congenital talipes equinovarus - mr m g uglow.pdfctev rigid equinus: supine, extend knees, foot in...

CTEV

Congenital Talipes

Equinovarus

M G UGLOW M G UGLOW FRCS(Tr & Orth)FRCS(Tr & Orth)

CTEV

Definition

Displacement of the navicular, Displacement of the navicular,

calcaneus and cuboid around the calcaneus and cuboid around the

talus, characterised by equinus, talus, characterised by equinus,

internal rotation and varus of the internal rotation and varus of the

hindfoot with adduction and hindfoot with adduction and

supination of the forefoot. supination of the forefoot.

CTEV

Incidence

UsualUsual 1 per 1,000 1 per 1,000

M:F M:F = 2.5 : 1= 2.5 : 1

Bilateral Bilateral 50%50%

MaorisMaoris 7 per 1,0007 per 1,000

RiskRisk = 2= 2--5% in siblings5% in siblings

= 25% if both parent = 25% if both parent

and sibling affectedand sibling affected

CTEV

NeurologicalNeurological

–– MyelomeningoceleMyelomeningocele

–– Spina bifida occultaSpina bifida occulta

Arthrogryposis Congenita MultiplexArthrogryposis Congenita Multiplex

Associated conditions

CTEV

Other Congenital DefectsOther Congenital Defects

–– TOFTOF

–– Anorectal atresiaAnorectal atresia

–– Dysraphic conditionsDysraphic conditions

Sacral agenesisSacral agenesis

Chromosome AbnormalitiesChromosome Abnormalities

–– Trisomy 13 & 18Trisomy 13 & 18

–– Diastrophic DwarfismDiastrophic Dwarfism

Associated conditions

CTEV

Aetiology UnknownUnknown

TheoriesTheories

–– Packaging defect Packaging defect (Hippocrates)(Hippocrates)

–– Neuromuscular defect Neuromuscular defect

–– Reduced anterior horn cells Reduced anterior horn cells (Swart)(Swart)

–– Increase in type I (slow) fibresIncrease in type I (slow) fibres

–– Arrest of foetal developmentArrest of foetal development

–– Primary germ plasm defect of talusPrimary germ plasm defect of talus

–– Retracting fibrosisRetracting fibrosis

CTEV

Pathoanatomy

DescriptiveDescriptive

–– EquinusEquinus

–– VarusVarus

–– SupinationSupination

–– CavusCavus

–– Short medial column (adductus)Short medial column (adductus)

–– Lateralisation of heelLateralisation of heel

CTEV

Bony Deformities

Talus Talus

–– Short (absent) neckShort (absent) neck

–– Facet for navicular faces medially and Facet for navicular faces medially and

downwarddownward

–– Anterior and middle facets distortedAnterior and middle facets distorted

–– ? Anterior part of dome too wide for ? Anterior part of dome too wide for

morticemortice

CTEV

Bony Deformities

CalcaneusCalcaneus

–– Relatively normal but supinatedRelatively normal but supinated

–– Sustentaculum underdevelopedSustentaculum underdeveloped

NavicularNavicular

–– Relatively normalRelatively normal

–– May have medial articular facet for May have medial articular facet for

medial malleolusmedial malleolus

TibiaTibia

–– ?internal torsion?internal torsion

CTEV

Bony Relationships

Talus Talus

–– EquinusEquinus

–– Talar dome laterally rotated in mortiseTalar dome laterally rotated in mortise

Calcaneus Calcaneus

–– Internally rotated on talusInternally rotated on talusequinusequinus

Navicular Navicular

–– Displaced medially and plantarward.Displaced medially and plantarward.

Cuboid Cuboid

–– Medially displacedMedially displaced

CTEV

Soft Tissues

All structures on medial and posterior All structures on medial and posterior

aspect of ankle are contractedaspect of ankle are contracted

–– MusclesMuscles

–– TendonsTendons

–– Tendon sheathsTendon sheaths

–– LigamentsLigaments

–– VesselsVessels

–– NervesNerves

–– SkinSkin

CTEV

Diagnosis

Structural Structural

PosturalPostural

CTEV

Diagnosis

Postural CTEVDeformity Flexible RigidNavicular Normal Abutts med mall

Lat malleolus Normal PosteriorLat border Sl Curved CurvedForefoot Varus EquinovarusPlantar Soft TautCalf Normal Atrophic

CTEV

Radiology

TaloTalo--calcaneal anglescalcaneal angles

–– APAP

–– LateralLateral

TaloTalo--metatarsal angles (adductus)metatarsal angles (adductus)

CalcaneoCalcaneo--cuboid relationship on APcuboid relationship on AP

CTEV

CTEV

Without a preWithout a pre--operative operative

classification the outcome of classification the outcome of

treatment cannot be accurately treatment cannot be accurately

assessedassessed

–– Dangelmajer 1961Dangelmajer 1961

–– Attenborough 1972Attenborough 1972

–– Harrold & Walker 1983Harrold & Walker 1983

–– Porter 1987Porter 1987

–– Uglow & Clarke 2000Uglow & Clarke 2000

Classification

CTEV

Dimeglio et al 1995Dimeglio et al 1995–– Classification of ClubfootClassification of Clubfoot JPOJPO

Bensahel et al 1995Bensahel et al 1995–– Final Evaluation of ClubfootFinal Evaluation of Clubfoot JPOJPO

Pirani et al 1995Pirani et al 1995–– A method of clubfoot evaluationA method of clubfoot evaluation POSNAPOSNA

Classification

CTEV

Di Meglio- Classification

Reducibility of three dimensional Reducibility of three dimensional

deformitydeformity

Deformity Plane Range Points

Equinus Saggital 90-45 4

Varus Coronal 45-20 3

CFF Block Horizontal 20-0 2

Adduction Horizontal 0-(-20) 1

CTEV

VarusVarus EquinusEquinus

CalcaneoCalcaneo--

pedalpedal

blockblock

ForefootForefoot

adductionadduction

Dimeglio- deformities

CTEV

Varus, reduciblityVarus, reduciblity

to zero degreesto zero degrees--

two points!two points!

Derotation of theDerotation of the

calcaneopedal blockcalcaneopedal block--

reducibility to reducibility to --10 10

degreesdegrees--

one point!one point!

Di Meglio Reducibility

CTEV

Secondary detailsSecondary details

1 point each for1 point each for

–– deep posterior creasedeep posterior crease

–– deep mediotarsal creasedeep mediotarsal crease

–– cavus, plantar retractioncavus, plantar retraction

–– muscle conditionmuscle condition

TA,triceps hypertonic, contracted or TA,triceps hypertonic, contracted or

fibrous, or weak peronealsfibrous, or weak peroneals

Di Meglio

CTEV

PosteriorPosterior

creasecrease Medial Medial

creasecrease

CavusCavus

Di Meglio - Secondary

factors

CTEV

Grade from score out of 20Grade from score out of 20

GRADE TERM POINTS PROPORTION

1 soft-soft 0-4 20%

2 stiff-soft 5-9 33%

3 soft-stiff 10-14 35%

4 stiff-stiff 15-20 12%

Di Meglio - Classification

CTEV

Hindfoot Contracture (HFC)Hindfoot Contracture (HFC)

–– Posterior CreasePosterior Crease 11

–– Empty HeelEmpty Heel 11

–– Rigid EquinusRigid Equinus 11

Midfoot ContactureMidfoot Contacture (MFC)(MFC)

–– Lateral BorderLateral Border 11

–– Medial CreaseMedial Crease 11

–– TalusTalus 11

Total ScoreTotal Score 66

Pirani

CTEV

Posterior Crease: Posterior Crease: Hold foot in maximum Hold foot in maximum

correction, examine back of heelcorrection, examine back of heel

00 Multiple fine creases which do not Multiple fine creases which do not

change contour of heelchange contour of heel

0.50.5 One or two deep creases which do One or two deep creases which do

not change contour of heelnot change contour of heel

11 Deep creases which change contour Deep creases which change contour

of heelof heel

Hindfoot Contracture

CTEV

Empty Heel:Empty Heel: Hold foot in max correction, Hold foot in max correction,

apply gentle pressure to corner of heelapply gentle pressure to corner of heel

00 Tuberosity of calcaneus immediately Tuberosity of calcaneus immediately

palpablepalpable

0.50.5 Calcaneus somewhat plantarflexed, Calcaneus somewhat plantarflexed,

posterior tuberosity not easily palpableposterior tuberosity not easily palpable

11 Calcaneus severely plantarflexed, Calcaneus severely plantarflexed,

posterior tuberosity not palpableposterior tuberosity not palpable

Hindfoot Contracture

CTEV

Rigid Equinus: Rigid Equinus: Supine, extend knees, Supine, extend knees,

foot in maximum correction, view from foot in maximum correction, view from

lateral sidelateral side

00 Ankle dorsiflexes until dorsum of Ankle dorsiflexes until dorsum of

foot almost touches front of shinfoot almost touches front of shin

0.50.5 Ankle dorsiflexes to or beyond Ankle dorsiflexes to or beyond

neutral, but not fullyneutral, but not fully

11 Ankle dorsiflexion not to neutralAnkle dorsiflexion not to neutral

Hindfoot Contracture

CTEV

Curvature of Lateral Border: Curvature of Lateral Border: Examine plantar Examine plantar

surface at restsurface at rest

00 Straight lateral border from heel to 5th Straight lateral border from heel to 5th

metatarsalmetatarsal

0.50.5 Mildly curved lateral borderMildly curved lateral border

11 Pronounced curvaturePronounced curvature

Midfoot Contracture

CTEV

Medial Crease: Medial Crease: Hold foot in maximum Hold foot in maximum

correction, examine longitudinal arch of correction, examine longitudinal arch of

midfootmidfoot

00 Multiple fine creases which do notMultiple fine creases which do not

change contour of archchange contour of arch

0.50.5 One or two deep creases which do One or two deep creases which do

not change contour of arch not change contour of arch

11 Deep creases change contour of archDeep creases change contour of arch

Midfoot Contracture

CTEV

Lateral part of Head of Talus: Lateral part of Head of Talus: externally externally

rotate forefoot onto talusrotate forefoot onto talus

00 Complete reduction of navicular onto Complete reduction of navicular onto

head of talus head of talus

0.50.5 Partial reduction of navicular onto Partial reduction of navicular onto

head head of talus of talus

11 Fixed medial subluxation of navicularFixed medial subluxation of navicular

Midfoot Contracture

CTEV

Pirani

LookLook

–– Lateral borderLateral border

–– Medial creaseMedial crease

–– Posterior creasePosterior crease

FeelFeel

–– Lateral head of Lateral head of

talustalus

–– Empty heelEmpty heel

MoveMove

–– Rigidity of ankle Rigidity of ankle

equinusequinus

CTEV

Scores graphed every weekScores graphed every week

Scores reduce Scores reduce

–– corrected footcorrected foot

Persistance of HFCPersistance of HFC

–– ? posterior release? posterior release

Persistance of MFC and HFCPersistance of MFC and HFC

–– ? full release? full release

Monitoring

CTEV

Management

ObjectivesObjectives

–– Produce a mobile foot with “normal” Produce a mobile foot with “normal”

function and weight bearingfunction and weight bearing

–– Reduction of taloReduction of talo--calcaneocalcaneo--navicular navicular

joint and maintain reductionjoint and maintain reduction

–– Establish muscle balance Establish muscle balance

CTEV

Closed Management

Standard initial managementStandard initial management

Possibility of stretching tight soft Possibility of stretching tight soft

tissues under influence of maternal tissues under influence of maternal

hormones.hormones.

Cast change weekly (above knee)Cast change weekly (above knee)

CTEV

Casting

CavusCavus

AdductusAdductus

Supination & varusSupination & varus

Equinus (with achilles tenotomy)Equinus (with achilles tenotomy)

Attempting to correct equinus first Attempting to correct equinus first

produces midproduces mid--foot breachfoot breach

CTEV

Closed Management

If fails at 6 to 10 weeks If fails at 6 to 10 weeks --

?operative approach is indicated?operative approach is indicated

Tachdjian Tachdjian

–– success rate 5% success rate 5% -- 10%10%

Ponseti Ponseti Cooper DM and Dietz FR. JBJSCooper DM and Dietz FR. JBJS--Am 1995Am 1995

–– only 5% need surgeryonly 5% need surgery

DimeglioDimeglio

–– passive motion reduces severitypassive motion reduces severity

CTEV

Treatment

CTEV

Method

Correction of deformityCorrection of deformity

–– Serial castingSerial casting

Maintain correctionMaintain correction

–– Boots & barBoots & bar

CTEV

Ponseti

CTEV

Ponseti - 1944

CTEV

Articles

Laaveg SJ and Ponseti IV. JBJSLaaveg SJ and Ponseti IV. JBJS--Am 1980Am 1980“Long“Long--term results of treatment of congenital term results of treatment of congenital clubfoot”clubfoot”

Cooper DM and Dietz FR. JBJSCooper DM and Dietz FR. JBJS--Am 1995Am 1995

“Treatment of idiopathic clubfoot. A 30 yr follow“Treatment of idiopathic clubfoot. A 30 yr follow--up note.” up note.”

45pts 71 feet 34 yr (25 45pts 71 feet 34 yr (25 –– 42). 42). 78% Excellent 78% Excellent or Goodor Good

(Occupation. Obesity)(Occupation. Obesity)

CTEV

Model

CTEV

Ponseti - stretching

CTEV

First cast

CTEV

Week 3

CTEV

Week 6 - Tenotomy

CTEV

Release toes dorsally

CTEV

Ponseti series

CTEV

CTEV

Maintain correction

CTEV

Boots & bar

CTEV

Boots & bar

CTEV

Beware!

CTEV

2 year follow up

CTEV

Technical points

StretchingStretching

1 layer single 1 layer single

overlap thin wooloverlap thin wool

Plaster of Paris Plaster of Paris

betterbetter

Mould footMould foot

1 or 2 piece cast1 or 2 piece cast

CTEV

Tips from the Master

Stretching the Stretching the footfoot

SupinationSupination

Overcorrection of Overcorrection of abductionabduction

Palpate os calcis Palpate os calcis under LHTunder LHT

Delay tenotomy Delay tenotomy if necessaryif necessary

Boots Boots -- 7070°°abductionabduction

CTEV

Setting up a clinic

CTEV

Get good assistants!

CTEV

Requirements

EnthusiasmEnthusiasm

TimeTime

SpaceSpace

AssistantsAssistants

Back upBack up

OrthotistOrthotist

LiteratureLiterature

CTEV

Operative Management

Release what is tightRelease what is tight

Posterior releasePosterior release

PosteroPostero--medial releasemedial release

PosteroPostero--medial and lateral releasemedial and lateral release

No outcome studies to tell us what No outcome studies to tell us what

to doto do

Timing??Timing??

CTEV

Incisions

CincinattiCincinatti U posteriorlyU posteriorly

CarrollCarroll Medial longitudinal and Medial longitudinal and

posteropostero--lateral verticallateral vertical

TurcoTurco Straight inclined Straight inclined

posteropostero--medialmedial

ParsonsParsons

CTEV

Structures

TendonsTendons

–– AchillesAchilles

–– Tibialis PosteriorTibialis Posterior

–– Abductor HallucisAbductor Hallucis

–– FHL, FDLFHL, FDL

Plantar FasciaPlantar Fascia

CTEV

Structures

LigamentsLigaments

–– Subtalar capsule (circumferential)Subtalar capsule (circumferential)

–– Ankle joint (preserve deep deltoid)Ankle joint (preserve deep deltoid)

–– CalcaneoCalcaneo--fibular, post talofibular, post talo--fibular fibular ligaments Taloligaments Talo--navicular capsulenavicular capsule

–– CalcaneoCalcaneo--cuboid jointcuboid joint

–– Interosseous taloInterosseous talo--calcaneal ligament calcaneal ligament should be left alone or risk should be left alone or risk overcorrectionovercorrection

CTEV

Overcorrection

CTEV

CTEV

CTEV

CTEV

CTEV

CTEV

CTEV

CTEV

CTEV

Post Operative Management

BackBack--slab 1slab 1--2 weeks2 weeks

Cast change for total 6 weeksCast change for total 6 weeks

Further cast 4Further cast 4--6 weeks6 weeks

Bracing until child is ambulatoryBracing until child is ambulatory

–– (delay surgery, bracing unnecessary)(delay surgery, bracing unnecessary)

CTEV

My Surgical Approach

Operate at 6Operate at 6--7 months7 months

–– Rationale: Minimise overcorrection, Rationale: Minimise overcorrection,

No post op bracing for mostNo post op bracing for most

Turco posteromedial approachTurco posteromedial approach

Carroll posterolateral for severe Carroll posterolateral for severe

deformitydeformity

CTEV

My Surgical Approach

Leave Spring Ligament if possibleLeave Spring Ligament if possible

–– Rationale: Avoid dorsal subluxation of Rationale: Avoid dorsal subluxation of

navicular and overcorrectionnavicular and overcorrection

Leave interosseos ligamentLeave interosseos ligament

KK--wires to stabilise reductionwires to stabilise reduction

CTEV

Complications

WoundWound

OvercorrectionOvercorrection

Pes planusPes planus

Inadequate releaseInadequate release

Dorsal subluxation of navicularDorsal subluxation of navicular

Amputation of sustentaculum taliAmputation of sustentaculum tali

CTEV

Dorsal Subluxation of

Navicular

Can occur even if navicular pinned Can occur even if navicular pinned

correctlycorrectly

Occurs with release of spring Occurs with release of spring

ligament and tight tibialis anteriorligament and tight tibialis anterior

Early recognition and reductionEarly recognition and reduction

CTEV

Left foot

Right foot

CTEV

Recurrence

Soft tissueSoft tissue

–– Repeat castRepeat cast

–– Repeat ST releaseRepeat ST release

–– Tibialis anterior transferTibialis anterior transfer

BonyBony

Frame correctionFrame correction

CTEV

Follow up

Outcome studies paramountOutcome studies paramount

Bensahel, Dimeglio & SouchetBensahel, Dimeglio & Souchet

–– Final Evaluation of ClubfootFinal Evaluation of Clubfoot

JPO 1995JPO 1995

CTEV

Conclusions

Aetiology not definedAetiology not defined

Classification essentialClassification essential

Initial manipulative treatmentInitial manipulative treatment

Surgical correction before standingSurgical correction before standing

Follow upFollow up

CTEV

Questions on CTEV

CTEV

Congenital Vertical Talus

Irreducible dorsal dislocation of Irreducible dorsal dislocation of

navicular on talus with a fixed navicular on talus with a fixed

talocalcaneal complex. talocalcaneal complex.

Dislocation can be limited to Dislocation can be limited to

talonavicular joint or can also talonavicular joint or can also

involve calcaneocuboid joint.involve calcaneocuboid joint.

Common cause of rigid flatfootCommon cause of rigid flatfoot

50% bilateral50% bilateral

CTEV

Congenital Vertical Talus

Teratologic Teratologic -- most CVTmost CVT

–– Chromosomal abnormalitiesChromosomal abnormalities

–– ArthrogryposisArthrogryposis

–– MyelomeningocoeleMyelomeningocoele

NeurogenicNeurogenic

Iatrogenic Iatrogenic -- overcorrection CTEVovercorrection CTEV

Idiopathic Idiopathic -- rarerare

CTEV

CVT Pathology

Navicular dorsally Navicular dorsally

dislocated, wedge dislocated, wedge

shaped with hypoplastic shaped with hypoplastic

plantar componentplantar component

Peronei and tib post Peronei and tib post

sublux anteriorly sublux anteriorly

becoming dorsiflexors becoming dorsiflexors

Talar head flattened Talar head flattened

dorsally, only posterior dorsally, only posterior

1/3 of talar dome 1/3 of talar dome

articulates with tibiaarticulates with tibia

Calcaneus plantar Calcaneus plantar

flexed and everted, flexed and everted,

hypoplastic hypoplastic

sustentaculum talisustentaculum tali

CTEV

CVT

Differential diagnosis

Oblique talusOblique talus

Tarsal coalitionTarsal coalition

Calcaneovalgus footCalcaneovalgus foot

Posteromedial bowing of tibiaPosteromedial bowing of tibia

Idiopathic pes planusIdiopathic pes planus

Paralytic pes valgusParalytic pes valgus

CTEV

CVT

CTEV

CVT - Radiology

AP XAP X--RaysRays::

talocalcaneal angle & forefoot abductiontalocalcaneal angle & forefoot abduction

Plantarflexed lateral XPlantarflexed lateral X--Ray:Ray:

Fixed forefoot dorsal dislocationFixed forefoot dorsal dislocation

Dorsiflexed lateral XDorsiflexed lateral X--Ray:Ray:

Fixed equinus of hindfootFixed equinus of hindfoot

CTEV

NORMAL OBLIQUE TALUS VERTICAL TALUS

CTEV

Resolution

CTEV

CVT Treatment

NonNon--operative initially operative initially -- stretchingstretching

-- serial castingserial casting

Plantarflexion/inversionPlantarflexion/inversion

Stretch soft tissues in Stretch soft tissues in

preparation for surgerypreparation for surgery

CTEV

CVT Surgery

Surgery is aimed at correcting Surgery is aimed at correcting

hindfoot equinus and forefoot hindfoot equinus and forefoot

dorsiflexion and abductiondorsiflexion and abduction

Correction of hindfoot is the Correction of hindfoot is the

primary step in correction of the primary step in correction of the

footfoot

CTEV

CVT Surgery

LengthenLengthen–– AchillesAchilles

–– PeronealPeroneal

–– Tibialis AnteriorTibialis Anterior

–– Toe ExtensorsToe Extensors

ReleaseRelease–– Posterior anklePosterior ankle

–– Posterior subtalarPosterior subtalar

–– CalcaneocuboidCalcaneocuboid

–– TalonavicularTalonavicular

PlicatePlicate–– Tibialis PosteriorTibialis Posterior

–– Talonavicular capsuleTalonavicular capsule

Reduce & pin jointsReduce & pin joints

–– SSubtalarubtalar

–– Talonavicular Talonavicular

–– +/+/-- CalcaneocuboidCalcaneocuboid

CTEV

CVT Treatment

Recurrent deformity corrected through Recurrent deformity corrected through

revision STR between 2revision STR between 2--6 years6 years

Late treatment:Late treatment:

STR + navicular excisionSTR + navicular excision

Subtalar arthrodesis 2Subtalar arthrodesis 211//22--6 yr6 yr

Triple arthrodesis >6 yrTriple arthrodesis >6 yr

CTEV

Oblique Talus

Talonavicular subluxation that reduces Talonavicular subluxation that reduces

with plantar flexion of the foot.with plantar flexion of the foot.

TreatmentTreatment

–– ObservationObservation

–– UCBL insertUCBL insert

–– Pinning reduced talonavicular joint & Pinning reduced talonavicular joint &

tendoachilles lengtheningtendoachilles lengthening

CTEV

CVT

RareRare

AetiologyAetiology

AssociationsAssociations

RadiologyRadiology

TreatmentTreatment

CTEV