Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus(Congenital Clubfoot)(Congenital Clubfoot)
Dr. Mohamed M. ZamzamDr. Mohamed M. Zamzam
Associate Professor & Associate Professor & Consultant Pediatric Consultant Pediatric Orthopedic SurgeonOrthopedic Surgeon
THE NORMAL FOOTTHE NORMAL FOOT
Complex organ that is required to beComplex organ that is required to be
Stable:Stable: for supporting the body weight in standing for supporting the body weight in standing
Resilient:Resilient: for walking and running for walking and running
Mobile:Mobile: to accommodate variations of surfaceto accommodate variations of surface
CosmeticCosmetic
CLUB FOOTCLUB FOOTGross deformity of the foot that is giving Gross deformity of the foot that is giving
it the stunted lumpy appearanceit the stunted lumpy appearance
CLUB FOOTCLUB FOOT
DefinitionsDefinitions
Talipes:Talipes: Talus = ankle Talus = ankle
Pes = footPes = foot
Equinus:Equinus: (Latin = horse)(Latin = horse)
Foot that is in a position of Foot that is in a position of
planter flexion at the ankle,planter flexion at the ankle,
looks like that of the horse.looks like that of the horse. Calcaneus:Calcaneus: Full dorsiflexion at the ankleFull dorsiflexion at the ankle
CLUB FOOTCLUB FOOT
Planus:Planus: flatfoot flatfoot
Cavus:Cavus: highly arched foothighly arched foot
Varus:Varus: heal going towards heal going towards the midlinethe midlineValgus:Valgus: heel going away heel going away from the midlinefrom the midlineAdduction:Adduction: forefoot going forefoot going towards the midlinetowards the midlineAbduction:Abduction: forefoot going away forefoot going away From the midlineFrom the midline
Forefoot Hind foot
CLUB FOOTCLUB FOOT
TypesTypesPostural :Postural :Calcaneo-Valgus Equino-VarusCalcaneo-Valgus Equino-Varus
Look for CDH Look for CDH Minor and correctable Minor and correctable
CLUB FOOTCLUB FOOT
TypesTypes
Idiopathic (Unknown Etiology) :Idiopathic (Unknown Etiology) : Congenital Talipes Equino-Varus Congenital Talipes Equino-Varus CTEVCTEV
Acquired, Secondary to :Acquired, Secondary to : CNS Disease : Spina bifida, PoliomyelitisCNS Disease : Spina bifida, Poliomyelitis ArthrogryposisArthrogryposis Absent Bone : fibula / tibiaAbsent Bone : fibula / tibia
Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEVCongenital clubfoot or CTEV occursCongenital clubfoot or CTEV occurs
typically in an otherwise normal child.typically in an otherwise normal child.
Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEV
EtiologyEtiology
Polygenic Polygenic MultifactorialMultifactorial although many of these factors are speculativealthough many of these factors are speculative
Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEV
EtiologyEtiologySome of these factors are :Some of these factors are : Abnormal intrauterine forcesAbnormal intrauterine forces Arrested fetal developmentArrested fetal development Abnormal muscle and tendon insertionsAbnormal muscle and tendon insertions Abnormal rotation of the talus in the mortiseAbnormal rotation of the talus in the mortise Germ plasm defectsGerm plasm defects
Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEV
IncidenceIncidence Occurs approximately in one of every 1000 Occurs approximately in one of every 1000
live birthlive birth In affected families, clubfeet are about 30 In affected families, clubfeet are about 30
times more frequent in offspringtimes more frequent in offspring Male are affected in about 65% of casesMale are affected in about 65% of cases Bilateral cases are as high as 30 – 40 %Bilateral cases are as high as 30 – 40 %
Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEV
Geographic DistributionGeographic Distribution
Middle East , KSA commonMiddle East , KSA common Mediterranean Coast & North AfricaMediterranean Coast & North Africa White raceWhite race
Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEV
Basic PathologyBasic Pathology
Abnormal Tarsal RelationAbnormal Tarsal Relation Congenital Dislocation / Subluxation Congenital Dislocation / Subluxation Talo Calcaneo Navicular JointTalo Calcaneo Navicular Joint Soft Tissue ContractureSoft Tissue Contracture Congenital AtresiaCongenital Atresia
EGG & CHICKENEGG & CHICKEN
Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEV
Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEV
Adaptive ChangesAdaptive Changes Wolff’s LawWolff’s Law
“ “ Every change in the use of static function of bone Every change in the use of static function of bone caused a change in the internal form or architecture caused a change in the internal form or architecture
as well as alteration in its external formation and as well as alteration in its external formation and function according to mechanical law ”function according to mechanical law ”
Davis LawDavis Law“ “ When ligaments and soft tissue are in loose or lax When ligaments and soft tissue are in loose or lax
state; they gradually shorten ”state; they gradually shorten ”
Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEV
Adaptive ChangesAdaptive Changes Bony :Bony :
Change in the shape of tarsal and metatarsalChange in the shape of tarsal and metatarsalbones especially after walkingbones especially after walking
Soft Tissue :Soft Tissue :
Shortening ? Contracture in the Concave Side Shortening ? Contracture in the Concave Side 1- Muscles 2- Tendons1- Muscles 2- Tendons
3- Ligaments 3- Ligaments 4- Joints Capsule4- Joints Capsule 5- Skin 6- Nerves & Vessels5- Skin 6- Nerves & Vessels
Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEV
Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEVDiagnosisDiagnosis
General Examination :General Examination : ExcludeExclude Neurological lesion that can cause the deformity Neurological lesion that can cause the deformity
“Spina Bifida”“Spina Bifida” Other abnormalities that can explain the deformity Other abnormalities that can explain the deformity
“Arthrogryposis, Myelodysplasia”“Arthrogryposis, Myelodysplasia” Presence of concomitant congenital anomalies Presence of concomitant congenital anomalies “ “Proximal femoral focal deficiency”Proximal femoral focal deficiency” Syndromatic clubfootSyndromatic clubfoot “ “Larsen’s syndrome, Amniotic band Syndrome”Larsen’s syndrome, Amniotic band Syndrome”
Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEVDiagnosisDiagnosis
Spina Bifida = Paralytic TEVSpina Bifida = Paralytic TEV
Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEV
DiagnosisDiagnosisCharacteristic Deformity :Characteristic Deformity :Hind footHind foot Equinus (Ankle joint)Equinus (Ankle joint) Varus (Subtalar joint)Varus (Subtalar joint)Fore footFore foot Adduction (Med tarsal joint) Adduction (Med tarsal joint) Supination fore footSupination fore foot CavusCavus
Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEV
DiagnosisDiagnosis
Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEV
DiagnosisDiagnosis
“ “Hind foot “ “ Fore footHind foot “ “ Fore foot “ “ Equinus, Varus Adduction, Supination, CavusEquinus, Varus Adduction, Supination, Cavus
Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEV
DiagnosisDiagnosis
Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEV
DiagnosisDiagnosis Short Achilles tendonShort Achilles tendon High and small heel High and small heel No creases behind HeelNo creases behind Heel Abnormal crease in middle of the footAbnormal crease in middle of the foot Foot is smaller in unilateral affectionFoot is smaller in unilateral affection Callosities at abnormal pressure areasCallosities at abnormal pressure areas Internal torsion of the legInternal torsion of the leg Calf muscles wastingCalf muscles wasting Deformities don’t prevent walkingDeformities don’t prevent walking
Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEV
DiagnosisDiagnosis
Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEV
DiagnosisDiagnosisX-RayX-Ray needed to assess progress of treatmentneeded to assess progress of treatment
Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEV
TreatmentTreatment The goal of treatment for clubfoot is to The goal of treatment for clubfoot is to
obtain a plantigrade foot that is obtain a plantigrade foot that is functional, painless, and stable over timefunctional, painless, and stable over time
A cosmetically pleasing appearanceA 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
Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEV
TreatmentTreatmentNon surgical treatment should begin shortly after birthNon surgical treatment should begin shortly after birth1.1. Gentle manipulationGentle manipulation
2.2. ImmobilizationImmobilization
- Strapping ????- Strapping ????
- POP or synthetic cast- POP or synthetic cast
Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEV
TreatmentTreatmentNon surgical treatment should begin shortly after birthNon surgical treatment should begin shortly after birth3.3. Splints to maintain correctionSplints to maintain correction
- Ankle-foot orthosis ????- Ankle-foot orthosis ????
- Dennis Brown splint - Dennis Brown splint
Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEV
TreatmentTreatmentManipulation and serial castsManipulation and serial casts
Validity, up to 6 months !Validity, up to 6 months !
Technique Technique “Ponseti”“Ponseti” Avoid false correctionAvoid false correction When to stop ?When to stop ? Maintaining the correctionMaintaining the correction Follow up to watch and avoid recurrenceFollow up to watch and avoid recurrence
Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEV
TreatmentTreatmentPonseti techniquePonseti technique
1.1. Always use long leg casts, change weekly. Always use long leg casts, change weekly. 2.2. First manipulation raises the 1st metatarsal First manipulation raises the 1st metatarsal
to decrease the cavus to decrease the cavus 3.3. All subsequent manipulations include pure All subsequent manipulations include pure
abduction of forefoot with counter-pressure abduction of forefoot with counter-pressure on neck of talus.on neck of talus.
4.4. Never pronate ! Never pronate ! 5.5. Never put counter pressure on calcaneus or Never put counter pressure on calcaneus or
cuboid.cuboid.
Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEVTreatmentTreatment
Ponseti technique (cont.)Ponseti technique (cont.)6.6. Cast until there is about 60 degrees of external Cast until there is about 60 degrees of external
rotation (about 4-6 casts) rotation (about 4-6 casts) 7.7. Percutaneous tendo Achilles tenotomy in cast room Percutaneous tendo Achilles tenotomy in cast room
under local anesthesia, followed by final cast (3 under local anesthesia, followed by final cast (3 weeks) weeks)
8.8. After final cast removal, apply Normal last shoes with After final cast removal, apply Normal last shoes with Denis Browne bar set at 70 degrees external rotation Denis Browne bar set at 70 degrees external rotation (40 degrees on normal side) (40 degrees on normal side)
9.9. Denis Browne splint full time for two months, then Denis Browne splint full time for two months, then night time only for two-four years. night time only for two-four years.
10.10.35% need Anterior Tibialis tendon transfer at age 2-335% need Anterior Tibialis tendon transfer at age 2-3
Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEV
Surgical TreatmentSurgical TreatmentIndicationsIndications Late presentation, after 6 months of age !Late presentation, after 6 months of age ! Complementary to conservative treatmentComplementary to conservative treatment Failure of conservative treatmentFailure of conservative treatment Residual deformities after conservative Residual deformities after conservative
treatmenttreatment Recurrence after conservative treatmentRecurrence after conservative treatment
Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEV
Surgical TreatmentSurgical Treatment Types (soft tissue and bony operations)Types (soft tissue and bony operations) Time of surgeryTime of surgery Selection of the procedure and the incision Selection of the procedure and the incision Post operative carePost operative care Follow upFollow up Complications Complications
Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEV
Surgical TreatmentSurgical TreatmentSoft tissue operationsSoft tissue operations1.1. Release of contracturesRelease of contractures
2.2. TenotomyTenotomy
3.3. Tendon elongationTendon elongation
4.4. Tendon transferTendon transfer
5.5. Restoration of normal bony relationshipRestoration of normal bony relationship
Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEV
Surgical TreatmentSurgical Treatment
Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEV
Surgical TreatmentSurgical Treatment
Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEVSurgical TreatmentSurgical Treatment
Bony operationsBony operations IndicationsIndications Usually accompanied with soft tissue operationUsually accompanied with soft tissue operation Types:Types:
- Osteotomy, to correct foot deformity or int. tibial torsion- Osteotomy, to correct foot deformity or int. tibial torsion
- Wedge excision- Wedge excision
- Arthrodesis (usually after bone maturity)- Arthrodesis (usually after bone maturity)
one or several jointsone or several joints
- Salvage operation to restore shape- Salvage operation to restore shape
Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEVSurgical TreatmentSurgical Treatment
Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEVSurgical TreatmentSurgical Treatment
Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEVSurgical TreatmentSurgical Treatment
Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus
CTEVCTEVSurgical TreatmentSurgical Treatment