ClubfootCongenital Talipes Equino Varus

(CTEV)

ClubfootCongenital Talipes Equino Varus

(CTEV)

Definition

Twisting of the scaphoid, os calcis and cuboid around the astragalusCongenital Talipes Equino Varus or club foot has 4 basic deformation:1. fore foot : adduction2. hind foot : inversion or varus3. hind foot : equinus4. mid foot : cavus

Incidence : - (1-2) per 1000 births - male : female = 7:5 - 50% bilateralIncidence : of CTEV in various races

Race Cases perthousand birth

Chinese 0.39Japanese 0.53Malay 0.68Filipino 0.76Caucasian 1.12Puerto Rican 1.36Indian 1.51South African black 3.50Polynesian 6.81

Tachjian, The child foot

ETIOLOGY

Chromosomal theory Embryonic theory Otogenic theory Fetal theory Neurological theory Muscular theory

ETIOLOGY

Chromosomal theorydefect : in unfertilized germ cell (defect exists before fertilization)

ETIOLOGY

Embryonic theorydefect : within fertilized germ cellOccurs : between conception-12 weeks (Irani,

Sherman and Settle)

ETIOLOGY

Otogenic theory (arrest theory)arrest of developmentrelated to a change in genetic factor known as “cronon”Cronon : guide the precise time of the progressive

modification every structure during development

ETIOLOGY

Neurologic theoryMuscular theory

ETIOLOGY

Fetal theory (packing syndrome)Intrauterine packing (mechanical factors)

Schematic illustration of the critical periods in human development. During the first two weeks development, of the embryo is usually not susceptible to teratogens. During these pre-embryonic stages, a teratogen either damages all or most of the cells, resulting in its death, or damages only a few cells, allowing the conceptus to recover and the embryo to develop without birth defects. Red denotes highly sensitive periods when major defects may be produced (e.g. amelia, absence of limbs). Yellow indicates stages that are less sensitive to teratogens when minor defects may be induced (e.g. hypoplastic thumbs)

Etiology

- chromosomal theory polygenic (multi factorial)- defect in unfertilized germ cell : - in family - race (palynesia-Maori)

WeekTERM30128 50

- Embryonic theory (0-12) weeks defect occurs during fertilized germ cell

Otogenic theory -- arrest theory - Cronon : genetic factor which determine the precise time for progression modification during development- Cronon may be changed by certain element (teratogen) abnormal development of the limb- growth arrest : permanent, temporair, slowed growth permanent deformity temporary CTEV, slow – steroid- occur during (7-8) week marked CTEV- occur during (9-12) week moderate to mild CTEVSpecification defect (Hoofnick)limb specification at 5 month (teratogen)- neuromuscular- vascular- bone

CTEV : post specification defect

primary muscleabnormality?

Intra uterine pressure(packing syndrome)

20

Ponseti : genetic, embryonic malformation, collagen over production in ligament, collagen fibres wavy arranged, dense, many cells

PATHOANATOMY

Major deformity• Inward rotation of the whole foot on the talus

Rotation primarily takes place in :• talocalcaneal joint• talonavicular joint• calcaneocuboid joint

PATHOANATOMY

Talocrural (ankle ) joint :• Talus in equinus• Talus in mortise = external rotation (horizontal breach)• Posterior = capsule & ligament contracted

“Horizontal breach” according to the concept of Swann, Lloyd-Roberts, and Catterall

PATHOANATOMY

TALUS Constriction encasement Head & neck : medial & plantar deviation

PATHOANATOMY

TALOCALCANEAL JOINT:Calcaneus :rotation in 3 dimensions :

• Sagittal• Coronal• Horizontal

Pathomechanics of talipes equinovarusA. Posterolateral view of the calcaneus and talus of normal

foot. B. Lateral rotation of the talus, C. The anterior part of the calcaneus is pressed by the head of the talus and forced into plantar flexion, rotation, and varus position. (From Carroll, N., Murphy, R, and Leete, S.F. : The pathoanatomy of congenital clubfoot, Orthop.Clin.N. Amer., 9 : 227, 1978)

The articular relationship of the calcaneus to the talus as seen from the front in the left foot.

Pathoanatomy

Talonavicular joint : Navicular : displaced medial & plantarward Tib.posterior tendon Tibio-navic. Ligament (deltoid lig.) Calcaneo-navic.lig. (spring lig.) Talo-navic. Ligament Bifurcate ligament Cubonavic. Oblique ligament All navicular ligament

contracted

PATHOANATOMY

Calcaneo-cuboid joint: Cuboid displaced medially on calcaneus and under navicular &

cuneiform All ligaments : contracted Forefoot : supination and adduction Calcaneo-cuboid joint corrected nicely if other 2 subtalar complex

are corrected except in resistant CTEV

PATHOANATOMY

Muscles Imbalance between agonist and antagonist Muscles tonus determined by the amount of muscle

fibres type I & II All muscle below knee in CTEV fibre Type I > II [similar

with L.M.N lesion : AMC, sacral agenesis, Charcot-Marie, post poliomyelitis]

Some CTEV tendency to be recurrent

PATHOANATOMY VascularBy Doppler Technique : In normal population : a.dorsalis pedis 2.2.% absent In mild & moderate CTEV : a.dorsalis pedis = normal In severe CTEV : a.dorsalis pedis = 6.7% absent

MECHANISM of the CTEV

Fetal posture abnormality : foot in equinovarus

Muscle imbalance : tib. post. contracted

Factors determine the severity of the CTEV

Intrauterine position. The hips are always flexed and externally rotated, while the knees are usually flexed and the feet turned inward

EXAMINATION

History Physical examination Radiologic examination

Radiology : age more than (4-5) months

N : AP : talo-calcaneal angle : (200-400), CTEV < 200

Lat : talo-calcaneal angle : (350-500), CTEV<350

DIAGNOSIS

1. Non rigid type (packing syndrome)2. Rigid type :

• Moderate• Severe

3. Resistance rigid type :• AMC• Myelomeningocele• Constriction band

DIFFERENTIAL DIAGNOSIS

1. Constriction bands (Streeter disease)2. A.M.C3. Myelomeningocel4. Sacral agenesis5. Tibial agenesis6. Charcot-Marie disease

Constriction bands

Arthrogryposis Multiplex Congenita

Spina bifida

Sacral agenesis

Tibial agenesis

Charcot-Mary disease

TREATMENT

The goal of treatment :• Realign the os calcis, scaphoid and cuboid

around the astragalus by correcting the varus, adduction, varus and equinus

• Maintain the correction until stable normal function, no pain, plantigrade, good mobility, no callus formation, wearing normal shoe

HISTORY

Egyptian : tomb painting India (1.000 BC) : Tx Hippocrates (400 BC) : manipulative Tx,

early Tx Indian (Aztecs) Pre Columbian American

Tx : splint with cactus leaves

HISTORY : 20th century

Hugh Owen Thomas (1834 -1891)

Wrench

W.H. Trethewan (1882-1934) :

Thomas Wrench is a barbarous weapon

TREATMENT

1. Conservative2. Operative

Conservative treatment

Golden period:• 1st week• laxity :estrogen

1. Serial plastering2. Stretching Dennis Brown splint3. Adhesive strapping4. Physiotherapy

HIRAM KITE : Brought Hippocrates’ view info focus :Stressing slow, gentle, manipulative correction of the adduction, varus and equinus with minimal surgery

Three magic words for the successful and enthusiasm carrying out his treatment : knowledge,patience andenthusiasm

Ponseti :

Concept biomechanical understanding

SURGERY is the wrong approach for the treatment of the clubfoot. Ponseti

Ponseti

Based on kinematic of the subtalar joint.1st concept : the whole foot moves under the talus “calcaneo- pedis block”2nd concept : fore foot and hind foot are corrected simultaneously by abductionEquinus correction :

• mostly close tenotomy• tendo achilles non stretchable collagen, thick and stiff

COMPARISON KITE and PONSETI treatment

Clubfoot

1. Adduction2. Varus3. Equinus

KITE

Fulcrum : calcaneo cuboidCorrection by serial plastering :

PONSETI

1. Adduction Abduction2. Varus valgus

4 Cavus and pronation

Rigid 3 Equinus tenotomy

Fulcrum : head talus

Correction by serial plastering :

Surgery no yes

plastering

(10-11) months Shoe Denis-Brown splint

(3-4) years Evaluation

3 Equinus Rigid close tenotomy 90%

12 weeks

no =5% yes=95% Surgery

plastering

Shoe splint

(3-4) years Evaluation

4. Cavus and pronation (realign cavus by supination) to “unlock” subtalar movement1. Adduction Abduction 600-750

2. Varus : will be corrected by 4 & 1

6 weeks

Abduction of fore foot in pronation the cavus becomes more severe, calcaneus locked (jammed) under the head of talus; mid foot and forefoot are twisted eversion

Kite Clubfoot correction

Kite

Calcaneo-cuboid is used as fulcrum which is pressed medial ward while fore foot is moved lateral ward (abduction); calcaneus will not move lateral ward (no abduction) that is why the varus will not be corrected; only naviculare and fore foot will move lateral ward. To press the posterior part of calcaneus to correct varus is a big mistake

Kite

Clubfoot correction

a. realign cavus : forefoot supinated (3,4)b. fulcrum : caput tali – stabilisator (5)c. forefoot in supination – abduction (6)d. maximal abduction of forefoot (7)e. dorso flexion of the ankle (+TAL)

Process of a,b,c,d (5-6) x each (5-7) days.Plaster cast above knee (groin), knee

flexion 900

Ponseti

Ponseti (Clubfoot correction)

Ponseti

TAL

After 6x plastering TAL (close), local anaesthesia Plaster 3 weeks bracing for 3 months (24hours)

(2-4) hours day time, 12 hours at nigh (3-4) years night splint Ponseti success = 90%

Pre ATL

Pre ATL

Daffa pre ATL

Daffa Post ATL

Daffa

Common errors

1. Forefoot still in pronation during correction of adduction to abduction

2. Not using head of talus as fulcrum

3. Calcaneus is pressed lateral ward to correct varus

4. Equinus is corrected before adduction and varus are corrected Rocker bottom foot

5. Plaster immobilisation below knee

BK plastering High heel

Post posterior release ATL & capsulotomy

Plaster correction complication

1. Neuromuscular2. Pressure necrosis

Plaster correction complication

3. Rocker bottom foot

Plaster correction complication

4. Flat top talus

Plaster correction complication

5. Increase cavus deformity6. Longitudinal breach7. Stiff joint

Operative treatment

Indication1. Conservative Tx—fail Ponseti + 10%2. Neglected

Postero medial release (Turco)

Cincinati

Ilizaroff

Tripple arthrodesis (adult)

Surgical complication

1. Infection2. Bad scar3. Stiff joint4. Over/under correction5. Navicular dislocation6. Flattening or beaking talar head7. Talar necrosis8. Weakening of the muscles 9. Skew foot (severe valgus of the heel and adduction

of the fore foot)10. Main artery injury foot necrosis

Out patient clinic

RSUD.Dr.Soetomo