CTEV : Pathoanatomy and management

 DR. SUSHIL PAUDEL
 DR. PRATYUSH  Dr. Shah Alam Khan

Definition
 Developmental deformation

of foot  Rotational subluxation of talocalcaneonavicular joint complex with talus in plantar flexion & subtalar complex in medial rotation & inversion  Clinically characterized by  Equinus & varus of heel  Forefoot adduction  Midfoot supination

Classification (Attenborough 1966)
Type I(Extrinsic) Non Rigid Foot size Heel
Normal
Normal

Type II(Intrinsic) Rigid
Smaller
Small

size Can be brought down with ease Minimal varus More or less normal

, elevated Cannot be brought down with ease Marked varus Deep medial, posterior and lateral creases Reduced creases laterally

Creases

short. shortening of the first metatarsal with hyperextension of the metatarsal phalangeal joint.chubby with a deep crease in sole of foot and behind ankle. occurs in otherwise normal infant  Syndromic clubfoot: The clubfoot part of a syndrome  Teratologic clubfoot – such as congenital tarsal synchondrosis  Neurogenic clubfoot – associated with a neurological disorder such as meningomyelocele .Definitions in clubfoot  Rigid or resistant atypical clubfoot : Stiff.

3:1000 live births  Males>Females – 2:1  30-50% bilateral  Much more common in Polynesian & Maori & lower in Asians .Epidemiology  Commonest congenital orthopaedic abnormality  1.

**Muir L et al. 2006 . with subsequent soft-tissue changes in the joints and musculotendinous complexes *Sodre H et al. 26(1):91-93. J Pediatr Orthop. J Bone Joint Surg Br. . 1990.77:114-6 # Milan B MD et al. Journal of Pediatric Orthopedics. 1995.10:101-4.Pathogenesis  Unknown at this stage  Gray et al (1981) : increase in % of type I fibres in soleus muscle.     suggested defective neural influence Recent study*: no evidence of type I fiber grouping Hypoplasia or absence of the anterior tibial artery in majority of CTEV patients** Absence of the dorsalis pedis pulse in the parents of children with clubfoot# Primary germ plasm defect in the talus: continued plantar flexion and inversion of this bone.

 Wynne-Davies : polygenic inheritance  Multifactorial inheritance established by genetic epidemiologic      research by Idelberger 32. 33:272–276 .9% among dizygotic twins Major gene effect (inherited in recessive manner) with additional polygenes and environmental factors Tachdjian Patient with CTEV that has one child affected then 25% chance of another affected If both parents are normal & have affected child then chance of another is 5% Idelberger K.5% concordance rate among monozygotic twins as compared to 2. et al 1939.

Intrauterine factors
 Pressure theories:  Oligohydramnios  Abnormal fetal positioning  Placental insufficiency  Constriction bands  Toxins ( Maternal alcoholism, smoking)  Maternal illness ( anemia, thyroid disorders )  Infective pathogens (enteroviruses)  Drugs (abortifacients, salicylates, barbiturates)  Electromagnetic radiation

Bony abnormalities
 Talus:
 Head & neck deviated medially

& plantarward  Body rotated externally in the ankle mortise  Body extruded anteriorly  Smaller than normal

 Navicular:  Medially displaced  Close to medial malleolus  Articulates with medial surface of head of talus  Calcaneus
 Anterior portion lies beneath

the head of talus causin gvarus and equinus of heel
 In equinus
 Rotated medially

 Cuboid  Displaced medially on the dysmorphic distal end of the calcaneus  Talonavicular joint  In inversion .

Tibio-talar plantar flexion Medially displaced navicular Adducted and inverted calcaneus Medially displaced cuboid .

Soft tissue changes  Posterior structures :  Tendo achilles  Post. talo fibular  Calcaneo-fibular ligaments . capsule of ankle joint & subtalar joint  Post.

Master Knot of Henry  Talonavicular ligament  Calcaneo-navicular ligament  Deltoid ligament  Interossseus talo calcaneal ligaments  Capsules of naviculo cuneiform & cuneiform first metatarsal .FDL. Medial :  Tibialis posterior  FHL.

 Plantar wards :  Plantar fascia  Plantar ligaments  Flexor digitorum brevis & abductor hallucis Laterally  Calcaneofibular ligament  Bifurcated ligament  Calcaneocuboid joint capsule .

Deformity  Heel equinus  Heel varus  Midfoot supination  Forefoot adduction  Maybe cavus .Clinical features  1.

Features  Curved lateral border of foot  Devil’s thumbprint over the 3. General  Calf atrophy  Calf shortening  Restricted ankle motion lateral malleolus  Medial & Lateral skin creases  Navicular fixed to medial malleolus  Os calcis fixed to the lateral malleolus  Heel small & high  Other Conditions should be excluded  Spinal Dysraphism  Arthrogryposis  Neuromuscular Disorders . 2.

or simulated weight-bearing  AP view: Taken with foot in 30° of plantar flexion and tube at 30° from vertical  Lat. with weightbearing. foot in 30° of plantar flexion .Radiology  Plain radiograph: Can be assessed prior to treatment with A-P & Lateral of foot  Foot held in position of best correction. View: Transmalleolar with the fibula overlapping the posterior half of the tibia.

Anteroposterior view  Talocalcaneal angle  Calcaneal-second metatarsal angle  Talus –first metatarsal angle .

 Any angle less than 20° considered abnormal . and they usually subtend an angle of 25-40°.AP radiograph: Talo-Calcaneal angle  Lines drawn through center of the long axis of talus (parallel to medial border) and through the long axis of calcaneum (parallel to lateral border).

Lateral view  Talocalcaneal view  Calcaneal-first metatarsal view  Tibiocalcaneal  Tibiotalar angle  Talus-first metatarsal angle  Talocalcaneal index (Kite's angles from AP and Lateral views added) .

5: moderately abnormal  1: severely abnormal Pirani s et al. Annual meeting of Pediatric orthopaedic society of North America 1995 . A method of evaluating virgin clubfoot with substantial interobserver reliability.Pirani’s severity scoring  Six parameters : 3 of midfoot and 3 of hindfoot  Each parameter is given a value as follows:  0: normal  0.

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] .

Donohoe M. Issue 8. of casts reqd*  Very good interobserver reliability and reproducibility** * J. Vol 88-B.British Volume. 10821084P. Dyer et al Journal of Bone and Joint Surgery . Mackenzie WG.18:323-7 . ** Flynn JM.Uses of Pirani’s score  Assessment of progress by serial plotting of the score  Predicting need for tenotomy (hs>1& ms<1)  Estimation of probable no. J Pediatr Orthop 1999.

. functional (24 pts) & radiological (12 pts) parameters  Maximum of 60 for most deformed and 0 for normal feet  **Celebi L et al J Pediatr Orthop B.15:34-36.International Clubfoot Study Group Score  Introduced by Henri Bensahel et al in 2003  Found to have good interobserver reliability and reproducibility**  Morhological (12 pts). 2006.

Morphological parameters .

Functional parameters .

Radiological parameters .

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

Reducibility( degrees) 90-45 45-20 20-0 Score 4 3 2 Additional parameters Marked posterior crease Score 1 Marked 1 mediotarsal crease Cavus 1 0 t0 -20 1 Poor muscle condition 1 .

partially reducible <10% stiffstiff. soft-stiff. resistant. partially resistant >50%.resistant iii Severe 10-14 iv Very severe 15-20 .Grade Type Score Reducibility i ii Benign Moderate 1-4 5-9 >90% >50%. reducible. stiff-soft.

Aims of treatment  After sucessful treatment foot should  Look good  Feel good  Move good  Measure good .

Ponseti cast correction .

up to age of four . and then at nights and naps. an abduction foot orthosis worn full time for 12 weeks.Outline of Ponseti regimen  Serial casting of lower limb using a strictly defined technique and weekly change of casts  Percutaneous tenotomy of tendo achilles for “hind foot stall”  Once foot corrected.

Manipulation and cast application 1.Manipulation  Manipulation: start as soon after birth as possible  Setup for casting includes calming the child with a bottle or breast feeding  Assistant holds the foot while the manipulator performs the correction .

varus and inversion. Tarsal joints functionally interdependent  Movement of each tarsal bone involves simultaneous shifts in the adjacent bones SIMULTANEOUS correction of adduction.  Necessiates .

2. . Correction of cavus  Cavus results from pronation of the forefoot in relation to hindfoot “ THE PRONATION TWIST “  Attempting to correct the supination of hindfoot before correction of varus results in an iatrogenic increase in cavus  Corrected by supinating the forefoot to place it in proper alignment with the hindfoot.

Cast application Manipulation Padding .

Plaster at toes Below knee pop .

Molding

Extension upto the thigh

Plantar support to toes

Final appearance

Casts and foot

Adequate abduction
 Best sign of sufficient

abduction: ability to palpate the anterior process of the calcaneus as it abducts out from beneath talus  Abduction of approx.70 degrees in relationship to the frontal plane of the tibia possible

Complications of casting  Tight cast  Rocker bottom deformity  Crowded toes  Flat heel pad  Superficial sores  Deep sores  Pressure sores  Injury to distal tibial physis .

Common errors(Kite errors)  No manipulation  Pronation/eversion of 1st metatarsal  Premature dorsiflexion of heel  Counterpressure at calcaneocuboid joint  External rotation  Below knee casts  Short splints .

Rocker bottom deformity  Dorsiflexion via midfoot before correction of hindfoot varus  Dorsal dislocation of navicular on talus  Fixed equinus of calcaneus .

Correction of equinus and tenotomy  No direct attempt at equinus correction is made until heel varus is corrected  Equinus deformity gradually improves with correction of adductus and varus. adductus. and varus fully corrected but ankle dorsiflexion remains less than 10 degrees above neutral .manipulation and casting +/percutaneous tenotomy  Tenotomy : Indicated to correct equinus when cavus.calcaneus dorsiflexes as it abducts under talus  Residual equinus.

Percutaneous tenotomy under LA     Foot held in max dorsiflexion by an assistant Tenotomy done 1.5 cm above calcaneal insertion Additional 25-30 deg dorsiflexion obtained Cast with the foot abducted 60 to 70 degrees with respect to the frontal plane of the ankle. and 15 degrees dorsiflexion for 3 weeks .

Foot Abduction braces  Shoes mounted to bar in position of 70° of ER and 15° of dorsiflexion in B/L cases and incase of U/L cases 30 to 40° of ER in normal side. so the child can kick them “straight” to stretch gastrosoleus tendon . distance between shoes set at about 1˝ wider than width of shoulders  Knees left free.

Haemish A.March 1. PhD. Walker. MD. Crawford. 2007. FRACS. Cameron G. Geoffrey F. Volume 89A(3).487–493 .J Bone Joint Surg Am.Bracing protocol  Worn 24 hours each day for first 3 months  For 12 hours at night and 2 to 4 hours in middle of day for a total of 14 to 16 hours during each 24-hour period  Continued until the child is 3 to 4 years of age  Haft et al: noncompliance with bracing protocol – the most common cause of recurrence in children on Ponseti regimen Haft.

Mitchell brace Dobbs dynamic brace .

Dennis brown Romanus .

CTEV Splint  Straight inner border to prevent       forefoot adduction Outer shoe raise to prevent fooot inversion No heel to prevent equinus Slight(1/8”) lateral sole raise Inner iron bar Outer t trap Walking age to 5 yrs of age .

but functioned well despite this Cooper DM. who had been managed with the Ponseti method.Results of Ponseti method Cooper and Dietz in 1995:  Reviewed a group of 45 adults.  Based on structured examination. with 71 clubfeet. Dietz FR.77-A:1477-89. electrogoniometry and measurements using a pedobarography.  Using the Laaveg and Ponseti score. 30 years after treatment  Results compared with NORMAL CONTROLS. the results in the normal controls and in those with treated clubfeet same  Radiographs showed :feet not completely corrected. . J Bone Joint Surg [Am] 1995. radiographs.

Dietz FR.Results of Ponseti’s method. . Radical reduction in the rate of extensive correctivesurgery for clubfoot using the Ponseti method.5% required extensive corrective surgery.  Study from Iowa (2004) : short-term results of a more       recent series of 256 feet Correction obtained in 98% with one to seven casts 2. Pediatrics 2004.. Mean angle of dorsiflexion : 20° (0° to 35°) Minor cast complications in 8% Rate of relapse: 10%. Morcuende JA. Ponseti IV. Dolan LA. Percutaneous tenotomy in 86%.113:376-80.

2010 Sep. Ponseti's manipulation in neglected clubfoot in children more than 7 years of age: a prospective evaluation of 25 feet with long-term follow-up.  Recommend Ponseti's method as initial treatment modality for neglected clubfeet J Pediatr Orthop B. average Dimeglio score for 19 feet 0. recurrence in 6 feet (24%)  At 4-year follow-up.18.Khan et al  Evaluated results of Ponseti's method in 21 children (25 feet) with neglected club feet  Underwent percutaneous tenotomy of Achilles tendon  Mean age at the time of treatment 8.19(5):385-9. Khan SA.9 years  Mean follow-up period 4.7%) full correction.95 at the end of treatment at 1-year follow-up  18 feet (85.7 years  Average Dimeglio score at start of treatment 14. Kumar A .2 compared with an average score of 0.

Ponseti IV. (2005) 7 day Vs 5 day interval  Average time to tenotomy: 16 days in 5 day group and 24 days in 7 day group Morcuende JA.25:623-6 . Abbasi D.Modifications of Ponseti’s method  Accelerated Ponseti  Morcuende et al . J Pediatr Orthop 2005. Results of an accelerated Ponseti protocol for clubfoot. Dolan LA.

Kite method  Believed heel varus would correct simply by everting      calcaneus Did not realize calcaneus can evert only when it is abducted (i. heel varus and equinus) Forefoot overcorrected into mild flatfoot Calcaneus rolled out of inversion by placing plantar surface of a slipper cast on glass plate to flatten the sole Dorsiflexion of foot with wedging casts .e.. laterally rotated) under the talus Each component corrected separately ( adduction.

J Pediatr Orthop 2005.The French method Bensahel/Dimeglio regime  Daily manipulations by a skilled physiotherapist and temporary immobilisation with elastic and non-elastic adhesive taping  Mobilisation during the hours of sleep with CPM machine  Successful in 51% of cases ( of which 9% req TA tenotomy) .25:98-102. Wilson H. Johnston CE. 49% Reqd extensive soft tissue release -29% post release and 20% comprehensive posteromedial release**. ** Richards BS. Nonoperative clubfoot treatment using the French physical therapy method. .

a deep crease just above heel and across the sole of the midfoot . short hyperextended big toe. fibrotic muscles  Treatment by manipulation and Ponseti method .Atypical clubfoot  2-3% Feet highly resistant to correction  Severe plantarflexion of all metatarsals.

change emphasis to correction of the cavus and equinus. When manipulating.index finger should rest over posterior aspect of lateral malleolus while thumb of same hand applies counter pressure over the lateral aspect of the talar head  Do not abduct more than 30 degrees  After 30 degrees abduction is achieved.  All metatarsals are extended simultaneously with both thumbs  Above-knee cast in 110 degrees flexion .

Follow up protocol  2 weeks: to troubleshoot compliance issues  3 months: to graduate to the nights and naps protocol  Every 4 months: until age 3 years to monitor compliance and check for relapses  Every 6 months: until age 4 years.  Every 1 to 2 years: until skeletal maturity .

Surgery in clubfoot  Resistant clubfoot( non-responsive to serial casting and manipulation)  Persistently deformed clubfoot(non-operative correction inadequately done with/without compliant bracing)  Relapsed clubfoot( initially satisfactorily corrected that recurs in part or whole)  Neglected clubfoot( no treatment given till age of 2 yrs) .

extent  Index surgery.General Principles  Goal: address all pathoantomic structures  Decision regarding timing. the most important  “A la carte" approach [Bensahel]  Turco’s ‘one size fits all’ approach  Posteromedial-plantar-lateral release: all deformities present  Posterior release: straight lateral border. and palpable gap between medial malleolus and navicular tuberosity . flexible forefoot and hindfoot.

Approaches Turco Cincinnati .

across tmedial malleolus to Achilles tendon Straight lateral incision along the lateral subtalar joint antr to distal fibula .straight oblique incision from first metatarsal.Caroll’s two incision technique Medial incision .

Extensile posteromedial and posterolateral release  Modified McKay procedure  Cincinnati incision Posterolateral release  Z lengthening of the TA  Posterior capsulotomy of Ankle joint &Subtalar joint .

 Incise superior peroneal retinaculum  Cut off calcaneofibular and talofibular ligament  Incise talocalcaneal ligament and lateral capsule of talocalcaneal joint  EDB. inferior extensor retinaculum and dorsal calcaneocuboid ligamner cut incase of severe clubfoot .

Medial release  Dissect and protect N-V bundle  Master knot of Henry  Z-lengthening of the Tibialis Posterior & release of sheath  Follow to navicular insertion  Capsule of T-N joint released .

 Medial tibial navicular ligament. dorsal talonavicular ligamnet. and plantar calcaneonavicular ligament cut  Capsule of T-N cut all the way around .

if not incise post. post. talofibular ligament. Portion of deep deltoid ligament . Bifurcated ligament cut  Complete release of talocalcaneal joint ligaments except interosseous ligaments  Detach origin of quadratus plantae muscle from calcaneus  Roll talus back into ankle koint.

talocalcaneal joints . to ankle joint  K wire through talonavicular . medially push calcaneus post. Line up medial side of head and neck of talus with medial side of cuneiforms.

 Check for proper position of foot  Longitudinal plane of foot 85-90° to bimalleolar ankle plane. heel under tibia in slight valgus  Suture all tendons with foot in 20° dorsiflexion  Wound closure .

if applied during surgery for stabilisation  AFO given for 6 months . plantigrade position and cast applied – above knee  Cast kept for 4 – 6 weeks  Cast removed along with any K wires.Follow up :  Wound inspection done under sedation at 1 week  Foot held in neutral.

Residual deformities  Residual hindfoot equinus : Achilles tendon lengthening and posterior capsulotomy of ankle and subtalar joints  Dynamic metatarsus adductus : Transfer of anterior tibial tendon. either as split transfer or entire tendon .

ankle joint / Lambrinudi procedure  All three deformities >10 yrs triple arthrodesis .Resistant clubfoot  Metatarsus adductus : >5 yrs metatarsal osteototomy  Hindfoor varus : <2-3 yrs modified Mckay procedure 3.10 yrs Dwyer osteotomy ( isolated heel varus) Dilwyn Evans procedure (short medial column) Lichtblau procedure( long lateral column) 10-12 yrs triple arthrodesis  Equinus : Achilles tendon lengthening and posterior capsulotomy of subtalar joint.

Lichtblau procedure Triple arthrodesis Ilizarov/ JESS Lourenco et al . and rigid  Modified Ponseti*: manipulation for 5-10 mins. 2007 .Neglected clubfoot  No / incomplete initial treatment till the age of 2 years  Moderately flexible. and AFO for 1 year Extensive soft tissue release upto 4 yrs Dilwyn-Evans. two weekly      cast change. Correction of neglected club foot by ponseti method. JBJS Br. correction of foot to 30-40° abduction. moderately stiff.

Bony procedures Dwyer osteotomy  Osteotomy of calcaneus  Opening wedge medial osteotomy to increase the length and height of calcaneus  For isolated heel varus  Modified method uses lateral incisions .

Litchblau procedure  Medial soft tissue release  Lateral closing wedge osteotomy of calcaneus  Prevents long term stiffness of hindfoot  Shortens the lateral column .

Dilwyn Evans Osteotomy  Posteromedial release  Calcaneocuboid wedge resection and arthrodesis of the joint  Shortens lateral column  Stiffness at subtalar and midfoot joints  Preferred in older children (4-8 yrs) .

Salvage procedures Triple arthrodesis  Salvage procedure for pain after previous surgical correction. at age 10 to 12  Lateral closing wedge osteotomy through subtalar and midtarsal joints .  Correction of large degrees of deformity in neglected clubfeet.  Not performed before advanced skeletal maturity.

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Triple arthrodesis Dunn arthrodesis Hoke and kite .

untreated clubfoot  Previously treated clubfoot that is uncorrectable by any other surgical procedures  Resistant neuromuscular or syndromic clubfoot .Talectomy  Severe.

multilevel correction Deformity correction without shortening the foot  .Ilizarov    Correction slow enough to protect soft tissue Correction at the focus of deformity Simultaneous threedimensional.

Huerta et al.220-224 . Bradish et al. Heymann et al.March 2007.. Volume 27(2). pediatr. Hosny et al) over the last 15 years  Recent long term follow-up study** by Hari et al (2007):74% good/excellent result **Prem: J.Results with Ilizarov  Good to excellent results reported by various surgeons( Grill et al. orthop.

B. III MT. Medial half pin through I. V MT  2 transfixing and 1 axial wire through calcaneum . II. MUMBAI  2 to 4 transfixing wires in prox tibia  Metatarsal Transfixing wire through I &V MT. JOSHI.JOSHI EXTERNAL STABILISATION SYSTEM  DR.B. Lat half pin thro’ IV.

25 mm every 12 hours)  Distraction continued until approximately 20 degrees of dorsiflexion and overcorrection of the forefoot deformities was achieved  Maintained in this overcorrected position for twice as long as the distraction phase by casts/braces . differential distraction used to Sequentially correct deformities (Medial.0.0.JESS  Fractional.Lateral.25 mm every 6 hours .

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 Similar good results have been reported by other authors** **Suresh et al. Journal of Orthopaedic Surgery 2003: 11(2): 194–201 .2003.Results with JESS  Good or excellent results reported by Joshi in 84% of his patients  Recommended in all who have not responded to serial plaster casting methods.

Complications of surgery  Neurovascular injury  Loss of foot (10% have atrophic dorsalis pedis artery bundle)  Skin dehiscence  Wound infection  AVN talus  Dislocation of the navicular  Flattening and breaking of the talar head  Undercorrection/ Overcorrection (esp with Cincinatti)  Forefoot adductus  Hindfoot varus  Severe scarring  Stiff joints  Weakness of the plantar flexors of the ankle .

Conclusion  Proper understanding of the patho-anatomy a must  Ponseti method is now the standard treatment method  Indications of surgery limited but well defined  Turco’s posteromedial soft tissue release remains the treatment of choice in most cases amenable to surgical treatment .

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