Detailed description with recent advances

1. CONGENITAL TALIPES EQUINOVARUS

2. Definition
Developmental deformation of the foot characterized by
rotational subluxation of the talocalcaneonavicular joint
complex with Talus in plantar flexion and Subtalar complex
in medial rotation and inversion

3. Extrinsic (intrauterine) factors
Intrinsic (genetic) factors
Etiological factors

4. Multifactorial causation
Established by genetic epidemiologic research by Idelberger
32.5% concordance rate among monozygotic twins as
compared to 2.9% among dizygotic twins
genetic heritability of 80% .
Idelberger K. et al 1939; 33:272–276.

5. GENETIC FACTORS
A major gene effect (inherited in recessive manner) with
additional polygenes and environmental factors
complex segregation analyses of idiopathic clubfoot
populations. (de Andrade M ,1998)
 deletion on Chromosome 2 (2q31-33) related to the
CASP10 gene.
Heck AL et al. J Pediatr Orthop 2005;25:598-602

6. Extrinsic factors
(intrauterine environment)
Pressure theories:
Oligohydramnios
Abnormal fetal positioning
Unstrctched uterus
Placental insufficiency
Constriction bands
Toxins
Temperature
Infective pathogens (enteroviruses)
Drugs (including abortifacients)
Electromagnetic radiation

7. Pressure theory
Conclusively disproved by Wynne-Davies
concordance between dizygotic twins was identical to the
non-twin sibling rate
Dizygotic twins “crowded” into a single uterus did not
demonstrate a higher concordance with respect to non-twin
siblings.

8. Infective pathogens (enteroviruses)
Seasonal variation with significant increase in CTEV
incidence was seen in the winter (December–March ) in
some studies*
Infective pathogens exhibiting seasonal activity
postulated as potential causes
Conflicting evidence –Carney et al (2005)**
* Barker SL. J Pediatr Orthop B 2002; 11:129–133.
** Carney BT. J Pediatr Orthop 2005;25:351-2.

9. Toxins and electromagnetic
radiation
Maternal alcohol
consumption
(Halmesmaki et al. 1985)
Maternal smoking
(Alderman et al.)
Paternal smoking
(HONEIN M ,2000)
High-power radio
transmitters
The results are
preliminary, and further
work is required
Irgens LM, et al.Teratology 1998;
57:34.

10. Drugs:
Salicylate use in first
trimester
Prenatal exposure to
barbiturates.
Chung C et al. Hum Hered. 1969;19:321-42
Maternal disorders
Maternal anaemia
Maternal hyperemesis
Thyroid disorders
Byron-Scott R, et al. Paediatr Perinat Epidemiol
2005;19:227-37.

11. Neuromuscular theory
Gray et al (1981) : increase in % of type I fibres in the soleus
muscle; suggested defective neural influence.
Recent study**: no evidence of type I fiber grouping
** Milan B MD et al. Journal of Pediatric Orthopedics. 26(1):91-93, January/February
2006.

12. Vascular theory
hypoplasia or absence of the anterior tibial
artery in majority of CTEV patients*
absence of the dorsalis pedis pulse in the
parents of children with clubfoot**
*Sodre H et al. J Pediatr Orthop. 1990;10:101-4.
**Muir L et al. J Bone Joint Surg Br. 1995;77:114-6.

13. Generalized disorder of development of
the limb
 Lower limb in unilateral CTEV
- Redn in calf and thigh girth
- Significant shortening, most prominent
at ankle and least at femur
Shimode K, Myagi N, Majima T, Yasuda K, Minami A. J Pediatr Orthop [B] 2005;14:280-4.

14. Conditions associated with CTEV

15. THE BASIS OF PONSTEI’S METHOD
BIOLOGY OF CTEV

16. Pathoanatomy of soft tissues
1. The plantar calcaneonavicular
ligament.
2. The tibionavicular ligament
3. The superior, medial and plantar
parts of the talonavicular capsule
4. The posterior tibial tendon
5. The master knot of Henry
6. The calcaneofibular ligament
7. The superior
peroneal(calcaneofibular)
retinaculum
8. The posterior talocalcanel ligament
9. The posterior capsule of the
tibiotalarjoint
10. The tendo Achillis
11. The interosseous ligament
12. The long toe flexors

17. Micro architecture
increase of collagen fibers and
cells in the ligaments.
The bundles of collagen fibers
display a wavy appearance
known as crimp.
crimp allows the ligaments to be
stretched.
The crimp reappears a few days
later, allowing for further
stretching
TA : non-stretchable, thick,
tight collagen bundles with few
cells

18. Bony abnormalities
 The tarsal bones, which are mostly
made of cartilage, are in the most
extreme positions of flexion,
adduction, and inversion at birth
 The talus: severe plantar flexion, neck
medially and plantarly deflected, and
head wedge shaped.
 Navicular: severely medially displaced,
close to the medial malleolus, and
articulates with the medial surface of the
head of the talus.
 The Calcaneus adducted and inverted.
anterior portion of the Calcaneus lies
beneath the head of theTalus.

19. BIOMECHANICAL FACTORS
Tarsal joints are functionally interdependent. The
movement of each tarsal bone involves simultaneous shifts in
the adjacent bones.
No single axis of rotation
Necessiates SIMULTANEOUS correction of adduction,
varus and inversion.

20. Clinical features

21. A standardized examination initially and after each interval of
treatment
reference posn, usually the knee in 90° of flexion, chosen.
All deformities assessed in relation to the next most proximal
segment
Exmn of the entire child to look for associated anomalies, esp the
spine.

23. Foot shorter and wider than
normal.
Transverse plantar creases or
clefts at the midfoot and
posterior part of the ankle.
 Atrophy of the calf

24. Assessment of equinus
 posterior aspect of the calcaneus
must be palpated carefully when the
equinus is measured
Equinus assessed with the knee
both in extension and in flexion.
equinus with knee extended
-The true contractureof the
gastro-soleus muscle complex.
The difference between the
equinus in knee flex and extn
indicates the amount of stiffness
in the ankle joint.

25.  heel is in varus but the forefoot is well
aligned with the heel.There is no
supination of the forefoot on the
hindfoot.
The varus of the heel at rest
and in the position of best
correction
Posn of forefoot in relation
to midfoot
Palpation of the lateral
column with the foot in
dorsiflexion
Tibial torsion

26. Awkward gait

27. Congenital vs Acquired
CongenitalCongenital AcquiredAcquired
HistoryHistory Since birthSince birth Appears laterAppears later
BilateralBilateral In >50%In >50% Usually unilateralUsually unilateral
DeformityDeformity EquinovarusEquinovarus
Forefoot adductionForefoot adduction
CavusCavus
EquinovarusEquinovarus
Congenital grooveCongenital groove PresentPresent Not presentNot present
HeelHeel SmallerSmaller Usually maintainsUsually maintains
shapeshape
CalfCalf Cylindrical and toughCylindrical and tough NormalNormal

28. Classification Systems
TypeType
I(Extrinsic)I(Extrinsic)
Non RigidNon Rigid
TypeType
II(Intrinsic)II(Intrinsic)
RigidRigid
Foot sizeFoot size NormalNormal SmallerSmaller
HeelHeel Normal sizeNormal size
Can be broughtCan be brought
down with easedown with ease
Minimal varusMinimal varus
Small , elevatedSmall , elevated
Cannot be broughtCannot be brought
down with easedown with ease
Marked varusMarked varus
CreasesCreases More or less normalMore or less normal Deep medial,Deep medial,
posterior and lateralposterior and lateral
creasescreases
Reduced creasesReduced creases
laterallylaterally
TelescopingTelescoping NegativeNegative PositivePositive

29. Differential diagnosis
Club foot like appearance in cong. absence or hypoplasia of
tibia and in cong. dislocation of ankle
Careful palpation of Anatomical relationship and Radiograph
will establish the diagnosis

30. IMAGING

31. Plain radiography

32. Limitations
1. Difficult to position the foot
2. The ossific nuclei do not represent the true shape
3. In the first year of life, only the talus, calcaneus, and
metatarsals may be ossified
4. Failure to hold the foot in the position of
best correction makes the foot look worse than it is

33. Plain radiograph
The foot should be held in the position of best correction,
with weight-bearing, or, if an infant is being examined, with
simulated weight-bearing
Focused on the hindfoot (about 30° from the vertical for AP
view)
Lat. View: transmalleolar with the fibula overlapping the
posterior half of the tibia

34. AP Radiograph
normalnormal CTEVCTEV
AP TaloAP Talo
calcanealcalcaneal
angleangle
20 -50 deg20 -50 deg <20 deg<20 deg
Tarsal-1Tarsal-1stst
MTMT
angleangle
Upto 30 degUpto 30 deg
valgusvalgus
VarusVarus
anglulationanglulation
cuboid os.cuboid os.
center w.r.tcenter w.r.t
calcaneal axiscalcaneal axis
medialmedial
displacementdisplacement

35. AP radiograph: Talo-Calcaneal angle
Normal foot: 20`-50` CTEV:<20 deg

36. AP Radiograph: convergence of base of
MT

37. Lateral radiograph
normalnormal CTEVCTEV
TaloTalo
calcanealcalcaneal
angleangle
25 to 5025 to 50
degdeg
<25 deg<25 deg
Tarsal-1Tarsal-1stst
MT angleMT angle
hyperflexiohyperflexio
nn

38. Lateral view: Talo-CalcanealLateral view: Talo-Calcaneal
angleangle
 Normal foot : 25`Normal foot : 25`
to 50`to 50`
 CTEV: <25 `CTEV: <25 `

39. Ultrasonogram

40. ANTENATAL DIAGNOSIS
Ideally done at 20 to 24 weeks
Recent reports*: positive predictive value of 83% with a
false positive rate of 17%.
26% no Rx reqd; 61% reqd Sx
* Baron E, Mashiach R, Inbar O, et al. J Bone Joint Surg [Br] 2005;87-B:990-3.

41. Research tool
1. Recent study: to describe the morphological changes in a
comparative study of treatment methods
2. Used for demonstrating complete healing of TA at 3 wks
foll. Percutaneous tenotomy

42. MRI

43. ROLE OF MRI
NOT used in routine clinical practice
Important tool in research studies

44. PIRANI’S MRI PROTOCOL
Sagittal images perpendicular to the bimalleolar axis
Oblique axial images perpendicular to the talonavicular joint
Oblique axial images perpendicular to the calcaneocuboid
joint
Oblique coronal images perpendicular to the subtalar joint

45. SAGITTAL IMAGES
Tibiotalar plantarflexion
Inferior talar neck inclination, and
Inferior talonavicular displacement

46. Oblique axial images perpendicular to the
talonavicular joint
medial talar neck
inclination,
 medial talonavicular
displacement,
 the wedge-shaped head of
the talus, and navicular

47. Oblique axial images perpendicular to the
calcaneocuboid joint
the wedge-shaped distal calcaneus
Medial calcaneocuboid displacement

48. Oblique coronal images perpendicular to the
subtalar joint
The inverted and adducted calcaneus
The abnormal facets of the subtalar joint

49. EVALUATION SYSTEMS

50. Pirani’s severity scoring
Six parameters 3 of midfoot and 3 of hindfoot taken into
account
Each parameter is given a value as foll:
0 normal
0.5 moderately
abnormal
1 severely
abnormal

51. Mid foot score
Curved lateral
border [A]
Medial crease [B]
Talar head coverage
[C]

52. Hind foot score
Posterior crease [D]
Rigid equinus [E]
Empty heel [F]

53. Uses of Pirani’s score
Assessment of progress by serial plotting of the score
Predicting need for tenotomy (hs>1& ms<1)
Estimation of probable no. of casts reqd*
very good interobserver reliability and reproducibility**
* J. Dyer et al Journal of Bone and Joint Surgery - British Volume, Vol 88-B, Issue 8, 1082-1084P.
** Flynn JM, Donohoe M, Mackenzie WG. J Pediatr Orthop 1999;18:323-7

54. International Clubfoot
Study Group (ICFSG)
score.

55. ICFSG
Introduced by Bensahel et al in 2003
Found to have good interobserver reliability and
reproducibility**
Morhological (12 pts), functional (24 pts) & radiological
(12 pts) parameters
Maximum of 60 for most deformed and 0 for normal feet
**Celebi L et al J Pediatr Orthop B. 2006;15:34-36.

56. MORPHOLOGICAL PARAMETERS

57. FUNCTIONAL PARAMETERS

58. RADIOLOGICAL PARAMETERS

59. Treatment

60. Aims of treatment
Strong, painless, plantigrade and supple foot by conservative
management
Plantigrade, painless foot that can wear shoes by surgical
means if conservative regimen fails

61. PONSETI’S METHOD
DR. IGNACIO PONSETI
Introduction of Ponseti’s
method and its wide spread
use over the last decade
following the publication of
long-term results has been
the most significant event in
the history of CTEV

62. Outline of Ponseti regimen
Serial casting of the lower limb using a strictly defined
technique and weekly change of casts
Percutaneous tenotomy of the tendo achilles for “hind
foot stall”
Once the foot is corrected, an abduction foot orthosis
worn full time for 12 weeks, and then at nights and naps,
up to the age of four.
Transfer of the tibialis anterior tendon for dynamic
supination deformity

63. Cavus correction
Cavus results from pronation of the forefoot in relation
to the hind­foot –“ THE PRONATION TWIST “
Attempting to correct the supination of hindfoot before
correction of varus results in an iatrogenic increase in
cavus
cavus corrected first by supinating the forefoot to place
it in proper alignment with the hindfoot.

65. Varus, inversion, and adduction
correction
varus, inversion, and adduction of the hindfoot are corrected
after correction of cavus
Correction of all three components done simultaneously
as the tarsal joints are in a strict mechanical interdependence

66. Stabilise the talus

67. abducting the foot in supination

70. Correction of equinus
No direct attempt at equinus correction is made until the
heel varus is corrected
The equinus deformity gradually improves with correction of
adductus and varus- calcaneus dorsiflexes as it abducts under
the talus
Residual equinus- manipulation and casting +/-
percutaneous tenotomy

71. Percutaneous TA tenotomy
Tenotomy of the tendo Achillis is an integral step in the Ponseti
technique
Tenotomy is indicated when HS > 1, MS < 1(Pirani’s hindfoot
and midfoot scores resp.), and the head of the talus is covered
The best sign of sufficient abduction is the ability to palpate the
anterior process of the calcaneus as it abducts out from beneath
the talus .

72. Percutaneous tenotomy under LA
* Foot held in max dorsiflexion by an assistant
* Tenotomy done 1.5 cm above calcaneal insertion
* additional 25-30 deg dorsiflexion obtained

73. POST TENOTOMY CAST WITH FOOT IN 60-
70 DEG ABDN

74. Complications of tenotomy
Healing of ruptured tendon:
. Barker et al* used USG studies to demonstrate complete
healing of TA BY 3 weeks
. Bleeding:
Dobbs MB et al ** reported a 2% incidence of serious
bleeding following tenotomy
* Barker SL et al. J Bone Joint Surg [Br] 2006;88-B:377-9.
** Dobbs MB et al. J Pediatr Orthop 2004;24:353-7.

75. Bracing protocol
Applied immediately after the last cast is removed, 3 weeks
after tenotomy
The brace consists of open toe high-top straight last shoes
attached to a bar

76. 5 to 10
deg

78. Bracing protocol
worn full time (day and night) for the first 3 months after the
last cast is removed.
After that, for 12 hours at night and 2 to 4 hours in the middle
of the day for a total of 14 to16 hours during each 24-hour
period.
continued until the child is 3 to 4 years of age.

79. Significance of bracing
Haft et al**: noncompliance with bracing protocol – the most
common cause of recurrence in children on Ponseti regimen
**Haft, Geoffrey F. MD; Walker, Cameron G. PhD;
Crawford,Haemish A. FRACS.J Bone Joint Surg Am, Volume 89-
A(3).March 1, 2007.487–493

80. Atypical clubfoot
2-3% Feet highly resistant to correction
Deep skin creases, rigid and severe deformities, fibrotic
muscles
60 deg supination in 1st
cast.
AK casts with knee in 120 deg flexn
Tenotomy after correction of hyperflexion of
metatarsals
Post tenotomy casts changed every5 days

81. Follow up protocol
 2 weeks: to troubleshoot compliance
issues.
 3 months: to graduate to the nights-and-
naps protocol.
 every 4 months: until age 3 years to monitor
compliance and check for relapses
 every 6 months: until age 4 years.
 every 1 to 2 years: until skeletal maturity

82. Examine the toddler walking
Look for supination
Look for heel varus

83. Treatment of relapse
Equinus relapse: corrective casting +/- percutaneous
tenotomy in child < 2 yrs;
TA lengthening in older children
Varus relapse: recasting and restitution of bracing

84. Dynamic supination deformity
 persistent varus and supination during walking
 thickening of lateral plantar skin.
 Will require anterior tibialis tendon transfer
 fixed deformity corrected by casts before
transfer.
 best performed when the child is between 3
and 5 years of age.
 delayed till radiographs show ossification of
lateral cuneiform.
 No bracing is necessary after the procedure.

85. Results of Ponseti’s method
 The key paper by Cooper and Dietz in 1995.
 reviewed a group of 45 adults, with 71 clubfeet, who had been managed with
the Ponseti method, 30 years after treatment.
 The results were compared with NORMAL CONTROLS.
 Based on structured examination, radiographs, electrogoniometry and
measurements using a pedobarography.
 Using the Laaveg and Ponseti score, the results in the normal controls and in
those with treated clubfeet were the same.
 Radiographs showed that the feet were not completely corrected, but
functioned well despite this.
Cooper DM, Dietz FR. J Bone Joint Surg [Am] 1995;77-A:1477-89.

86. Results of Ponseti’s method..
study from Iowa (2004) described the short-term results of a
more recent series of 256 feet.
Correction obtained in 98% with one to seven casts.
 2.5% required extensive corrective surgery.
Percutaneous tenotomy in 86%.
 The mean angle of dorsiflexion : 20° (0° to 35°).
 Minor cast complications in 8%
Rate of relapse: 10%.
Morcuende JA, Dolan LA, Dietz FR, Ponseti IV. Radical reduction in the rate of extensive correctivesurgery
for clubfoot using the Ponseti method. Pediatrics 2004;113:376-80.

87. OUTCOME AFTER CORRECTIVE SURGERY –
A STARK CONTRAST
Laaveg and Ponseti scores: 0% excellent, 33% good, 20% fair and
47% poor results.
significantly reduced scores in physical functioning, role physical,
general health, vitality, social functioning and physical components
similar to those with pain in the cervical spine with
radiculopathy,Parkinson‘s,haemodialysis, CHF and those awaiting
CABG
 Dobbs MB, Nunley R, Schoenecker PL. Long term follow up of patients with clubfeet treated with extensive soft-tissue release. J Bone
Joint Surg [Am] 2006;88-A:986- [on 73 feet in 45 patients after a minimum follow-up of 25 years ]

88. Ponseti regime Vs surgical correction
CT at skeletal maturity
manipulation and serial casting, followed by posteromedial release
for the resisting feet vs modified Ponseti regime [open z-
lengthening of TA]
Ponseti group: better correction of cavus, supination and
adduction
Ippolito et al. J Bone Joint Surg [Br] 2004;86-B:574-80

89. Ponseti Vs Kite technique
PonsetiPonseti KiteKite
Mean followMean follow
upup
(months)(months)
2929 5454
ResidualResidual
deformitydeformity
6%6% 44%44%
Need forNeed for
surgerysurgery
6%6% 57%57%
Segev E, Keret D, Lokiec F, et al. Early experience with the Ponseti method for the treatment of congenital
idiopathic clubfoot. Isr Med Assoc J 2005;7:307-10.

90. Modifications of Ponseti’s method
ACCELERATED PONSETI PROTOCOL
Morcuende et al , (2005) 7 day Vs 5 day interval
Average time to tenotomy: 16 days in 5 day group and
24 days in 7 day group
Morcuende JA, Abbasi D, Dolan LA, Ponseti IV. Results of an accelerated Ponseti protocol for clubfoot. J
Pediatr Orthop 2005;25:623-6

91. Botulinum toxin injection into the
gastrocsoleus
Alvarez et al (2005)*: alternative to Achilles tenotomy
producing satisfactory results with less skin scarring and deep
tissue fibrosis
prospective RCT(Cummings et al,2005)**:NO significant
difference between injections of a placebo or Botulinum
toxin.
* Alvarez CM, Tredwell SJ, Keenan SP, et al. J Pediatr Orthop 2005;25:229-35.
** Cummings RJ, Shanks DE. POSNA Annual Meeting,

92. Paramedical staff-delivered Ponseti
service
Good results can be achieved by trained physiotherapists and
orthopedic clinical officers
enables many families in rural and remote areas to receive
treatment which would otherwise have been inaccessible and
unaffordable.
Shack N, Eastwood DM.. J Bone Joint Surg [Br] 2006;88-B:1085-9.
Tindall AJ et al.J Pediatr Orthop 2005;25:627

93. Application in neglected club foot
Lourenco et al,2007: retrospective study on 17 children (24
feet) presenting after walking age (mean age 3.9 years)
Correction in 66.67% with ponseti’s method alone.
 A. F. Lourenço, MD et al. Journal of Bone and Joint Surgery - British Volume,2007. Vol 89-B, Issue 3, 378-
381.

94. The French method
Bensahel/Dimeglio regime
daily manipulations by a skilled physiotherapist and temporary
immobilisation with elastic and non-elastic adhesive taping
mobilisation during the hours of sleep with CPM machine
Successful in 51% of cases ( of which 9% req TA tenotomy) ; 49%
Reqd extensive soft tissue release -29% post release and 20%
comprehensive posteromedial release**.
** Richards BS, Johnston CE, Wilson H. Nonoperative clubfoot treatment using the French physical therapy
method. J Pediatr Orthop 2005;25:98-102.

95. Custom AFO’s
Manipulation and appln of
adjustable hinged orthosis
Dyanmic splinting
Correction reported in
76% of cases with mild to
severe CTEV **
**Adnan A.Faraj et al.Foot and Ankle Surgery.Volume 10,Issue 2,
2004,Pages 57-58

96. Dennis Browne splint
 The child’s ‘physiological motions’
are used to correct the deformity
 Application of corrective shoes
attached to a bar allowing
progressive external rotation of the
foot
 Constant kicking by the infant
stretches the contracted tissues
correcting the deformity
..

97. Surgical management of CTEV

98. INDICATIONS
RESISTANT CTEV
RELAPSE AND RESIDUAL DEFORMITY ESP. AFTER
PREVIOUS SURGERY
NEGLECTED CLUB FOOT

99. RELAPSED VS NEGLECTED CTEV
Relapsed CTEV
Initial correction done and
susequent deformity less
severe
Post surgical: extensive
scarring and stiff foot
Neglected CTEV
Deformity severe and
worsens as child starts
walking
Lateral skin callosities and
fissures- prone to infection

100. Surgical correction
2-4 years :
Soft tissue release
4 – 11 years :
Soft tissue release with
Osteotomy performed according to the deformities
>11 years :Salvage procedures:
Triple arthrodesis
Talectomy (astragalectomy)

101. SOFT TISSUE RELEASE

102. EXTENT OF RELEASE
"À LA CARTE" approach [Bensahel]
-Full posteromedial plantar lateral release only if All
components of deformity present
-postr release: persistent isolated equinus
Turco’s ‘one size fits all’ approach

103. TIMING OF SURGERY
3-6 months: high remodelling potential in 1st
yr of life
9-12 months: pathoanatomy clearer and surgery easier to
perform
Simons: size of foot >8 cm.

104. Incisions
 TURCO’S APPROACH
 hockey-stick posteromedial type of
incision
 Crosses the skin creases on the
medial side of the foot and ankle.
 more difficult to reach the
posterolateral structures, origin of
plantar fascia

105. Cincinnati approach
Circumferential incision
problems with the skin
edges.
limited exposure of the
Achilles tendon.

106. Caroll’s two incision technique
medial incision - straight
oblique incision from the
first metatarsal, across the
medial malleolus to the
Achilles tendon

107. A second short, straight
lateral incision made
along the lateral subtalar
joint antr to distal fibula

108. Medial Plantar Release
posterior and medial subtalar joint capsule (leaving the
interosseous ligaments intact),
 talonavicular joint capsulotomy (including the spring
ligament and bifurcate Y ligament),
medial calcaneocuboid joint capsulotomy,
knot of Henry,
the abductor hallucis,
lengthening of posterior tibial tendon
The plantar fascia, if cavus is present

109. Structures preserved
The dorsal structures-
tibialis anterior and
extensor tendons,
neurovascular bundle,
the deep deltoid ligament

110. Posterior release
release of the posterior capsule of the ankle and subtalar joint
open Achilles tendon lengthening.
The posterior talofibular ligament

111. Lateral release
lateral subtalar joint
capsule,
peroneal tendon
sheath, and
 calcaneofibular
ligament

112. Talonavicular joint fixn
The talonavicular joint,
often with the subtalar
joint, is routinely pinned
with a K-wire

113. Soft tissue release
Follow up :
Wound inspection done under sedation at 1 week
Foot held in neutral, plantigrade position and cast applied –
above knee
Cast kept for 4 – 6 weeks
Cast removed along with any K wires, if applied during surgery
for stabilisation
AFO given for 6 months

114. AFO

115. Osteotomies
Soft tissue release alone may not fully correct the deformity
because of secondary bony deformity.
The combination of this soft tissue release with midfoot
osteotomy is usually required in children between
approximately 4 and 12 years of age

116. Correction of Adductus
bony lateral column is longer than the medial column,
relative lengthening of the lateral portion of the anterior
process of the calcaneus
obliquity of the calcaneocuboid joint
Shortening through the distal calcaneus to make the
calcaneocuboid joint transverse.

117. Litchblau procedure
excision of the anterior
process of calcaneus
Calcaneocuboid
Pseudoarthrosis
Stiffness minimized
Preferred in younger
children

118. Dilwyn Evans Osteotomy
calcaneocuboid wedge resection
Arthrodesis of the joint
Reduced risk of relapse
Stiffness at subtalar and midfoot joints
Preferred in older children

119. TRANS-MIDTARSAL OSTEOTOMY
Köse et al., in 1999, described trans-midtarsal osteotomy
for>6yr olds
opening-wedge osteotomy of the medial cuneiform and
dorsal, truncated wedge osteotomies of the middle and
lateral cuneiforms
Better correction of rotational and cavus deformities

120. Correction of Equinus
adequacy of release of the lateral tether
lateral column shortening
excision of a portion of the head of the talus or
naviculectomy.
final resort is to consider adding a distal tibial dorsiflexion
osteotomy.

121. Correction of Calcaneal Varus
Calcaneal varus corrects as
the foot abducts after medial
soft tissue release.
Persistent calcaneal varus: a
lateral slide osteotomy of the
calcaneus is performed
 Alternative: Dwyer lateral
closing wedge osteotomy

122. Correction of CAVUS
Steindler’s release of plantar fascia
Japas ’V’ osteotomy
Patients >6 years
Rigid cavus
Allows midfoot correction without foot shortening
Akron midtarsal Osteotomy :
Correction at midfoot
A dome shaped osteotomy for dorsoplantar and varus / valgus control

123. Salvage procedures
TRIPLE ARTHRODESIS
Salvage procedure for pain after previous surgical correction.
Correction of large degrees of deformity in neglected
clubfeet.
Not performed before advanced skeletal maturity, at age 10
to 12.

125. TRIPLE ARTHRODESIS
 Modification of the classic
lambrinudi triple arthrodeses
 Resection through the talus should
be minimized because of its
tenuous blood supply and
 Most of the correction made
through the calcaneus.
 Recent study in Uganda: 92%
patients happy with the procedure

126. TRIPLE ARTHRODESIS
TWO STAGE :
extensive posteromedial
release + triple arthrodesis
minimizes bone rescection
risk of AVN talus
SINGLE STAGE
ARTHRODESIS:
 less time consuming
 reduced risk of AVN
Penny, John Norgrove 2005.Uganda

127. Ilizarov in CTEV

128. Ilizarov
1) Correction slow enough to protect soft tissues;
2) correction at the focus of deformity,
3) simultaneous three-dimensional, multilevel correction;
4) deformity correction without shortening the foot;

129. Ilizarov
Rings are fixed to the tibia connected to half rings for the
calcaneus and the forefoot.
Asymmetric distraction corrects the various deformities
bony deformity not severe,(<8 yr): unconstrained frame
Severe deformities,(>8 yrs): distraction osteogenesis
through osteotomies using constrained frame with hinges

130. The construct

131. Correction of adductus

132. Correction of Equinus

133. Results with Ilizarov
good to excellent results reported by various surgeons( Grill et
al, Huerta et al, Bradish et al, Heymann et al, Hosny et al) over
the last 15 years
Recent long term follow-up study**
by Hari et al (2007):74% good/excellent result
**Prem: J. pediatr. orthop., Volume 27(2).March 2007.220-224

134. DR.B.B. JOSHI, MUMBAI.
JOSHI EXTERNAL STABILISATION
SYSTEM

135. JESS
2 to 4 transfixing wires in
prox tibia
Metatarsal segt:
Transfixing wire thro’
I &V MT; Medial half pin
thro’I, II, III MT; Lat half pin
thro’ IV, V MT
2 transfixing and 1 axial wire
thro calcaneum

136. JESS
Fractional, differential distraction used to Sequentially
correct deformities.
Distraction continued until approximately 20 degrees of
dorsiflexion and overcorrection of the forefoot
deformities was achieved
maintained in this overcorrected position for twice as
long as the distraction phase by casts/braces

137. Results with JESS
Good or excellent results reported by Joshi in 84% of his
patients
Recommended in all who have not responded to serial
plaster casting methods.
Similar good results have been reported by other authors**
**Suresh et al,2003. Journal of Orthopaedic Surgery 2003: 11(2): 194–201

138. Advantages over Ilizarov
The wires are not tensioned
stability depends on the placement of the wires, the use of
half pins and pre-tensioning.
Hinges are not used in this method.Thus the corrective
forces are not directed along a single axis, instead, the soft
tissue envelope in conjunction with the shape of the
articulating surfaces guide the correction.
 frame is less bulky, is less expensive, and more simple to
apply

139. Complications of surgery
Wound infection
Skin dehiscence
Severe scarring
Stiff joints
Over/under correction
Dislocation of the navicular
Flattening and breaking of the talar head
AVN of the talus
Weakness of the plantar flexors of the ankle

140. Skin dehiscence
Cincinnati incision, neglected clubfeet
left in partly corrected posn in post op cast & remanipulation
done at 1 to 2 weeks .
Local rotation flap from the dorsum of the foot (Mittal,1987)
Posterior V-Y advancement flap.

141. Rotation flap
Flap taken superficial to
venous plexus
Large proximal base
ensures adequate blood
supply

142. conclusion
Proper understanding of the pathology and kinematics of
clubfoot, meticulous application of therapeutic methods,
laying stress on parental education to ensure compliance and
resorting to surgery only as the last resort, and is essential to
successful therapy of this complex condition