CTEV - Congenital Club Foot

8/12/2019 CTEV - Congenital Club Foot

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Pathology and

Non-surgical Treatment of

Congenital Clubfoot

Dr. Irfan Ali ShujahB.Victoria Hospital

Bwpr, Pak


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OVERVIEW Definition

Epedemiology Types of Clubfoot

Etiology

Components

Pathology

Diagnosis

Classification

Non-Surgical Treatment

Management of Recurrence


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Normal Foot

Complex organ that is required to be:

StableResilient

Mobile

Cosmetic


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Club Foot

( Congenital Talipes EquinoVarus )

A condition in which one or bothfeet are twisted into an abnormal

position at birth.


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Definitions

Talipes:Talus = Ankle

Pes = Foot

Equinus: Horse

Foot that is in a position of

planter flexion at the ankle,Looks like that of the Horses foot


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Planus: Flat Foot

Cavus: Highly Arched Foot

Varus: Heel going towards midline

Valgus: Heel going away from midline

Adduction: Forefoot going towards midline

Abduction: Forefoot going away from midline


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Epidemiology

Incidence 1 : 1,000 live births

Sporadic

Bilateral in 50%

Males 65%


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Types of Clubfoot

Flexible (Postural)

Rigid (Structural)


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Etiology

Primary Germ Plasm defect in Talus

Primary Soft tissue abnormalities

Arrested fetal development

Abnormal Intra-uterine forces

( Oligohydramnios, Amniotic Band Syndrome )


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Components of ClubFoot

Cavus

Adduction

Varus

Equinus


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Pathology

Osseous Changes

Soft Tissue Anomalies/Changes


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Osseous Changes

TALUS

- Diminished in size

- Medial & Plantarward deviation of

the head, neck and articular facet

- Neck internally rotated, Body ext. rotated

CALCANEUS

- Hypoplastic, Inverted under the Talus

- Post. EndUpward and Laterally

- Ant. End Downward and Medially

- Tuberosity towards Lat. Mal. posteriorly


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NAVICULAR

- Severe Medial Positioning- Articulates with Tibia

CUBOID

- Displaced medially on Calcaneus

FOREFOOT

- Metatarsals and Phalanges Adducted


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Soft Tissue Changes

TENDONS

- Tibialis Post, Flexor Hallucis Longus &

Flexor Digitorum Longus contracted

- Abductor Hallucis contracted

- Histologically normal

LIGAMENTS

- Deltoid, TMT & Spring Ligaments contracted- Long and Short planter ligaments

- Histologically normal


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OTHERS-Blood vessels, nerves and skin

adaptively shortened along the

medial and plantar aspects

- Calf circumference, girth and

overall foot size diminished


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Diagnosis

PHYSICAL EXAMINATION

Short Achilles Tendon High and Small heel No creases behind Heel Abnormal crease in middle of

the foot Foot is smaller in unilateral

cases Callosities at abnormal

pressure areas Calf muscles wasting


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Radiologic Evaluation

Antero-Posterior view

Stress Dorsiflexion Lateral view


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Talo-Calcaneal Angle (AP)

(Normal 30-55)

Talo-Calcaneal Angle (LAT.)

(Normal 25-50)


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Talus-1stMetatarsal Angle

Radiographic measurement of forefoot

adduction

Useful in Rx. of Metatarsus Adductus &

Clubfoot

Normal 5-15

Negative in Clubfoot


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Classification

PiranisClassification

Dimeglio et al. Classification


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Pirani Classification of Clubfoot


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Pirani system composed of 10 different Physical

Examination Findings

0 for No Abnormality

0.5 for Moderate Abnormality

1 for Severe Abnormality


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Dimeglio et. al Classification


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In Dimeglio et. al system, 4 parameters are

assessed on the basis of their Reducibility with

gentle manipulation measured with goniometer.

Equinus Deviation Adduction Deviation


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Treatment

Each day the foot remains deformed

is a day of golden opportunity lost forever.

- Lenoir

NON-SURGICAL / CONSERVATIVE

SURGICAL


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Non-Surgical Treatment

Manipulation and Casting

Splints to Maintain Correction

- Ankle-Foot Arthrosis (AFO)

- Denis Brown Splint


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Ponseti Casting

Abundant young wavy collagen - easilystretched

Navicular, Cuboid & Calcaneus can be

abducted back under Talus without surgeryMost widely accepted technique

Success rate >90% of children 2yrs & younger

Recurrence rate 10-30%

Ideally is used in New borns

Success rates are lower in Older children


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Treatment Phase of Ponseti Casting

o Should begin ASAP .. Within 1stweek of life

o Gentle manipulation and casting weekly

Order of Correction1. Correction of forefoot Cavus & Adduction

2. Correction of Heel Varus

3. Correction of hindfoot Equinus

Generally 5-6 casts are required


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First apply short leg castbelow kneeThen extend above knee

when plaster sets.

Long Leg Casts are essential

1stcast removed after 1 week

1 minute of gentlemanipulation and re-castingfocusing on Abducting thefoot around head of Talusmaintaining Supinatedposition


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Never pronate

Never manipulate the heel directly

Casting in gradual abduction for 2-3weeks

Percutaneous Tendo-AchillesTenotomy under local anesthesia,followed by final cast

Final Cast is applied in maximallyAbducted position (70 degrees) andDorsiflexion in 15 degrees for 3 weeks


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Percutaneous TA Tenotomy

S i f C i


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Series of Castings


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Maintenace Phase of Ponsati Casting

Final Cast is removed after 3 weeksAFO

Abduction 70 degrees

Dorsiflexion 15 degrees

Distance btw the shoes is 1 inch wider than

the width of infants shoulders

Brace is worn 23hrs/day (3 months)

then while sleeping (2-3 years)

Brace compliance is very important


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M f R


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Management of Recurrence

Infrequent if Bracing protocol is followed closely

Repeated manipulation and casting

1stcast with dorsiflexion of 1stray if Cavus

Subsequent castings with Abduction and

ultimately ankle dorsiflexion

Achilles Tendon Lengthening and Ant. Tibial

Tendon transfer may be required

S


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Summary

4 Components of Clubfoot deformity CAVE

Bony and Soft tissue adaptive Changes

Pirani and Dimeglio Classification systems

Non-Surgical treatment should start ideallywithin 1st week

Ponsati Casting is worldwide accepted

technique

Brace wear Compliance is important

Recurrence is treated with Re-manipulation

and casting


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Documents

CTEV - Congenital Club Foot