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CONGENITAL TALIPES

EQUINO VARUS
(CTEV)

Andrianto Wisnu Nugroho


Orthopaedics & Traumatology Department
RSU Karsa Husada Batu
CTEV
Forefoot : Adduction

Hindfoot : Inversion or
varus

Hindfoot : Equinus

Midfoot : Cavus
Tibiotalar
plantar flexion

Medial
displacement
of navicular

Wedge-shaped
head of talus

Wedge-shaped
Navicular

Adducted and
inverted
calcaneus

Medially
displaced
cuboid
Etiology
• 1. Genetic factor
- Chinese : 0,39 per 1000
- Caucasians : 1,2 per 1000
- Polynesia : 6,8 per 1000
 Male : Female = 2,5 : 1
(Lachmiller et all)
2. Histologic anomalie
Some theories :
 A primary germ plasma defect of bone
-- deformity Talus + Navicular

 Reduction in cell number + cytoplasma


in the posterior tibial tendon sheath
-- regional growth disturbance

 Ippolito & Ponseti :


retraction fibrosis of the distal muscle of the
calf & the supporting connective tissue
3. Vascular anomalie
- Absence of
Anterior tibial artery
Dorsalis pedis artery
4. Anomalous muscle
Anomalous flexor muscle in the calf
 Clubfoot could be corrected only after
release of an accessory soleus muscle
5. Intrauterine factors
Hippocrates  foot is held in position of
equinovarus by external
uterine compression &
oligohydramnion
• Turco :
- Left CF > R CF
 positioning is not a factor

Interuption in development  deformity

Normal foot appears to be similar to a club


foot during 9th week of gestation
PHYSICAL EXAMINATION

Important : examine entire body of patient !

Reference point :
- Knee in 90º :
should be assessed :
 Torsional alignment
 Varus & valgus
 Overall size & shape of the leg, ankle
foot
• Associated anomalies :
- Dwarfism
- Spina bifida
- Myelomeningocele
- Arthrogryposis
• Deformities findings :
1. Affected foot is shorter and wider
2. Ankle equinus
 in knee extended
Deformities finding
3. Heel : inverted
4. Forefoot : adducted & supinated

Assessed :
forefoot on the midfoot
midfoot on the hindfoot
hindfoot on the ankle
Deformities finding

5. Arthrophy of calf muscles

6. Medial displacement of navicular &


calcaneal

7. Talus : head and neck deviated medially

8. Rotation of talocalcaneal joint


Radiography Examination
- Hard to :  produce
 evaluate
 measure
Reasons :
a. Position of the foot :difficult! Stiff,deformed
b. Ossific nuclei : not represent the true shape of tarsal
bone
c. 1st year of life : ossified only : talus, calcaneal &
metatarsal
d. Talar dome appear flattened
e. Failure to hold the foot in the position of best correction
Radiographs measurement
I. AP View
a. Talocalcaneal angle (Kite’s Angle)
<20º in CF
b. Talar first metatalsal angle
c. Medial displacemented of cuboid
ossification
Radiographs measurement
II. Lateral View
a. Talocalcaneal angle (Kite’s Angle)
<25º in CF
b. Talar first metatarsal angle : N 0-20º
• TREATMENT :

- Non surgical treatment :


a. Ponseti Method
b. Kite’s
c. French metod
- Surgical treatment :
Postero medial, postero lateral
release
I. Ponseti Method
First four or five casts (more if necessary)

1. Allow the infant to feed during the manipulation


and casting processes

2. Casting should be performed by a surgeon when


possible
3. Reduce cavus
Right Left

The first element of management is correction of the


cavus deformity by positioning the forefoot in proper
alignment with the hindfoot.

The cavus, high medial arch (red arc) is due to the


pronation of the forefoot in relation to the hindfoot.
Forefoot is supinate
to extent visual
inspection of plantar
surface of the foot
-- Forward to palpate head of talus

-- Can feel the prominent lateral talar head

-- navicular and calcaneal moves lateraly


under the talar head

naviculare
calcaneus

Head of talus
-Abducting the foot in supination

-- stabilze it then for 60 seconds  then release


Appearance of casts and foot

1st 2nd 3rd 4th


After cast removal
• Foot abduction orthosis :
Dennis Brown bar
 Prevent reccurence
 To favor remodelling of joint and
bone in a proper alignment.
 Increase ankle and foot muscle
strenght.
• Bar + shoe : 750 ext.rot. +
100 dorsiflex.
CTEV
Normal side 45ºext rot

• Full time 2-3 months, afterward


night and overnight 2-4 years
THANK YOU