congenital talipes equinovarus - mr m g uglow.pdfctev rigid equinus: supine, extend knees, foot in...
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CTEV
Congenital Talipes
Equinovarus
M G UGLOW M G UGLOW FRCS(Tr & Orth)FRCS(Tr & Orth)
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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.
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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
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CTEV
NeurologicalNeurological
–– MyelomeningoceleMyelomeningocele
–– Spina bifida occultaSpina bifida occulta
Arthrogryposis Congenita MultiplexArthrogryposis Congenita Multiplex
Associated conditions
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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
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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
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CTEV
Pathoanatomy
DescriptiveDescriptive
–– EquinusEquinus
–– VarusVarus
–– SupinationSupination
–– CavusCavus
–– Short medial column (adductus)Short medial column (adductus)
–– Lateralisation of heelLateralisation of heel
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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
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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
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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
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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
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CTEV
Diagnosis
Structural Structural
PosturalPostural
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CTEV
Diagnosis
Postural CTEVDeformity Flexible RigidNavicular Normal Abutts med mall
Lat malleolus Normal PosteriorLat border Sl Curved CurvedForefoot Varus EquinovarusPlantar Soft TautCalf Normal Atrophic
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CTEV
Radiology
TaloTalo--calcaneal anglescalcaneal angles
–– APAP
–– LateralLateral
TaloTalo--metatarsal angles (adductus)metatarsal angles (adductus)
CalcaneoCalcaneo--cuboid relationship on APcuboid relationship on AP
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CTEV
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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
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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
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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
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CTEV
VarusVarus EquinusEquinus
CalcaneoCalcaneo--
pedalpedal
blockblock
ForefootForefoot
adductionadduction
Dimeglio- deformities
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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
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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
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CTEV
PosteriorPosterior
creasecrease Medial Medial
creasecrease
CavusCavus
Di Meglio - Secondary
factors
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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)
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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
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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
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CTEV
Treatment
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CTEV
Method
Correction of deformityCorrection of deformity
–– Serial castingSerial casting
Maintain correctionMaintain correction
–– Boots & barBoots & bar
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CTEV
Ponseti
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CTEV
Ponseti - 1944
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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)
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CTEV
Model
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CTEV
Ponseti - stretching
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CTEV
First cast
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CTEV
Week 3
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CTEV
Week 6 - Tenotomy
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CTEV
Release toes dorsally
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CTEV
Ponseti series
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CTEV
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CTEV
Maintain correction
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CTEV
Boots & bar
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CTEV
Boots & bar
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CTEV
Beware!
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CTEV
2 year follow up
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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
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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
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CTEV
Setting up a clinic
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CTEV
Get good assistants!
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CTEV
Requirements
EnthusiasmEnthusiasm
TimeTime
SpaceSpace
AssistantsAssistants
Back upBack up
OrthotistOrthotist
LiteratureLiterature
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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??
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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
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CTEV
Structures
TendonsTendons
–– AchillesAchilles
–– Tibialis PosteriorTibialis Posterior
–– Abductor HallucisAbductor Hallucis
–– FHL, FDLFHL, FDL
Plantar FasciaPlantar Fascia
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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
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CTEV
Overcorrection
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CTEV
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CTEV
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CTEV
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CTEV
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CTEV
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CTEV
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CTEV
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CTEV
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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)
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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
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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
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CTEV
Complications
WoundWound
OvercorrectionOvercorrection
Pes planusPes planus
Inadequate releaseInadequate release
Dorsal subluxation of navicularDorsal subluxation of navicular
Amputation of sustentaculum taliAmputation of sustentaculum tali
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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
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CTEV
Left foot
Right foot
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CTEV
Recurrence
Soft tissueSoft tissue
–– Repeat castRepeat cast
–– Repeat ST releaseRepeat ST release
–– Tibialis anterior transferTibialis anterior transfer
BonyBony
Frame correctionFrame correction
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CTEV
Follow up
Outcome studies paramountOutcome studies paramount
Bensahel, Dimeglio & SouchetBensahel, Dimeglio & Souchet
–– Final Evaluation of ClubfootFinal Evaluation of Clubfoot
JPO 1995JPO 1995
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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
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CTEV
Questions on CTEV
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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
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CTEV
Congenital Vertical Talus
Teratologic Teratologic -- most CVTmost CVT
–– Chromosomal abnormalitiesChromosomal abnormalities
–– ArthrogryposisArthrogryposis
–– MyelomeningocoeleMyelomeningocoele
NeurogenicNeurogenic
Iatrogenic Iatrogenic -- overcorrection CTEVovercorrection CTEV
Idiopathic Idiopathic -- rarerare
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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
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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
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CTEV
CVT
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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
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CTEV
NORMAL OBLIQUE TALUS VERTICAL TALUS
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CTEV
Resolution
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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
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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
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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
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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
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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
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CTEV
CVT
RareRare
AetiologyAetiology
AssociationsAssociations
RadiologyRadiology
TreatmentTreatment
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CTEV