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CTEV : Pathoanatomy and management

DR. SUSHIL PAUDEL


DR. PRATYUSH Dr. 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 by Equinus & varus of heel Forefoot adduction Midfoot supination

Classification (Attenborough 1966)


Type I(Extrinsic) Non Rigid Foot size Heel
Normal
Normal

Type II(Intrinsic) Rigid


Smaller
Small

size Can be brought down with ease Minimal varus More or less normal

, elevated Cannot be brought down with ease Marked varus Deep medial, posterior and lateral creases Reduced creases laterally

Creases

Definitions in clubfoot
Rigid 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

Epidemiology
Commonest congenital orthopaedic abnormality
1.3:1000 live births Males>Females 2:1 30-50% bilateral Much more common in Polynesian & Maori & lower in

Asians

Pathogenesis
Unknown at this stage Gray et al (1981) : increase in % of type I fibres in soleus muscle;

suggested defective neural influence Recent study*: no evidence of type I fiber grouping Hypoplasia 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 inheritance Multifactorial inheritance established by genetic epidemiologic

research by Idelberger 32.5% concordance rate among monozygotic twins as compared to 2.9% among dizygotic twins Major 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; 33:272276

Intrauterine factors
Pressure theories: Oligohydramnios Abnormal fetal positioning Placental insufficiency Constriction bands Toxins ( Maternal alcoholism, smoking) Maternal illness ( anemia, thyroid disorders ) Infective pathogens (enteroviruses) Drugs (abortifacients, salicylates, barbiturates) Electromagnetic radiation

Bony abnormalities
Talus:
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 talus Calcaneus
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 changes


Posterior 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 Devils thumbprint over the

3. General
Calf atrophy Calf shortening Restricted ankle motion

lateral malleolus Medial & Lateral skin creases Navicular fixed to medial malleolus Os calcis fixed to the lateral malleolus Heel small & high

Other Conditions should be

excluded
Spinal Dysraphism Arthrogryposis Neuromuscular Disorders

Radiology
Plain radiograph: Can be assessed prior to treatment

with A-P & Lateral of foot Foot held in position of best correction, with weightbearing, or simulated weight-bearing AP view: Taken with foot in 30 of plantar flexion and tube at 30 from vertical Lat. 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 view Talocalcaneal view Calcaneal-first metatarsal view Tibiocalcaneal Tibiotalar angle Talus-first metatarsal angle Talocalcaneal index (Kite's angles from AP and Lateral views added)

Piranis severity scoring


Six parameters : 3 of midfoot and 3 of hindfoot
Each parameter is given a value as follows: 0: normal 0.5: moderately abnormal 1: 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 score


Curved lateral border [A]
Medial crease [B] Talar head coverage [C]

Hind foot score


Posterior crease [D]

Rigid equinus [E]

Empty heel [F]

Uses of Piranis score


Assessment 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, 10821084P.

** Flynn JM, Donohoe M, Mackenzie WG. J Pediatr Orthop 1999;18:323-7

International Clubfoot Study Group Score


Introduced by Henri Bensahel et al in 2003
Found to have good interobserver reliability and

reproducibility** Morhological (12 pts), functional (24 pts) & radiological (12 pts) parameters Maximum 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 Dimglio A.Equinus deviation B. Varus deviation C. Derotation D. Adduction.

Reducibility( degrees) 90-45 45-20 20-0

Score 4 3 2

Additional parameters Marked posterior crease

Score 1

Marked 1 mediotarsal crease Cavus 1

0 t0 -20

Poor muscle condition

Grade

Type

Score

Reducibility

i
ii

Benign
Moderate

1-4
5-9

>90%
>50%, soft-stiff, reducible, partially resistant >50%, stiff-soft, resistant, partially reducible <10% stiffstiff,resistant

iii

Severe

10-14

iv

Very severe

15-20

Aims of treatment
After sucessful treatment foot should Look good Feel good Move good Measure good

Ponseti cast correction

Outline of Ponseti regimen


Serial 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.Manipulation
Manipulation: 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 SIMULTANEOUS correction of adduction, varus and inversion.

Necessiates

2. Correction of cavus
Cavus 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 casting
Tight cast
Rocker bottom deformity Crowded toes Flat heel pad Superficial sores Deep sores Pressure sores

Injury to distal tibial physis

Common errors(Kite errors)


No manipulation

Pronation/eversion of 1st

metatarsal Premature dorsiflexion of heel Counterpressure at calcaneocuboid joint External rotation Below knee casts Short splints

Rocker bottom deformity


Dorsiflexion 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 braces


Shoes 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 protocol
Worn 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 age Haft 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 89A(3).March 1, 2007.487493

Mitchell brace

Dobbs dynamic brace

Dennis brown

Romanus

CTEV Splint
Straight inner border to prevent

forefoot adduction Outer shoe raise to prevent fooot inversion No heel to prevent equinus Slight(1/8) lateral sole raise Inner iron bar Outer t trap Walking 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 Ponsetis method..


Study from Iowa (2004) : short-term results of a more

recent series of 256 feet Correction 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 clubfeet
J 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 Ponsetis method


Accelerated Ponseti
Morcuende et al , (2005) 7 day Vs 5 day interval Average 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 method
Believed heel varus would correct simply by everting

calcaneus Did not realize calcaneus can evert only when it is abducted (i.e., laterally rotated) under the talus Each component corrected separately ( adduction, heel varus and equinus) Forefoot overcorrected into mild flatfoot Calcaneus 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 clubfoot
2-3% Feet highly resistant

to correction Severe 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 protocol
2 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 Principles
Goal: address all pathoantomic structures
Decision regarding timing, extent Index surgery, the most important A la carte" approach [Bensahel] Turcos one size fits all approach Posteromedial-plantar-lateral release: all deformities

present Posterior release: straight lateral border, flexible forefoot and hindfoot, and palpable gap between medial malleolus and navicular tuberosity

Approaches
Turco

Cincinnati

Carolls two incision technique


Medial 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 release


Modified McKay procedure Cincinnati 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 release Dissect and protect N-V bundle Master knot of Henry Z-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 week Foot held in neutral, plantigrade position and cast

applied above knee Cast kept for 4 6 weeks Cast removed along with any K wires, if applied during surgery for stabilisation AFO given for 6 months

Residual deformities
Residual 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 clubfoot
Metatarsus adductus : >5 yrs metatarsal osteototomy Hindfoor 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 arthrodesis Equinus : Achilles tendon lengthening and posterior capsulotomy of subtalar joint, ankle joint / Lambrinudi procedure
All three deformities

>10 yrs triple arthrodesis

Neglected clubfoot
No / incomplete initial treatment till the age of 2 years
Moderately flexible, moderately stiff, and rigid Modified 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 yrs Dilwyn-Evans, Lichtblau procedure Triple arthrodesis Ilizarov/ JESS
Lourenco et al . Correction of neglected club foot by ponseti method. JBJS Br. 2007

Bony procedures
Dwyer osteotomy
Osteotomy of calcaneus Opening wedge medial

osteotomy to increase the length and height of calcaneus For isolated heel varus Modified method uses lateral incisions

Litchblau procedure
Medial soft tissue release
Lateral closing wedge

osteotomy of calcaneus Prevents long term stiffness of hindfoot Shortens the lateral column

Dilwyn Evans Osteotomy


Posteromedial release
Calcaneocuboid wedge

resection and arthrodesis of the joint Shortens lateral column Stiffness at subtalar and midfoot joints Preferred in older children (4-8 yrs)

Salvage procedures
Triple arthrodesis Salvage 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 12 Lateral 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 threedimensional, multilevel correction Deformity correction without shortening the foot

Results with Ilizarov


Good 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 SYSTEM


DR.B.B. JOSHI, MUMBAI
2 to 4 transfixing wires in

prox tibia Metatarsal 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

JESS
Fractional, 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 JESS


Good 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): 194201

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

Conclusion
Proper understanding of the patho-anatomy a must
Ponseti method is now the standard treatment

method Indications of surgery limited but well defined Turcos posteromedial soft tissue release remains the treatment of choice in most cases amenable to surgical treatment

THANK YOU