04 congenital talipes equino varus

7/31/2019 04 Congenital Talipes Equino Varus

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Congenital Talipes Equino

Varus

Dr. Mohammad Imran Khan

04/01/2011


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CTEV

1 in 1000 live births.

Bilateral in 50%.

Cause (several theories)

1. Primary germ plasm defect in the talus cause continued plamterflexion and inversion followed by soft tissue changes.

1. Soft tissue abnormatilies are primary.


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CTEV is composed of;

1. Forefoot adduction.

2. Heel varus.

3. Ankle equinus

4. Midfoot cavus.

5. Intrernal tibial torsion


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Pathoanatomy

Very important to understand

TURCO in early 1970s

Medial displacement of calcaneus andnavicular around the talus.

Talus goes into equinus while its head andneck deviated medially.

Calcaneus is inverted under the talus.


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McKay

Gave awareness of three dimential aspect ofbony deformity.

Abnormal relation of calcaneus to talus in allthree planes.

A. CALCANEUM

Rotates horizontally tuberiosity movestowards fibular malleolus.

Heel goes into varus in coronal plane.


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B. TALONAVICULAR JOINT

Goes into extreme inversion.

Navicular displaces on the talus.

Cuboid displaces on the calcaneum.

C. Soft tissue contracture follows apposingcorrection of various joints.

D. BONY CHANGES


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Radiological Evaluation

Part of clinical evaluation.

Done before, during and after treatment.

Non-ambulatory child

AP & stress dorsiflexion lateral views.

Ambulatory child

Standing AP & lateral views


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Radiological Evaluation

Important angles are

On AP view

1. Talocalcaneal angle

2. Talus-first metatarsal angle

On lateral view

1. Talocalcaneal angle2. Tibiocalcaneal angle


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Talocalcaneal angle on AP view

Normal is 30-55

Decreases in clubfootdue to calcaneal

rotation in horizontalplane.


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Talus-first metatarsal angle on AP view

Normal is 5-15

Decreases in clubfootdue to forefoot

adduction


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Talocalcaneal angle on lateral view

Taken in dorsiflexion

Normal is 25-50

Decreases to 0 in clubfoot as cacaneum and

talus become parallel.


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Tibiocalcaneal angle on lateral view

Normal is 10-40

In clubfoot it becomes negative due to heelequinus.


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Classifications

Currently in use

Pirani classification.

Dimglio

Others classifications are

Harrold and Walker

Somppii


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Piranis Classification


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Dimglio

Classification


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Harrold & Walker Classification

Mild

Moderate

Fixed varus or equinus < 20 degrees

Severe

Fixed varus or equinus > 20 degrees.


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Non-operative treatment

Kite method:1. Weekly MUA & casting for

first 6 weeks of life.

2. Fortnightly MUA & casting

until foot is clinically &radiologically corrected.

3. Correction done in the orderof forefoot reduction, heelvarus & ankle equinus.

4. Rocker Bottom foot(success rate 15-80%reported)


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Ponseti Technique

Consists of treatment phase andmaintenance phase.

TREATMENT PHASE:

Should begin early.

Gentle MUA & casting on weekly basis.

Six casts required.

70% require TAL in the last cast.


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First Cast

Corrects cavus by aligning forefoot and hindfoot.

Supinating the forefoot and elevating the first

metatarsal.

Long leg cast applied (toe to groin).


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Second Cast

Gradual abduction.

Maintain supination.

Never manipulate the heel directly which isthe most common mistake, as also seen inKite method.


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3rd, 4th & 5th Casts

Gradual correction continued with even moregradual correction of pronation.

Final Cast Maximum abduction 70 degrees.

15 degrees dorsiflexion. TAL usually done to avoid Rocker Bottom

deformity.


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Sequence of correction


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Maintenance Phase

Foot placed in food abduction orthosis (FAO).

Worn 23 hours a day for 3 months and thenfor 2-3 years while asleep.


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Operative Treatment

Depends on

Age.

Severity

Deformity to be corrected.

1. Mild with no rotational deformity of calcaneum

TURCOs PMR.

2. Mild with severe rotational deformity modifiedMcKay procedure through a single Cincinnatiincision or 2 incisions of Carroll.


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3. Severe deformities Modified McKayprocedure.

Studies show better results of modifiedMcKay procedure than TURCOs procedure

for severe deformities.


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Cincinnati Incision


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RESISTANT CLUBFOOT

The appropriate procedures and combination of procedures

depend on; The age of the child.

The severity of the deformity

The pathological processes involved.

Common components of resistant clubfoot deformity are:

1. Adduction or supination, or both, of the forefoot

2. A short medial column or long lateral column of the foot3. Internal rotation and varus of the calcaneus

4. Equinus.


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Forefoot deformity:

1. Dynamic deformity tendon balancing procedure (split orcomplete transfer of tibialis anterior to middle cuneform).

2. Rigid deformity (5years): Bony procedures like domeosteotomies of metatarsal bases and cuniform-cuboidosteotomy.


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HINDFOOT


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Triple Arthrodesis


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HEEL EQUINUS

Achilles tendon lengthening plus posteriorcapsulotomy of subtalar joint, ankle joint(mild-to-moderate deformity)

Lambrinudi procedure (severe deformity,skeletal immaturity)


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Tendoachilles Lengthening


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Lambrinudi Procedure


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ALL THE THREE DEFORMITIES

Triple arthrodesis in patients age > 10years


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INTERNAL TIBIAL TORSION

Occationally occur in resistant cases

Rarely require tibial derotational osteotomies

Foot deformity should be excluded beforedoing osteotomy on the tibia


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HOWZZAT

04 congenital talipes equino varus

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