CTEV : Pathoanatomy and management DR. SUSHIL PAUDEL DR. PRATYUSH Dr. Shah Alam Khan
CTEV : Pathoanatomy and management
DR. SUSHIL PAUDELDR. PRATYUSHDr. 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 byEquinus & varus of heelForefoot adductionMidfoot supination
Classification (Attenborough 1966)Type Type
I(Extrinsic)I(Extrinsic)
Non RigidNon Rigid
Type Type II(Intrinsic)II(Intrinsic)
RigidRigid
Foot sizeFoot size Normal Normal Smaller Smaller
Heel Heel Normal sizeNormal sizeCan be brought Can be brought down with easedown with easeMinimal varusMinimal varus
Small , elevatedSmall , elevatedCannot be brought Cannot be brought down with easedown with easeMarked varusMarked varus
Creases Creases More or less normalMore or less normal Deep medial, Deep medial, posterior and lateral posterior and lateral creasescreases
Reduced creases Reduced creases laterallylaterally
Definitions in clubfootRigid or resistant atypical clubfoot : Stiff,
short,chubby with a deep crease in sole of foot and behind ankle, shortening of the first metatarsal with hyperextension of the metatarsal phalangeal joint; 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
EpidemiologyCommonest congenital orthopaedic abnormality
1.3:1000 live births
Males>Females – 2:1
30-50% bilateral
Much more common in Polynesian & Maori & lower in Asians
PathogenesisUnknown at this stageGray et al (1981) : increase in % of type I fibres in soleus
muscle; suggested defective neural influenceRecent study*: no evidence of type I fiber groupingHypoplasia 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, with subsequent soft-tissue changes in the joints and musculotendinous complexes
*Sodre H et al. J Pediatr Orthop. 1990;10:101-4.**Muir L et al. J Bone Joint Surg Br. 1995;77:114-6
# Milan B MD et al. Journal of Pediatric Orthopedics. 26(1):91-93, 2006.
Wynne-Davies : polygenic inheritanceMultifactorial inheritance established by genetic epidemiologic research
by Idelberger32.5% concordance rate among monozygotic twins as compared to 2.9%
among dizygotic twinsMajor 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. et al 1939; 33:272–276
.
Intrauterine factors
Pressure theories: Oligohydramnios Abnormal fetal positioning
Placental insufficiencyConstriction bandsToxins ( Maternal alcoholism, smoking)Maternal illness ( anemia, thyroid disorders )Infective pathogens (enteroviruses)Drugs (abortifacients, salicylates, barbiturates)Electromagnetic radiation
Bony abnormalitiesTalus:
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 talusCalcaneus
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 changesPosterior
structures : Tendo achilles Post. capsule of ankle
joint & subtalar joint Post. talo fibular Calcaneo-fibular
ligaments
Medial : Tibialis posterior FHL,FDL, Master Knot of
Henry Talonavicular ligament Calcaneo-navicular
ligament Deltoid ligament Interossseus talo calcaneal
ligaments Capsules of naviculo
cuneiform & cuneiform first metatarsal
Plantar wards : Plantar fascia Plantar ligaments Flexor digitorum
brevis & abductor hallucis
Laterally Calcaneofibular
ligament Bifurcated ligament Calcaneocuboid
joint capsule
Clinical features 1. Deformity
Heel equinus Heel varus Midfoot supination Forefoot adduction Maybe cavus
2. Features Curved lateral border of
foot Devil’s thumbprint over
the lateral malleolus Medial & Lateral skin
creases Navicular fixed to
medial malleolus Os calcis fixed to the
lateral malleolus Heel small & high
3. General Calf atrophy Calf shortening Restricted ankle motion
Other Conditions should be excluded Spinal Dysraphism Arthrogryposis Neuromuscular Disorders
RadiologyPlain radiograph: Can be assessed prior to
treatment with A-P & Lateral of footFoot held in position of best correction, with
weight-bearing, or simulated weight-bearing AP view: Taken with foot in 30° of plantar flexion
and tube at 30° from verticalLat. View: Transmalleolar with the fibula
overlapping the posterior half of the tibia; foot in 30° of plantar flexion
Anteroposterior view
Talocalcaneal angle
Calcaneal-second metatarsal angle
Talus –first metatarsal angle
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), and they usually subtend an angle of 25-40°.
Any angle less than 20° considered abnormal
Lateral viewTalocalcaneal viewCalcaneal-first metatarsal
viewTibiocalcanealTibiotalar angleTalus-first metatarsal
angleTalocalcaneal index
(Kite's angles from AP and Lateral views added)
Pirani’s severity scoringSix parameters : 3 of midfoot and 3 of hindfoot Each parameter is given a value as follows:0: normal0.5: moderately abnormal1: severely abnormal
Pirani s et al. A method of evaluating virgin clubfoot with substantial interobserver reliability. Annual meeting of Pediatric orthopaedic society of North America 1995
Mid foot scoreCurved lateral
border [A]
Medial crease [B]
Talar head coverage [C]
Hind foot scorePosterior crease [D]
Rigid equinus [E]
Empty heel [F]
Uses of Pirani’s scoreAssessment of progress by serial plotting of the score
Predicting need for tenotomy (hs>1& ms<1)
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 ScoreIntroduced by Henri Bensahel et al in 2003Found to have good interobserver reliability
and reproducibility**Morhological (12 pts), functional (24 pts) &
radiological (12 pts) parametersMaximum of 60 for most deformed and 0 for
normal feet**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.
Reducibility( degrees)
Score Additional parameters
Score
90-45 4 Marked posterior crease
1
45-20 3 Marked mediotarsal crease
1
20-0 2 Cavus 1
0 t0 -20 1 Poor muscle condition
1
Grade Type Score Reducibility
i 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
Aims of treatmentAfter sucessful treatment foot should
Look good Feel good Move good Measure good
Ponseti cast correction
Outline of Ponseti regimenSerial 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, an abduction foot orthosis worn full time for 12 weeks, and then at nights and naps, up to age of four
Manipulation and cast application
1.ManipulationManipulation: 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
.
Tarsal joints functionally interdependent
Movement of each tarsal bone involves simultaneous shifts in the adjacent bones
Necessiates SIMULTANEOUS correction of adduction, varus and inversion.
2. Correction of cavusCavus 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 castingTight castRocker bottom deformityCrowded toesFlat heel padSuperficial soresDeep soresPressure soresInjury to distal tibial physis
Common errors(Kite errors)No manipulationPronation/eversion
of 1st metatarsalPremature
dorsiflexion of heelCounterpressure at
calcaneocuboid jointExternal rotationBelow knee castsShort splints
Rocker bottom deformityDorsiflexion 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- calcaneus dorsiflexes as it abducts under talus
Residual equinus- manipulation and casting +/- percutaneous tenotomy
Tenotomy : Indicated to correct equinus when cavus, adductus, and varus fully corrected but ankle dorsiflexion remains less than 10 degrees above neutral
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 bracesShoes 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, distance between shoes set at about 1˝ wider than width of shoulders
Knees left free, so the child can kick them “straight” to stretch gastrosoleus tendon
Bracing protocolWorn 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 ageHaft et al: noncompliance with bracing protocol –
the most common cause of recurrence in children on Ponseti regimen
Haft, Geoffrey F. MD; Walker, Cameron G. PhD; Crawford,Haemish A. FRACS.J Bone Joint Surg Am, Volume 89-A(3).March 1, 2007.487–493
Mitchell brace Dobbs dynamic brace
Dennis brown Romanus
CTEV SplintStraight inner border to
prevent forefoot adductionOuter shoe raise to prevent
fooot inversionNo heel to prevent equinusSlight(1/8”) lateral sole
raise Inner iron barOuter t trapWalking age to 5 yrs of age
Results of Ponseti method Cooper and Dietz in 1995: Reviewed a group of 45 adults, with 71 clubfeet,
who had been managed with the Ponseti method, 30 years after treatment
Results compared with NORMAL CONTROLS. Based on structured examination, radiographs,
electrogoniometry and measurements using a pedobarography.
Using the Laaveg and Ponseti score, the results in the normal controls and in those with treated clubfeet same
Radiographs showed :feet not completely corrected, but functioned well despite this
Cooper DM, Dietz FR. J Bone Joint Surg [Am] 1995;77-A:1477-89.
Results of Ponseti’s method..Study from Iowa (2004) : short-term results of a
more recent series of 256 feetCorrection obtained in 98% with one to seven
casts 2.5% required extensive corrective surgery.Percutaneous tenotomy in 86%. Mean angle of dorsiflexion : 20° (0° to 35°) Minor cast complications in 8% Rate of relapse: 10%.
Morcuende JA, Dolan LA, Dietz FR, Ponseti IV. Radical reduction in the rate of extensive correctivesurgery for clubfoot using the Ponseti method. Pediatrics 2004;113:376-80.
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 8.9 years Mean follow-up period 4.7 years Average Dimeglio score at start of treatment 14.2 compared with
an average score of 0.95 at the end of treatment at 1-year follow-up 18 feet (85.7%) full correction, recurrence in 6 feet (24%) At 4-year follow-up, average Dimeglio score for 19 feet 0.18. Recommend Ponseti's method as initial treatment modality for
neglected clubfeetJ Pediatr Orthop B.2010 Sep;19(5):385-9.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. Khan SA, Kumar A
Modifications of Ponseti’s method Accelerated Ponseti Morcuende et al , (2005) 7 day Vs 5 day intervalAverage time to tenotomy: 16 days in 5 day
group and 24 days in 7 day group
Morcuende JA, Abbasi D, Dolan LA, Ponseti IV. Results of an accelerated Ponseti protocol for clubfoot. J Pediatr Orthop 2005;25:623-6
Kite methodBelieved heel varus would correct simply by
everting calcaneusDid not realize calcaneus can evert only when it
is abducted (i.e., laterally rotated) under the talusEach component corrected separately
( adduction, heel varus and equinus)Forefoot overcorrected into mild flatfootCalcaneus 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
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) ; 49% Reqd extensive soft tissue release -29% post release and 20% comprehensive posteromedial release**.
** Richards BS, Johnston CE, Wilson H. Nonoperative clubfoot treatment using the
French physical therapy method. J Pediatr Orthop 2005;25:98-102.
Atypical clubfoot2-3% Feet highly
resistant to correctionSevere plantarflexion of
all metatarsals, 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
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, change emphasis to correction of the cavus and equinus.
All metatarsals are extended simultaneously with both thumbs
Above-knee cast in 110 degrees flexion
Follow up protocol2 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)
General PrinciplesGoal: address all pathoantomic structuresDecision regarding timing, extentIndex surgery, the most important“A la carte" approach [Bensahel]Turco’s ‘one size fits all’ approachPosteromedial-plantar-lateral release: all
deformities presentPosterior release: straight lateral border, flexible
forefoot and hindfoot, and palpable gap between medial malleolus and navicular tuberosity
ApproachesTurco Cincinnati
Caroll’s two incision techniqueMedial incision - straight oblique incision from first metatarsal, across tmedial malleolus to Achilles tendon
Straight lateral incision along the lateral subtalar joint antr to distal fibula
Extensile posteromedial and posterolateral releaseModified McKay
procedureCincinnati 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 releaseDissect and protect N-
V bundleMaster knot of HenryZ-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
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, if not incise post. talofibular ligament, post. Portion of deep deltoid ligament
Line up medial side of head and neck of talus with medial side of cuneiforms, medially push calcaneus post. to ankle joint
K wire through talonavicular ,talocalcaneal joints
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
Follow up :Wound inspection done under sedation at 1
weekFoot held in neutral, plantigrade position and
cast applied – above kneeCast kept for 4 – 6 weeksCast removed along with any K wires, if
applied during surgery for stabilisationAFO given for 6 months
Residual deformitiesResidual 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
Resistant clubfootMetatarsus adductus : >5 yrs metatarsal osteototomyHindfoor 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 arthrodesisEquinus : Achilles tendon lengthening and posterior
capsulotomy of subtalar joint, ankle joint / Lambrinudi procedure
All three deformities >10 yrs triple arthrodesis
Neglected clubfootNo / incomplete initial treatment till the age of 2
yearsModerately flexible, moderately stiff, and rigidModified Ponseti*: manipulation for 5-10 mins, two
weekly cast change, correction of foot to 30-40° abduction, and AFO for 1 year
Extensive soft tissue release upto 4 yrsDilwyn-Evans, Lichtblau procedureTriple arthrodesisIlizarov/ JESS
Lourenco et al . Correction of neglected club foot by ponseti method. JBJS Br. 2007
Bony proceduresDwyer osteotomy
Osteotomy of calcaneus
Opening wedge medial osteotomy to increase the length and height of calcaneus
For isolated heel varusModified method uses
lateral incisions
Litchblau procedureMedial soft tissue
release Lateral closing
wedge osteotomy of calcaneus
Prevents long term stiffness of hindfoot
Shortens the lateral column
Dilwyn Evans OsteotomyPosteromedial releaseCalcaneocuboid
wedge resection and arthrodesis of the joint
Shortens lateral column
Stiffness at subtalar and midfoot joints
Preferred in older children (4-8 yrs)
Salvage proceduresTriple arthrodesisSalvage procedure for pain after previous
surgical correction.Correction of large degrees of deformity in
neglected clubfeet.Not performed before advanced skeletal
maturity, at age 10 to 12Lateral closing wedge osteotomy through
subtalar and midtarsal joints
Triple arthrodesis Dunn arthrodesis Hoke and kite
Talectomy
Severe, untreated clubfoot
Previously treated clubfoot that is uncorrectable by any other surgical procedures
Resistant neuromuscular or syndromic clubfoot
Ilizarov Correction slow
enough to protect soft tissue
Correction at the focus of deformity
Simultaneous three-dimensional, multilevel correction
Deformity correction without shortening the foot
Results with IlizarovGood to excellent results reported by various
surgeons( Grill et al, Huerta et al, Bradish et al, Heymann et al, 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. pediatr. orthop., Volume 27(2).March 2007.220-224
JOSHI EXTERNAL STABILISATION SYSTEMDR.B.B. JOSHI, MUMBAI2 to 4 transfixing wires in
prox tibiaMetatarsal Transfixing wire through I &V MT; Medial half pin
through I, II, III MT; Lat half pin thro’ IV, V MT
2 transfixing and 1 axial wire through calcaneum
JESSFractional, differential distraction used to
Sequentially correct deformities (Medial- 0.25 mm every 6 hours ,Lateral- 0.25 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
Results with JESSGood or excellent results reported by Joshi in
84% of his patients Recommended in all who have not responded
to serial plaster casting methods. Similar good results have been reported by
other authors**
**Suresh et al,2003. Journal of Orthopaedic Surgery 2003: 11(2): 194–201
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
ConclusionProper understanding of the patho-anatomy a
mustPonseti method is now the standard
treatment methodIndications of surgery limited but well
definedTurco’s posteromedial soft tissue release
remains the treatment of choice in most cases amenable to surgical treatment
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