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  2. 2.  Children with physical disabilities are often socially and economically disadvantaged Importance of Clubfoot – easily diagnosed -easily treated
  3. 3.  CTEV – congenital talipes equino-varusTalipes - The term talipes is derived from a contraction of the Latin words for ankle, talus, and foot, pes. The term refers to the gait of severely affected patients, who walked on their ankles
  4. 4. Definition Club foot is a congenital deformity of the foot and ankle characterized by equinus deformity at the ankle, inversion at the subtalar ,adduction at the midtarsal joint,cavus and internal tibial torsion
  5. 5. INCIDENCE About 1 in 1000 live births Most cases sporadic Sometimes Autosomal dominant trait with incomplete penetrance
  6. 6.  More common in boys than girls 50 % cases are bilateral In unilateral cases right side is more often involved
  7. 7. Types According To Cause 1) Idiopathic 2) Secondary 3) Postural / Positional
  8. 8. Idiopathic Diagnosed when child has normal upper and lower extremities spine and neurological status apart from club foot Can be detected by USG by 16 wks gestation Combination of genetic and environmental factors are involved
  9. 9. Theories regarding cause Primary germ plasm defect of talus Contractile myofibroblastic tissue in the musculotendinous units
  10. 10. Secondary Clubfoot Diagnosed when deformity forms part of another health condition a) Neuropathic – deformity in association with neurological abnormalities or spina bifida b) Syndromic – clubfoot in association with other syndromes
  11. 11. Congenital Talipes Equino-Varus CTEV Spina Bifida = Paralytic TEV
  12. 12. Syndromes Producing CTEV Streetersdysplasia Arthrogryposis Edwards syndrome – trisomy 18
  13. 13. Postural Due to abnormal intrauterine position Easily corrected by massage by mother or by 1 or 2 casts
  14. 14. Types of Clubfoot According to Treatment Stage Untreated Treated Resistant Recurrent Neglected Complex
  15. 15.  Untreated – affected child is under 2 yrs of age and had no or very little treatment Treated– affected childs feet have corrected with ponseti mehod and they have completed the casting phase
  16. 16.  Resistant– child has previously untreated clubfoot and that does not correct with Ponseti method. This is usually syndromic and surgery may be necessary
  17. 17.  Recurrent clubfoot – children who show signs of deformity in previously treated clubfoot supination of foot – tib ant hindfoot equinus – tendoachilles usually due to failure to wear FAO treated by casting or surgery
  18. 18.  Neglected clubfoot – child older than two years who had little or no treatment usually severe soft tissue contractures and bony deformities Ponseti treatment has some success but many require surgery
  19. 19.  Complex clubfoot – clubfoot treated by any method other than ponseti technique - complicated by additional pathology or scarring
  20. 20. Pathological Changes Fourbasic components are midfoot Cavus (tight intrinsics, FHL, FDL)
  21. 21.  forefoot Adductus (tight tibialis posterior)
  22. 22.  hindfoot Varus (tight tendoachilles, tibialis posterior)
  23. 23.  hindfoot Equinus (tight tendoachilles )
  24. 24.  The ankle, subtalar and midtarsal joints are involved The severity of deformity varies and is graded by the pirani score
  25. 25. McKay’s Description of Pathological Anatomy calcaneus rotates horizontally and the tuberosity moves towards the lat malleolus The taolonavicular joint is in extreme inversion Cuboid is displaced medially on the calcaneus
  26. 26. Congenital Talipes Equino-Varus CTEV
  27. 27.  Associated findings- hypotrophic anterior tibial artery -atrophy of muscles around the calf -abnormal foot is smaller
  28. 28. Soft Tissue Abnormalities Talocalcaneal (subtalar) joint realignment is opposed by- - calcaneo fibular ligament - peroneal tendon sheath - posterior talo calcaneal ligament
  29. 29.  Talonavicular joint realignment is opposed by- posterior tibial tendon - deltoid ligament - spring ligament - joint capsule - dorsal talonavicular ligament - bifurcated Y ligamant
  30. 30.  Calcaneocuboid joint realignment is opposed by-bifurcated Y ligament - long plantar ligament - plantar calcaneo cuboid ligament
  31. 31.  If the deformity is left untreated late adaptive changes occur in the bones. These depend on the severity of soft tissue contracture and effect of walking
  32. 32. Radiological Evaluation Talocalcaneal angle - Anteroposterior view: 30-55 degrees
  33. 33.  Talocalcaneal angle - Dorsiflexion lateral view: 25-50 degrees
  34. 34.  Tibiocalcaneal angle Stress lateral view: 60-90 degrees
  35. 35.  Talus–firstmetatarsal angle Anteroposterior view: 5-15 degrees
  36. 36. Treatment Non operative – Ponseti technique Kite technique French technique Surgical–Posteromedial soft tissue release Osteotomies Triple arthrodesis Achilles tendon lengthening Ilizarov / JESS
  37. 37. Ponseti technique Weekly Serial manipulation and casting (long leg cast) goal is to rotate foot lateraly around a fixed talus order of correction (cave)  midfoot cavus  forefoot adductus  hindfoot varus  hindfoot equinus (TAL)
  38. 38.  After the last cast TA lengthening FAB for 23 hrs a day for 3 months and night splint till 2-3 yrs of age Chance of recurrence up to 4 or 5 yrs of age
  39. 39. Kite’s technique Foot manipulated with calcaneo cuboid joint as fulcrum Casting done after manipulation After correction Denis Browne splint applied
  40. 40. French Technique Daily manipulation by physical therapist for 30 mts Electrical stimulation of peroneal muscles done Reduction maintained by adhesive taping
  41. 41. PMR Done at age 1 yr Tight structures in posterior and medial aspect of the foot is released or lengthened
  42. 42.  Osteotomies – for residual hind foot varus Triple arthrodesis – in children more than 12 yrs old TA lengthening – for residual equinus
  43. 43.  Ilizarovand JESS are for older children with recurrence or residual deformity
  44. 44. THANK YOU