Clubfoot

CTEV BY –SAIKRISHNA.K

FOREFOOT

MIDFOOT

HINDFOOT

ANATOMY-JOINTS ANKLE JOINT : TIBIA AND TALUS SUBTALAR JOINT : TALUS AND CALCANEUM TALONAVICULAR JOINT CALCANEO- CUBOID JOINTS

NOMENCLATUREPlanus: flatfoot

Cavus: highly arched foot

Varus: heel going towards the midlineValgus: heel going away from the midlineAdduction: forefoot going towards the midlineAbduction: forefoot going away From the midline

CLUB FOOT

INTRODUCTIONOssific development of the foot begins in utero.During embryonic development the foot passes

through 3 different positions.15mm---- Foot is Straight30mm----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 ClubfootSecondary 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 AnatomyA 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-ANATOMYMUSCLES CAPSULES AND LIGAMENTS

STRCTURES CONTRACTED ON THE MEDIAL SIDE

3 MUSCLES

• AHL• TP• FHL

3 LIGAMENTS

• DELTOID• SPRING• PLANTAR

3 CAPSULES OF

• SUBTALAR• TARSAL• TARSOMETATARSAL

2 MUSCLES

• TIBIALIS POST.• TENDO-ACHILLES

2 LIGAMENTS

• TALOFIBULAR• CALCANEOFIBULAR

2 CAPSULES OF

• ANKLE JNT• SUBTALAR JNT

PATHO-ANATOMYMUSCLES CAPSULES AND LIGAMENTS

STRCTURES CONTRACTED ON THE POSTERIOR SIDE

1 MUSCLE

• TIBIALIS ANT.

1 LIGAMENT

• SUPERIOR PARONEAL RETINACULA

1 CAPSULES

• CALCANEO-CUBOID JNT

PATHO-ANATOMYMUSCLES CAPSULES AND LIGAMENTS

STRCTURES CONTRACTED ON THE ANTERIOR SIDE

PATHO-ANATOMYSKIN

Adapts shortening on the medial sideDeep creases on the medial sideDimples on the lateral aspect

SECONDARY CHANGESOccurs when the child starts walking-exaggerates the

deformityCallosities 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 scoringSix 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 EquinusB-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( degrees)

Score Additional parameters

Score

90-45 4 Marked posterior crease

1

45-20 3 Marked mediotarsal crease

1

20-0 2 Cavus 10 t0 -20 1 Poor muscle

condition1

Grade Type Score Reducibilityi 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

Limitations1. Difficult to position the foot2. The ossific nuclei do not represent the

true shape3. 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 radiographThe 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 calcaneal angle

20 -50 deg <20 deg

Tarsal-1st MT angle

Upto 30 deg valgus

Varus anglulation

cuboid os. center w.r.t calcaneal axis

medialdisplacement

AP radiograph: Talo-Calcaneal angle

Normal foot: 20`-50` CTEV:<20 deg

AP Radiograph: convergence of base of MT

Lateral radiographnormal CTEV

Talo calcaneal angle

25 to 50 deg

<25 deg

Tarsal-1st MT angle

hyperflexion

Lateral view: Talo-Calcaneal angle

Normal foot : 25` to 50`

CTEV: <25 `

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 DIAGNOSISIdeally 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 PROTOCOLSagittal images perpendicular to the bimalleolar

axisOblique axial images perpendicular to the

talonavicular jointOblique axial images perpendicular to the

calcaneocuboid jointOblique coronal images perpendicular to the

subtalar joint

SAGITTAL IMAGES

Tibiotalar plantarflexionInferior 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 calcaneusThe abnormal facets of the subtalar joint

Thankyou