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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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