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CTEV : Pathoanatomy and management
DR. SUSHIL PAUDELDR. PRATYUSHDr. Shah Alam Khan
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DefinitionDevelopmental deformationof foot Rotational subluxation of
talocalcaneonavicular jointcomplex with talus in plantarflexion & subtalar complex inmedial rotation & inversionClinically characterized by
Equinus & varus of heelForefoot adductionMidfoot supination
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Classification (Attenborough 1966)
TypeI(Extrinsic)
Non Rigid
TypeII(Intrinsic)
RigidFoot size Normal Smaller
Heel Normal sizeCan be brought
down with easeMinimal varus
Small , elevatedCannot be brought
down with easeMarked varus
Creases More or less normal Deep medial,posterior and lateralcreasesReduced creaseslaterally
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Definitions in clubfootRigid or resistant atypical clubfoot : Stiff, short,chubby with a deep crease in sole of foot and behind ankle,shortening of the first metatarsal with hyperextension ofthe metatarsal phalangeal joint; occurs in otherwisenormal infantSyndromic clubfoot: The clubfoot part of a syndromeTeratologic clubfoot such as congenital tarsalsynchondrosis Neurogenic clubfoot associated with a neurologicaldisorder such as meningomyelocele
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EpidemiologyCommonest congenital orthopaedic abnormality
1.3:1000 live births
Males>Females 2:1
30-50% bilateral
Much more common in Polynesian & Maori & lower in Asians
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PathogenesisUnknown at this stageGray et al (1981) : increase in % of type I fibres in soleus muscle;suggested defective neural influence
Recent study*: no evidence of type I fiber groupingHypoplasia or absence of the anterior tibial artery in majority of CTEVpatients**
Absence of the dorsalis pedis pulse in the parents of children withclubfoot#Primary germ plasm defect in the talus: continued plantar flexion andinversion of this bone, with subsequent soft-tissue changes in the joints and musculotendinous complexes
*Sodre H et al. J Pediatr Orthop. 1990;10:101-4.**Muir L et al. J Bone Joint Surg Br. 1995;77:114-6
# Milan B MD et al. Journal of Pediatric Orthopedics. 26(1):91-93, 2006 .
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Wynne-Davies : polygenic inheritanceMultifactorial inheritance established by genetic epidemiologicresearch by Idelberger
32.5% concordance rate among monozygotic twins as compared to2.9% among dizygotic twinsMajor gene effect (inherited in recessive manner) with additionalpolygenes and environmental factorsTachdjian
Patient with CTEV that has one child affected then 25% chance ofanother affectedIf both parents are normal & have affected child then chance ofanother is 5%
Idelberger K. et al 1939; 33:272276
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Intrauterine factorsPressure theories:
Oligohydramnios
Abnormal fetal positioningPlacental insufficiencyConstriction bandsToxins ( Maternal alcoholism, smoking)Maternal illness ( anemia, thyroid disorders )Infective pathogens (enteroviruses)Drugs (abortifacients, salicylates, barbiturates)Electromagnetic radiation
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Bony abnormalitiesTalus:
Head & neck deviated medially& plantarwardBody rotated externally in theankle mortiseBody extruded anteriorlySmaller than normal
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Navicular:Medially displacedClose to medial malleolus Articulates with medialsurface of head of talus
Calcaneus Anterior portion lies beneaththe head of talus causingvarus and equinus of heelIn equinusRotated medially
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CuboidDisplaced medially onthe dysmorphic distalend of the calcaneus
Talonavicular jointIn inversion
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Tibio-talar plantar flexion
Medially displaced navicular
Adducted and invertedcalcaneus
Medially displacedcuboid
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Soft tissue changesPosterior structures :Tendo achilles Post. capsule of ankle joint& subtalar jointPost. talo fibularCalcaneo-fibular ligaments
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Medial :Tibialis posteriorFHL,FDL, Master Knot ofHenry Talonavicular ligamentCalcaneo-navicular ligamentDeltoid ligament
Interossseus talo calcanealligamentsCapsules of naviculocuneiform & cuneiform firstmetatarsal
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Plantar wards :Plantar fasciaPlantar ligamentsFlexor digitorumbrevis & abductorhallucis
Laterally
CalcaneofibularligamentBifurcated ligamentCalcaneocuboid joint
capsule
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Clinical features 1. Deformity
Heel equinusHeel varusMidfoot supinationForefoot adductionMaybe cavus
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2. FeaturesCurved lateral border of footDevils thumbprint over the
lateral malleolusMedial & Lateral skin creasesNavicular fixed to medialmalleolusOs calcis fixed to the lateralmalleolusHeel small & high
3. GeneralCalf atrophyCalf shortening
Restricted ankle motion
Other Conditions should beexcluded
Spinal Dysraphism
ArthrogryposisNeuromuscular Disorders
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RadiologyPlain radiograph : Can be assessed prior to treatment with A-P & Lateral of footFoot held in position of best correction, with weight-bearing, or simulated weight-bearing AP view: Taken with foot in 30 of plantar flexion and tubeat 30 from verticalLat. View: Transmalleolar with the fibula overlapping theposterior half of the tibia; foot in 30 of plantar flexion
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Anteroposterior view Talocalcaneal angle
Calcaneal-secondmetatarsal angle
Talus first metatarsalangle
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AP radiograph: Talo-Calcaneal angle
Lines drawn throughcenter of the long axis oftalus (parallel to medialborder) and through thelong axis of calcaneum(parallel to lateral border),and they usually subtendan angle of 25-40. Any angle less than 20considered abnormal
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Lateral viewTalocalcaneal view
Calcaneal-first metatarsal viewTibiocalcanealTibiotalar angle
Talus-first metatarsal angleTalocalcaneal index (Kite'sangles from AP and Lateral views added)
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Piranis severity scoring Six parameters : 3 of midfoot and 3 of hindfootEach parameter is given a value as follows:
0: normal0.5: moderately abnormal1: severely abnormal
Pirani s et al. A method of evaluating virgin clubfoot with substantial interobserver reliability. Annualmeeting of Pediatric orthopaedic society of North America 1995
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Mid foot scoreCurved lateral border [A]
Medial crease [B]
Talar head coverage [C]
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Hind foot scorePosterior crease [D]
Rigid equinus [E]
Empty heel [F]
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Uses of Piranis score Assessment of progress by serial plotting of the scorePredicting need for tenotomy (hs>1& ms
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International Clubfoot Study Group ScoreIntroduced by Henri Bensahel et al in 2003Found to have good interobserver reliability andreproducibility**Morhological (12 pts), functional (24 pts) &radiological (12 pts) parametersMaximum of 60 for most deformed and 0 for normal
feet**Celebi L et al J Pediatr Orthop B. 2006;15:34-36.
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Morphological parameters
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Radiological parameters
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Classification of clubfoot severity by Dimglio A.Equinusdeviation B. Varus deviation C. Derotation D. Adduction.
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Reducibility(
degrees)
Score Additional
parameters
Score
90-45 4 Marked posteriorcrease
1
45-20 3 Markedmediotarsal crease
1
20-0 2 Cavus 10 t0 -20 1 Poor muscle
condition1
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Grade Type Score Reducibility
i Benign 1-4 >90%ii Moderate 5-9 >50%, soft-stiff,reducible, partiallyresistant
iii Severe 10-14 >50%, stiff-soft,resistant, partiallyreducible
iv Very severe 15-20
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Aims of treatment After sucessful treatment foot shouldLook goodFeel goodMove goodMeasure good
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Outline of Ponseti regimenSerial casting of lowerlimb using a strictlydefined technique and weekly change of casts
Percutaneous tenotomy oftendo achilles for hindfoot stall
Once foot corrected, anabduction foot orthosis worn full time for 12 weeks,and then at nights andnaps, up to age of four
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Manipulation and cast application
1.Manipulation
Manipulation: start as soonafter birth as possible
Setup for casting includes
calming the child with abottle or breast feeding Assistant holds the foot while the manipulator
performs the correction
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2. Correction of cavusCavus results from pronation ofthe forefoot in relation to
hindfoot THE PRONATION
TWIST Attempting to correct thesupination of hindfoot beforecorrection of varus results in an
iatrogenic increase in cavusCorrected by supinating theforefoot to place it in properalignment with the hindfoot.
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Plaster at toes Below knee pop
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Molding Extension upto the thigh
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Plantar support to toes Final appearance
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Casts and foot Adequate abduction
Best sign of sufficientabduction: ability topalpate the anteriorprocess of the calcaneus asit abducts out frombeneath talus
Abduction of approx.70degrees in relationship tothe frontal plane of thetibia possible
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Complications of castingTight castRocker bottom deformityCrowded toesFlat heel padSuperficial soresDeep sores
Pressure soresInjury to distal tibial physis
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Common errors(Kite errors)No manipulationPronation/eversion of 1 st metatarsal
Premature dorsiflexionof heelCounterpressure atcalcaneocuboid joint
External rotationBelow knee castsShort splints
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Rocker bottom deformityDorsiflexion via midfootbefore correction ofhindfoot varusDorsal dislocation ofnavicular on talusFixed equinus ofcalcaneus
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Correction of equinus and tenotomy No direct attempt at equinus correction is made untilheel varus is corrected Equinus deformity gradually improves with correctionof adductus and varus- calcaneus dorsiflexes as itabducts under talus Residual equinus- manipulation and casting +/-percutaneous tenotomy
Tenotomy : Indicated to correct equinus when cavus,adductus, and varus fully corrected but ankledorsiflexion remains less than 10 degrees aboveneutral
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Percutaneous tenotomy under LA
Foot held in max dorsiflexion by an assistantTenotomy done 1.5 cm above calcaneal insertion Additional 25-30 deg dorsiflexion obtainedCast with the foot abducted 60 to 70 degrees with respect to the frontal plane of theankle, and 15 degrees dorsiflexion for 3 weeks
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Foot Abduction bracesShoes mounted to bar inposition of 70 of ER and 15of dorsiflexion in B/L casesand incase of U/L cases 30 to40 of ER in normal side,distance between shoes set atabout 1 wider than width ofshoulders
Knees left free, so the childcan kick them straight tostretch gastrosoleus tendon
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Mitchell brace Dobbs dynamic brace
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CTEV SplintStraight inner border to preventforefoot adductionOuter shoe raise to prevent foootinversionNo heel to prevent equinusSlight(1/8) lateral sole raise Inner iron barOuter t trap
Walking age to 5 yrs of age
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Results of Ponseti methodCooper and Dietz in 1995: Reviewed a group of 45 adults, with 71 clubfeet, who hadbeen managed with the Ponseti method, 30 years aftertreatmentResults compared with NORMAL CONTROLS .Based on structured examination, radiographs,electrogoniometry and measurements using apedobarography.Using the Laaveg and Ponseti score, the results in thenormal controls and in those with treated clubfeet same Radiographs showed :feet not completely corrected, butfunctioned well despite this
Cooper DM, Dietz FR. J Bone Joint Surg [Am] 1995;77-A:1477-89.
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Results of Ponsetis method ..Study from Iowa (2004) : short-term results of a morerecent series of 256 feetCorrection obtained in 98% with one to seven casts 2.5% required extensive corrective surgery.Percutaneous tenotomy in 86%. Mean angle of dorsiflexion : 20 (0 to 35) Minor cast complications in 8%Rate of relapse: 10%.
Morcuende JA, Dolan LA, Dietz FR, Ponseti IV. Radical reduction in the rate of extensivecorrectivesurgery for clubfoot using the Ponseti method. Pediatrics 2004;113:376-80.
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Khan et alEvaluated results of Ponseti's method in 21 children (25 feet) with neglectedclub feetUnderwent percutaneous tenotomy of Achilles tendonMean age at the time of treatment 8.9 years Mean follow-up period 4.7 years Average Dimeglio score at start of treatment 14.2 compared with an averagescore of 0.95 at the end of treatment at 1-year follow-up18 feet (85.7%) full correction, recurrence in 6 feet (24%) At 4-year follow-up, average Dimeglio score for 19 feet 0.18.Recommend Ponseti's method as initial treatment modality for neglectedclubfeet
J Pediatr Orthop B.2010 Sep;19(5):385-9.Ponseti's manipulation in neglected clubfoot in children more than 7 years of age: a prospective evaluation of 25 feet with
long-term follow-up. Khan SA, Kumar A
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Modifications of Ponsetis method Accelerated Ponseti Morcuende et al , (2005) 7 day Vs 5 day interval Average time to tenotomy: 16 days in 5 day group and 24days in 7 day group
Morcuende JA, Abbasi D, Dolan LA, Ponseti IV. Results of an accelerated Ponseti protocol forclubfoot. J Pediatr Orthop 2005;25:623-6
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Kite methodBelieved heel varus would correct simply by evertingcalcaneusDid not realize calcaneus can evert only when it isabducted (i.e., laterally rotated) under the talusEach component corrected separately ( adduction, heel varus and equinus)Forefoot overcorrected into mild flatfootCalcaneus rolled out of inversion by placing plantarsurface of a slipper cast on glass plate to flatten the soleDorsiflexion of foot with wedging casts
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Atypical clubfoot2-3% Feet highly resistantto correctionSevere plantarflexion of all
metatarsals, a deep crease just above heel and acrossthe sole of the midfoot ,short hyperextended big
toe, fibrotic musclesTreatment bymanipulation and Ponsetimethod
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When manipulating,index fingershould rest over posterior aspect oflateral malleolus while thumb ofsame hand applies counter pressure
over the lateral aspect of the talarhead Do not abduct more than 30degrees After 30 degrees abduction isachieved, change emphasis tocorrection of the cavus and equinus. All metatarsals are extendedsimultaneously with both thumbs Above-knee cast in 110 degreesflexion
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Surgery in clubfootResistant clubfoot( non-responsive to serial casting andmanipulation)
Persistently deformed clubfoot(non-operative correctioninadequately done with/without compliant bracing)Relapsed clubfoot( initially satisfactorily corrected thatrecurs in part or whole)
Neglected clubfoot( no treatment given till age of 2 yrs)
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General PrinciplesGoal: address all pathoantomic structuresDecision regarding timing, extentIndex surgery, the most importantA la carte" approach [Bensahel] Turcos one size fits all approach Posteromedial-plantar-lateral release: all deformitiespresentPosterior release: straight lateral border, flexible forefootand hindfoot, and palpable gap between medial malleolusand navicular tuberosity
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ApproachesTurco Cincinnati
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Carolls two incision technique Medial incision - straight oblique incisionfrom first metatarsal, across tmedialmalleolus to Achilles tendon
Straight lateral incision along the lateralsubtalar joint antr to distal fibula
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Extensile posteromedial and posterolateral releaseModified McKay procedureCincinnati incision
Posterolateral release
Z lengthening of the TAPosterior capsulotomy of
Ankle joint &Subtalar joint
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Incise superior peronealretinaculumCut off calcaneofibular and
talofibular ligamentIncise talocalcaneal ligamentand lateral capsule oftalocalcaneal jointEDB, inferior extensorretinaculum and dorsalcalcaneocuboid ligamner cutincase of severe clubfoot
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Medial releaseDissect and protect N-Vbundle
Master knot of HenryZ-lengthening of theTibialis Posterior & releaseof sheath
Follow to navicularinsertionCapsule of T-N jointreleased
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Medial tibial navicularligament, dorsaltalonavicular ligamnet,
and plantarcalcaneonavicularligament cutCapsule of T-N cut all the
way around
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Bifurcated ligament cutComplete release oftalocalcaneal joint ligaments
except interosseousligamentsDetach origin of quadratusplantae muscle fromcalcaneus
Roll talus back into anklekoint, if not incise post.talofibular ligament, post.Portion of deep deltoidligament
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Line up medial side ofhead and neck of talus with medial side of
cuneiforms, medially pushcalcaneus post. to ankle jointK wire through
talonavicular,talocalcaneal joints
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Check for proper positionof footLongitudinal plane of foot
85-90 to bimalleolar ankleplane, heel under tibia inslight valgusSuture all tendons with
foot in 20 dorsiflexion Wound closure
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Follow up : Wound inspection done under sedation at 1 weekFoot held in neutral, plantigrade position and castapplied above kneeCast kept for 4 6 weeksCast removed along with any K wires, if applied duringsurgery for stabilisation AFO given for 6 months
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Residual deformitiesResidual hindfoot equinus : Achilles tendonlengthening and posterior capsulotomy of ankle andsubtalar jointsDynamic metatarsus adductus : Transfer of anteriortibial tendon, either as split transfer or entire tendon
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Resistant clubfootMetatarsus adductus : >5 yrs metatarsal osteototomyHindfoor varus : 10 yrs triple arthrodesis
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Neglected clubfootNo / incomplete initial treatment till the age of 2 yearsModerately flexible, moderately stiff, and rigidModified Ponseti*: manipulation for 5-10 mins, two weeklycast change, correction of foot to 30-40 abduction, and AFO for 1 yearExtensive soft tissue release upto 4 yrsDilwyn-Evans, Lichtblau procedureTriple arthrodesisIlizarov/ JESSLourenco et al . Correction of neglected club foot by ponseti method. JBJS Br. 2007
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Bony proceduresDwyer osteotomyOsteotomy of calcaneusOpening wedge medialosteotomy to increase thelength and height ofcalcaneusFor isolated heel varusModified method useslateral incisions
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Litchblau procedureMedial soft tissue releaseLateral closing wedgeosteotomy of calcaneusPrevents long termstiffness of hindfootShortens the lateral
column
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Dilwyn Evans OsteotomyPosteromedial releaseCalcaneocuboid wedgeresection andarthrodesis of the jointShortens lateral columnStiffness at subtalar andmidfoot jointsPreferred in olderchildren (4-8 yrs)
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Salvage proceduresTriple arthrodesis
Salvage procedure for pain after previous surgicalcorrection.Correction of large degrees of deformity in neglectedclubfeet.Not performed before advanced skeletal maturity, at
age 10 to 12Lateral closing wedge osteotomy through subtalar andmidtarsal joints
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Triple arthrodesis
Dunn arthrodesis Hoke and kite
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Talectomy
Severe, untreated clubfootPreviously treated clubfootthat is uncorrectable by
any other surgicalproceduresResistant neuromuscularor syndromic clubfoot
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JOSHI EXTERNAL STABILISATION SYSTEMDR.B.B. JOSHI, MUMBAI2 to 4 transfixing wires inprox tibia
MetatarsalTransfixing wire throughI &V MT; Medial half pinthrough I, II, III MT; Lathalf pin thro IV, V MT 2 transfixing and 1 axial wire through calcaneum
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JESSFractional, differential distraction used to Sequentiallycorrect deformities (Medial- 0.25 mm every 6 hours,Lateral- 0.25 mm every 12 hours)
Distraction continued until approximately 20 degrees ofdorsiflexion and overcorrection of the forefoot deformities was achieved
Maintained in this overcorrected position for twice as longas the distraction phase by casts/braces
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Results with JESSGood or excellent results reported by Joshi in 84% ofhis patientsRecommended in all who have not responded to serialplaster casting methods.Similar good results have been reported by otherauthors**
**Suresh et al,2003. Journal of Orthopaedic Surgery 2003: 11(2): 194 201
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Complications of surgery Neurovascular injuryLoss of foot (10% have atrophic dorsalis pedis artery bundle)Skin dehiscence Wound infection
AVN talusDislocation of the navicularFlattening and breaking of the talar headUndercorrection/ Overcorrection (esp with Cincinatti)Forefoot adductusHindfoot varusSevere scarringStiff joints Weakness of the plantar flexors of the ankle
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ConclusionProper understanding of the patho-anatomy a mustPonseti method is now the standard treatmentmethodIndications of surgery limited but well definedTurcos posteromedial soft tissue release remains thetreatment of choice in most cases amenable to surgicaltreatment
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