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Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus(Congenital Clubfoot)(Congenital Clubfoot)
Dr. Mohamed M. ZamzamDr. Mohamed M. Zamzam
sso!iate "rofessor #sso!iate "rofessor #Consultant "ediatri!Consultant "ediatri!
$rthopedi! %urgeon$rthopedi! %urgeon
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THE NORMAL FOOTTHE NORMAL FOOT
Complex organ that is required to beCom
plex organ that is required to be
Stable:Stable: for supporting the body weight in standingfor supporting the body weight in standing
Resilient:Resilient: for walking and runningfor walking and running
Mobile:Mobile: to accommodate variations of surfaceto accommodate variations of surface
CosmeticCosmetic
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CLUB FOOTCLUB FOOT
Gross deformity of the foot that is givingGross deformity of the foot that is givingit the stunted lumpy appearanceit the stunted lumpy appearance
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CLUB FOOTCLUB FOOT
DefinitionsDefinitions
Talipes:Talipes: Talus = anleTalus = anle!es = foot!es = foot
Equinus:Equinus: "#atin = horse$"#atin = horse$
%oot that is in a position of%oot that is in a position of
planter flexion at the anle&planter flexion at the anle&
loos lie that of the horse'loos lie that of the horse' Calcaneus:Calcaneus: %ull dorsiflexion at the anle%ull dorsiflexion at the anle
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CLUB FOOTCLUB FOOT
Planus:Planus: flatfoot flatfoot
Cavus:Cavus: highly arched foothighly arched foot
Varus:Varus: heal going to(ardsheal going to(ards
the midlinethe midline
Valgus:Valgus: heel going a(ayheel going a(ay
from the midlinefrom the midline Adduction: Adduction: forefoot goingforefoot going
to(ards the midlineto(ards the midline
Abduction: Abduction: forefoot going a(ayforefoot going a(ay
%rom the midline%rom the midline
%orefoot )ind foot
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CLUB FOOTCLUB FOOT
TypesTypesPostural :Postural :
Calcaneo-Valgus Equino-VarusCalcaneo-Valgus Equino-Varus
Look for CDHLook for CDH inor and correctable inor and correctable
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CLUB FOOTCLUB FOOT
TypesTypes
Idiopathic (Unknown Etiolog! :Idio pathic (Unknown Etiolog! :
Congenital Talipes *quino+,arusCongenital Talipes *quino+,arus CT*,CT*,
Acquired" #econdar to : Acquired" #econdar to :
C-S .isease : Spina bifida& !oliomyelitisC-S .isease : Spina bifida& !oliomyelitis
/rthrogryposis/rthrogryposis
/bsent 0one : fibula 1 tibia/bsent 0one : fibula 1 tibia
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Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEVCongenital clubfoot or C!EV occursCongenital clubfoot or C!EV occurstypically in an otherwise normal child"typically in an otherwise normal child"
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Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEVEtiologyEtiology
!olygenic!olygenic
MultifactorialMultifactorial
although many of these factors are speculativealthough many of these factors are speculative
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Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEVEtiologyEtiology
Some of these factors are :Some of these factors are :
/bnormal intrauterine forces/bnormal intrauterine forces
/rrested fetal development/rrested fetal development
/bnormal muscle and tendon insertions/bnormal muscle and tendon insertions
/bnormal rotation of the talus in the mortise/bnormal rotation of the talus in the mortise
Germ plasm defectsGerm plasm defects
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Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEVIncidenceIncidence
2ccurs approximately in one of every 34442ccurs approximately in one of every 3444live birthlive birth
5n affected families& clubfeet are about 645n affected families& clubfeet are about 64
times more frequent in offspringtimes more frequent in offspring
Male are affected in about 789 of casesMale are affected in about 789 of cases
0ilateral cases are as high as 64 ;4 90ilateral cases are as high as 64 ;4 9
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Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEVGeog!p"ic Disti#$tionGeog!p"ic Disti#$tion
Middle *ast & hite race
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Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEVB!sic %!t"ologyB!sic %!t"ology
/bnormal Tarsal Relation/bnormal Tarsal Relation Congenital .islocation 1 SubluxationCongenital .islocation 1 Subluxation
Talo Calcaneo -avicular ?ointTalo Calcaneo -avicular ?oint Soft Tissue ContractureSoft Tissue Contracture
Congenital /tresiaCongenital /tresia
*GG C)5C
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Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEV
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Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEVAd!pti&e C"!ngesAd!pti&e C"!nges
$ol%%&s 'aw $ol%%&s 'aw
@@ *very change in the use of static function of bone*very change in the use of static function of bonecaused a change in the internal form or architecturecaused a change in the internal form or architecture
as (ell as alteration in its external formation andas (ell as alteration in its external formation andfunction according to mechanical la( Afunction according to mechanical la( A
avis 'aw avis 'aw @@ >hen ligaments and soft tissue are in loose or lax>hen ligaments and soft tissue are in loose or lax
stateB they gradually shorten AstateB they gradually shorten A
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Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEVAd!pti&e C"!ngesAd!pti&e C"!nges
0ony :0ony :
Change in the shape of tarsal and metatarsalChange in the shape of tarsal and metatarsalbones especially after (alingbones especially after (aling
Soft Tissue :Soft Tissue : Shortening Contracture in the Concave SideShortening Contracture in the Concave Side
3+ Muscles D+ Tendons3+ Muscles D+ Tendons
6+ #igaments6+ #igaments ;+ ?oints Capsule;+ ?oints Capsule
8+ Sin 7+ -erves ,essels8+ Sin 7+ -erves ,essels
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Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEV
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Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEVDi!gnosisDi!gnosisGeneral *xamination :General *xamination :
*xclude*xclude -eurological lesion that can cause the deformity-eurological lesion that can cause the deformity@Spina 0ifidaA@Spina 0ifidaA
2ther abnormalities that can explain the deformity2ther abnormalities that can explain the deformity@/rthrogryposis& MyelodysplasiaA@/rthrogryposis& MyelodysplasiaA
!resence of concomitant congenital anomalies!resence of concomitant congenital anomalies@ @!roximal femoral focal deficiencyA!roximal femoral focal deficiencyA
Syndromatic clubfootSyndromatic clubfoot
@ @#arsenEs syndrome& /mniotic band SyndromeA#arsenEs syndrome& /mniotic band SyndromeA
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Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEVDi!gnosisDi!gnosis
Spina 0ifida = !aralytic T*,Spina 0ifida = !aralytic T*,
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Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CT*,CT*,Di!gnosisDi!gnosis
Characteristic .eformity :Characteristic .eformity :
)ind foot)ind foot *quinus "/nle Foint$*quinus "/nle Foint$
,arus "Subtalar Foint$,arus "Subtalar Foint$
%ore foot%ore foot /dduction "Med tarsal Foint$/dduction "Med tarsal Foint$
Supination fore footSupination fore foot
CavusCavus
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Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CT*,CT*,Di!gnosisDi!gnosis
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Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CT*,CT*,Di!gnosisDi!gnosis
@@)ind foot @ @ %ore foot)ind foot @ @ %ore foot@@
*quinus& ,arus /dduction& Supination& Cavus*quinus& ,arus /dduction& Supination& Cavus
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Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CT*,CT*,Di!gnosisDi!gnosis
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Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CT*,CT*,Di!gnosisDi!gnosis
Short /chilles tendonShort /chilles tendon
)igh and small heel)igh and small heel -o creases behind )eel-o creases behind )eel /bnormal crease in middle of the foot/bnormal crease in middle of the foot %oot is smaller in unilateral affection%oot is smaller in unilateral affection
Callosities at abnormal pressure areasCallosities at abnormal pressure areas 5nternal torsion of the leg5nternal torsion of the leg Calf muscles (astingCalf muscles (asting .eformities donEt prevent (aling.eformities donEt prevent (aling
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Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CT*,CT*,Di!gnosisDi!gnosis
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Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CT*,CT*,Di!gnosisDi!gnosis
)*+a )*+a needed to assess progress of treatmentneeded to assess progress of treatment
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Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CT*,CT*,Te!t'entTe!t'ent
The goal of treatment for clubfoot is toThe goal of treatment for clubfoot is to
obtain a plantigrade foot that isobtain a plantigrade foot that isfunctional& painless& and stable over timefunctional& painless& and stable over time
/ cosmetically pleasing appearance/ cosmetically pleasing appearance
is also an important goal sought byis also an important goal sought by
the surgeon and the familythe surgeon and the family
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Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CT*,CT*,Te!t'entTe!t'ent
Non s$gic!l te!t'ent s"o$ld #egin s"otly !fte #it"Non s$gic!l te!t'ent s"o$ld #egin s"otly !fte #it"
3'3' Gentle manipulationGentle manipulation
D'D' 5mmobiliation5mmobiliation
+ Strapping + Strapping
+ !2! or synthetic cast+ !2! or synthetic cast
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Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CT*,CT*,Te!t'entTe!t'ent
Non s$gic!l te!t'ent s"o$ld #egin s"otly !fte #it"Non s$gic!l te!t'ent s"o$ld #egin s"otly !fte #it"
6'6' Splints to maintain correctionSplints to maintain correction + /nle+foot orthosis + /nle+foot orthosis
+ .ennis 0ro(n splint+ .ennis 0ro(n splint
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Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CT*,CT*,Te!t'entTe!t'ent
M!nip$l!tion !nd sei!l c!stsM!nip$l!tion !nd sei!l c!sts
V!lidity( $p to ) 'ont"s *V!lidity( $p to ) 'ont"s *
Tec"ni+$eTec"ni+$e ,%onseti-,%onseti-
A&oid f!lse coectionA&oid f!lse coection
."en to stop /."en to stop /
M!int!ining t"e coectionM!int!ining t"e coection
Follo0 $p to 0!tc" !nd !&oid ec$enceFollo0 $p to 0!tc" !nd !&oid ec$ence
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Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CT*,CT*,Te!t'entTe!t'ent
%onseti tec"ni+$e%onseti tec"ni+$e
3'3' /l(ays use long leg casts& change (eely'/l(ays use long leg casts& change (eely'D'D' %irst manipulation raises the 3st metatarsal%irst manipulation raises the 3st metatarsalto decrease the cavusto decrease the cavus
6'6' /ll subsequent manipulations include pure/ll subsequent manipulations include pure
abduction of forefoot (ith counter+pressureabduction of forefoot (ith counter+pressureon nec of talus'on nec of talus'
;';' -ever pronate H-ever pronate H8'8' -ever put counter pressure on calcaneus or-ever put counter pressure on calcaneus or
cuboid'cuboid'
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Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CT*,CT*,Te!t'entTe!t'ent%onseti tec"ni+$e 1cont23%onseti tec"ni+$e 1cont23
7'7' Cast until there is about 74 degrees of externalCast until there is about 74 degrees of external
rotation "about ;+7 casts$rotation "about ;+7 casts$I'I' !ercutaneous tendo /chilles tenotomy in cast room!ercutaneous tendo /chilles tenotomy in cast room
under local anesthesia& follo(ed by final cast "6under local anesthesia& follo(ed by final cast "6(ees$(ees$
J'J' /fter final cast removal& apply -ormal last shoes (ith/fter final cast removal& apply -ormal last shoes (ith
.enis 0ro(ne bar set at I4 degrees external rotation.enis 0ro(ne bar set at I4 degrees external rotation";4 degrees on normal side$";4 degrees on normal side$
K'K' .enis 0ro(ne splint full time for t(o months& then.enis 0ro(ne splint full time for t(o months& thennight time only for t(o+four years'night time only for t(o+four years'
34'34'689 need /nterior Tibialis tendon transfer at age D+6689 need /nterior Tibialis tendon transfer at age D+6
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Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CT*,CT*,4$gic!l Te!t'ent4$gic!l Te!t'ent
5ndications5ndications
#ate presentation& after 7 months of age H#ate presentation& after 7 months of age H
Complementary to conservative treatmentComplementary to conservative treatment
%ailure of conservative treatment%ailure of conservative treatment
Residual deformities after conservativeResidual deformities after conservativetreatmenttreatment
Recurrence after conservative treatmentRecurrence after conservative treatment
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Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CT*,CT*,4$gic!l Te!t'ent4$gic!l Te!t'ent
Types 1soft tiss$e !nd #ony ope!tions3Types 1soft tiss$e !nd #ony ope!tions3
Ti'e of s$geyTi'e of s$gey
4election of t"e poced$e !nd t"e incision4election of t"e poced$e !nd t"e incision
%ost ope!ti&e c!e%ost ope!ti&e c!e
Follo0 $pFollo0 $p
Co'plic!tionsCo'plic!tions
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Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CT*,CT*,4$gic!l Te!t'ent4$gic!l Te!t'ent
Soft tissue operationsSoft tissue operations
3'3' Release of contracturesRelease of contractures
D'D' TenotomyTenotomy
6'6' Tendon elongationTendon elongation
;';' Tendon transfer Tendon transfer 8'8' Restoration of normal bony relationshipRestoration of normal bony relationship
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Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CT*,CT*,4$gic!l Te!t'ent4$gic!l Te!t'ent
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Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CT*,CT*,4$gic!l Te!t'ent4$gic!l Te!t'ent
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Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CT*,CT*,4$gic!l Te!t'ent4$gic!l Te!t'entBony ope!tionsBony ope!tions Indic!tionsIndic!tions
Us$!lly !cco'p!nied 0it" soft tiss$e ope!tionUs$!lly !cco'p!nied 0it" soft tiss$e ope!tion
Types5Types5
6 Osteoto'y( to coect foot defo'ity o int2 ti#i!l tosion6 Osteoto'y( to coect foot defo'ity o int2 ti#i!l tosion
6 .edge e7cision6 .edge e7cision 6 At"odesis 1$s$!lly !fte #one '!t$ity36 At"odesis 1$s$!lly !fte #one '!t$ity3
one o se&e!l 8ointsone o se&e!l 8oints
6 4!l&!ge ope!tion to estoe s"!pe6 4!l&!ge ope!tion to estoe s"!pe
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Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CT*,CT*,4$gic!l Te!t'ent4$gic!l Te!t'ent
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Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CT*,CT*,4$gic!l Te!t'ent4$gic!l Te!t'ent
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Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CT*,CT*,4$gic!l Te!t'ent4$gic!l Te!t'ent
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Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CT*,CT*,4$gic!l Te!t'ent4$gic!l Te!t'ent
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