CTEV

BY –SAIKRISHNA.K
 ANATOMY-JOINTS
 ANKLE JOINT : TIBIA AND TALUS

 SUBTALAR JOINT : TALUS AND CALCANEUM

 TALONAVICULAR JOINT

 CALCANEO- CUBOID JOINTS

 NOMENCLATURE
Planus: flatfoot

Cavus: highly arched foot

Varus: heel going towards

the midline
Valgus: heel going away
from the midline
Adduction: forefoot going
towards the midline
Abduction: forefoot going away
From the midline
CLUB FOOT
 INTRODUCTION
 Ossific development of the foot begins in utero.
 During embryonic development the foot passes through
3 different positions.

 15mm---- Foot is Straight

 30mm----Foot is in equinovarus and adducted.
 50mm---Foot returns to neutral slightly adducted and
equinovarus position known as fetal position.
 Growth of Foot--
 The foot has its own Growth pattern, which differs from
the growth rate of rest of the body.

 Foot grows rapidly between infancy and 5 years of age

and slows to 0.9 cm per year between 5-12 years in
girls and 5-14 yrs in boys and growth usually ceases.

Foot Ankle.1990 Feb;10(4)211-3

 Clubfoot--
 Clubfoot is probably the most common (1-2 in 1000 live
births) congenital orthopaedic condition that requires
intensive treatment.

 It most likely represents congenital dysplasia of all

musculoskeletal structures below the knee.
 Etiology
 Idiopathic Clubfoot
 Secondary Clubfoot
Arthrogryposis

Diastrophic dysplasia

Streeter`s dysplasia

Freeman Sheldon Syndrome

Mobius syndrome etc.

 Many theories have been proposed recently to explain
the etiology of idiopathic clubfoot including vascular
deficiencies , environmental factors, in utero positioning
, abnormal muscle insertions , and genetic factors .
 While it is becoming more clear that clubfoot is
multifactorial in origin, genetic factors clearly play a
role as suggested by the 33% concordance of identical
twins and the fact that nearly 25% of all cases are
familial .
J Pediatr Orthop B. 2012 Jan; 21(1): 7–9.
 Additional evidence for a genetic etiology is provided
by differences in clubfoot prevalence across ethnic
populations with the lowest prevalence in Chinese
(0.39 cases per 1000 live births) and the highest in
Hawaiians and Maoris (seven per 1000)

J Pediatr Orthop B. 2012 Jan; 21(1): 7–9.

 Theories
 1)Arrest in embryonic development.
 2)MyoFibroblastic retractile tissue in the medial
ligaments.

 3)Primary Germ plasm defect in the cartilaginous

talar anlage produces the dysmorphic neck and
navicular subluxation.

 4)Local Neuro myogenic imbalance especially

involving the peroneals, has been proposed.
 Environmental factors may play a role in some cases of
clubfoot. Early amniocentesis (< 13 weeks gestation) was
associated with an increased risk in talipes equinovarus
compared to midgestational amniocentesis or chorionic
villus sampling .
.Increased risk of clubfoot was partially associated with
amniotic fluid leakage, suggesting that oligohydramnios
occurring at a critical gestational period may be detrimental to
foot development .

.
 Unlike positional foot deformities, such as metatarsus
adductus, that occur at increased frequency in twin
pregnancies, there are little data to support an
association of clubfoot with late gestational uterine
compression.

Environmental exposure to cigarette smoke in utero is

another independent risk factor for clubfoot.
 Finally it is safe to say that etiology of idiopathic club
foot is multifactorial and modulated significantly by
developmental aberrations early in the limb bud
development.

 Club foot does cluster in families but doesn`t fit in any

inheritance patterns.
 Pathologic Anatomy
 A postural deformity needs to be distinguished from a
true clubfoot. The cause of the postural deformity is the
position in utero in contrast to the true clubfoot, which
has an underlying pathology.

 Additionally, the postural condition usually

responds to passive manipulation by the mother.
 The anatomy was first described by Scarpa in 1800
and has been subsequently verified by other authors
such as Kite and Turco. (Turco VJ. Clubfoot. New York:
Churchill Livingstone; 1981)

 According to Scarpa, clubfoot is a congenital

talocalcaneonavicular (TCN) joint dislocation, which
is the currently accepted view.

 In contrast, Goldstein believes that the primary

abnormality is outward rotation of the talus in the
ankle mortise.
 The true clubfoot is characterized by equinus, varus,
adductus and cavus.
 The equinus deformity is present at the ankle joint,
TCN joint and the forefoot.
 In the varus component, the hind foot is rotated inwards
and this occurs primarily at the TCN joint.
 The whole of the tarsus, except for the talus, is rotated
inward with respect to the lower leg. Since the forefoot
follows the hind foot, the medial border of the forefoot
faces upward.
 The adductus deformity takes place at the talonavicular
and the anterior subtalar joints. The cavus component
involves forefoot plantar flexion, which contributes to
the composite equinus.
 Talus—Medial and plantar deviation of the anterior
end.

 Short talar neck projecting medially from a

dysmorphic,small body that is poorly placed within
ankle joint.
 The talar neck-body declination angle is invariably
decreased to 90 degrees from the normal 150 to 160
degrees.
 The articular surface of the talar head is so close to the
body that true neck is not present.

 On the inferior aspect of talus,the anterior and medial

facets are absent or fused or misshapen.
Calcaneum—Contour is generally normal although
calcaneus is often small.

 The sustentaculum tali is ususally under developed.

 Anterior articular surface is of the calcaneus is medially
deviated and deformed because of the interosseus
deformity of the calcaneocuboid joint.
 Both the navicular and cuboid tend to have normal
shapes and are misshapen only due to their inter
osseus relation ships with talus and calcaneus.

 Navicular is consistently displaced medially and

plantarward on the talar head and has a false articular
relation ship with the medial malleolus.
 Cuboid is similarly medially displaced on the anterior
end of the calcaneus.

 Controversy exists regarding the presence or absence

of internal tibial torsion.
 Tibio-talar plantar flexion

Medially displaced navicular

Adducted and inverted

calcaneus

Medially displaced
cuboid
 PATHO-ANATOMY
 MUSCLES CAPSULES AND LIGAMENTS

STRCTURES CONTRACTED ON THE MEDIAL SIDE

3 MUSCLES 3 LIGAMENTS 3 CAPSULES OF

• AHL • DELTOID • SUBTALAR

• TP • SPRING • TARSAL
• FHL • PLANTAR • TARSOMETATARSAL
 PATHO-ANATOMY
 MUSCLES CAPSULES AND LIGAMENTS

STRCTURES CONTRACTED ON THE POSTERIOR SIDE

2 MUSCLES 2 LIGAMENTS 2 CAPSULES OF

• TIBIALIS POST. • TALOFIBULAR • ANKLE JNT

• TENDO-ACHILLES • CALCANEOFIBULAR • SUBTALAR JNT
 PATHO-ANATOMY
 MUSCLES CAPSULES AND LIGAMENTS

STRCTURES CONTRACTED ON THE ANTERIOR SIDE

1 MUSCLE 1 LIGAMENT 1 CAPSULES

• TIBIALIS ANT. • SUPERIOR • CALCANEO-

PARONEAL CUBOID JNT
RETINACULA
 PATHO-ANATOMY
 SKIN
 Adapts shortening on the medial side
 Deep creases on the medial side
 Dimples on the lateral aspect

 SECONDARY CHANGES
 Occurs when the child starts walking-exaggerates the
deformity
 Callosities and bursae
 Master knot of Henry Fibrous slip that envelops the
FDL and FHL tendons.

 Binds the plantar medial surface of the navicular.

 Flexor digitorum accessorius longus muscle may be
identified in 7% children,deficiencies of dorsalis pedis
and posterior tibial also noted.
CLASSIFICATIONS
 Pirani’s severity scoring
 Six parameters : 3 of midfoot and 3 of hindfoot
 Each parameter is given a value as follows:
 0: normal
 0.5: moderately abnormal
 1: severely abnormal
Mid foot score

 Curved lateral border [A]

 Medial crease [B]

 Talar head coverage [C]

 Hind foot score

 Posterior crease [D]

 Rigid equinus [E]

 Empty heel [F]

 Uses of Pirani’s score
 Assessment of progress by serial plotting of the score

 Predicting need for tenotomy.

 Estimation of probable no. of casts reqd*

 Very good interobserver reliability and reproducibility**

* J. Dyer et al Journal of Bone and Joint Surgery - British Volume, Vol 88-B, Issue 8, 1082-
1084P.

** Flynn JM, Donohoe M, Mackenzie WG. J Pediatr Orthop 1999;18:323-7

 International Clubfoot Study Group Score
 Introduced by Henri Bensahel et al in 2003
 Found to have good interobserver reliability and
reproducibility.**

 Morhological (12 pts), functional (24 pts) & radiological

(12 pts) parameters

 **Celebi L et al J Pediatr Orthop B. 2006;15:34-36.

Morphological parameters
Functional parameters
Radiological parameters
Classification of clubfoot severity by Diméglio
A.Equinus deviation B. Varus deviation C. Derotation D. Adduction.

 A-Sagittal plane evaluation of Equinus

 B-Frontal plane evaluation of varus.
 C-Horizontal plane evaluation of derotation of
Calcanopedal block.

 D-Horizontal plane evaluation of Forefoot relative to

Hind foot.
Reducibility( Score Additional Score
degrees) parameters
90-45 4 Marked posterior 1
crease
45-20 3 Marked 1
mediotarsal
crease
20-0 2 Cavus 1
0 t0 -20 1 Poor muscle 1
condition
Grade Type Score Reducibility
i Benign 1-4 >90%
ii Moderate 5-9 >50%, soft-stiff,
reducible, partially
resistant
iii Severe 10-14 >50%, stiff-soft,
resistant, partially
reducible
iv Very severe 15-20 <10% stiff-
stiff,resistant
IMAGING
Plain radiography
 Limitations
1. Difficult to position the foot
2. The ossific nuclei do not represent the true
shape
3. In the first year of life, only the talus,
calcaneus, and metatarsals may be ossified
4. Failure to hold the foot in the position of
best correction makes the foot look worse than
it is
 Plain radiograph
 The foot should be held in the position of best
correction, with weight-bearing, or, if an infant is being
examined, with simulated weight-bearing

 Focused on the hindfoot (about 30° from the vertical for

AP view)

 Lat. View: transmalleolar with the fibula overlapping the

posterior half of the tibia
 AP Radiograph
normal CTEV

AP Talo 20 -50 deg <20 deg

calcaneal
angle
Tarsal-1st MT Upto 30 deg Varus
angle valgus anglulation
cuboid os. medial
center w.r.t displacement
calcaneal axis
 AP radiograph: Talo-Calcaneal
angle
 Normal foot: 20`-50`  CTEV:<20 deg
AP Radiograph: convergence of
base of MT
 Lateral radiograph
normal CTEV

Talo 25 to 50 <25 deg

calcaneal deg
angle
Tarsal-1st hyperflexio
MT angle n
 Lateral view: Talo-Calcaneal
angle
 Normal foot : 25` to  CTEV: <25 `
50`
Hindfoot equinus is plantar flexion of
the anterior calcaneus (similar to a
horse's hoof) such that the angle
between the long axis of the tibia and
the long axis of the calcaneus
(tibiocalcaneal angle) is greater than
90°
On the lateral view, instead of having the
normal overlapped appearance, the
metatarsals are arranged in a ladder like
configuration, with the first being most
dorsal
SUMMARY OF
RADIOLOGICAL
FINDINGS
Ultrasonogram
 ANTENATAL DIAGNOSIS
 Ideally done at 20 to 24 weeks

 Recent reports*: positive predictive value of 83%

with a false positive rate of 17%.

 26% no Rx reqd; 61% reqd Sx

* Baron E, Mashiach R, Inbar O, et al. J Bone Joint Surg [Br] 2005;87-

B:990-3.
 Research tool

1. Recent study: to describe the morphological changes in

a comparative study of treatment methods

2. Used for demonstrating complete healing of TA at 3

wks foll. Percutaneous tenotomy
MRI
 ROLE OF MRI

 NOT used in routine clinical practice

 Important tool in research studies

 PIRANI’S MRI PROTOCOL
 Sagittal images perpendicular to the bimalleolar axis
 Oblique axial images perpendicular to the talonavicular
joint

 Oblique axial images perpendicular to the

calcaneocuboid joint

 Oblique coronal images perpendicular to the subtalar

joint
 SAGITTAL IMAGES

 Tibiotalar plantarflexion
 Inferior talar neck inclination, and
 Inferior talonavicular displacement
Oblique axial images perpendicular to the
talonavicular joint
 medial talar neck inclination,
 medial talonavicular
displacement,
 the wedge-shaped head of
the talus, and navicular
 Oblique axial images perpendicular to the
calcaneocuboid joint

 the wedge-shaped distal calcaneus

 Medial calcaneocuboid displacement
Oblique coronal images perpendicular to the
subtalar joint

 The inverted and adducted calcaneus

 The abnormal facets of the subtalar joint
 Thankyou 