PATHOLOGY AND MGT OF CLUB FOOT.pptx

Pathology and management of clubfoot
orthopedics
Management of CTEV

1. PATHOLOGY AND MANAGEMENT OF CLUB FOOT Dr Pirfa Shindang Registrar Orthopedic department

2. OUTLINE INTRODUCTION INCIDENCE BRIEF HISTORY ANATOMY OF THE FOOT AETIOLOGY PATHOANATOMY CLASSIFICATION MANAGEMENT History Physical examination Investigations Treatment COMPLICATIONS CONCLUSION

3. INTRODUCTION Also called Talipes Equinovarus The term talipes is derived from the word Talus in Latin ( ankle bone) and Pes ( foot ) Equinovarus is the most important talipes deformity Diagnosis is made clinically with a resting equinovarus deformity of the foot. Treatment is usually nonoperative method. Supplemental surgical procedures such as tendo-achilles lengthening and tibialis anterior transfer may be required to correct residual deformity.

4. Talipes | 4 Equinus: plantar flexed (talus pointing down) Varus: deviation of heel (calcaneus) and forefoot (inward) Supination: foot rests on outer side (upward rotation) Equinus Varus Supination

5. INCIDENCE Globally 100,000 to 200,000 cases are born yearly 80% occur in low and middle income countries Global average incidence 1 in 1000 live births Male to female ratio 2:1 Bilateral in 50% of cases When unilateral is commoner in the left

6. WEST AFRICAN PERSPECTIVE Ukoha U , Egwu OA a Department of Anatomy, Nnamdi Azikiwe University, Nnewi Campus, Anambra State,2011 Incidence of club foot was found to be 3.4 per 1000 (60%) of CTEV occurred bilaterally while (40%) were unilateral Adjoa Nkrumah Benson et al in Northern Ghana: a two year retrospective descriptive study, 2017 Bilateral clubfoot formed 65.5% of case presentations  Idiopathic clubfoot made up 67.9% of total clubfoot types.

7. BRIEF HISTORY 400 BC - Described by Hippocrates 1803 - Patho - anatomy was first described by Scarpa 1823 – Delpech performed subcutaneous tenotomy 1838 – M .Guerin described the use of Plaster of Paris in treatment of congenital club foot 1950s – Ponsetti technique It was developed by Ignacio V. Ponseti of the University of Iowa Hospitals and Clinics. 2000 - John Herzenberg repopularized the technique by Ponsetti in the USA and Europe.

8. Talipes | 8 Illustration source: http://medicaldictionary.thefreedictionary.com/_/viewer.aspx?path=dorland&name=talipes.jpg&url=http%3A%2F%2Fmedical-dictionary.thefreedictionary.com%2Ftalipes Forefoot Midfoot Hindfoot Normal Foot Anomalies of the Foot Calcaneus Talus Navicular ANATOMY OF THE FOOT

9. AETIOLOGY The most common cause of CTEV is Idiopathic. Other than idiopathic is secondary CTEV which is associated with an underlying cause

10. IDIOPATHIC CTEV Arrested fetal development : BOHM suggested arrest of fetal development of the lower limb at 6 to 8 weeks 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.

11. IDIOPATHIC CTEV Mechanical factor in utero : Oldest theory proposed by HIPPOCRATES suggesting foot was held in equino - varus by external uterine contraction. Vascular hypothesis : KEITH suggested temporary cessation of circulation in developing fetus resulted in contractures of soft tissues and defective development of cartilage

12. IDIOPATHIC CTEV   Musculo - ligamentous fibrosis : IPPOLITO and PONSETI found considerable increase in collagen fibers and fibroblastic cells in ligament and tendon of club foot The considered it to be the primary defect, cartilaginous and bony changes are secondary  

13. IDIOPATHIC CTEV Primary germ plasma defect : WAISBROD suggested defect in primary germ plasma of cartilaginous talar analage resulting in dysmorphic talar neck and navicular subluxation.  Hereditary : WYNNE- DAVIES suggested club foot are part of numerous syndromes following mendellian patterns of either Autosomal dominant or Recessive inheritance

14. SECONDARY CTEV Associated with neuromuscular or syndromic etiologies Arthrogyroposis multiplex congenita Diastrophic dysplasia Streeter syndrome (Constriction band syndrome) Associated with paralytic disorder Poliomyelitis Spina Bifida Myelodysplasia Fredrichs Ataxia

15. PATHOANATOMY The key point is that the os calcis is internally rotated around the talocalcaneal ligament The rotation forces the heel into equinus and varus And the connections of the forefoot with the hindfoot through the navicular and cuboid result in the forefoot being in an adducted and supinated position.

16. Talipes | 16 Illustration source: http://medicaldictionary.thefreedictionary.com/_/viewer.aspx?path=dorland&name=talipes.jpg&url=http%3A%2F%2Fmedical-dictionary.thefreedictionary.com%2Ftalipes Photo Source: Staheli-Clubfoot:Ponseti Management – www.global-help.org Navicular Calcaneus Talus Normal Talipes The talus is deformed and the navicular is medially displaced The foot is rotated around the head of the talus (arrow)

17. Bone Tibia : Slight shortening is possible. Fibula : Shortening is common. Talus : In equinus in the ankle mortise, with the body of the talus being in external rotation, the body of the talus is extruded anterolaterally and is uncovered and can be palpated. The neck of the talus is medially deviated and plantar flexed. All relationships of the talus to the surrounding bones are abnormal.

18. Calcaneous : Medial rotation and an equinus and adduction deformity are present. The posterior part of the calcaneum is held close to the fibula by a tight calcaneofibular ligament, and is tilted into equinus and varus Navicular : The navicular is medially subluxated over the talar head. Cuboid : The cuboid is medially subluxated over the calcaneal head. Forefoot : The forefoot is adducted and supinated

19. Muscle Atrophy of the leg muscles, especially in the peroneal group, . The number of fibers in the muscles is normal, but the fibers are smaller in size. The triceps surae, tibialis posterior, flexor digitorum longus (FDL), and flexor hallucis longus (FHL) are contracted. The calf is of a smaller size and remains so throughout life, even following successful long-lasting correction of the feet.

20. Muscle contractures contribute to the characteristic deformity that includes (CAVE)      Cavus (tight intrinsics, FHL, FDL) Adductus of forefoot (tight tibialis posterior) Varus (tight tendoachilles, tibialis posterior, tibialis anterior) Equinus (tight tendoachilles)

21. Tendon sheaths : Thickening frequently is present, especially of the tibialis posterior and peroneal sheaths. Joint capsules : Contractures of the posterior ankle capsule, subtalar capsule, and talonavicular and calcaneocuboid joint capsules commonly are seen. Ligaments: Contractures are seen in the calcaneofibular, talofibular, (ankle) deltoid, long and short plantar, spring, and bifurcate ligaments. Fascia : The plantar fascial contracture contributes to the cavus, as does contracture of fascial planes in the foot

22. The skin and soft tissues of the calf and the medial side of the foot are short and underdeveloped. If the condition is not corrected early, secondary growth changes occur in the bones; these are permanent

23. CLASSIFICATION 1. Idiopathic and Secondary 2. Cummin Classification 3. Ponseti and Smoley classification ; based on extent of deformity 4. Harold and Walker classification ; based on ability to correct the deformity 5. Manes, Costa and Innao classification; assesses the severity of the deformity.

24. CUMMIN CLASSIFICATION Supple ; foot can be brought to normal position and all joints are supple Neglected ; affected child is older than 2 years with little or no treatment Relapsed ; corrected deformity appears again Recurrent ; child shows signs of deformity in previously treated club foot this type of relapse due to muscle imbalances Resistant ; no correction after conservative management Rigid ; after conservative treatment forefoot deformity corrected and hind foot remain uncorrected

25. CLINICAL FEATURES The deformity is usually obvious at birth; the foot is both turned and twisted inwards so that in the worst cases the sole faces poster medially. The clinical features have been classified by Pirani so that the severity can be assessed at birth and the progress of treatment can be monitored.

26. In a normal baby the foot can be abducted, everted and the ankle dorsiflexed. The infant must always be examined for associated disorders such as congenital hip dislocation and spina bifida. The absence of creases may suggest arthrogryposis; look to see if other joints are affected Treatments attempted and results and any complications of previous treatments.

27. SCORING SYSTEMS Pirani scoring system Dimeglio scoring system

28. PIRANI SCORING SYSTEM Simple and reliable system to determine severity and monitor and assesses progress during treatment Six signs are assessed 3 signs in mid foot 3 signs in hind foot Based on 6 well described clinical signs If sign is severely abnormal it scores - 1 If partial abnormal it scores - 0.5 If its normal it scores - 0 Total score of - 6

29. PIRANI SCORING SYSTEM

30. Dimeglio et al Classification Assess parameters degrees score Equinus in sagital plane 90-45 4 Varus in frontal plane 45-20 3 Calcaneopedal block – horiz 20-0 2 Adduction forefoot “ 0- (-20) 1 In addition Posterior crease 1 Mediotarsal crease 1 Planter retraction – Cavus 1 Poor muscle condition 1 Grade Type Score total 20 I Benign 1-4 II Moderate 5-9 III Severe 10-14 IV Very Severe 15-20

31. RADIOLOGICAL EXAMINATION X-rays are used to assess progress after treatment in the older child and are rarely used in the initial assessment and management The AP film is taken with the foot 30 degrees plantar flexed Lines drawn through the long axis of the talus parallel to its medial border Through that of the calcaneum parallel to its lateral border; They normally cross at an angle of 20–40 degrees (Kite’s angle)

32. AP VIEW

33. The lateral film is taken with the foot in forced dorsiflexion. Lines drawn through the mid - longitudinal axis of the talus and the lower border of the calcaneum should meet at an angle of about 40 degrees. A measurement of less than 20 degrees shows that the calcaneum cannot be tilted up into true dorsiflexion The foot may seem to be dorsiflexed but it may actually have ‘broken’ at the midtarsal level, producing the so-called rocker-bottom deformity

34. LATERAL VIEW

35. TREATMENT The aim of treatment is to produce and maintain a Plantigrade, Supple foot Pain free Stable over time Cosmetically pleasing appearance That function well

36. CONSERVATIVE TREATMENT Treatment should begin early, preferably within the first 2 weeks after birth. This consists of manipulation repeated weekly, with the foot held in place with a plaster cast. The procedure is the brainchild and result of a lifetime of dedicated work to finesse the program by Dr Ignacio Ponseti, whose name is synonymous with the procedure.

37. PONSETI TECHNIQUE: 2 PHASE Treatment and maintenance phase TREATMENT PHASE- starts as early as possible During first week of life only manipulation is carried out but cast is not applied ORDER OF CORRECTION CAVUS ADDUCTION WITH VARUS EQUINUS Talus head used as a fulcrum 5 to 6 serial casting with manipulation is generally enough to correct the deformity Maximum up to 10 casting can be done

38. CORRECTION OF CAVUS DEFORMITY Corrected by forefoot supination relative to hind foot along with adduction of forefoot Tend to exaggerate foot inversion Pronation of the forefoot should not be done as it increases cavus deformity because first metatarsal is further planter flexed

39. CORRECTION OF VARUS AND ADDUCTION Correction of cavus brings metatarsal cuneiforms navicular and cuboid in the 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 prolonged stretching of medial tarsal ligament and tendons

40. CORRECTION OF EQUINUS Should be attempted when hind foot is in neutral position to slight valgus and foot is abducted 70 degrees relative to leg Equinus is corrected by progressive dorsiflexing the foot To facilitate correction subcutaneous tenotomy is done Care should be taken while dorsiflexing the foot by applying pressure under entire sole and not under metatarsal head.

41. Foot is further abducted up to 70 degrees to stretch medial tarsal ligament . Note: Heel is not grasped by hand thus allowing calcaneus to abduct with foot and heel varus to correct

42. MAINTENANCE PHASE After removal of cast infant is placed on foot abduction orthosis Brace is worn for 23hrs a day for the first 3 months then only while sleeping for 3 to 4 years Frequent follow ups is important to detect early recurrence It prevent recurrence of deformity It favors remodeling of joints with bones in proper alignment and to increase leg and foot muscle strength

43. FOOT ABDUCTION ORTHOSIS Also known as Dennis Browne splint Consist of shoes mounted to crossbar in position 70 external rotation and 15 dorsiflexion Distance between shoes is set at about 1 inch wider then the width of the infants shoulder In unilateral cases normal foot should be in 40 outward rotation

44. CTEV SHOES Modified shoes for child who starts walking These shoes are used until 5 years Special features Straight inner border, Outer shoe rise, No heel.

45. Stretching and adhesive strapping ( Robert Jones ) Principle : Apply eversion correction force on foot with the help of adhesive strapping French technique Goal is to reduce Talonavicular joint, stretch out medial tissues and sequentially correct fore foot adduction hind foot varus and equinus of calcaneum

46. COMPLICATIONS OF NONOPERATIVE TREATMENT Rocker bottom foot Bean shaped foot Fractures Pressure sores Failure of correction Recurrence or relapse of deformity.

47. SURGICAL TREATMENT Indication In cases of neglected CTEV, relapsed CTEV Recurrent CTEV Resistant CTEV, Rigid CTEV Choice of surgery : Ideal age – when the limb is big enough for safety usually 6 months. But best time is just before walking – 8-12 months 1 to 4 years Soft tissue release 4 to 11 years Soft tissue release with Osteotomy performed according to deformities > 11years – Salvage procedures Triple Arthrodesis Talectomy

48. SOFT TISSUE RELEASE OPERATION TURCO’S OPERATION- it is a one stage posteromedial release He emphasized on subtalar release along with calcanofibular ligament CAROLL’S INCISION- CAROLL emphasized on plantar fascia release and capsulotomy of calcanealcubiod joint It includes two incisions medial and postero lateral incision CINCINATTI INCISION- it is done for posteromedial and postero lateral soft tissue release Preferred 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, Tendo Achilles and posterior neurovascular bundles 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 joint , subtalar joint and dividing talofibular ligament and calcaneofibular ligament

50. Medial plantar release – divide tibialis posterior, superficial deltoid ligament, talonavicular capsule and spring ligament Subtalar release – divide medial part of talocalcaneal interosseus ligament and bifurcation of Y ligament After reducing navicular bone transfix talonavicular joint by K – wire and subtalar by 2 nd k wire

51. CINCINATTI INCISION Transverse circumfrencial incision

52. ACHILLES TENDON LENTHENING AND POSTERIOR CAPSULOTOMY To correct residual hind foot equinus Z- Plasty done lengthen the Achilles tendon Releasing medial half distally and lateral half proximally Posterior capsulotomy of ankle and subtalar joint to release capsule contracture

53. TENDON TRANSFER Indication – passively correctable deformity resulting from muscle imbalance Anterior tibialis tendon transfer – tendon is transferred either to middle cuneiform or to base of 5 th metatarsal SPLATT ( Split anterior tibialis tendon transfer) – lateral part of the tendon is split and inserted to cuboid.

54. DWYER OSTEOTOMY Indication – Persistent varus deformity of heel when soft tissue surgeries are contraindicated Age 3 to 4 years Done by lateral closed wedge or medial open wedge osteotomy

55. LATERAL COLUMN SHORTENING PROCEDURE Indication – recurrence of club foot 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 procedures to shorten lateral column are Dillwynn Evans procedure Lichtblau procedure Fowler procedure.

56. LATERAL COLUMN SHORTENING PROCEDURE DILLWYN EVANS PROCEDURE Age – 4 to 8 years Indications – midfoot varus due to talonavicular and calcaneocubiod subluxation LICHTBLAU PROCEDURE Age 3 to 4 years Indication – heel varus and residual internal deformity of calcaneous with long lateral column

57. FOWLER PROCEDURE Indication – sufficient scarring that medial soft tissue and subtalar release would be effective Age 6 to 8 years Procedure – lateral column shortening combining with medial column lengthening by removing wedge from cubiod and transferring it to an opening wedge

58. SALVAGE PROCEDURE Indication Uncorrected club foot or with residual deformity after the age of 10 years Painful stiff foot with poor function Difficult to accommodate to footwear Goal Correct residual deformity which is resistant to soft tissue release To attain functionality and cosmetically acceptable foot Procedure Triple arthrodesis Talectomy

59. TRIPLE ARTHRODESIS Indication – Painful stiff foot with poor function Difficult to accommodate to foot wear All other corrections failed Age 10 to 12 years Procedure – osteotomy followed by fusion of talonavicular talocalcaneum and calcaneocubiod joint

60. TALECTOMY Indication – reserved for severe untreated clubfoot Age > 10 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

61. EXTERNAL FIXATOR Indication - in cases of neglected and recurrent deformity with severe scaring Modalities - Illizarov External Fixator Advantages Prevent crushing of tissues on convex side Lengthens the limb Effectively corrects the deformity at the same time

62. ILLIZAROV’S EXTERNAL FIXATOR Principle – fracture distraction Indication – severe deformities with severe scarring or trophic ulcers which make operative intervention contraindicated because of tissue necrosis Steps of correction – angular correction of hind foot , correction of fore foot supination , correction of foot equinus

63. COMPLICATIONS OF SURGERY Post operative- General or specific ,early or late Haemorrhage Vascular injury - gangrene Compartment syndrome Wound infection Skin necrosis Scaring Overcorrection Recurrence Stiff joints AVN of talus

64. FOLLOW-UP Despite initially successful surgery, deformities do still recur The foot, in its corrected position, is immobilized in a plaster cast K-wires are sometimes inserted across the talonavicular and subtalar joints to augment the hold and are removed after 6-8 weeks Boots or a custom-made ankle–foot orthosis is used, depending on whether the child has started walking. Stretching exercises that were performed prior to surgery are continued. Active dorsiflexion and eversion are established before splintage is discontinued

65. CONCLUSION Congenital talipes equinovarus is the most common birth deformity of the foot. The prognosis for clubfoot is related to the severity of the presenting deformity, graded from postural to mild, moderate or severe. Correction involves both non-operative and operative measures. If left untreated the deformity has severe disabling effect on morbidity and quality of life

66. REFRENCES Frederick M.A, James H.B, Campbells Operative Orthopedic, 14 th Edition Ashley .B, David W, Michael R.W , Apleys and Solomon, System of Orthopedics and Trauma E.Q Achampong S.B Naaeder, B . Ugwu BAJAS Principles and practice of surgery in the tropics Ukoha U, Egwu O, Okafor I, Ogugua P, Udemezue O, Olisah R, et al. Incidence of congenital talipes equinovarus among children in southeast Nigeria. Int J Biol Med Res. 2011;2(3):712-5. Clubfoot (congenital talipes equinovarus) - Pediatrics - Orthobullets Online http://medicaldictionary.thefreedictionary.com Google images.

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