CLUB FOOT (CTEV) Flashcards
WHAT IS CLUBFOOT?
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
WHAT ARE THE MAIN CLINICAL COMPONENTS OF CLUBFOOT?
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)
OUTLINE THE EPIDEMIOLOGY OF CLUBFOOT
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
DESCRIBE THE PATHOANATOMY OF THE BONES IN CLUBFOOT
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
OUTLINE THE PATHOANATOMY OF THE MUSCLES IN CLUBFOOT
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
OUTLINE THE PATHOANATOMY OF THE LIGAMENTS IN CLUBFOOT
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
OUTLINE THE PATHOANATOMY OF THE JOINTS IN CLUBFOOT
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
OUTLINE THE PATHOANATOMY OF THE SKIN AND VASCULATION IN CLUBFOOT
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
WHAT ARE THE CLINICAL FEATURES OF CLUBFOOT?
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
HOW IS CLUBFOOT CLASSIFIED?
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
OUTLINE THE AETIOLOGICAL CLASSIFICATION OF CLUBFOOT
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
OUTLINE PIRANI’S SCORING SYSTEM FOR CLUBFOOT
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
OUTLINE THE DIMEGLIO ET AL SCORING SYSTEM OF CLUBFOOT
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
WHICH ANGLES SHOULD BE MEASURED IN THE RADIOLOGICAL EVALUATION OF CLUB FOOT?
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
DESCRIBE THE RADIOLOGICAL FINDINGS OF A CLUB FOOT BASED ON THE VIEW
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)
WHAT ARE THE GOALS OF CLUB FOOT TREATMENT?
- Goal: to achieve
Plantigrade foot
Flexibilty
Cosmetically acceptable functional and pain free foot in shortest tx time
WHAT ARE THE PRINCIPLES OF CLUB FOOT TREATMENT?
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
OUTLINE THE PONSETI TECHNIQUE FOR TREATING CLUBFOOT
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
WHAT ARE THE COMPLICATIONS OF CASTING CLUBFOOT?
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
OUTLINE A PERCUTANEOUS TENOTOMY OF CLUBFOOT
- 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
WHAT FACTORS CONTRIBUTE TO THE CORRECT TIMING OF A CLUBFOOT TENOTOMY?
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
WHICH TYPES OF CTEV REQUIRE SURGICAL TREATMENT?
Reccurent CTEV, resistant CTEV, rigid CTEV
WHAT ARE THE CHOICES OF SURGERIES FOR CLUBFOOT IN RELATION TO THE PTS AGE?
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
WHAT IS THE CINCINNATI INCISION OF CLUBFOOT?
Transverse circumferential incision- This incision provides exposure of subtalar jt & is useful in pts with a severe IR deformity of calcaneus.
