Congenital Talipes Equino Varus

1. Congenital Talipes Equino Varus Dr. Mohammad Imran Khan 04/01/2011

2. CTEV 1 in 1000 live births. Bilateral in 50%. Cause (several theories) Primary germ plasm defect in the talus cause continued plamter flexion and inversion followed by soft tissue changes. Soft tissue abnormatilies are primary.

3. CTEV is composed of; Forefoot adduction. Heel varus. Ankle equinus Midfoot cavus. Intrernal tibial torsion

4. Pathoanatomy Very important to understand TURCO in early 1970’s Medial displacement of calcaneus and navicular around the talus. Talus goes into equinus while its head and neck deviated medially. Calcaneus is inverted under the talus.

5. McKay Gave awareness of three dimential aspect of bony deformity. Abnormal relation of calcaneus to talus in all three planes. CALCANEUM Rotates horizontally – tuberiosity moves towards fibular malleolus. Heel goes into varus in coronal plane.

6. B. TALONAVICULAR JOINT Goes into extreme inversion. Navicular displaces on the talus. Cuboid displaces on the calcaneum. C. Soft tissue contracture follows apposing correction of various joints. D. BONY CHANGES

7. Radiological Evaluation Part of clinical evaluation. Done before, during and after treatment. Non-ambulatory child AP & stress dorsiflexion lateral views. Ambulatory child Standing AP & lateral views

8. Radiological Evaluation Important angles are On AP view Talocalcaneal angle Talus-first metatarsal angle On lateral view Talocalcaneal angle Tibiocalcaneal angle

9. Talocalcaneal angle on AP view Normal is 30-55 Decreases in clubfoot due to calcaneal rotation in horizontal plane.

10. Talus-first metatarsal angle on AP view Normal is 5-15 Decreases in clubfoot due to forefoot adduction

11. Talocalcaneal angle on lateral view Taken in dorsiflexion Normal is 25-50 Decreases to 0 in clubfoot as cacaneum and talus become parallel.

12. Tibiocalcaneal angle on lateral view Normal is 10-40 In clubfoot it becomes negative due to heel equinus.

13. Classifications Currently in use Pirani classification. Diméglio Others classifications are Harrold and Walker Somppii

14. Pirani’s Classification

15. Diméglio Classification

18. Harrold & Walker Classification Mild Moderate Fixed varus or equinus < 20 degrees Severe Fixed varus or equinus > 20 degrees.

19. Non-operative treatment Kite method: Weekly MUA & casting for first 6 weeks of life. Fortnightly MUA & casting until foot is clinically & radiologically corrected. Correction done in the order of forefoot reduction, heel varus & ankle equinus. Rocker Bottom foot (success rate 15-80% reported)

20. Ponseti Technique Consists of treatment phase and maintenance phase. TREATMENT PHASE: Should begin early. Gentle MUA & casting on weekly basis. Six casts required. 70% require TAL in the last cast.

21. First Cast Corrects cavus by aligning forefoot and hind foot. Supinating the forefoot and elevating the first metatarsal. Long leg cast applied (toe to groin).

22. Second Cast Gradual abduction. Maintain supination. Never manipulate the heel directly which is the most common mistake, as also seen in Kite method.

23. 3rd, 4th & 5th Casts Gradual correction continued with even more gradual correction of pronation. Final Cast Maximum abduction – 70 degrees. 15 degrees dorsiflexion. TAL usually done to avoid Rocker Bottom deformity.

26. Maintenance Phase Foot placed in food abduction orthosis (FAO). Worn 23 hours a day for 3 months and then for 2-3 years while asleep.

28. Operative Treatment Depends on Age. Severity Deformity to be corrected. Mild with no rotational deformity of calcaneum – TURCO’s PMR. Mild with severe rotational deformity – modified McKay procedure through a single Cincinnati incision or 2 incisions of Carroll.

29. Severe deformities – Modified McKay procedure. Studies show better results of modified McKay procedure than TURCO’s procedure for severe deformities.

30. Cincinnati Incision

31. RESISTANT CLUBFOOT The appropriate procedures and combination of procedures depend on; The age of the child. The severity of the deformity The pathological processes involved. Common components of resistant clubfoot deformity are: Adduction or supination, or both, of the forefoot A short medial column or long lateral column of the foot Internal rotation and varus of the calcaneus Equinus.

32. Forefoot deformity: Dynamic deformity – tendon balancing procedure (split or complete transfer of tibialis anterior to middle cuneform). Rigid deformity (<5years): Multiple MTPJ capsulotomies. Rigid deformity (>5years): – Bony procedures like dome osteotomies of metatarsal bases and cuniform-cuboid osteotomy.

35. HINDFOOT <2-3 years: - modified McKay procedure 3-10 years: Its important to find out if hindfoot deformity is because of isolated heel varus, short medial column or long lateral column.    Dwyer osteotomy (isolated heel varus)  Dillwyn-Evans procedure (short medial column)  Lichtblau procedure (long lateral column)  10-12 years: triple arthrodesis 

38. Triple Arthrodesis

39. HEEL EQUINUS Achilles tendon lengthening plus posterior capsulotomy of subtalar joint, ankle joint (mild-to-moderate deformity) Lambrinudi procedure (severe deformity, skeletal immaturity)

40. Tendoachilles Lengthening

41. Lambrinudi Procedure

42. ALL THE THREE DEFORMITIES Triple arthrodesis in patients age > 10years

43. INTERNAL TIBIAL TORSION Occationally occur in resistant cases Rarely require tibial derotational osteotomies Foot deformity should be excluded before doing osteotomy on the tibia

44. HOWZZAT