CTEV (CONGENITAL

TELIPES EQUINOVARUS)
CTEV
WHAT IS CTEV ?
 CONGENITAL TELIPES EQUINOVARUS.
 TALIPES MEANS ANKLE;
PES MEANS FOOT
 A DIFORMITY THAT CAUSES THE PATIENT TO
WALK ON THE ANKLE.
 CLUBFOOT :- IT IS CALLED BECAUSE SEVERE
UNTREATED TALIPES EQUINOVARUS HAS A
CLUB LIKE APPEARANCE.
 IT IS 1 OR 2 PER 1000 BIRTHS.
 MALE AFFECTED MORE THAN FEMALE.
 IT IS BILATERAL 1/3 OF CASES.
 HIPPOCRATES FIRST DESCRIBED CTEV.
VARIOUS TYPES OF FOOT
DEFORMITY:-
ANATOMY :-
AETIOLOGY:-
 IN MAJORITY OF CASES ,
AETIOLOGY IS NOT KNOWN.
 SO, IT IS IDIOPATHIC.
 BUT SOMETIMES UNDERLYING
CAUSES SUCH AS
ARTHROGRYPOSIS MULTIPLEX
CONGENITA (AMC) IN SECONDARY
CLUBFOOT.
(a)IDIOPATHIC CLUBFOOT
:-
 MECHANICAL THEORY:- THE RAISED
INTRAUTERINE PRESSURE FORCES
THE FOOT AGAINST THE WALL OF THE
UTERUS IN THE POSITION OF THE
DEFORMITY.
 ISCHAEMIC THEORY:- ISCHAEMIA OF
THE CALF MUSCLES DURING
INTRAUTERINE LIFE DUE TO
UNKNOWN FACTOR LEADING TO FOOT
DEFORMITY.
 CONT…
 GENETIC THEORY:- SOME
GENETICALLY RELATED
DISTURBANCES IN THE
DEVELOPMENT OF THE FOOT
CAUSE FOOT DEFORMITY.
(b)SECONDARY
CLUBFOOT :-
 PARALYTIC DISORDERS:- IN CASE WHERE
THERE IS A MUSCLE IMBALANCE.
e.g. THE INTROVER AND PLANTAR
FLEXORS ARE STRONGER THAN THE
EVERTORS AND DORSIFLEXORS ; AN
EQUINO-VARUS DEFORMITY WILL
DEVELOP.
 PARALYTIC DESORDERS SUCH AS, POLIO,
SPINA BIFIDA, MYELODYSPLASIA ..ETC…..
 ARTHROGRYPOSIS MULTIPLEX
CONGINITA (AMC):- DEFECTIVE
DEVELOPMENT OF
MUSCLE.MUSCLE ARE FIBROTICAND
RESULT IN FOOT DEFORMITIES AT
OTHE RJT.
PATHOLOGY :-
 SECONDARY CHANGES ARE IN THE
BONE ; CAUSE BY ABNORMALITY IN
SOFT TISSUES.
 POSTEROMEDIAL ASPECT OF ANKLE
AND FOOT IN CTEV.
 SOFT TISSUES SHOULD BE
RELEASED DURING SURGERY TO
BRING BACK THE BONES TO
NORMAL ALIGNMENT.
CLINICAL FEATURES :-
 FOOT IS IN EQUINUS, VARUS AND
ADDUCTION. IT IS JUDGED BY THE
INABILITY TO BRING THE FOOT IN
THE OPPOSITE DIRECTION. IN LATE
CASES, CAVUS OF THE FOOT MAY
ALSO BE PRESENT
 HEEL IS SMALL IN SIZE.THE
CALCANEUM MAY BE FELT WITH
VERY DIFFICULTLY.
 CONT…
 DEEP SKIN CREASES ON THE BACK OF
THE HEEL AND ON THE MEDIAL SIDE OF
THE SOLE.
 BONY PROMINANCE FELT ON LATERAL
SIDE OF THE FOOT, THE HEAD OF THE
TALUS AND LATERAL MALLEOLUS.
 PUTER SIDE OF THE FOOT IS GENTALY
CONVEX.THERE ARE DIMPLES ON THE
OUTER ASPECT OF THE ANKLE.
INVESTIGATION AND DX BY XRAY:-

KITE’S ANGLE(TALO CALCANEAL ANGLE):- NORMAL 30-35 DEGREE

NORMAL ANGLE IS 25-50 DEGREE
IT IS REUSED IN CTEV.
TESTS TO EXAMINE CLUBFOOT:-
 DORSIFLEXION TEST:- IN NEW BORN
CHILD, IT IS POSSIBLE TO
DORSIFLEX THE FOOT UNTIL ITS
DORSAL SURFACE MEETS THE
ANTERIOR SURFACE OF THE TIBIA.IT
IS NOT POSSIBLE IN CTEV.
 PLUMB LINE TEST:- IT IS TO DETECT TIBIAL
TORSION.
 THE CHILD IS MADE TO SIT ON THE TABLE WITH
BOTH THE LOWER LIMB HANGING FROM THE
EDGE.
 THE LINE DRAWN FROM THE CENTER OF THE
PATELLA TO TIBIAL TUBERCLE WHEN EXTENDED
DOWN SHOULD CUT THE FOOT AT 1ST OR 2ND
INTERMETATARSAL SPACE NORMALLY.
 IN CTEV, WITH MEDIALROTATION OF TIBIA, IT
CUTS THE 4TH OR 5TH METATARSAL SPACE.
 SCRATCH TEST:-
 MEDIAL SCRATCH TEST : IN NORMAL
CHILD;WHEN MEDIAL SOLE IS
SCRATCHED, THE FOOT
EVERTS.THIS TESTS PERONEALS.
 LATERAL SCRATCH : WHEN LATERAL
SOLE IS SCRATCHED, THE CHILD
INVERTS THE FOOT.THIS TESTS THE
INVERTORS.
TREATMENT:-
1. CORRECTION OF THE DEFORMITY
2. MAINTENANCE OF CORRECTION
1. CORRECTION OF DEFORMITY
 NON-OPERATIVE MATHOD:-
a) MANIPULATION ALONE:
IN NEW BORN, THE FOOT IS DORSIFLEXED
AND EVERTED,SUFFICIENT PRESSURE
SHOULD BE MAINTAINED FOR ABOUT 5 SEC.
AND THIS IS REPEATED SAVERAL TIMES
FOR ROUGHLY 5 MIN.
MINOR DEFORMITIES ARE USUALLY
CORRECTED BY THIS MATHOD BUT FOR
MAJOR DEFORMITIES CARRECTIVE
PLASTER CAST IS REQUIRED.
a) CONT…
b) MANIPULATION AND POP:
SURGEON MANIPULATES THE FOOT
AFTER SEDATING THE CHILD. THE
FOOT HELD IN CORRECT POSITION
WITH PLASTER CAST.
i. KITE’S PHILOSOPHY
ii. PONSETTI’S PHILOSOPHY
i. KITE’S PHILOSOPHY :- POPULAR METHOD OVER 40
YEARS.
 BEGINNING AT AGE 1 MONTH
 FIRST ADDUCTION DEFORMITY IS CORRECTED THE
SECOND IS EQUINUS DEFORMITY.
 BELOW KNEE PLASTER CAST IS IS SUFFICIENT.
 THE CASTS ARE CHANGE EVERY 2 WEEKS AND CONT.
UNTIL POSSIBLE TO CORRECT THE DEFORMITY.
 AFTER THAT FOOT KEPT IN A SUITABLE MAINTAINING
DEVICE.
 IT ACHIEVED IN 30% OF CASES OVER A PERIOD OF 6-9
MONTHS. THE REST NEED SURGICAL CORRECTION.
i. CONT…
 PONSETTI’S PHILOSOPHY :- ACCORDING TO PONSETTI, THE
CALCANEO-CUBOID-NAVICULAR COMPLEX IS INTERNALLY
ROTATED(ADDUCTED) UNDER THE PLANTERFLEXED TALUS.
 SO, BRINGING COMPLEX UNDER THE TALUS BY GRADUAL
STETCHING THE TIGHT STRUCTURES, DEFORMITY CAN BE
CORRECTED.
 PUTTING THUMB PRESSURE OVER THE TALUS HEAD.(NOT OVER
CALCANEO-CUBOID JT. AS KITE’S)
 THE Rx IS STARTED WITHIN 1 WEEK OF LIFE.
 CAVUS ASPECT CORRECTED FIRST FOLOWED BY ADDUCTION,THEN
VARUS AND LASTLY EQUINUS.
 AFTER MANIPULATION, ABOVE KNEE POP IS APPLIED.
 CAST IS CHANGED EVERY 5-7 DAYS.
 POSSIBLE TO CORRECT ALL COMPONENT WITHIN 6 WEEKS.
 THE EQUINUS DEFORMITY IS CORRECTED BY ACHILLOTENOTOMY.
 OPERATIVE METHOD:-
A. POSTERO-MEDIAL SOFT TISSUE RELEASE
B. LIMITED SOFT TISSUE RELEASE
C. TENDON TRANSFERS
D. DWYER’S OSTEOTOMY
E. DILWYN EVAN’S PROCEDURE
F. WEDGE TARSECTOMY
G. TRIPLE ARTHRODESIS
H. ILIZAROV’S TECHNIQUE
2. MAINTENANCE OF
CORRECTION
 CTEV SPLINTS:- MADE OF PLASTIC,
MOULDED IN SUCH A WAY THAT
WHEN TIED WITH STRAPS,IT KEEP
THE FOOT IN CORRECT POSITION.
 DENIS-BROWN SPLINT(DB SPLINT):-
THIS USED THROUGHOUT THE DAY
BEFORE CHILD START WALKING.
ONCE CHILD STARTS TO WALK, CTEV
SHOES ATE USED AT DAY TIME AND DB
SPLINT AT NIGHT.
 CTEV SHOES:- ONCE CHILD START
WALKING,FOLLOWING
MODIFICATIONS ARE MADE IN THE
SHOES.
 STAIGHT INNER BORDER-PREVENT
FOREFOOT ADDUCTION
 OUTER SHOE RAISE- PERVENT
FOOT INVERSION
 NO HEEL - PREVENT EQUINUS
 THESE SHOES ARE USED UNTIL THE
CHILD IS 5 YEARS OLD.
THANK
YOU