTENANCE PHASE TREATMENT PHASE- BEGINS AS EARLY AS POSSIBLE. DURING FIRST WEEK OF LIFE ONLY MANIPULATION IS CARRIED OUT BUT CAST IS NOT APPLIED. ORDER OF CORRECTION- TALUS HEAD IS USED AS FULCRUM . 5-6 SERIAL CASTING WITH MANIPULATION IS GENERALLY ENOUGH TO CORRECT THE DEFORMITY. MAXIMUM UPTO 1O CASTING CAN BE DONE.

32. PONSETI TECHNIQUE: CORRECTION OF CAVUS DEFORMITY : CORRECTED BY FOREFOOT SUPINATION RELATIVE TO HINDFOOT ALONG WITH ADDUCTION OF FOREFOOT. TENDS TO EXAGGERATE FOOT INVERSION. PRONATION OF FOREFOOT SHOULD NOT BE DONE AS IT INCREASES CAVUS DEFORMITY BECAUSE 1 ST METATARSAL IS FURTHER PLANTAR FLEXED. E- RIGHT MANEUVER TO CORRECT CAVUS DEFORMITY F- WRONG MANEUVER TO CORRECT CAVUS DEFORMITY

33. PONSETI TECHNIQUE A: THUMB IS POSITIONED OVER LATERAL ASPECT OF HEAD OF TALUS AND FINGER CORRECT THE FOREFOOT. B: CAVUS AND ADDUCTION ARE CORRECTED BY SLIGHT SUPINATION OF FOREFOOT IN RELATION TO HINDFOOT.

34. PONSETI TECHNIQUE CORRECTION OF VARUS AND ADDUCTION : CORRECTION OF CAVUS BRINGS METATARSAL, CUNIEFORM, NAVICULAR, AND CUBOID IN SAME PLANE OF SUPINATION. NOW FOOT IS ABDUCTED AND HELD IN FLEXION AND SUPINATION TO ACCOMMODATE THE INVERSION OF TARSAL BONES WHILE COUNTER PRESSURE IS APPLIED WITH THUMB ON LATERAL ASPECT OF HEAD OF TALUS. THIS MANEUVER NECESSITATES PROLONG STRETCHING OF MEDIAL TARSAL LIGAMENTS AND TENDONS.

35. PRESSURE EXERTED ON METATARSAL AND COUNTERPRESSURE ON LATERAL ASPECT OF HEAD OF TALUS. FURTHER ABDUCTION OF FOOT HELD IN FLEXION AND SUPINATION.

36. FOOT IS FURTHER ABDUCTED AND SUPINATION DECREASED BUT WITHOUT PRONATING THE FOOT

37. PONSETI TECHNIQUE CORRECTION OF EQUINUS : SHOULD BE ATTEMPTED WHEN HINDFOOT IS IN NEUTRAL POSITION TO SLIGHT VALGUS AND FOOT IS ABDUCTED 70* RELATIVE TO LEG. EQUINUS IS COORECTED BY PROGRESSIVE DORSIFLEXING THE FOOT. TO FACILITATE RAPID CORRECTION SUBCUTANEOUS TENOTOMY IS DONE. CARE SHOULD BE TAKEN WHILE DORSIFLEXING FOOT BY APPYLING PRESSURE UNDER ENTIRE SOLE AND NOT UNDER METATARSAL HEADS.

38. FOOT IS FURTHER ABDUCTED UPTO 70* TO STRETCH TO STRETCH MEDIAL TARSAL LIGAMENT. NOTE : HEEL IS NOT GRASPED BY HAND THUS ALLOWING CALCANEUS TO ABDUCT WITH FOOT AND HEEL VARUS TO CORRECT

39. EQUINUS CORRECTED BY SUBCUTANEOUS SECTION OF TENDO ACHILLES

40. PERCUTANEOUS TENOTOMY

41. PERCUTANEOUS ACHILLES TENOTOMY FROM MEDIAL TO LATERAL

42. PONSETI TECHNIQUE MAINTAENANCE PHASE : AFTER REMOVAL OF CAST INFANT IS PLACED IN FOOT ABDUCTION ORTHOSIS . BRACE IS WORN FOR 23HRS PER DAY FOR FIRST 3 MONTH THEN ONLY WHILE SLEEPING FOR 3-4 YEARS. FREQUENT FOLLOW UP IS IMPORTANT TO DETECT EARLY RECCURENCE. IT PREVENT RECURRENCE OF DEFORMITY IT FAVORS REMODELLING OF JOINTS WITH THE BONES IN PROPER ALINGMENT AND TO INCREASE LEG AND FOOT MUSCLE STRENGTH.

43. FOOT ABDUCTION ORTHOSIS ALSO KNOWN AS DENIS BROWN SPLINT . CONSIST OF SHOES MOUNTED TO CROSSBAR IN POSITION OF 70* EXTERNAL ROTATION AND 15* DORSIFLEXION. DISTANCE BETWEEN SHOES IS SET AT ABOUT 1INCH WIDER THAN THE WIDTH OF INFANT’S SHOULDER. IN UNILATERAL CASES NORMAL FOOT SHOULD IN 40* OUTWARD ROTATION.

44. CTEV SHOES MODIFIED SHOES FOR CHILD WHO START WALKING. THESE SHOES ARE USE UNTILL 5 YEARS OF AGE. SPECIAL FEATURES: STRAIGHT INNER BORDER OUTER SHOE RISE NO HEEL

45. NONOPERATIVE TREATMENT STRETCHING AND ADHESIVE STRAPPING(ROBERT JONES): PRINCIPLE- APPLY EVERSION CORRECTION FORCE ON FOOT WITH HELP OF ADHESIVE STRAPPING. FRENCH TECHNIQUE: GOAL IS TO REDUCE TALONAVICULAR JOINT, STRETCH OUT MEDIAL TISSUES AND THEN SEQUENTIALLY CORRECT FOREFOOT ADDUCTION, HINDFOOT VARUS AND EQUINUS OF CALCANEUM.

46. COMPLICATIONS OF NONOPERATIVE TREATMENT ROCKER BOTTOM FOOT BEAN SHAPED FOOT FRACTURES PRESSURE SORES FLAT TOP TALUS FAILURE OF CORRECTION RECCURENCE OR RELAPSE OF DEFORMITY

47. SURGICAL TREATMENT INDICATION : IN CASE OF NEGLECTED CTEV, RELAPSED CTEV, RECCURENT CTEV, RESISTANT CTEV, RIGID CTEV. CHOICE OF SURGERY : 1-4 YEARS- SOFT TISSUE RELEASE 4-11 YEARS- SOFT TISSUE RELEASE WITH OSTEOTOMY PERFORMED ACCORDING TO THE DEFORMITIES >11YRS- SALVAGE PROCEDURES TRIPLE ARTHRODESIS TALECTOMY

48. SOFT TISSUE RELEASE OPERATION TURCO’S OPERATION- IT IS ONE STAGE POSTEROMEDIAL RELEASE. HE EMPHASIZED ON SUBTALAR RELEASE ALONG WITH CALCANEOFIBULAR LIGAMENT. CAROLL’S INCISION- CAROLL EMPHASIZED ON PLANTAR FASCIA RELEASE AND CAPSULOTOMY OF CALCANEOCUBOID JOINT. IT INCLUDE 2 INCISIONS, MEDIAL AND POSTERO-LATERAL INCISION. CINCINATTI INCISION- IT IS DONE FOR POSTEROMEDIAL AND POSTEROLATERAL SOFT TISSUE RELEASE. PREFFERED TECHNIQUE FOR INITIAL SURGICAL MANAGEMENT OF CLUB FOOT. TENDOACHILLES TENDON RELEASE WITH POSTERIOR CAPSULOTOMY- TO CORRECT RESIDUAL HIND FOOT EQUINUS

49. TURCO OPERATION MEDIAL INCISION GIVEN EXPOSE TIBIALIS POSTERIOR, FDL,FHL, TENDOACHILLES AND POSTERIOR NEUROVASCULAR BUNDLE. DIVIDE MASTER KNOT OF HENRY. DIVIDE CALCANEONAVICULAR LIGAMENT AND ABDUCTOR HALLUCIS FROM TIBIALIS POSTERIOR TENDON,NAVICULAR TUBEROSITY AND 1 ST METATARSAL. POSTERIOR RELEASE- BY DOING Z-PLASTY OF TENDO ACHILLES, INCISING POSTERIOR CAPSULE OF ANKLE JOIN, SUBTALAR JOINT AND DIVIDING TALOFIBULAR LIGAMENT AND CALCANEOFIBULAR LIGAMENT. MEDIAL PLANTAR RELEASE- DIVIDE TIBIALIS POSTERIOR, SUPERFICIAL DELTOID LIGAMENT, TALONAVICULAR CAPSULE AND SPRING LIGAMENT. SUTALAR RELEASE- DIVIDE MEDIAL PART OF TALOCALCANEAL INTERROSEOUS LIGAMENT AND BIFURCATION OF Y LIGAMENT. AFTER REDUCING NAVICULAR BONE TRANSFIX TALONAVICULAR JOINT BY K-WIRE AND SUBTALAR JOINT BY 2 ND K-WIRE.

50. CINCINATTI INCISION TRANSVERSE CIRCUMFERENTIAL INCISION

51. ACHILLES TENDON LENTHENING AND POSTERIOR CAPSULOTOMY TO CORRECT RESIDUAL HINDFOOT EQUINUS Z-PLASTY IS DONE TO LENGTHEN THE ACHILLES TENDON. RELEASING MEDIAL HALF DISTALLY AND LATERAL HALF PROXIMALLY. POSTERIOR CAPSULOTOMY OF ANKLE AND SUBTALAR JOINT TO RELEASE CAPSULE CONTRACTURE.

52. TENDON TRANSFER INDICATION - PASSIVELY CORRECTABLE DEFORMITY RESULTING FROM MUSCLE IMBALANCE. ANTERIOR TIBIALIS TENDON TRANSFER- TENDON IS TRANSFERRED EITHER TO MIDDLE CUNIEFORM OR TO BASE OF 5 TH METATARSAL. SPLATT ( SPLit ANTERIOR TIBIALIS TENDON TRANSFER)- LATERAL PART OF TENDON IS SPLIT AND INSERTED TO CUBOID.

53. DWYER OSTEOTOMY INDICATION- PERSISTENT VARUS DEFORMITY OF HEEL WHEN SOFT TISSUE SURGERIES ARE CONTRAINDICATED. AGE- 3-4YRS DONE BY MEDIAL OPEN WEDGE OSTEOTOMY OR BY LATERAL CLOSED WEDGE OSTEOTOMY

54. 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 DO SHORTEN LATERAL COLUMN ARE- DILLWYNN EVANS PROCEDURE LICHTBLAU PROCEDURE FOWLER PROCEDURE

55. LATERAL COLUMN SHORTENING PROCEDURE DILLWYN EVANS PROCEDURE LICHTBLAU PROCEDURE AGE- 4-8 YRS INDICATION- MIDFOOT IN VARUS DUE TO TALONAVICULAR AND CALCANEOCUBOID SUBLUXATION AGE- 3-4 YRS INDICATION- HEEL VARUS & RESIDUAL INTERNAL DEFORMITY OF CALCANEUS WITH LONG LATERAL COLUMN

56. FOWLER PROCEDURE INDICATION - SUFFICIENT SCARRING THAT MEDIAL SOFT TISSUE AND SUBTALAR RELEASE WOULD BE IN EFFECTIVE. AGE- 6-8 YEARS PROCEDURE - LATERAL COLUMN SHORTENING COMBINING WITH MEDIAL COLUMN LENGTHING BY REMOVING WEDGE FROM CUBOID AND TRANSFERING IT TO AN OPENING WEDGE.

57. SALVAGE PROCEDURE INDICATION- UNCORRECTED CLUBFOOT OR WITH RESIDUAL DEFORMITY AFTER THE AGE OF 10 YRS. PAINFUL STIFF FOOT WITH POOR FUNCTION DIFFICULT TO ACCOMMODATE TO FOOT WEAR GOAL- CORRECT RESIDUAL DEFORMITY WHICH IS RESISTANT TO SOFT TISSUE RELEASE. TO ATTAIN FUNCTIONALLY AND COSMETICALLY ACCEPTABLE FOOT. PROCEDURE- TRIPLE ARTHRODESIS TALECTOMY

58. TRIPLE ARTHRODESIS INDICATION- PAINFUL STIFF FOOT WITH POOR FUNCTION DIFFICULT TO ACCOMMODATE TO FOOT WEAR ALL OTHER CORRECTION FAILED AGE – 10 – 12 YEARS PROCEDURE - OSTEOTOMY FOLLOWED BY FUSION OF TALONAVICULAR, TALOCALCANEUM AND CALCANEOCUBOID JOINT.

59. TALECTOMY INDICATION- RESERVED FOR SEVERE UNTREATED CLUBFOOT AGE - <6 YEARS 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

60. EXTERNAL FIXATOR INDICATION- IN CASE OF NEGLECTED AND RECCURENT DEFORMITY WITH SEVERE SCARRING MODALITIES- ILLIZAROV’S EXTERNAL FIXATOR JESS (JOSHI EXTERNAL STABILIZING SYSTEM) ADVANTAGE- PREVENT CRUSHING OF THE TISSUES ON CONVEX SIDE LENGHTENS THE LIMB EFFECTIVELY CORRECT THE DEFORMITY AT SAME TIME

61. ILLIZAROV’S EXTERNAL FIXATOR PRINCIPLE - FRACTIONAL DISTRACTION INDICATION - SEVERE DEFORMITIES WITH SEVERE SCARING OR TROPHIC ULCERS WHICH MAKE OPERATIVE INTERVENTION CONTRAINDICATION BECAUSE OF RISK OF TISSUE NECROSIS. STEPS OF CORRECTION-

62. JESS PRINCIPLE- DIFFERENTIAL DISTRACTION ADVANTAGE- LENTHENS ALL CONTRACTED TISSUES PREVENTING HISTIOGENESIS AND THUS AVOID CUTTING OF THESE IMMINENT SCARRING. POSSIBLE TO CONTROL MAGNITUDE OF CORRECTION. NO FURTHER SHORTHENING OF FOOT RESULTANT FEET IS VERY SUPPLE.

63. SUMMARIZING PLAN OF TREATMENT

64. A. FRESH CASE OF CTEV AT BIRTH ALL DEFORMITIES LEFT: PMSTR ONLY EQUINUS: POSTERIOR RELEASE ONLY HEEL VARUS: DWYER’S OSTEOTOMY FOLLOW TILL 10-12 YEARS OF AGE TREATMENT SUCCESSFUL TREAT AS B

65. B. OLD AND NEGLECTED CASES < 3 YEARS OLD SOFT TISSUE RELEASE 4-8 YEARS OLD SOFT TISSUE RELEASE + OSTEOTOMY 10-12 YEARS OLD ALREADY OPERATED

66. THANK YOU 3 RD JUNE