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1. CTEV : PaThoanaTomy and managEmEnT
dR. SUShIL PaUdEL
dR. PRaTyUSh
dR. Shah aLam Khan
2. 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
3. Classification (Attenborough 1966)
Type Type
I(Extrinsic) II(Intrinsic)
Non Rigid Rigid
Foot size Normal Smaller
Heel Normal size Small, elevated
Can be brought Cannot be brought
down with ease down with ease
Minimal varus Marked varus
Creases More or less normal Deep medial,
posterior and lateral
creases
Reduced creases
laterally
4. 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
6. 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 .
7. 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; 33:272–276
9. Bony abnormalities
Talus:
Head & neck deviated medially
& plantarward
Body rotated externally in the
ankle mortise
Body extruded anteriorly
Smaller than normal
10. 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
11. Cuboid
Displaced medially on
the dysmorphic distal
end of the calcaneus
Talonavicular joint
In inversion
17. 2. Features 3. General
Curved lateral border of foot Calf atrophy
Devil’s thumbprint over the Calf shortening
lateral malleolus Restricted ankle motion
Medial & Lateral skin creases
Navicular fixed to medial Other Conditions should be
malleolus excluded
Os calcis fixed to the lateral Spinal Dysraphism
malleolus Arthrogryposis
Heel small & high Neuromuscular Disorders
18. Radiology
Plain radiograph: Can be assessed prior to treatment
with A-P & Lateral of foot
Foot held in position of best correction, with weight-
bearing, 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
20. 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
21. 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)
22. Pirani’s 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
25. Uses of Pirani’s 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, 1082-
1084P.
** Flynn JM, Donohoe M, Mackenzie WG. J Pediatr Orthop 1999;18:323-7
26. 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.
32. Grade Type Score Reducibility
i Benign 1-4 >90%
ii Moderate 5-9 >50%, soft-stiff,
reducible, partially
resistant
iii Severe 10-14 >50%, stiff-soft,
resistant, partially
reducible
iv Very severe 15-20 <10% stiff-
stiff,resistant
33. Aims of treatment
After sucessful treatment foot should
Look good
Feel good
Move good
Measure good
35. 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
36. 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
37. Tarsal joints functionally
interdependent
Movement of each tarsal
bone involves
simultaneous shifts in the
adjacent bones
Necessiates
SIMULTANEOUS
correction of adduction,
varus and inversion.
38. 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.
43. 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
44. Complications of casting
Tight cast
Rocker bottom deformity
Crowded toes
Flat heel pad
Superficial sores
Deep sores
Pressure sores
Injury to distal tibial physis
45. 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
46. Rocker bottom deformity
Dorsiflexion via midfoot
before correction of
hindfoot varus
Dorsal dislocation of
navicular on talus
Fixed equinus of
calcaneus
47. 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
48. 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
49. 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
50. 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 89-
A(3).March 1, 2007.487–493
53. 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
54. 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.
55. Results of Ponseti’s 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.
56. 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
57. Modifications of Ponseti’s 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
58. 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
59. 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.
60. 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
61. 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
62. 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
63. 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)
64. General Principles
Goal: address all pathoantomic structures
Decision regarding timing, extent
Index surgery, the most important
“A la carte" approach [Bensahel]
Turco’s ‘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
66. Caroll’s two incision technique
Medial incision - straight oblique incision
Straight lateral incision along the lateral
from first metatarsal, across tmedial
subtalar joint antr to distal fibula
malleolus to Achilles tendon
67. Extensile posteromedial and posterolateral release
Modified McKay
procedure
Cincinnati incision
Posterolateral release
Z lengthening of the TA
Posterior capsulotomy of
Ankle joint &Subtalar joint
68. 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
69. 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
70. Medial tibial navicular
ligament, dorsal
talonavicular ligamnet,
and plantar
calcaneonavicular
ligament cut
Capsule of T-N cut all the
way around
71. 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
72. 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
73. 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
74. 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
75. 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
77. 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
78. 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
79. Litchblau procedure
Medial soft tissue
release
Lateral closing wedge
osteotomy of calcaneus
Prevents long term
stiffness of hindfoot
Shortens the lateral
column
80. 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)
81. 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
85. Ilizarov
Correction slow enough
to protect soft tissue
Correction at the focus
of deformity
Simultaneous three-
dimensional, multilevel
correction
Deformity correction
without shortening the
foot
86. 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
87. 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
88. 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
89.
90. 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): 194–201
91. 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
92. Conclusion
Proper understanding of the patho-anatomy a must
Ponseti method is now the standard treatment
method
Indications of surgery limited but well defined
Turco’s posteromedial soft tissue release remains the
treatment of choice in most cases amenable to
surgical treatment