CTEV : Pathoanatomy and management

DR. SUSHIL PAUDELDR. PRATYUSHDr. Shah Alam Khan

Definition Developmental

deformation of foot Rotational subluxation of

talocalcaneonavicular joint complex with talus in plantar flexion & subtalar complex in medial rotation & inversion

Clinically characterized byEquinus & varus of heelForefoot adductionMidfoot supination

Classification (Attenborough 1966)Type Type

I(Extrinsic)I(Extrinsic)

Non RigidNon Rigid

Type Type II(Intrinsic)II(Intrinsic)

RigidRigid

Foot sizeFoot size Normal Normal Smaller Smaller

Heel Heel Normal sizeNormal sizeCan be brought Can be brought down with easedown with easeMinimal varusMinimal varus

Small , elevatedSmall , elevatedCannot be brought Cannot be brought down with easedown with easeMarked varusMarked varus

Creases Creases More or less normalMore or less normal Deep medial, Deep medial, posterior and lateral posterior and lateral creasescreases

Reduced creases Reduced creases laterallylaterally

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 of the metatarsal phalangeal joint; occurs in otherwise normal infant

Syndromic clubfoot: The clubfoot part of a syndrome

Teratologic clubfoot – such as congenital tarsal synchondrosis

Neurogenic clubfoot – associated with a neurological disorder such as meningomyelocele

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

PathogenesisUnknown at this stageGray et al (1981) : increase in % of type I fibres in soleus

muscle; suggested defective neural influenceRecent study*: no evidence of type I fiber groupingHypoplasia or absence of the anterior tibial artery in

majority of CTEV patients**Absence of the dorsalis pedis pulse in the parents of children

with clubfoot#Primary germ plasm defect in the talus: continued plantar

flexion and inversion 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.

Wynne-Davies : polygenic inheritanceMultifactorial inheritance established by genetic epidemiologic research

by Idelberger32.5% concordance rate among monozygotic twins as compared to 2.9%

among dizygotic twinsMajor gene effect (inherited in recessive manner) with additional

polygenes and environmental factors Tachdjian Patient with CTEV that has one child affected then 25% chance of

another affected If both parents are normal & have affected child then chance of another

is 5% Idelberger K. et al 1939; 33:272–276

.

Intrauterine factors

Pressure theories: Oligohydramnios Abnormal fetal positioning

Placental insufficiencyConstriction bandsToxins ( Maternal alcoholism, smoking)Maternal illness ( anemia, thyroid disorders )Infective pathogens (enteroviruses)Drugs (abortifacients, salicylates, barbiturates)Electromagnetic radiation

Bony abnormalitiesTalus:

Head & neck deviated medially & plantarward

Body rotated externally in the ankle mortise

Body extruded anteriorly Smaller than normal

Navicular: Medially displaced Close to medial

malleolus Articulates with medial

surface of head of talusCalcaneus

Anterior portion lies beneath the head of talus causin gvarus and equinus of heel

In equinus Rotated medially

Cuboid Displaced medially

on the dysmorphic distal end of the calcaneus

Talonavicular joint In inversion

Tibio-talar plantar flexion

Medially displaced navicular

Adducted and inverted calcaneus

Medially displaced cuboid

Soft tissue changesPosterior

structures : Tendo achilles Post. capsule of ankle

joint & subtalar joint Post. talo fibular Calcaneo-fibular

ligaments

Medial : Tibialis posterior FHL,FDL, Master Knot of

Henry Talonavicular ligament Calcaneo-navicular

ligament Deltoid ligament Interossseus talo calcaneal

ligaments Capsules of naviculo

cuneiform & cuneiform first metatarsal

Plantar wards : Plantar fascia Plantar ligaments Flexor digitorum

brevis & abductor hallucis

Laterally Calcaneofibular

ligament Bifurcated ligament Calcaneocuboid

joint capsule

Clinical features 1. Deformity

Heel equinus Heel varus Midfoot supination Forefoot adduction Maybe cavus

2. Features Curved lateral border of

foot Devil’s thumbprint over

the lateral malleolus Medial & Lateral skin

creases Navicular fixed to

medial malleolus Os calcis fixed to the

lateral malleolus Heel small & high

3. General Calf atrophy Calf shortening Restricted ankle motion

Other Conditions should be excluded Spinal Dysraphism Arthrogryposis Neuromuscular Disorders

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 tube at 30° from verticalLat. View: Transmalleolar with the fibula

overlapping the posterior half of the tibia; foot in 30° of plantar flexion

Anteroposterior view

Talocalcaneal angle

Calcaneal-second metatarsal angle

Talus –first metatarsal angle

AP radiograph: Talo-Calcaneal angle

Lines drawn through center of the long axis of talus (parallel to medial border) and through the long axis of calcaneum (parallel to lateral border), and they usually subtend an angle of 25-40°.

Any angle less than 20° considered abnormal

Lateral viewTalocalcaneal viewCalcaneal-first metatarsal

viewTibiocalcanealTibiotalar angleTalus-first metatarsal

angleTalocalcaneal index

(Kite's angles from AP and Lateral views added)         

Pirani’s severity scoringSix parameters : 3 of midfoot and 3 of hindfoot Each 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. Annual meeting of Pediatric orthopaedic society of North America 1995

Mid foot scoreCurved lateral

border [A]

Medial crease [B]

Talar head coverage [C]

Hind foot scorePosterior crease [D]

Rigid equinus [E]

Empty heel [F]

Uses of Pirani’s scoreAssessment of progress by serial plotting of the score

Predicting need for tenotomy (hs>1& ms<1)

Estimation of probable no. of casts reqd*

Very good interobserver reliability and reproducibility**

* J. Dyer et al Journal of Bone and Joint Surgery - British Volume, Vol 88-B, Issue 8, 1082-1084P.

** Flynn JM, Donohoe M, Mackenzie WG. J Pediatr Orthop 1999;18:323-7

International Clubfoot Study Group ScoreIntroduced by Henri Bensahel et al in 2003Found to have good interobserver reliability

and reproducibility**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.

Morphological parameters

Functional parameters

Radiological parameters

Classification of clubfoot severity by Diméglio A.Equinus deviation B. Varus deviation C. Derotation D. Adduction.

Reducibility( degrees)

Score Additional parameters

Score

90-45 4 Marked posterior crease

1

45-20 3 Marked mediotarsal crease

1

20-0 2 Cavus 1

0 t0 -20 1 Poor muscle condition

1

Grade Type Score Reducibility

i Benign 1-4 >90%

ii Moderate 5-9 >50%, soft-stiff, reducible, partially resistant

iii Severe 10-14 >50%, stiff-soft, resistant, partially reducible

iv Very severe 15-20 <10% stiff-stiff,resistant

Aims of treatmentAfter sucessful treatment foot should

Look good Feel good Move good Measure good

Ponseti cast correction

Outline of Ponseti regimenSerial casting of lower

limb using a strictly defined technique and weekly change of casts

Percutaneous tenotomy of tendo achilles for “hind foot stall”

Once foot corrected, an abduction foot orthosis worn full time for 12 weeks, and then at nights and naps, up to age of four

Manipulation and cast application

1.ManipulationManipulation: start as soon

after birth as possible

Setup for casting includes calming the child with a bottle or breast feeding

Assistant holds the foot while the manipulator performs the correction

.

Tarsal joints functionally interdependent

Movement of each tarsal bone involves simultaneous shifts in the adjacent bones

Necessiates SIMULTANEOUS correction of adduction, varus and inversion.

2. Correction of cavusCavus results from

pronation of the forefoot in relation to hindfoot “ THE PRONATION TWIST “

Attempting to correct the supination of hindfoot before correction of varus results in an iatrogenic increase in cavus

Corrected by supinating the forefoot to place it in proper alignment with the hindfoot.

Cast application Manipulation Padding

Plaster at toes Below knee pop

Molding Extension upto the thigh

Plantar support to toes Final appearance

Casts and foot Adequate abduction

Best sign of sufficient abduction: ability to palpate the anterior process of the calcaneus as it abducts out from beneath talus

Abduction of approx.70 degrees in relationship to the frontal plane of the tibia possible

Complications of castingTight castRocker bottom deformityCrowded toesFlat heel padSuperficial soresDeep soresPressure soresInjury to distal tibial physis

Common errors(Kite errors)No manipulationPronation/eversion

of 1st metatarsalPremature

dorsiflexion of heelCounterpressure at

calcaneocuboid jointExternal rotationBelow knee castsShort splints

Rocker bottom deformityDorsiflexion via

midfoot before correction of hindfoot varus

Dorsal dislocation of navicular on talus

Fixed equinus of calcaneus

Correction of equinus and tenotomy No direct attempt at equinus correction is

made until heel varus is corrected Equinus deformity gradually improves with

correction of adductus and varus- calcaneus dorsiflexes as it abducts under talus

Residual equinus- manipulation and casting +/- percutaneous tenotomy

Tenotomy : Indicated to correct equinus when cavus, adductus, and varus fully corrected but ankle dorsiflexion remains less than 10 degrees above neutral

Percutaneous tenotomy under LA

Foot held in max dorsiflexion by an assistant Tenotomy done 1.5 cm above calcaneal insertion Additional 25-30 deg dorsiflexion obtained Cast with the foot abducted 60 to 70 degrees with respect to the

frontal plane of the ankle, and 15 degrees dorsiflexion for 3 weeks

Foot Abduction bracesShoes mounted to bar in

position of 70° of ER and 15° of dorsiflexion in B/L cases and incase of U/L cases 30 to 40° of ER in normal side, distance between shoes set at about 1˝ wider than width of shoulders

Knees left free, so the child can kick them “straight” to stretch gastrosoleus tendon

Bracing protocolWorn 24 hours each day for first 3 months For 12 hours at night and 2 to 4 hours in middle

of day for a total of 14 to 16 hours during each 24-hour period

Continued until the child is 3 to 4 years of ageHaft et al: noncompliance with bracing protocol –

the most common cause of recurrence in children on Ponseti regimen

Haft, Geoffrey F. MD; Walker, Cameron G. PhD; Crawford,Haemish A. FRACS.J Bone Joint Surg Am, Volume 89-A(3).March 1, 2007.487–493

Mitchell brace Dobbs dynamic brace

Dennis brown Romanus

CTEV SplintStraight inner border to

prevent forefoot adductionOuter shoe raise to prevent

fooot inversionNo heel to prevent equinusSlight(1/8”) lateral sole

raise Inner iron barOuter t trapWalking age to 5 yrs of age

Results of Ponseti method Cooper and Dietz in 1995: Reviewed a group of 45 adults, with 71 clubfeet,

who had been managed with the Ponseti method, 30 years after treatment

Results compared with NORMAL CONTROLS. Based on structured examination, radiographs,

electrogoniometry and measurements using a pedobarography.

Using the Laaveg and Ponseti score, the results in the normal controls and in those with treated clubfeet same

Radiographs showed :feet not completely corrected, but functioned well despite this

Cooper DM, Dietz FR. J Bone Joint Surg [Am] 1995;77-A:1477-89.

Results of Ponseti’s method..Study from Iowa (2004) : short-term results of a

more recent 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 extensive correctivesurgery for clubfoot using the Ponseti method. Pediatrics 2004;113:376-80.

Khan et al Evaluated results of Ponseti's method in 21 children (25 feet) with

neglected club feet Underwent percutaneous tenotomy of Achilles tendon Mean 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 average score of 0.95 at the end of treatment at 1-year follow-up 18 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

neglected clubfeetJ 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

Modifications of Ponseti’s method Accelerated Ponseti Morcuende et al , (2005) 7 day Vs 5 day intervalAverage time to tenotomy: 16 days in 5 day

group and 24 days in 7 day group

Morcuende JA, Abbasi D, Dolan LA, Ponseti IV. Results of an accelerated Ponseti protocol for clubfoot. J Pediatr Orthop 2005;25:623-6

Kite methodBelieved heel varus would correct simply by

everting calcaneusDid not realize calcaneus can evert only when it

is abducted (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

plantar surface of a slipper cast on glass plate to flatten the sole

Dorsiflexion of foot with wedging casts

The French method Bensahel/Dimeglio regime Daily manipulations by a skilled physiotherapist

and temporary immobilisation with elastic and non-elastic adhesive taping

Mobilisation during the hours of sleep with CPM machine

Successful in 51% of cases ( of which 9% req TA tenotomy) ; 49% Reqd extensive soft tissue release -29% post release and 20% comprehensive posteromedial release**.

** Richards BS, Johnston CE, Wilson H. Nonoperative clubfoot treatment using the

French physical therapy method. J Pediatr Orthop 2005;25:98-102.

Atypical clubfoot2-3% Feet highly

resistant to correctionSevere plantarflexion of

all metatarsals, a deep crease just above heel and across the sole of the midfoot , short hyperextended big toe, fibrotic muscles

Treatment by manipulation and Ponseti method

When manipulating,index finger should rest over posterior aspect of lateral malleolus while thumb of same hand applies counter pressure over the lateral aspect of the talar head

Do not abduct more than 30 degrees

After 30 degrees abduction is achieved, change emphasis to correction of the cavus and equinus.

All metatarsals are extended simultaneously with both thumbs

Above-knee cast in 110 degrees flexion

Follow up protocol2 weeks: to troubleshoot compliance issues

3 months: to graduate to the nights and naps protocol

Every 4 months: until age 3 years to monitor compliance and check for relapses

Every 6 months: until age 4 years.

Every 1 to 2 years: until skeletal maturity

Surgery in clubfoot

Resistant clubfoot( non-responsive to serial casting and manipulation)

Persistently deformed clubfoot(non-operative correction inadequately done with/without compliant bracing)

Relapsed clubfoot( initially satisfactorily corrected that recurs in part or whole)

Neglected clubfoot( no treatment given till age of 2 yrs)

General PrinciplesGoal: address all pathoantomic structuresDecision regarding timing, extentIndex surgery, the most important“A la carte" approach [Bensahel]Turco’s ‘one size fits all’ approachPosteromedial-plantar-lateral release: all

deformities presentPosterior release: straight lateral border, flexible

forefoot and hindfoot, and palpable gap between medial malleolus and navicular tuberosity

ApproachesTurco Cincinnati

Caroll’s two incision techniqueMedial incision - straight oblique incision from first metatarsal, across tmedial malleolus to Achilles tendon

Straight lateral incision along the lateral subtalar joint antr to distal fibula

Extensile posteromedial and posterolateral releaseModified McKay

procedureCincinnati incision

Posterolateral release

Z lengthening of the TA

Posterior capsulotomy of Ankle joint &Subtalar joint

Incise superior peroneal retinaculum

Cut off calcaneofibular and talofibular ligament

Incise talocalcaneal ligament and lateral capsule of talocalcaneal joint

EDB, inferior extensor retinaculum and dorsal calcaneocuboid ligamner cut incase of severe clubfoot

Medial releaseDissect and protect N-

V bundleMaster knot of HenryZ-lengthening of the

Tibialis Posterior & release of sheath

Follow to navicular insertion

Capsule of T-N joint released

Medial tibial navicular ligament, dorsal talonavicular ligamnet, and plantar calcaneonavicular ligament cut

Capsule of T-N cut all the way around

Bifurcated ligament cut Complete release of

talocalcaneal joint ligaments except interosseous ligaments

Detach origin of quadratus plantae muscle from calcaneus

Roll talus back into ankle koint, if not incise post. talofibular ligament, post. Portion of deep deltoid ligament

Line up medial side of head and neck of talus with medial side of cuneiforms, medially push calcaneus post. to ankle joint

K wire through talonavicular ,talocalcaneal joints

Check for proper position of foot

Longitudinal plane of foot 85-90° to bimalleolar ankle plane, heel under tibia in slight valgus

Suture all tendons with foot in 20° dorsiflexion

Wound closure

Follow up :Wound inspection done under sedation at 1

weekFoot held in neutral, plantigrade position and

cast applied – above kneeCast kept for 4 – 6 weeksCast removed along with any K wires, if

applied during surgery for stabilisationAFO given for 6 months

Residual deformitiesResidual hindfoot equinus : Achilles tendon

lengthening and posterior capsulotomy of ankle and subtalar joints

Dynamic metatarsus adductus : Transfer of anterior tibial tendon, either as split transfer or entire tendon

Resistant clubfootMetatarsus adductus : >5 yrs metatarsal osteototomyHindfoor varus : <2-3 yrs modified Mckay procedure 3- 10 yrs Dwyer osteotomy ( isolated heel varus) Dilwyn Evans procedure (short medial

column) Lichtblau procedure( long lateral column) 10-12 yrs triple arthrodesisEquinus : Achilles tendon lengthening and posterior

capsulotomy of subtalar joint, ankle joint / Lambrinudi procedure

All three deformities >10 yrs triple arthrodesis

Neglected clubfootNo / incomplete initial treatment till the age of 2

yearsModerately flexible, moderately stiff, and rigidModified Ponseti*: manipulation for 5-10 mins, two

weekly cast change, correction of foot to 30-40° abduction, and AFO for 1 year

Extensive soft tissue release upto 4 yrsDilwyn-Evans, Lichtblau procedureTriple arthrodesisIlizarov/ JESS

Lourenco et al . Correction of neglected club foot by ponseti method. JBJS Br. 2007

Bony proceduresDwyer osteotomy

Osteotomy of calcaneus

Opening wedge medial osteotomy to increase the length and height of calcaneus

For isolated heel varusModified method uses

lateral incisions

Litchblau procedureMedial soft tissue

release Lateral closing

wedge osteotomy of calcaneus

Prevents long term stiffness of hindfoot

Shortens the lateral column

Dilwyn Evans OsteotomyPosteromedial releaseCalcaneocuboid

wedge resection and arthrodesis of the joint

Shortens lateral column

Stiffness at subtalar and midfoot joints

Preferred in older children (4-8 yrs)

Salvage proceduresTriple arthrodesisSalvage procedure for pain after previous

surgical correction.Correction of large degrees of deformity in

neglected clubfeet.Not performed before advanced skeletal

maturity, at age 10 to 12Lateral closing wedge osteotomy through

subtalar and midtarsal joints

Triple arthrodesis Dunn arthrodesis Hoke and kite

Talectomy

Severe, untreated clubfoot

Previously treated clubfoot that is uncorrectable by any other surgical procedures

Resistant neuromuscular or syndromic clubfoot

Ilizarov Correction slow

enough to protect soft tissue

Correction at the focus of deformity

Simultaneous three-dimensional, multilevel correction

Deformity correction without shortening the foot

Results with IlizarovGood to excellent results reported by various

surgeons( Grill et al, Huerta et al, Bradish et al, Heymann et al, Hosny et al) over the last 15 years

Recent long term follow-up study** by Hari et al (2007):74% good/excellent result

**Prem: J. pediatr. orthop., Volume 27(2).March 2007.220-224

JOSHI EXTERNAL STABILISATION SYSTEMDR.B.B. JOSHI, MUMBAI2 to 4 transfixing wires in

prox tibiaMetatarsal Transfixing wire through I &V MT; Medial half pin

through I, II, III MT; Lat half pin thro’ IV, V MT

2 transfixing and 1 axial wire through calcaneum

JESSFractional, differential distraction used to

Sequentially correct deformities (Medial- 0.25 mm every 6 hours ,Lateral- 0.25 mm every 12 hours)

Distraction continued until approximately 20 degrees of dorsiflexion and overcorrection of the forefoot deformities was achieved

Maintained in this overcorrected position for twice as long as the distraction phase by casts/braces

Results with JESSGood or excellent results reported by Joshi in

84% of his patients Recommended in all who have not responded

to serial plaster casting methods. Similar good results have been reported by

other authors**

**Suresh et al,2003. Journal of Orthopaedic Surgery 2003: 11(2): 194–201

Complications of surgery Neurovascular injury Loss of foot (10% have atrophic dorsalis pedis artery bundle) Skin dehiscence Wound infection AVN talus Dislocation of the navicular Flattening and breaking of the talar head Undercorrection/ Overcorrection (esp with Cincinatti) Forefoot adductus Hindfoot varus Severe scarring Stiff joints Weakness of the plantar flexors of the ankle

ConclusionProper understanding of the patho-anatomy a

mustPonseti method is now the standard

treatment methodIndications of surgery limited but well

definedTurco’s posteromedial soft tissue release

remains the treatment of choice in most cases amenable to surgical treatment

THANK YOU