CLUB FOOT (CTEV)

Question 1

WHAT IS CLUBFOOT?

Answer 1

 Rotatory subluxation of talocalnoenavicular joint (subtalar) complex with talus in plantar flexion and subtalar complex in medial rotation and inversion
 CTEV (Congenital Talipes Equino Varus) is also known as Clubfoot.
 Congenital - Present at birth

Question 2

WHAT ARE THE MAIN CLINICAL COMPONENTS OF CLUBFOOT?

Answer 2

4 Clinical Components: CAVE
a) C- Cavus- Exaggerated medial longitudinal arch at midfoot
b) A- Adduction- Forefoot in adduction at tarsometatarsal junction (Mid/forefoot adductus)
c) V- Varus- Hindfoot rotated inward at talonavicular joint (Hind foot varus)
d) E- Equinus- Foot fixed in plantar flexion at ankle joint (Hind foot equinus)

Question 3

OUTLINE THE EPIDEMIOLOGY OF CLUBFOOT

Answer 3

 Incidence- 1-2 per 1000 live birth
 Incidence in first degree relation- 2%
 Incidence in second degree relation- 0.6%
 Incidence in male:female- 2.5:1
 Laterality- >50% cases are bilateral
 In unilateral affliction- right> lefT

Question 4

DESCRIBE THE PATHOANATOMY OF THE BONES IN CLUBFOOT

Answer 4

Talus-
 Head and neck deviated medially and downward.
 Medial and plantar deviation of navicular articulation.
 Body rotated externally and is in equinus of neck in ankle Mortise.
 Body extruded anteriorly
 Smaller than normal
 Neck- body angle is 90-110* (normal- 150*)
 Dislocation of head of talus out of its socket.
 Equinus: Severe tibio-talar & talocalcaneal plantar flexion and medial talar neck inclined
Navicular-
 Medially and plantar displacement close to medial malleolus
 Articulates with medial surface of dysmorphic talus
 Talonavicular joint subluxation
 Medial displacement of navicular & cuboid
Calcaneum-
 Often small in size
 Medially rotated
 Anterior portion lies beneath the head of talus causing varus and equinus of Heel.
 Sustentaculum tali is underdeveloped.
Cuboid-
 Medially subluxated over calcaneum head

Question 5

OUTLINE THE PATHOANATOMY OF THE MUSCLES IN CLUBFOOT

Answer 5

Muscles and tendons-
 Atrophy of peroneal group of muscles
 Contracture of tricep surae, tibialis posterior, flexor digitorum longus and flexor hallucis lungus.
 Number of fibres in muscle is normal but are smaller in size.
 Thickening and contracture of tendon sheaths especially of tibialis posterior and peroneal

Question 6

OUTLINE THE PATHOANATOMY OF THE LIGAMENTS IN CLUBFOOT

Answer 6

Ligaments-
Thickening and contractures are seen in
 Calcaneofibular ligament
 Talofibular ligament
 Deltoid ligament
 Long and short plantar ligament
 Spring ligament
 Bifurcate ligament
 Interosseous talo calcaneum ligament
 Master knot of HENRY

Question 7

OUTLINE THE PATHOANATOMY OF THE JOINTS IN CLUBFOOT

Answer 7

Joints capsule and fascia-
 Contractures are seen in:
* Posterior ankle capsule
* Subtalar capsule
* Talonavicular joint capsule
* Calcaneocuboid joint capsule
* Plantar fascia contracture are seen which is responsible cavus deformity

Question 8

OUTLINE THE PATHOANATOMY OF THE SKIN AND VASCULATION IN CLUBFOOT

Answer 8

Skin changes-
 Deep crease on medial side
 Dimples in lateral aspect of ankle and midfoot.
 Shortening on medial side of sole
 Callosities and bursa on lateral side of foot
Vascular changes-
 Hypoplasia or absence of dorsalis pedis and
 Anterior tibial artery

Question 9

WHAT ARE THE CLINICAL FEATURES OF CLUBFOOT?

Answer 9

Clinical features of clubfoot
b) Heel is small and in equinus
c) Foot inverted on end of tibia
d) Deep creases on medial and posterior aspect
e) Abnormal thin calf
f) Varying degree of resistance/ fixed deformity when try to dorsiflex and evert the foot.
g) Lack of correctability
h) Other joint abnormality
i) May be associated with other anomalies e.g., neuromuscular condition
j) Hind foot- posterior crease, rigid equinus & empty heel
k) Mid/Forefoot: cavus, curved lateral border and varus

Question 10

HOW IS CLUBFOOT CLASSIFIED?

Answer 10

1) Classified based on aetiology
2) Pirani scoring system
3) Ponseti and smoley classification- based on extent of deformity
4) Harrold & walker classification- based on ability to correct deformity.
5) Browne’s classification- based on type of deformity
6) Dimeglio et al scoring system based on severity of the deformitY
7) Cummin classification

Question 11

OUTLINE THE AETIOLOGICAL CLASSIFICATION OF CLUBFOOT

Answer 11

1) Classified based on aetiology
a) Idiopathic
b) Non-idiopathic and Secondary CTEV is associated with underlying cause.
((AA)) Associated with neuromuscular or syndromic etiologiesi. Arthrogryposis multiplex congenital
ii. Diastrophic dysplasia
iii. Streeter syndrome (constriction band syndrome)
iv. Freeman sheldon syndrome
v. Mobius syndrome
vi. Nail patella syndrome
vii. Diastrophic dwarfism
((BB)) Associated with paralytic disorder
i. poliomyelitis
ii. spina bifida
iii. myelodysplasia
iv. freidrich’s ataxia

Question 12

OUTLINE PIRANI’S SCORING SYSTEM FOR CLUBFOOT

Answer 12

 Simple and reliable system to determine severity and monitor progress in the assessment and treatment of clubfoot
 Six “signs” are assessed
* 3 signs in midfoot
* 3 signs in hindfoot
 Based on 6 well-described clinical signs of contracture characterizing a severe clubfoot:
If the sign is severely abnormal it scores 1
If it is partially abnormal it scores 0.5
If it is normal it scores 0
* Total score (ts) varies from 0 to 6 and is the sum of midfoot and hindfoot contracture scores

Question 13

OUTLINE THE DIMEGLIO ET AL SCORING SYSTEM OF CLUBFOOT

Answer 13

6) Dimeglio et al scoring system based on severity of the deformity
A. Equinus deviation- sagittal plane evaluation of equinus
B. varus deviation- frontal evaluation of varus
C. Derotation- Horizontal plane evaluation of derotation of calcanopedal block
D. Adduction- Horizontal plane evaluation of forefoot relative to hind foot

Question 14

WHICH ANGLES SHOULD BE MEASURED IN THE RADIOLOGICAL EVALUATION OF CLUB FOOT?

Answer 14

Important angles to be measured
1. Talocalcaneal angle on AP and Lat view
2. Tibiocalcaneal angle on Lat view
3. Talus first metatarsal angle radiographic
4. Talocalcaneal angle

Question 15

DESCRIBE THE RADIOLOGICAL FINDINGS OF A CLUB FOOT BASED ON THE VIEW

Answer 15

On AP view-
 1
st line via centre of long axis of talus (parallel to medial border)
 2
nd line via long axis of calcaneum (parallel to lateral border) =Normal 25-40*
Findings on AP VIEW: Increased talocalcaneal angle
 Increased talar first metatarsal angle
 Long axis of talus deviate laterally&passes along 3rd/4th metatarsal bone
On lateral view-
 1
st line midpoint of head and body of talus
 2
nd line along bottom of calcaneum =Normal 35-50*
Findings on lateral view:
 Decreased talocalcaneal angle (talocalcaneal parallelism)
 Disrupted talar first metatarsal angle
 Long axis of talus and calcaneum passes inferior to cuboid (normally crosses cuboid)

Question 16

WHAT ARE THE GOALS OF CLUB FOOT TREATMENT?

Answer 16

• Goal: to achieve
   Plantigrade foot
   Flexibilty
   Cosmetically acceptable functional and pain free foot in shortest tx time

Question 17

WHAT ARE THE PRINCIPLES OF CLUB FOOT TREATMENT?

Answer 17

Principles of treatment:
* Soft tissue contracture release or stretching to restore normal tarsal relationship.
* Once normal tarsal relationship attained, correction should be maintained till tarsal bones remoulds stable articular surface

Question 18

OUTLINE THE PONSETI TECHNIQUE FOR TREATING CLUBFOOT

Answer 18

Ponseti technique:
 Has 2 phase- treatment and maintenance phase
* Treatment phase-
* Begins as early as possible. During first wk of life only manipulation is carried out but cast is not applied.
* Order of correction- CAVUS → ADDUCTION WITH VARUS→EQUINUS
* Talus head is used as fulcrum.
* Then 5-6 serial casting with manipulation is may be generally enough to correct the deformity.
* Maximum upto 10 casting can be done.
Maintaenance phase:
* After removal of cast infant is placed in foot abduction orthosis.
* Brace is worn for 23hrs per day for first 3 month then only while sleeping for 3-4 years.
* This brace is FOOT ABDUCTION BRACE. It consists of shoes mounted to a bar in a position of 70 degrees of external rotation & 15 degrees of dorsiflexion and distace between shoes is set at about one inch wider than width of infant’s shoulder.
* Frequent follow up is important to detect early reccurence.
* It prevent recurrence of deformity
* It favors remodelling of joints with the bones in proper alignment and
* To increase leg and foot muscle strength

Question 19

WHAT ARE THE COMPLICATIONS OF CASTING CLUBFOOT?

Answer 19

Complications of Casting
1. Pressure Ulcers
2. Skin allergy
3. Swelling
4. Cast slip
5. Circulation problems- compartment syndrome
6. Rocker bottom foot
7. Muscle atrophy
8. Bean shaped foot
9. Fractures
10. Flat top talus
11. Failure of correction
12. Reccurence or relapse of deformity

Question 20

OUTLINE A PERCUTANEOUS TENOTOMY OF CLUBFOOT

Answer 20

• Percutaneous Achilles tenotomy from medial to lateral
• Foot held in dorsiflexion and tendon is felt
• Blade of 11 size enters parallel to medial border of tendoachilles 1cm above insertion at calcaneum.
• Blade is pushed medial to tendon and rotated 90* underneath it. Tendon is cut from medial to lateral direction.
• “Pop” is felt and cast is applied in maximal dorsiflexion and 70* abduction for 3-4wks

Question 21

WHAT FACTORS CONTRIBUTE TO THE CORRECT TIMING OF A CLUBFOOT TENOTOMY?

Answer 21

Timing of Tenotomy:
* Soon as Pirani score indicates MFCS is 1 / less.
* Score for LHT is zero.
* Heel is in Valgus.
* Foot is in Abduction

Question 22

WHICH TYPES OF CTEV REQUIRE SURGICAL TREATMENT?

Answer 22

Reccurent CTEV, resistant CTEV, rigid CTEV

Question 23

WHAT ARE THE CHOICES OF SURGERIES FOR CLUBFOOT IN RELATION TO THE PTS AGE?

Answer 23

Choice of surgery:
* 1-4 years- Soft tissue release
* 4-11 yrs- Soft tissue release with osteotomy performed according to the deformities
* >11yrs- salvage procedures
 Triple arthrodesis
 Talectomy

Question 24

WHAT IS THE CINCINNATI INCISION OF CLUBFOOT?

Answer 24

Transverse circumferential incision- This incision provides exposure of subtalar jt & is useful in pts with a severe IR deformity of calcaneus.

Question 25

OUTLINE THE SURGICAL PROCEDURE OF ACHILLES HEEL LENGTHENING AND POSTERIOR CAPSULOTOMY

Answer 25

2. Achilles tendon lenthening and posterior capsulotomy
   * To correct residual hindfoot equinus
   * Z-plasty is done to lengthen the achilles tendon.
   * Releasing medial half distally and lateral half proximally.
   * Posterior capsulotomy of ankle and subtalar joint to release capsule contracture. In case of dynamic metatarsus adductus caused by overpull of anterior tibial tendon in older children who have had correction of clubfoot.

Question 26

DIFFERENTIATE BETWEEN THE INDICATIONS FOR TENDON TRANSFER, DWYER OSTEOTOMY AND LATERAL COLUMN SHORTENING PROCEDURES FOR CLUBFOOT

Answer 26

Other surgical approaches
1. Tendon transfer- indication- passively correctable deformity resulting from muscle imbalance
2. Dwyer osteotomy indication- persistent varus deformity of heel when soft tissue surgeries are contraindicated.
3. Lateral column shortening procedure- Indication- recurrence of clubfoot deformity after surgical release is mostly due to disparity between medial and lateral border of foot. Any attempt to correct deformity is resisted by medial contracture and excessive length of lateral column.