Group27

reema mohamad
‫مافي شي زايد عن تفريغ‬

Causes of deformities ‫الدفع الي قبل‬

Some congenital deformities

• Congenital The baby born with it Club foot , metatarsus adductus,
congenital scoliosis, club hand

Acquired A cause for these deformities

• Neuromuscular disorders
-Cerebral palsy
- poliomyelitis
- spina bifida
- Peripheral nerve injuries
- Myopathies

• Bone and joint disorders Like arthritis, trauma, injuries to the growth
plate, fractures and so on Osteomyelitis, malunion
 The deformities can be flexible or mobile ,
flexible ‫ ﯾﻌﻨﻲ ﺗﺘﻌﺪل‬for ex ; flexible flat foot "
or ( pes planus ) when the child stand or the

Types of Deformities person stand on the ground the foot is flat

there’s no arch , when he’s sitting on a
chair or lay down the arch reform , when
Mobile or flexible means
you ask the person to stand on the tip toes
it’s correctable
you’ll see the arch reform again
• Mobile deformities = wrist drop Flexible ➡ correctable
/ foot drop

• Fixed deformities
Rigid deformities, ‫ ﻣﺎ ﺗﺘﻌﺪل‬example of that is the rigid pes planus or rigid flat foot , is caused usually like
tarsal coalition ‫ اﻟﻲ ھﻮ اﻟﺘﺼﺎق ﻣﺎ ﺑﯿﻦ ال‬hind foot , hind foot bones talus and calcaneus ‫ﻓﯿﻜﻮن اﻻﻟﺘﺼﺎق ھﺬا ﻣﺎ ﺑﯿﻨﮭﺎ‬
& maybe between calcaneus & the navicular bone these cause rigid flat foot.
1. Fixed deformities due to soft tissue
contractures.Like cerebral palsy; equinus they walk on
the tiptoes all the time & u try to lift the
foot beyond 90 degree you’ll not be able to
do that because of the tight heel cord .

2. Fixed deformities due to bony causes

Like children who have supracondylar fracture and end having cubitus varus
or gunstock deformity
This patient is having cerebral palsy so he’s having knee contraction he’s not able to extend the
knee beyond this and he’s having also equinus the foot is down because of the tight heel cord and
here because of tight hamstring muscle so the hamstring muscle they’re tight contracted that’s
why he’s unable to extend the knee, is this fixed or or mobile !? Fixed cause of soft tissue.

Cerebral palsy with

tight hamstring
 Rigid because it’s bony
Bony deformity like this one, this iscfixed also ( bony cause ) , the cause is
supracondilar fracture name of deformity is cubitus varus , or gunstock deformity .
skip

Nomenclature Skip
Skip

• Equinus = Derived from horse who walks on toes. Deformity

where foot is fixed in planter flexion. Pt. walks on toes.
• Calcaneus = Foot is fixed in dorsiflexion and pt. walks on
heel.
• Varus = Foot is inverted and adducted at the mid tarsal joint,
so that sole faces inwards. Pt. walks on outer border of foot.
• Valgus = Foot is everted and pt. walks on inner border of
foot.
• Talipes equino varus = pt. walks on toes and outer border of
foot.
• Talipes calcaneo valgus
CONGENITAL TALIPES
EQUINO VARUS
(CLUB FOOT)
Club foot is usually congenital
‫م هذا‬6‫قال نفس الك‬
We divided the foot into 3
sections or parts; fore-
foot , mid-foot , hind-foot

Forefoot ➡ metatarsus
➡ involves the phalanges
Midfoot➡ cuneiform ,cu
boid, navicular bone .
Hindfoot ➡ talus and
calcaneus bones .

‫ﻧﻘﺴﻤﮭﺎ اﻟﻰ ھﺬه اﻻﺟﺰاء ﻋﻠﻰ‬

deformity ‫أﺳﺎس ﻧﻌﺮف ال‬
Of the club foot "
 4 components of club foot
in adduction‫ _ اﻻﺻﺎﺑﻊ راﯾﺤﺔ‬1
‫ﯾﻌﻨﻲ ﻧﺎﺣﯿﺔ اﻟﻤﯿﺪ ﻻﯾﻦ‬
4 Deformities in club foot: The arch of the midfoot is high

Cave
‫اﻟﻜﻌﺐ‬-3
1) Forefoot : Adduction . into ‫راﯾﺢ‬
2) Mid foot : Cavus
➡ Arch is higher than normal opposite of planus

3) Hind foot : Varus . varus 4) Ankle: Equinus [ Achilles tendon] 4- because of the foot is down
because of the tight heel cord
 ‫سفل‬6‫تكون القدم ل‬

CTEV 1.Forefoot adduction What’s the difference between CTEV

2. Mid foot cavus and metatarsal adductus?
3. Hind foot Varus Metatarsal adductus only 1 deformity
4. Ankle equinus forefoot adduction

and common deformity in children $ % &

• Commonest congenital foot deformity. It occurs one
in every 1000 live births. ➡ like DDH

• Deformity, in which whole foot is pulled downwards

(equinus) and inwards (Varus)

What is the cause of CTEV? Because of the tight structures including;⬇

• It occurs due to shortness of muscles on the
posteromedial aspact of foot. The muscles involved
are calf muscles (tendo- achiles), tibialis posterior,
cavus deformity is due to Varus deformity is due to
F.D.L., F.H.L. tight Achilles’ tendon
Flexor hellucis longus , flexor digitorum longus .
tight tibialis posterior

All of them medial or posteromedial . responsible of the varus of the

hind foot, adduction for the fore foot , also cavus for mid foot .
 The heel(hind foot ) into varus
Forefoot? Into adductus
The arch is higher than normal ‫ ﻣﻔﺘﺮض ﯾﻜﻮن‬flat
The foot is pulled down because of the tightness
heel cord and cause equinus of ankle joint.
*Both feet are affected but the right one is more
effected

They walk on the dorsum of the foot

CLUB FOOT
Aetiology of CTEV
more common in boys

• Idiopathic (Congenital) 97% MC Congenital is easier to treat than acquired

• Acquired (Secondary) causes 3%

- Diseases of C.N.S. (Paralytic disorders)

- Spina bifida
- poliomyelitis Affects the anterior horn cells so it’s
a lower motor neuron lesion, they
don’t have hyper-reflexia
- cerebral palsy
He also said Charcot-Marie-Tooth
syndrome

- Arthrogryposis multiplex congenita

they’ve abnormal muscles so they have multiple contractures in
the elbow ,dislocation of the hip dislocation of the knee also club
foot on both sides and so on.
Difficult to treat
 muscle weakness in the feet, ankles and legs

CTEV
at first. feet that are very highly arched, which
‫من قوقل للفائدة‬ can make the ankle unstable, or having very
flat feet. curled toes (hammer toes) an
awkward or high step and difficulty using the
ankle muscles to lift the foot.
Skip Bilateral 30% Unilateral 70%

see
• Commonest congenital foot deformity. It occurs one
in every 1000 live births.

• Deformity, in which whole foot is pulled downwards

(equinus) and inwards (Varus)

• It occurs due to shortness of muscles on the

posteromedial aspact of foot. The muscles involved
are calf muscles (tendo- achiles), tibialis posterior,
F.D.L., F.H.L.
 ‫ﻟﻮ وﻗﻒ اﻟﻄﻔﻞ راح ﯾﻮﻗﻒ ﻋﻠﻰ ذي‬
Club foot deformity in left foot

cave ‫ممكن تختصرها في كلمة‬ Short foot, thin leg sometimes

C: Cavus they have leg length
discrepancy
A: Adductus
V: Varus
E: Equinus
Skip Skip(
 congenital ‫ وھﻲ‬calcaneovalgus ‫ ﻋﻨﺪھﻢ‬the opposite ‫ﯾﺠﻲ ﺣﺎﻻت وھﻢ‬
the shape of deformity is the opposite, , ً ‫وھﻲ اﻟﻌﻜﺲ ﺗﻤﺎﻣﺎ‬
The heel is valgus we should differentiate between them, same with metatarsus adductus

-Family history is important,

there are families where all
kids have CTEV and other
families where some kids get
CTEV not all

-girls are more difficult to

treat than boys in CTEV, but
in DDH girls are easier to
treat

-adolescence idiopathic
scoliosis is more common in
girls , but if boys get affected
they will be more difficult to
treat

The management is way harder in girls, why ?! IDK(

The outcome is better in boys

Patients don’t usually complain of pain it’s just a deformity, however they may start complaining of pain if they walk on the
deformed foot for a long time then they will have callosities in the skin(hard skin) in the dorsum of the foot , there will be difficulty
in movement, may have osteoarthritis of ankle joint, theses symptoms occur later, initially there will be no symptoms
 Skip

Notice Adduction of the fore foot , notice

the varus and you see the crease here , some
of them are severe to the point where they
have fold in skin (crease). The hind foot is
into varus & the foot in planter flexion we
call it equinus because of the tight heel cord.
It’s painless at the beginning but
as the patient grows it’s become Skip
painful

Skip
You have to know the difference between metatarsus adductus and clubfoot ,metatarsus
adductus is a benign deformity of the foot ,this patient only has metatarsus adductus
there is no varus, no equinus ,no Cavus just adductus treated by observation only but
sometimes casting of the foot , but clubfoot is progressive and may cause problems in
the future

Skip
 Neglected, patient at this age complain
from pain (dorsum of the foot) because
of the callosities, walking difficulties

This is sever in older

children , & u can see the
callosity in skin due to
pressure.
Due to walking on the
dorsum of foot .
 ‫‪Skip‬‬

‫يمشون على ظهر القدم‬

 neglected

Skip

Skip
So if neglected this is almost
adult person with neglected
club foot this is how they
stand , did stop them from
walking!? No , they don’t
prevent them from moving.
Neglected cavus of foot
this is almost adult, if it's unilateral clubfoot
the leg will be thinner and shorter than
the other side, with less muscle bulk,
some children have leg-length discrepancy.
means one leg is shorter than the other
rare to see nowadays
due to early diagnosis
and treatment
Even if you treat clubfoot the foot will not be
Skip
completely normal again , because there is
change in the muscle , if you take muscle
biopsy from the normal foot and abnormal
foot you will see that there is difference, also
the muscle bulk is different , and the length
of the affected leg is shorter than the other
leg, so you give the patient (‫الصوت ما كان واضح‬
15:35 ‫ )الدقيقه‬I think he said grey foot so he
can walk
 Rare
Sever cavus and equinus of ankle joint
 pain is progressing
gradually with pressure

Sever case there’s callosity at

the head of the metatarsals Callosity of skin in almost adult

*There’re touching the ground

 ‫‪Skip‬‬

‫‪Skip‬‬

‫‪Cavus‬‬

‫‪equinus‬‬

‫ھﻨﺎ اﻧﺘﮭﻰ ﺗﻔﺮﯾﻎ‬

‫وﺟﺪان ﺑﺎﻟﺘﻮﻓﯿﻖ‬
‫)‬
 ‫التشخيص سهل بس املهم نفرق بينه وبني‬ In the past the gold standard
was surgical management, but
metatarsus adductus‫ال‬ now the gold standard is
ponseti method

Treatment of CTEV
-if the baby present early(first month) the chance of
Based on the presentation:

successful management more than 95% and we don’t

need surgical intervention.
• Passive Stretching exercises In newborn.
-we don’t have an experience with this and we don’t know about the success.
-most of the people nowadays they do serial casting based on the ponseti
method.
• Serial plasters In newborn Based on
Pediatric orthopedic surgeon .
Serial casting (above knee cast)
modify the deformity gradually
• The Ponseti Method No surgical.
Only Cast , serial cast every week .
Gold standard.

• Surgical Tt. (posteromedial release)

• Triple arthrodesis of foot in neglected cases after the

age of 10 to 12 yrs.
surgery would be helpful but
there will be rigidity and pain
 We have to change the cast
every five days to 1 week

-The ponseti method:

G24
-we need(4-6) sessions. ‫هل قد يعترضون و‬d‫ غريب و احيانا ا‬cavus ‫ الي نعدل فيه ال‬cast ‫شكل ال‬
-we correct one deformity every time(CAVE): cavus ‫ عند تعديل ال‬,you are increasing the deformity ‫يقلون‬
-First cast: Cavus —>first week head of the first metatarsal and talus from the ‫نضغط على ال‬
other side
‫ و تنتهي‬Cavus ‫تبداء تعالج‬ -second cast: Adductus We treat them at the same time(second and third week)
equinus ‫بال ال‬
-Third cast: Varus.
‫حظ‬6‫ الثاني نبداء ن‬cast ‫من ال‬
-Fourth cast : Equinus—> we need three weeks here. improvement‫ال‬
When the toes are pushed at about 70 degrees to the opposite side
we start treating the equinus
-equinus is caused by tight Achilles tendon, if we forced the foot into dorsiflexion you may break
the joint of the midfoot that form rocker bottom foot deformity. So in ponseti we cut Achilles tendon
by small needle or blade and we do it in the clinic under local anesthesia (tenotomy), then we apply Last session
the cast for three weeks without change(the cast from tip of toes to mid thigh with knee flexed) .

-After the removal of the last cast we use Dennis Brown shoes and bar At 90 degrees

. external rotation ‫ حتى لو كانت الثانية سليمة وبينها مسطرة عشان تخلي الرجل في وضعية‬E‫الحذاء للجهت‬
-we use it 23 hrs a day for 3 months. ‫م قاله‬6‫نفس الك‬
-after that we use it only in sleeping time(that continue for 4 years or 3.5 years)

-We can use ponseti till one year.

-after one year we do surgical release (posteromedial release)
‫سف الى ان تم‬6‫ ما كان مثالي ل‬result ‫( ولكن ال‬posteromedial release) ‫ هو سيرجيري‬clubfoot ‫ لل‬gold standard ‫ سنه كان ال‬٢٠ ‫قبل‬
gold standard ‫ هي ال‬ponseti method ‫ اصبحت افضل واصبحت ال‬results ‫حظوا ان ال‬d‫ و‬ponseti method ‫اكتشاف ال‬
-When we do surgical intervention?
1-rigid deformity not corrected by ponseti method (rare) like in
neuromuscular disorder or resistant clubfoot that has high recurrence
rate of deformity, in idiopathic the correction is easy and the results good.
2-if the child age more than one year.

We do casting up to 1 year , after 1 year do posteromedial release

After 1 year to 5 years:
Posteromedial release:
Z lengthening (plasty) for all the 4 tendons and joint release.
Joint release :
-posterior capsule of the ankle joint
-subtalar joint
-Talnavicular joint.
-calcaneocuboid joint.

• after 5 to 10 years:
1- very rigid deformity.
2- contracted neurovascular bundle—> so if we do acute correction of deformity by posteromedial release that
will injure the neurovascular bundle.
3-we do posteromedial release but we apply llizarov ring( external fixator)to correct neurovascular bundle
gradually.

After 10 years:
• Triple arthrdesis(correction by fusion of the joint) .
• That will give us plantigrade foot.
• Llizarov not used after 10 years due to the recurrence rate is very high.
• Triple arthrdesis not cause sever stretch on the Neurovascular bundle.
 Skip
Skip

Flexible cast above

knee .
 i c G sessions-WeFirst
correct one deformity every time(CAVE):
cast correct : Cavus . first
week

The Ponseti Method

Skip Second cast correct: Adductus .
Third cast correct : Varus . attnesanet
secondmat
n
Fourth cast correct : Equinus . weeks
3

• Initially deformity is corrected by manipulation and

serial plasters

• The residual equinus deformity is corrected by

percutaneus tenotomy of achilles tendon
• Under local anaesthesia, the tendon is divided
completely 1 cm. above the calcaneus, and the foot
is dorsiflexed correcting the deformity. After 5
minutes of haemostasis , POP is applied. ‫ﻧﻌﻤﻞ اﻟﺠﻠﺴﺎت ﻟﺤﺪ ﻣﺎ ﯾﺼﯿﺮ ﺗﻌﺪﯾﻞ‬
Application of Dennis Apply cast for external )‫اﻻﺻﺎﺑﻊ اﻟﻰ اﻟﺨﺎرج‬
Brown shoes for 3 3weeks
Achilles’ ‫ درﺟﺔ او‬70( rotation
months continuously countinuously
tendon usually after 4-5‫اﻛﺜﺮ‬
then only at night until without changing
tenotomy sessions of casting
the child become 3&
half years old
 ‫للفائدة‬
Rx:(ponseti method ) G55
mostly Dx by neonatologist (orthopedic)
we do serial casting as soon as possible
(Cast from mid of thigh with flexed knee)
then Chang the cast every 5 d to 1w
I

1/frist cast: Rx (Cavus)

2/second and third cast: Rx Adductus then Varus
(by pushing foot externally).in 2-3 session (cast)
.

3/ correct Eguinus (heel cord release by needle through skin

.

we cut Achillis tendon completely ) percutaneously using

local anesthesia
Fourth cast

We use ponseti method from brith up to one year

 After 6 W of ponsti method .
For Equinus ( heel cord release) .
If baby less than 6 months ( Percutanously ) .
If baby > 6m in OR under general anaesthesia.

Tenotomy is done in clinic first

put lidocaine(Emla cream) on
the area of Achilles’ tendon
(heel cord) for about 1 to 1.5
hours then cut the heel cord
then put the final cast.

Doctor said in children older

than 6 months it’s difficult to
control them so it’s better to
do under general anesthesia
Skip
Do serial cast until one year ,
If not benefit go to surgery. skip ‫لو جا متاخر نسوي العمليه‬

Baby more than one year old .

Surgery
We do it after 1 year
old

Postero medial release PMR We have to do Z-

lengthening( Z plasty)
then we release the
Achilles’ tendon = Posteriorly ‫جاي‬ ligaments or capsules
tibialis posterior, flexor digitorum longus , flexor hellicus longus = Medially ‫جاي‬

• Release or lengthening of following muscles =

I - Lengthening of tendo achiles (z plasty)
2 - Tibialis posterior
- Flexor digitorum longus
- Flexor hellucis longus
These are the short muscles and tendons that are
responsible for moving the foot inward (‫)للداخل‬

• Release or division of tight ligaments=

t - Posterior capsulotomy of ankle joint
z - Division of talo navicular ligament

3 - Division of talo calcaneal ligament

Subtaler

f calcaneocuboid joint capsule release .

 proximal

cut the middle a middle

wecatiti
part first longitudinal

Neurovascular Digital thenwe

bundle the
tendon
First thing we do it when get
we the
we do posteromedial
release is identify the
neurovascular bundle to
not injure it.

Posterior tibial artery and tibial nerve form the

neurovasular bundle so when preforming the Z Lengthening of Achilles’ tendon
posteromedial release ,you have to be careful not
to damage these structures

Release Subtaler
joint.

Release
The joints that are released are the calcaneocuboid
ankle joint + the subtalar joint +
the talonavicular joint + the joint
calcaneocuboid joint so 4 joints
have to be released
 Z Lengethning surgery .
We use Tourniquet
Ternqate during surgery to
decrease bleeding.
-We can use it just for 2 hrs.
-If the surgeon needs more
than 2 hrs we release
tourniquet for 15 mins and then
apply it again.
Bad In posterior Release

We use tourniquet to apply pressure to

prevent the blood from reaching the
New tourniquet
area to avoid bleeding during the
surgery and it helps get clear view
deplete by itself
during the surgery because as we said after 2 hours
it prevent blood to get in the way when
a
we cut, the tourniquet is used when we
do surgery from mid thigh all the way
down, the tourniquet pressure is up to ‫ متواصله‬m‫ساعت‬
200 to 250 or 275

You can’t keep the tourniquet for more

than 2 hours so If the surgery becomes
complicated and you need more time
you have to deflate to allow blood to
pass for 15 to 20 minutes then do
reinflation again and continue the
surgery
Posterior Medial

No bleeding due
to use Terngate
Tourniquet.
Z Lengthning Surgery .
Achilis Tendon
Z Lengthning Surgery .
 Put the ankle on 90 degrees
then suture
Z Lengthning Surgery .
We split the tendon ( lengthning ) .
After we get the proper length we suture tow ends
together
Cut the middle part first
then the proximal and
distal parts ,after that
make sure that the foot
is extended and then
do ligation
Release of the ankle
joint
Release of the capsule of the posterior Ankle
And release of subtalar joint posteriorly
 Very aggressive surgery.
The most difficult surgery in
orthopedics is
posteriomedial release
Skip
Complication of
surgery:
1- stiffness of foot
M.C
2- neurovascular
injury.
-most difficult surgery in
orthopedic is the clubfoot
surgery due to :
1- aggressive release.
2-related to neurovascular
bundle.
3-judgement ( how much of
release we need?)
4-it can cause ischemia of
skin in the medial side.
This is massive dissection, no surgeon is
interested in doing this because it is the most
If the patient
difficult surgery in orthopedic because it requires
correct judgment to avoid over lengthening and
comes early we
the results of the surgery are not good , also due
to the massive tissue dissection it’s not preferred
can treat them
with serial cast
3- it also causes necrosis of the skin
because we use tourniquet for long time
and avoid
surgery
complications.

-result of posteromedial
release:
1-good shape but rigid
(can’t walk on uneven
ground like walk on gravel)
2-chronic pain.

-So ponseti is better due to

it has flexible corrected
foot.
 Less than one year. G55
At first years (age) we do serial cast (ponseti method)

we can use Posterior medial releas untle age of 5 years

I
Sy
if the pt. came too late (5-10 years):
you cannot correct the shorting of neurovascular structure
Ischemia... , Necrosis, Gangrene .
So we use ilizarove frame gradual correction
Then —>Sx releas (posterior medial release)

if >10 years triple arthrodesis


We do posteromedial release after one year or if
serial casting fails . After the posteromedial
release we put cast for 6 weeks , then we use
medical shoes like the rigid shoes
Triple Arthrodesis of foot
• Indicated in old neglected deformity (after 10 to 12
yrs. Age)
• It includes fusion of 3 joints =
- Talo-calcaneal joint
- Talo-navicular joint
- Calcaneo-cuboid joint
• Pantalar arthrodesis:
Triple arthrodesis+ankle joint fusion.
-we not need it .
-it has very bad result ( it eliminatesall foot movement)
If child comes after 5 years and he has
sever deformity we can do posteromedial
release but the problem is there will be
stretching on the neurovascular bundle
which may lead to gangrene of the toes or
injury to the tibial nerve , so you do
posteromedial release and then do gradual
correction using the circular external
fixator(ilizarov)part on the leg and the other
part on the foot to avoid any immediate
stretch on the neurovascular bundle and to
correct the neurovascular bundle gradually
• Subtalar
Become one joint.
In triple arthrodesis no need to do gradual
correction because here we operate on
joints which will not cause overstretching
on neurovascular bundle
The patient will have problems with:
Abduction & Addiction & Evertion & Invertion

Talo-navicular
Subtalar

Calcaneo-cuboid
Late patient
 In summary:
Triple arthrodesis eliminates abduction and
adduction and also the flextion and Less than one year ponseti method
extension of midfoot so all the stress will be
transferred to the distal joints and the ankle 1-5 years posteromedial release
joint leading to osteoarthritis of the ankle joint
so triple arthrodesis is not a good choice After 5 years to 10 years posteromedial
however it is used in neglected children release + gradual correction (ilizarov)

some surgeons use ilizarov up to 12

years to avoid triple arthrodesis

After Triple Arthodesis

-rigid foot

inversion and eversion ‫ يسوي‬subtalar joint‫فايده ال‬

Thank you