TEV-Clubfoot Flashcards
What are the 3 supination type podopediatric deformities?
TEV-Clubfoot
Cavus Foot
Metatarsus Adductus
What are the appendageal long axis changes from embryonic inception to adult form
~180 degrees (arm to leg)
What changes does the lower extremity foot go through from embryonic inception to adult form>
- abduction
- extension (DF)
- medial rotation embryology of bone
Club foot is a Quadra planar deformity. What is the appearance?
- equinus
- hindfoot varus
- forefoot adductus
- forefoot cavus
____% of club foot is an isolated deformity
80%
What are the classifications for club foot
- idiopathic TEV/ typical
- Complex idiopathic CITEV/atypical
What are some causes of ITEV/typical club foot
- positional (intrauterine molding)
- delayed treated club foot
- recurrent typical club foot
- alternatively treated typical clubfoot
What are some causes of CITEV/ atypical clubfoot
- rigid (high recurrence and can need more procedures)
- syndromic (associated with other genetic abnormalities)
- teratologic (associated with arthrogryposis/myelomeningocele)
- neurogenic
What are the points dimeglio based clubfoot on
- equinus
- varus deviation
- decoration around he talus-calcaneo-forefoot
- abduction forefoot on hindfoot in horizontal plane
- foot crease
What is 15-20 on Dimeglio scoring system?
Very severe
What is 10-15 on Dimeglio scoring system?
Severe
What is 5-10 on Dimeglio scoring system?
Moderate
What is 0-5 on Dimeglio scoring system?
Postural
What are their criteria for Pirani Scoring
- lateral foot
- dorsiflexion
- medial fold
- palpation of calcaneus
- palpation of the talar head
- posterior fold
What is the Pirani scoring system composed of?
Hindfoot and midfoot contracture score
What does the Pirani hindfoot contracture score consist of
- posterior crease
- empty heel
- rigid equinus
What does the Pirani midfoot contracture score consist of
- media crease
- curvature of lateral border
- position of head of talus
White is the Kite method
Gradual manipulation and casting
However did not allow heel to swing around talus
What are the characteristics of clubfoot
Equnivarus
Posterior skin crease
Medial skin crease
Navicular close to medial malleolus**
Short great toe
Hypoplastic skin over sinus tarsi
What happens to talocalcaneal angle on AP radiograph in TEV patient
It id decreased
What is normal talocalcaneal angle on AP film
30-55
What is normal talocalcaneal angle on lateral film
25-50
What happens to talocalcaneal angle on lateral film in TEV patient
Decrease toward an angle of 0
What is normal tibiocalcaneal angle on lateral film
10-40
What happens to tibiocalcaneal angle on lateral film in TEV patients
Angle is negative
What is the normal talo-first metatarsal angle on AP view
15-20
What happens to talocalcaneal-first metatarsal angle in TEV patients
Angle is negative (abduction of forefoot)
How did Kite define clubfoot
Irreducible and reducible
What did the Kite’s method emphasize about the benefits of casting
CORA is at the CC joint
What is the manipulation sequence in Kite’s method
1 - correction of forefoot abduction
2 - correction of heel varus
3 - correction of hindfoot equinus
How many times did casting fail with the Kite method
More than 50% of times
What types of clubfoot deformities are not reducible without major surgery
- arthrogryphosis multiplex
- spinal bifida
- phaecomyelias
How did Poseti describe clubfoot
As a Quadra planar deformity flexed about a normal talus but with abnormal fibroblastic hyperplasia of the posteriomedial tendons and ligaments that created equino varus foot deformity
When to start clubfoot manipulation with casting
Fibrous hyperplasia most rapid at birth until 4-5 years - intervene before 5 years
- technique harder with smaller feet
- no difference in results in children even up to 8 yrs
- typically start casting around 4 weeks of age
What is the treatment for recurrent club foot
Tib anterior transfer
What is Posenti magic movie
A dorsiflexory force is applied beneath the first metatarsal dead with counter pressure applied to the lateral talar head. This maneuver reduces the cavus and medial crease. This is performed as the forefoot is not inverted as compared to the hindfoot
How much degrees is needed abduction bar in Ponseti treatment
50-70 degrees of affected foot, externally rotated
30-40 degrees of unaffected foot
When do you perform a achilles tenotomy in clubfoot patients
If not able to dorsiflex the foot 15-20 degrees
What structural features causes equinus to be improved in clubfoot patients,
- once foot is abducted 60-70 degrees, because of kinetic coupling sometimes the equinus is improved a lot
— this is because the anterior portion of the calcaneus is dorsiflexed as it swings under the talus with manipulations
Post casting and Achilles tenotmy what is the angle foot orthosis protocol
Patient will wear an ankle foot orthosis with abduction bar at 70 degrees of abduction for 2-4 years
If patient has a unilateral clubfoot, how much abduction on the orthosis bar is there
45 degrees
What is the treatment for forefoot adductus in clubfoot relapse
Tib anterior tendon transfer
What is the tib anterior attached to in a tendon transfer
Cuboid or lateral cuneiform
How do you treat equinus in recurrent clubfoot
- open Achilles tendon lengthening with posterior ankle joint capsulotomy if needed
- z lengthening of Achilles tendon
- V-Y lengthening of Achilles at musculo tendinoud junction
- transverse ankle joint and subtalar capsulotomy
What are the common surgical goals in club football surgery
- posterior release
- medial release
- plantar release
- lateral release
- ‘fixation
- soft tissue repair
What are the pos op care for kite method for club foot
- cast for 6 weeks
- therapy dependent on age
- less than 6 months = manipulative
- greater than 2 years = ambulatory assistance
- night splints until 4-7 years
What is the best consistent long-term outcome result for clubfoot
Ponseti method
What are the two minor surgical procedures which in resolution of clubfoot
- percutaneous TAL
- Percutaneous tibialis anterior tendon transfer for recalcitrant cases
How to treat mature clubfoot
- start Ponseti casting therapy ASAP post partum
- Ponseti reductions possible up to age 7
How do you treat neglected or recurrent clubfoot
- talectomy
- triple arthrodesis
- pan-talar arthrodesis
