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CONGENITAL TALIPES

EQUINO VARUS
By Mohd Amirnizam Ahmad
Nazari

INTRODUCTION
Children with physical
disabilities are often
socially and
economically
disadvantaged
Importance of
Clubfoot - easily
diagnosed
- easily
treated

INTRODUCTION
CTEV congenital
talipes equino-varus
Talipes - The term
talipes is derived from
a contraction of the
Latin words for ankle,
ankle
talus, and foot, pes.
pes
The term refers to the
gait of severely
affected patients, who
walked on their ankles

DEFINITION
congenital deformity
of the foot and ankle
characterized by
equinus deformity at
the ankle
inversion at the
subtalar
adduction at the
midtarsal joint
cavus and internal tibial
torsion

INCIDENCE
Commonest congenital orthopedic abnormality
1.3:1000 live births
Males>Females 2:1
30-50% bilateral
In unilateral cases right side is more often involved
Much more common in Polynesian & Maori & lower in
Asians

TYPES ACCORDING TO
CAUSE
1) Idiopathic
2) Secondary
3) Postural / Positional

1. IDIOPATHIC CAUSE
Diagnosed when child has normal upper and
lower extremities spine and neurological status
apart from club foot
Can be detected by USG by 16 wks gestation
Combination of genetic and environmental factors
are involved

1. IDIOPATHIC CAUSE
Theories regarding
cause
Primary germ plasm
defect of talus
Contractile
myofibroblastic tissue in
the musculotendinous
units

2. SECONDARY CLUBFOOT
Diagnosed when deformity forms part of another
health condition
Neuropathic : deformity in association with
neurological abnormalities or spina bifida
Syndromic : clubfoot in association with other
syndromes
Streeters dysplasia
Arthrogryposis
Edwards syndrome

2. SECONDARY CLUBFOOT

3. POSTURAL
Due to abnormal intrauterine position
Easily corrected with massage by
mother or by casts

TYPES OF CLUBFOOT ACCORDING


TO TREATMENT STAGE

Untreated
Treated
Resistant
Recurrent
Neglected
Complex

TYPES OF CLUBFOOT
ACCORDING TO TREATMENT
STAGE

Untreated affected child is under 2 yrs of age


and had no or very little treatment

Treated affected childrens feet have corrected


with ponseti method and they have completed
the casting phase

TYPES OF CLUBFOOT
ACCORDING TO TREATMENT
STAGE

Resistant child has previously untreated


clubfoot and does not correct with Ponseti
method. This is usually syndromic and surgery
may be necessary
Recurrent clubfoot
- children who show signs of deformity in
previously treated clubfoot
- usually due to failure to wear FAO
- treated by casting or surgery

TYPES OF CLUBFOOT
ACCORDING TO TREATMENT
STAGE

Neglected clubfoot
child older than two years who had little or no
treatment
usually severe soft tissue contractures and bony
deformities
Ponseti treatment has some success but many
require surgery

Complex clubfoot
clubfoot treated by any method other than ponseti
technique
complicated by additional pathology or scarring

PATHOLOGICAL CHANGES
Four basic
components are
1. MidfootCavus

PATHOLOGICAL CHANGES
ForefootAdductus

PATHOLOGICAL CHANGES
HindfootVarus

PATHOLOGICAL CHANGES
HindfootEquinus

PATHOLOGICAL CHANGES
Associated findings
hypotrophic anterior tibial artery
atrophy of muscles around the calf
abnormal foot is smaller
If the deformity is left untreated late adaptive
changes occur in the bones.
These depend on the severity of soft tissue
contracture and effect of walking

Congenital Talipes Equino-Varus

CTEV

BONE CHANGES IN CTEV


Tibio-talar plantar
flexion

Medially displaced
navicular
Adducted and inverted
calcaneus

Medially displaced
cuboid

PATHOLOGICAL CHANGES
The ankle, subtalar and midtarsal joints are
involved
The severity of deformity varies and is graded by
the pirani score

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

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

RADIOLOGICAL EVALUATION
Talocalcaneal angle
Anteroposterior
view: 30-55 degrees

RADIOLOGICAL EVALUATION
Talocalcaneal angle
Dorsiflexion lateral
view: 25-50
degrees

RADIOLOGICAL EVALUATION
Tibiocalcaneal
angle
Stress lateral view:
60-90 degrees

RADIOLOGICAL EVALUATION
Talus first
metatarsal angle
Anteroposterior
view: 5-15 degrees

TREATMENT
Non operative Ponseti technique
Kite technique
French technique
Surgical
Posteromedial soft tissue release
Osteotomies
Triple arthrodesis
Achilles tendon lengthening
Ilizarov / JESS

TREATMENT

AIMS OF TREATMENT
After sucessful treatment foot should
Look good
Feel good
Move good
Measure good

NON SURGICAL
TREATMENT

1. PONSETI TECHNIQUE
Weekly Serial manipulation and casting(long leg
cast)
Goal is to rotate foot laterally around a fixed talus
Order of correction (cave)
cave
midfootcavus
forefootadductus
hindfootvarus
hindfootequinus (TAL)

PONSETI CAST CORRECTION

1. PONSETI TECHNIQUE
After the last cast, TA lengthening can be
considered
Foot Abduction Brace (FAB) for worn full time for
12 weeks, and then at nights and naps, up to age
of four
Chance of recurrence up to 4 or 5 yrs of age

2. KITES TECHNIQUE
Foot manipulated with calcaneo cuboid joint as
fulcrum
Casting done after manipulation
After correction, Denis Browne splint applied

3. FRENCH TECHNIQUE
Daily manipulation by physical therapist for 30
mts. Electrical stimulation of peroneal muscles
done
The purpose of muscle stimulation is to maintain
the correction obtained by manipulation.
After manipulation and muscle stimulation, taping
is applied.

3. FRENCH TECHNIQUE
The treatment has to be applied daily for two
months, followed by three treatments a week for
6 months.
This method gets good results but has decisive
disadvantages. The therapy involves too many
hospital visits, depends on the manipulation skills
of the physical therapist and is costly

SURGICAL TREATMENT

POSTEROMEDIAL SOFT TISSUE


RELEASE (PMR)
Done at age 1 years
old
Tight structures in
posterior and medial
aspect of the foot is
released or
lengthened

POSTEROMEDIAL SOFT TISSUE


RELEASE (PMR)

POSTEROLATERAL SOFT TISSUE RELEASE


(PMR)
Z lengthening of the
TA
Posterior capsulotomy
of Ankle joint
&Subtalar joint

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

TRIPLE ARTHRODESIS
Triple arthrodesis is a surgical procedure by fusing
of the three main joints of the hindfoot: the
subtalar joint, calcaneocuboid joint and the
talonavicular joint.
Performed in children more than 12 yrs old

TRIPLE ARTHRODESIS

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

ILIZAROV EXTERNAL
FIXATOR
Illizarov fixtor applied after correction of
deformities and maintain apparatus for 6 weeks
For residual or relapse club foot
between 3-10 years.
It is a blood less surge with minimal and scar.
The only disadvantage is pin tract infection in
some patient

ILIZAROV EXTERNAL
FIXATOR

PROGNOSIS
Depends mostly on the time the treatment
started.
When treatment is started within the first week
after birth, the chances of healing without relapse
in further life are high.
Persistence in wearing the abduction bar also
contributes to a good prognosis

THANK YOU