Congenital Talipes Equino-Varus (1)

8/20/2019 Congenital Talipes Equino-Varus (1)

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Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus(Congenital Clubfoot)(Congenital Clubfoot)

Dr. Mohamed M. ZamzamDr. Mohamed M. Zamzam

sso!iate "rofessor #sso!iate "rofessor #Consultant "ediatri!Consultant "ediatri!

$rthopedi! %urgeon$rthopedi! %urgeon


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THE NORMAL FOOTTHE NORMAL FOOT

Complex organ that is required to beCom

plex organ that is required to be

Stable:Stable: for supporting the body weight in standingfor supporting the body weight in standing

Resilient:Resilient: for walking and runningfor walking and running

Mobile:Mobile: to accommodate variations of surfaceto accommodate variations of surface

CosmeticCosmetic


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CLUB FOOTCLUB FOOT

Gross deformity of the foot that is givingGross deformity of the foot that is givingit the stunted lumpy appearanceit the stunted lumpy appearance


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CLUB FOOTCLUB FOOT

DefinitionsDefinitions

Talipes:Talipes: Talus = anleTalus = anle!es = foot!es = foot

Equinus:Equinus: "#atin = horse$"#atin = horse$

%oot that is in a position of%oot that is in a position of

planter flexion at the anle&planter flexion at the anle&

loos lie that of the horse'loos lie that of the horse' Calcaneus:Calcaneus: %ull dorsiflexion at the anle%ull dorsiflexion at the anle


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CLUB FOOTCLUB FOOT

Planus:Planus: flatfoot flatfoot

Cavus:Cavus: highly arched foothighly arched foot

Varus:Varus: heal going to(ardsheal going to(ards

the midlinethe midline

Valgus:Valgus: heel going a(ayheel going a(ay

from the midlinefrom the midline Adduction: Adduction: forefoot goingforefoot going

to(ards the midlineto(ards the midline

Abduction: Abduction: forefoot going a(ayforefoot going a(ay

%rom the midline%rom the midline

%orefoot )ind foot


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CLUB FOOTCLUB FOOT

TypesTypesPostural :Postural :

Calcaneo-Valgus Equino-VarusCalcaneo-Valgus Equino-Varus

Look for CDHLook for CDH inor and correctable inor and correctable


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CLUB FOOTCLUB FOOT

TypesTypes

Idiopathic (Unknown Etiolog! :Idio pathic (Unknown Etiolog! :

Congenital Talipes *quino+,arusCongenital Talipes *quino+,arus CT*,CT*,

Acquired" #econdar to : Acquired" #econdar to :

C-S .isease : Spina bifida& !oliomyelitisC-S .isease : Spina bifida& !oliomyelitis

/rthrogryposis/rthrogryposis

/bsent 0one : fibula 1 tibia/bsent 0one : fibula 1 tibia


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Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus

CTEVCTEVCongenital clubfoot or C!EV occursCongenital clubfoot or C!EV occurstypically in an otherwise normal child"typically in an otherwise normal child"


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CTEVCTEVEtiologyEtiology

!olygenic!olygenic

MultifactorialMultifactorial

although many of these factors are speculativealthough many of these factors are speculative


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CTEVCTEVEtiologyEtiology

Some of these factors are :Some of these factors are :

/bnormal intrauterine forces/bnormal intrauterine forces

/rrested fetal development/rrested fetal development

/bnormal muscle and tendon insertions/bnormal muscle and tendon insertions

/bnormal rotation of the talus in the mortise/bnormal rotation of the talus in the mortise

Germ plasm defectsGerm plasm defects


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CTEVCTEVIncidenceIncidence

2ccurs approximately in one of every 34442ccurs approximately in one of every 3444live birthlive birth

5n affected families& clubfeet are about 645n affected families& clubfeet are about 64

times more frequent in offspringtimes more frequent in offspring

Male are affected in about 789 of casesMale are affected in about 789 of cases

0ilateral cases are as high as 64 ;4 90ilateral cases are as high as 64 ;4 9


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CTEVCTEVGeog!p"ic Disti#$tionGeog!p"ic Disti#$tion

Middle *ast & hite race


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CTEVCTEVB!sic %!t"ologyB!sic %!t"ology

/bnormal Tarsal Relation/bnormal Tarsal Relation Congenital .islocation 1 SubluxationCongenital .islocation 1 Subluxation

Talo Calcaneo -avicular ?ointTalo Calcaneo -avicular ?oint Soft Tissue ContractureSoft Tissue Contracture

Congenital /tresiaCongenital /tresia

*GG C)5C


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CTEVCTEV


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CTEVCTEVAd!pti&e C"!ngesAd!pti&e C"!nges

$ol%%&s 'aw $ol%%&s 'aw

@@ *very change in the use of static function of bone*very change in the use of static function of bonecaused a change in the internal form or architecturecaused a change in the internal form or architecture

as (ell as alteration in its external formation andas (ell as alteration in its external formation andfunction according to mechanical la( Afunction according to mechanical la( A

avis 'aw avis 'aw @@ >hen ligaments and soft tissue are in loose or lax>hen ligaments and soft tissue are in loose or lax

stateB they gradually shorten AstateB they gradually shorten A


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CTEVCTEVAd!pti&e C"!ngesAd!pti&e C"!nges

0ony :0ony :

Change in the shape of tarsal and metatarsalChange in the shape of tarsal and metatarsalbones especially after (alingbones especially after (aling

Soft Tissue :Soft Tissue : Shortening Contracture in the Concave SideShortening Contracture in the Concave Side

3+ Muscles D+ Tendons3+ Muscles D+ Tendons

6+ #igaments6+ #igaments ;+ ?oints Capsule;+ ?oints Capsule

8+ Sin 7+ -erves ,essels8+ Sin 7+ -erves ,essels


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CTEVCTEV


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CTEVCTEVDi!gnosisDi!gnosisGeneral *xamination :General *xamination :

*xclude*xclude -eurological lesion that can cause the deformity-eurological lesion that can cause the deformity@Spina 0ifidaA@Spina 0ifidaA

2ther abnormalities that can explain the deformity2ther abnormalities that can explain the deformity@/rthrogryposis& MyelodysplasiaA@/rthrogryposis& MyelodysplasiaA

!resence of concomitant congenital anomalies!resence of concomitant congenital anomalies@ @!roximal femoral focal deficiencyA!roximal femoral focal deficiencyA

Syndromatic clubfootSyndromatic clubfoot

@ @#arsenEs syndrome& /mniotic band SyndromeA#arsenEs syndrome& /mniotic band SyndromeA


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CTEVCTEVDi!gnosisDi!gnosis

Spina 0ifida = !aralytic T*,Spina 0ifida = !aralytic T*,


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CT*,CT*,Di!gnosisDi!gnosis

Characteristic .eformity :Characteristic .eformity :

)ind foot)ind foot *quinus "/nle Foint$*quinus "/nle Foint$

,arus "Subtalar Foint$,arus "Subtalar Foint$

%ore foot%ore foot /dduction "Med tarsal Foint$/dduction "Med tarsal Foint$

Supination fore footSupination fore foot

CavusCavus


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@@)ind foot @ @ %ore foot)ind foot @ @ %ore foot@@

*quinus& ,arus /dduction& Supination& Cavus*quinus& ,arus /dduction& Supination& Cavus


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Short /chilles tendonShort /chilles tendon

)igh and small heel)igh and small heel -o creases behind )eel-o creases behind )eel /bnormal crease in middle of the foot/bnormal crease in middle of the foot %oot is smaller in unilateral affection%oot is smaller in unilateral affection

Callosities at abnormal pressure areasCallosities at abnormal pressure areas 5nternal torsion of the leg5nternal torsion of the leg Calf muscles (astingCalf muscles (asting .eformities donEt prevent (aling.eformities donEt prevent (aling


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)*+a )*+a needed to assess progress of treatmentneeded to assess progress of treatment


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CT*,CT*,Te!t'entTe!t'ent

The goal of treatment for clubfoot is toThe goal of treatment for clubfoot is to

obtain a plantigrade foot that isobtain a plantigrade foot that isfunctional& painless& and stable over timefunctional& painless& and stable over time

/ cosmetically pleasing appearance/ 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


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Non s$gic!l te!t'ent s"o$ld #egin s"otly !fte #it"Non s$gic!l te!t'ent s"o$ld #egin s"otly !fte #it"

3'3' Gentle manipulationGentle manipulation

D'D' 5mmobiliation5mmobiliation

+ Strapping + Strapping

+ !2! or synthetic cast+ !2! or synthetic cast


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Non s$gic!l te!t'ent s"o$ld #egin s"otly !fte #it"Non s$gic!l te!t'ent s"o$ld #egin s"otly !fte #it"

6'6' Splints to maintain correctionSplints to maintain correction + /nle+foot orthosis + /nle+foot orthosis

+ .ennis 0ro(n splint+ .ennis 0ro(n splint


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M!nip$l!tion !nd sei!l c!stsM!nip$l!tion !nd sei!l c!sts

V!lidity( $p to ) 'ont"s *V!lidity( $p to ) 'ont"s *

Tec"ni+$eTec"ni+$e ,%onseti-,%onseti-

A&oid f!lse coectionA&oid f!lse coection

."en to stop /."en to stop /

M!int!ining t"e coectionM!int!ining t"e coection

Follo0 $p to 0!tc" !nd !&oid ec$enceFollo0 $p to 0!tc" !nd !&oid ec$ence


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%onseti tec"ni+$e%onseti tec"ni+$e

3'3' /l(ays use long leg casts& change (eely'/l(ays use long leg casts& change (eely'D'D' %irst manipulation raises the 3st metatarsal%irst manipulation raises the 3st metatarsalto decrease the cavusto decrease the cavus

6'6' /ll subsequent manipulations include pure/ll subsequent manipulations include pure

abduction of forefoot (ith counter+pressureabduction of forefoot (ith counter+pressureon nec of talus'on nec of talus'

;';' -ever pronate H-ever pronate H8'8' -ever put counter pressure on calcaneus or-ever put counter pressure on calcaneus or

cuboid'cuboid'


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CT*,CT*,Te!t'entTe!t'ent%onseti tec"ni+$e 1cont23%onseti tec"ni+$e 1cont23

7'7' Cast until there is about 74 degrees of externalCast until there is about 74 degrees of external

rotation "about ;+7 casts$rotation "about ;+7 casts$I'I' !ercutaneous tendo /chilles tenotomy in cast room!ercutaneous tendo /chilles tenotomy in cast room

under local anesthesia& follo(ed by final cast "6under local anesthesia& follo(ed by final cast "6(ees$(ees$

J'J' /fter final cast removal& apply -ormal last shoes (ith/fter final cast removal& apply -ormal last shoes (ith

.enis 0ro(ne bar set at I4 degrees external rotation.enis 0ro(ne bar set at I4 degrees external rotation";4 degrees on normal side$";4 degrees on normal side$

K'K' .enis 0ro(ne splint full time for t(o months& then.enis 0ro(ne splint full time for t(o months& thennight time only for t(o+four years'night time only for t(o+four years'

34'34'689 need /nterior Tibialis tendon transfer at age D+6689 need /nterior Tibialis tendon transfer at age D+6


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CT*,CT*,4$gic!l Te!t'ent4$gic!l Te!t'ent

5ndications5ndications

#ate presentation& after 7 months of age H#ate presentation& after 7 months of age H

Complementary to conservative treatmentComplementary to conservative treatment

%ailure of conservative treatment%ailure of conservative treatment

Residual deformities after conservativeResidual deformities after conservativetreatmenttreatment

Recurrence after conservative treatmentRecurrence after conservative treatment


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Types 1soft tiss$e !nd #ony ope!tions3Types 1soft tiss$e !nd #ony ope!tions3

Ti'e of s$geyTi'e of s$gey

4election of t"e poced$e !nd t"e incision4election of t"e poced$e !nd t"e incision

%ost ope!ti&e c!e%ost ope!ti&e c!e

Follo0 $pFollo0 $p

Co'plic!tionsCo'plic!tions


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Soft tissue operationsSoft tissue operations

3'3' Release of contracturesRelease of contractures

D'D' TenotomyTenotomy

6'6' Tendon elongationTendon elongation

;';' Tendon transfer Tendon transfer 8'8' Restoration of normal bony relationshipRestoration of normal bony relationship


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CT*,CT*,4$gic!l Te!t'ent4$gic!l Te!t'entBony ope!tionsBony ope!tions Indic!tionsIndic!tions

Us$!lly !cco'p!nied 0it" soft tiss$e ope!tionUs$!lly !cco'p!nied 0it" soft tiss$e ope!tion

Types5Types5

6 Osteoto'y( to coect foot defo'ity o int2 ti#i!l tosion6 Osteoto'y( to coect foot defo'ity o int2 ti#i!l tosion

6 .edge e7cision6 .edge e7cision 6 At"odesis 1$s$!lly !fte #one '!t$ity36 At"odesis 1$s$!lly !fte #one '!t$ity3

one o se&e!l 8ointsone o se&e!l 8oints

6 4!l&!ge ope!tion to estoe s"!pe6 4!l&!ge ope!tion to estoe s"!pe


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Congenital Talipes Equino-Varus (1)