Congenital Talipes Equino-Varus (Congenital Clubfoot)

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

Dr. Mazloumi MDDr. Mazloumi MD

Associate Professor Pediatric Associate Professor Pediatric Orthopedic SurgeonOrthopedic Surgeon

THE NORMAL FOOTTHE NORMAL FOOT

Complex organ that is required to beComplex organ that is required to be

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

Resilient:Resilient: for walking and running for walking and running

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

CosmeticCosmetic

CLUB FOOTCLUB FOOTGross deformity of the foot that is giving Gross deformity of the foot that is giving

it the stunted lumpy appearanceit the stunted lumpy appearance

CLUB FOOTCLUB FOOT

DefinitionsDefinitions

Talipes:Talipes: Talus = ankle Talus = ankle

Pes = footPes = foot

Equinus:Equinus: (Latin = horse)(Latin = horse)

Foot that is in a position of Foot that is in a position of

planter flexion at the ankle,planter flexion at the ankle,

looks like that of the horse.looks like that of the horse. Calcaneus:Calcaneus: Full dorsiflexion at the ankleFull dorsiflexion at the ankle

CLUB FOOTCLUB FOOT

Planus:Planus: flatfoot flatfoot

Cavus:Cavus: highly arched foothighly arched foot

Varus:Varus: heal going towards heal going towards the midlinethe midlineValgus:Valgus: heel going away heel going away from the midlinefrom the midlineAdduction:Adduction: forefoot going forefoot going towards the midlinetowards the midlineAbduction:Abduction: forefoot going away forefoot going away From the midlineFrom the midline

Forefoot Hind foot

CLUB FOOTCLUB FOOTPostural :Postural :Calcaneo-Valgus Equino-VarusCalcaneo-Valgus Equino-Varus

Look for DDH Look for DDH Minor and correctable Minor and correctable

CLUB FOOTCLUB FOOT

TypesTypes

Idiopathic (Unknown Etiology) :Idiopathic (Unknown Etiology) : Congenital Talipes Equino-Varus Congenital Talipes Equino-Varus CTEVCTEV

Acquired, Secondary to :Acquired, Secondary to : CNS Disease : MyelomenegocelCNS Disease : Myelomenegocel ArthrogryposisArthrogryposis Absent Bone : fibula / tibiaAbsent Bone : fibula / tibia

Congenital Talipes Equino-VarusCongenital Talipes Equino-Varus

CTEVCTEVCongenital clubfoot or CTEV occursCongenital clubfoot or CTEV occurs

typically in an otherwise normal child.typically in an otherwise normal child.


CTEVCTEV

EtiologyEtiology

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


CTEVCTEV

EtiologyEtiologySome of these factors are :Some of these factors are : Abnormal intrauterine forcesAbnormal intrauterine forces Arrested fetal developmentArrested fetal development Abnormal muscle and tendon insertionsAbnormal muscle and tendon insertions Abnormal rotation of the talus in the mortiseAbnormal rotation of the talus in the mortise Germ plasm defectsGerm plasm defects


CTEVCTEV

IncidenceIncidence Occurs approximately in one of every 1000 Occurs approximately in one of every 1000

live birthlive birth In affected families, clubfeet are about 30 In affected families, clubfeet are about 30

times more frequent in offspringtimes more frequent in offspring Male are affected in about 65% of casesMale are affected in about 65% of cases Bilateral cases are as high as 30 – 40 %Bilateral cases are as high as 30 – 40 %


CTEVCTEV

Basic PathologyBasic Pathology

Abnormal Tarsal RelationAbnormal Tarsal Relation Congenital Dislocation / Subluxation Congenital Dislocation / Subluxation Talo Calcaneo Navicular JointTalo Calcaneo Navicular Joint Soft Tissue ContractureSoft Tissue Contracture Congenital AtresiaCongenital Atresia


CTEVCTEV


CTEVCTEV

Adaptive ChangesAdaptive Changes Bony :Bony :

Change in the shape of tarsal and metatarsalChange in the shape of tarsal and metatarsalbones especially after walkingbones especially after walking

Soft Tissue :Soft Tissue :

Shortening ? Contracture in the Concave Side Shortening ? Contracture in the Concave Side 1- Muscles 2- Tendons1- Muscles 2- Tendons

3- Ligaments 3- Ligaments 4- Joints Capsule4- Joints Capsule 5- Skin 6- Nerves & Vessels5- Skin 6- Nerves & Vessels


CTEVCTEV


CTEVCTEVDiagnosisDiagnosis

General Examination :General Examination : ExcludeExclude Neurological lesion that can cause the deformity Neurological lesion that can cause the deformity

“Spina Bifida”“Spina Bifida” Other abnormalities that can explain the deformity Other abnormalities that can explain the deformity

“Arthrogryposis, Myelodysplasia”“Arthrogryposis, Myelodysplasia” Presence of concomitant congenital anomalies Presence of concomitant congenital anomalies “ “Proximal femoral focal deficiency”Proximal femoral focal deficiency” Syndromatic clubfootSyndromatic clubfoot “ “Larsen’s syndrome, Amniotic band Syndrome”Larsen’s syndrome, Amniotic band Syndrome”


CTEVCTEVDiagnosisDiagnosis

Spina Bifida = Paralytic TEVSpina Bifida = Paralytic TEV


CTEVCTEV

DiagnosisDiagnosisCharacteristic Deformity :Characteristic Deformity :Hind footHind foot Equinus (Ankle joint)Equinus (Ankle joint) Varus (Subtalar joint)Varus (Subtalar joint)Fore footFore foot Adduction (Med tarsal joint) Adduction (Med tarsal joint) Supination fore footSupination fore foot CavusCavus


CTEVCTEV

DiagnosisDiagnosis


CTEVCTEV

DiagnosisDiagnosis

“ “Hind foot “ “ Fore footHind foot “ “ Fore foot “ “ Equinus, Varus Adduction, Supination, CavusEquinus, Varus Adduction, Supination, Cavus


CTEVCTEV

DiagnosisDiagnosis


CTEVCTEV

DiagnosisDiagnosis Short Achilles tendonShort Achilles tendon High and small heel High and small heel No creases behind HeelNo creases behind Heel Abnormal crease in middle of the footAbnormal crease in middle of the foot Foot is smaller in unilateral affectionFoot is smaller in unilateral affection Callosities at abnormal pressure areasCallosities at abnormal pressure areas Internal torsion of the legInternal torsion of the leg Calf muscles wastingCalf muscles wasting Deformities don’t prevent walkingDeformities don’t prevent walking


CTEVCTEV

DiagnosisDiagnosis


CTEVCTEV

DiagnosisDiagnosisX-RayX-Ray needed to assess progress of treatmentneeded to assess progress of treatment


CTEVCTEV

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

obtain a plantigrade foot that is obtain a plantigrade foot that is functional, painless, and stable over timefunctional, painless, and stable over time

A cosmetically pleasing appearanceA 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


CTEVCTEV

TreatmentTreatmentNon surgical treatment should begin shortly after birthNon surgical treatment should begin shortly after birth1.1. Gentle manipulationGentle manipulation

2.2. ImmobilizationImmobilization

- POP or synthetic cast- POP or synthetic cast


CTEVCTEV

TreatmentTreatmentNon surgical treatment should begin shortly after birthNon surgical treatment should begin shortly after birth3.3. Splints to maintain correctionSplints to maintain correction

- Ankle-foot orthosis- Ankle-foot orthosis

- Dennis Brown splint - Dennis Brown splint


CTEVCTEV

TreatmentTreatmentManipulation and serial castsManipulation and serial casts

Validity, up to 6 months !Validity, up to 6 months !

Technique Technique “Ponseti”“Ponseti” Avoid false correctionAvoid false correction When to stop ?When to stop ? Maintaining the correctionMaintaining the correction Follow up to watch and avoid recurrenceFollow up to watch and avoid recurrence


CTEVCTEV

TreatmentTreatmentPonseti techniquePonseti technique

1.1. Always use long leg casts, change weekly. Always use long leg casts, change weekly. 2.2. First manipulation raises the 1st metatarsal First manipulation raises the 1st metatarsal

to decrease the cavus to decrease the cavus 3.3. All subsequent manipulations include pure All subsequent manipulations include pure

abduction of forefoot with counter-pressure abduction of forefoot with counter-pressure on neck of talus.on neck of talus.

4.4. Never pronate ! Never pronate ! 5.5. Never put counter pressure on calcaneus or Never put counter pressure on calcaneus or

cuboid.cuboid.


CTEVCTEVTreatmentTreatment

Ponseti technique (cont.)Ponseti technique (cont.)6.6. Cast until there is about 60 degrees of external Cast until there is about 60 degrees of external

rotation (about 4-6 casts) rotation (about 4-6 casts) 7.7. Percutaneous tendo Achilles tenotomy in cast room Percutaneous tendo Achilles tenotomy in cast room

under local anesthesia, followed by final cast (3 under local anesthesia, followed by final cast (3 weeks) weeks)

8.8. After final cast removal, apply Normal last shoes with After final cast removal, apply Normal last shoes with Denis Browne bar set at 70 degrees external rotation Denis Browne bar set at 70 degrees external rotation (40 degrees on normal side) (40 degrees on normal side)

9.9. Denis Browne splint full time for two months, then Denis Browne splint full time for two months, then night time only for two-four years. night time only for two-four years.

10.10.35% need Anterior Tibialis tendon transfer at age 2-335% need Anterior Tibialis tendon transfer at age 2-3


CTEVCTEV

Surgical TreatmentSurgical TreatmentIndicationsIndications Late presentation, after 6 months of age !Late presentation, after 6 months of age ! Complementary to conservative treatmentComplementary to conservative treatment Failure of conservative treatmentFailure of conservative treatment Residual deformities after conservative Residual deformities after conservative

treatmenttreatment Recurrence after conservative treatmentRecurrence after conservative treatment


CTEVCTEV

Surgical TreatmentSurgical TreatmentSoft tissue operationsSoft tissue operations1.1. Release of contracturesRelease of contractures

2.2. TenotomyTenotomy

3.3. Tendon elongationTendon elongation

4.4. Tendon transferTendon transfer

5.5. Restoration of normal bony relationshipRestoration of normal bony relationship


CTEVCTEV

Surgical TreatmentSurgical Treatment


CTEVCTEV

Surgical TreatmentSurgical Treatment


CTEVCTEVSurgical TreatmentSurgical Treatment

Bony operationsBony operations IndicationsIndications Usually accompanied with soft tissue operationUsually accompanied with soft tissue operation Types:Types:

- Osteotomy, to correct foot deformity or int. tibial torsion- Osteotomy, to correct foot deformity or int. tibial torsion

- Wedge excision- Wedge excision

- Arthrodesis (usually after bone maturity)- Arthrodesis (usually after bone maturity)

one or several jointsone or several joints

- Salvage operation to restore shape- Salvage operation to restore shape









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Congenital Talipes Equino-Varus (Congenital Clubfoot)