Sushil seminar ctev


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Sushil seminar ctev

  1. 1. CTEV : PaThoanaTomy and managEmEnTdR. SUShIL PaUdELdR. PRaTyUShdR. Shah aLam Khan
  2. 2. DefinitionDevelopmental deformation of foot Rotational subluxation of talocalcaneonavicular joint complex with talus in plantar flexion & subtalar complex in medial rotation & inversionClinically characterized by  Equinus & varus of heel  Forefoot adduction  Midfoot supination
  3. 3. Classification (Attenborough 1966) Type Type I(Extrinsic) II(Intrinsic) Non Rigid RigidFoot size Normal SmallerHeel Normal size Small, elevated Can be brought Cannot be brought down with ease down with ease Minimal varus Marked varusCreases More or less normal Deep medial, posterior and lateral creases Reduced creases laterally
  4. 4. Definitions in clubfootRigid or resistant atypical clubfoot : Stiff, short,chubby with a deep crease in sole of foot and behind ankle, shortening of the first metatarsal with hyperextension of the metatarsal phalangeal joint; occurs in otherwise normal infantSyndromic clubfoot: The clubfoot part of a syndromeTeratologic clubfoot – such as congenital tarsal synchondrosisNeurogenic clubfoot – associated with a neurological disorder such as meningomyelocele
  5. 5. EpidemiologyCommonest congenital orthopaedic abnormality1.3:1000 live birthsMales>Females – 2:130-50% bilateralMuch more common in Polynesian & Maori & lower in Asians
  6. 6. Pathogenesis Unknown at this stage Gray et al (1981) : increase in % of type I fibres in soleus muscle; suggested defective neural influence Recent study*: no evidence of type I fiber grouping 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# Primary germ plasm defect in the talus: continued plantar flexion and inversion of this bone, with subsequent soft-tissue changes in the joints and musculotendinous complexes *Sodre H et al. J Pediatr Orthop. 1990;10:101-4. **Muir L et al. J Bone Joint Surg Br. 1995;77:114-6 # Milan B MD et al. Journal of Pediatric Orthopedics. 26(1):91-93, 2006 .
  7. 7.  Wynne-Davies : polygenic inheritance Multifactorial inheritance established by genetic epidemiologic research by Idelberger 32.5% concordance rate among monozygotic twins as compared to 2.9% among dizygotic twins Major gene effect (inherited in recessive manner) with additional polygenes and environmental factors Tachdjian Patient with CTEV that has one child affected then 25% chance of another affected If both parents are normal & have affected child then chance of another is 5% Idelberger K. et al 1939; 33:272–276
  8. 8. Intrauterine factorsPressure theories:  Oligohydramnios  Abnormal fetal positioningPlacental insufficiencyConstriction bandsToxins ( Maternal alcoholism, smoking)Maternal illness ( anemia, thyroid disorders )Infective pathogens (enteroviruses)Drugs (abortifacients, salicylates, barbiturates)Electromagnetic radiation
  9. 9. Bony abnormalities Talus:  Head & neck deviated medially & plantarward  Body rotated externally in the ankle mortise  Body extruded anteriorly  Smaller than normal
  10. 10. Navicular:  Medially displaced  Close to medial malleolus  Articulates with medial surface of head of talusCalcaneus  Anterior portion lies beneath the head of talus causin gvarus and equinus of heel  In equinus  Rotated medially
  11. 11. Cuboid  Displaced medially on the dysmorphic distal end of the calcaneusTalonavicular joint  In inversion
  12. 12. Tibio-talar plantar flexionMedially displaced navicular Adducted and inverted calcaneus Medially displaced cuboid
  13. 13. Soft tissue changes Posterior structures : Tendo achilles Post. capsule of ankle joint & subtalar joint Post. talo fibular Calcaneo-fibular ligaments
  14. 14.  Medial : Tibialis posterior FHL,FDL, Master Knot of Henry Talonavicular ligament Calcaneo-navicular ligament Deltoid ligament Interossseus talo calcaneal ligaments Capsules of naviculo cuneiform & cuneiform first metatarsal
  15. 15. Plantar wards :  Plantar fascia  Plantar ligaments  Flexor digitorum brevis & abductor hallucis Laterally  Calcaneofibular ligament  Bifurcated ligament  Calcaneocuboid joint capsule
  16. 16. Clinical features 1. Deformity  Heel equinus  Heel varus  Midfoot supination  Forefoot adduction  Maybe cavus
  17. 17.  2. Features 3. General  Curved lateral border of foot  Calf atrophy  Devil’s thumbprint over the  Calf shortening lateral malleolus  Restricted ankle motion  Medial & Lateral skin creases  Navicular fixed to medial  Other Conditions should be malleolus excluded  Os calcis fixed to the lateral  Spinal Dysraphism malleolus  Arthrogryposis  Heel small & high  Neuromuscular Disorders
  18. 18. RadiologyPlain radiograph: Can be assessed prior to treatment with A-P & Lateral of footFoot held in position of best correction, with weight- bearing, or simulated weight-bearing AP view: Taken with foot in 30° of plantar flexion and tube at 30° from verticalLat. View: Transmalleolar with the fibula overlapping the posterior half of the tibia; foot in 30° of plantar flexion
  19. 19. Anteroposterior viewTalocalcaneal angleCalcaneal-second metatarsal angleTalus –first metatarsal angle
  20. 20. AP radiograph: Talo-Calcaneal angle  Lines drawn through center of the long axis of talus (parallel to medial border) and through the long axis of calcaneum (parallel to lateral border), and they usually subtend an angle of 25-40°.  Any angle less than 20° considered abnormal
  21. 21. Lateral view Talocalcaneal view Calcaneal-first metatarsal view Tibiocalcaneal Tibiotalar angle Talus-first metatarsal angle Talocalcaneal index (Kites angles from AP and Lateral views added)
  22. 22. Pirani’s severity scoringSix parameters : 3 of midfoot and 3 of hindfootEach parameter is given a value as follows: 0: normal 0.5: moderately abnormal 1: severely abnormalPirani s et al. A method of evaluating virgin clubfoot with substantial interobserver reliability. Annual meeting of Pediatric orthopaedic society of North America 1995
  23. 23. Mid foot score Curved lateral border [A] Medial crease [B] Talar head coverage [C]
  24. 24. Hind foot scorePosterior crease [D]Rigid equinus [E]Empty heel [F]
  25. 25. 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
  26. 26. International Clubfoot Study Group ScoreIntroduced by Henri 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.
  27. 27. Morphological parameters
  28. 28. Functional parameters
  29. 29. Radiological parameters
  30. 30. Classification of clubfoot severity by Diméglio A.Equinusdeviation B. Varus deviation C. Derotation D. Adduction.
  31. 31. Reducibility( deg Score Additional Scorerees) parameters90-45 4 Marked posterior 1 crease45-20 3 Marked 1 mediotarsal crease20-0 2 Cavus 10 t0 -20 1 Poor muscle 1 condition
  32. 32. Grade Type Score Reducibilityi Benign 1-4 >90%ii Moderate 5-9 >50%, soft-stiff, reducible, partially resistantiii Severe 10-14 >50%, stiff-soft, resistant, partially reducibleiv Very severe 15-20 <10% stiff- stiff,resistant
  33. 33. Aims of treatmentAfter sucessful treatment foot should  Look good  Feel good  Move good  Measure good
  34. 34. Ponseti cast correction
  35. 35. Outline of Ponseti regimenSerial casting of lower limb using a strictly defined technique and weekly change of castsPercutaneous tenotomy of tendo achilles for “hind foot stall”Once foot corrected, an abduction foot orthosis worn full time for 12 weeks, and then at nights and naps, up to age of four
  36. 36. Manipulation and cast application 1.ManipulationManipulation: start as soon after birth as possibleSetup for casting includes calming the child with a bottle or breast feeding Assistant holds the foot while the manipulator performs the correction
  37. 37. Tarsal joints functionally interdependentMovement of each tarsal bone involves simultaneous shifts in the adjacent bonesNecessiates SIMULTANEOUS correction of adduction, varus and inversion.
  38. 38. 2. Correction of cavus Cavus results from pronation of the forefoot in relation to hindfoot “ THE PRONATION TWIST “ Attempting to correct the supination of hindfoot before correction of varus results in an iatrogenic increase in cavus Corrected by supinating the forefoot to place it in proper alignment with the hindfoot.
  39. 39. Cast applicationManipulation Padding
  40. 40. Plaster at toes Below knee pop
  41. 41. Molding Extension upto the thigh
  42. 42. Plantar support to toes Final appearance
  43. 43. Casts and foot Adequate abduction Best sign of sufficient abduction: ability to palpate the anterior process of the calcaneus as it abducts out from beneath talus Abduction of approx.70 degrees in relationship to the frontal plane of the tibia possible
  44. 44. Complications of castingTight castRocker bottom deformityCrowded toesFlat heel padSuperficial soresDeep soresPressure soresInjury to distal tibial physis
  45. 45. Common errors(Kite errors) No manipulation Pronation/eversion of 1st metatarsal Premature dorsiflexion of heel Counterpressure at calcaneocuboid joint External rotation Below knee casts Short splints
  46. 46. Rocker bottom deformityDorsiflexion via midfoot before correction of hindfoot varusDorsal dislocation of navicular on talusFixed equinus of calcaneus
  47. 47. Correction of equinus and tenotomy No direct attempt at equinus correction is made until heel varus is corrected Equinus deformity gradually improves with correction of adductus and varus- calcaneus dorsiflexes as it abducts under talus Residual equinus- manipulation and casting +/- percutaneous tenotomyTenotomy : Indicated to correct equinus when cavus, adductus, and varus fully corrected but ankle dorsiflexion remains less than 10 degrees above neutral
  48. 48. 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 Cast with the foot abducted 60 to 70 degrees with respect to the frontal plane of the ankle, and 15 degrees dorsiflexion for 3 weeks
  49. 49. Foot Abduction bracesShoes mounted to bar in position of 70° of ER and 15° of dorsiflexion in B/L cases and incase of U/L cases 30 to 40° of ER in normal side, distance between shoes set at about 1˝ wider than width of shoulders Knees left free, so the child can kick them “straight” to stretch gastrosoleus tendon
  50. 50. Bracing protocolWorn 24 hours each day for first 3 monthsFor 12 hours at night and 2 to 4 hours in middle of day for a total of 14 to 16 hours during each 24-hour periodContinued until the child is 3 to 4 years of age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
  51. 51. Mitchell brace Dobbs dynamic brace
  52. 52. Dennis brown Romanus
  53. 53. CTEV Splint Straight inner border to prevent forefoot adduction Outer shoe raise to prevent fooot inversion No heel to prevent equinus Slight(1/8”) lateral sole raise Inner iron bar Outer t trap Walking age to 5 yrs of age
  54. 54. Results of Ponseti method 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Results 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 same Radiographs showed :feet not completely corrected, but functioned well despite thisCooper DM, Dietz FR. J Bone Joint Surg [Am] 1995;77-A:1477-89.
  55. 55. Results of Ponseti’s method..Study from Iowa (2004) : 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%. 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.
  56. 56. Khan et al Evaluated results of Ponsetis method in 21 children (25 feet) with neglected club feet Underwent percutaneous tenotomy of Achilles tendon Mean age at the time of treatment 8.9 years Mean follow-up period 4.7 years Average Dimeglio score at start of treatment 14.2 compared with an average score of 0.95 at the end of treatment at 1-year follow-up 18 feet (85.7%) full correction, recurrence in 6 feet (24%) At 4-year follow-up, average Dimeglio score for 19 feet 0.18. Recommend Ponsetis method as initial treatment modality for neglected clubfeetJ Pediatr Orthop B.2010 Sep;19(5):385-9.Ponsetis manipulation in neglected clubfoot in children more than 7 years of age: a prospective evaluation of 25 feet with long-term follow-up. Khan SA, Kumar A
  57. 57. Modifications of Ponseti’s method Accelerated Ponseti 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 groupMorcuende JA, Abbasi D, Dolan LA, Ponseti IV. Results of an accelerated Ponseti protocol for clubfoot. J Pediatr Orthop 2005;25:623-6
  58. 58. Kite methodBelieved heel varus would correct simply by everting calcaneusDid not realize calcaneus can evert only when it is abducted (i.e., laterally rotated) under the talusEach component corrected separately ( adduction, heel varus and equinus)Forefoot overcorrected into mild flatfootCalcaneus rolled out of inversion by placing plantar surface of a slipper cast on glass plate to flatten the soleDorsiflexion of foot with wedging casts
  59. 59. 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.
  60. 60. Atypical clubfoot2-3% Feet highly resistant to correctionSevere plantarflexion of all metatarsals, a deep crease just above heel and across the sole of the midfoot , short hyperextended big toe, fibrotic musclesTreatment by manipulation and Ponseti method
  61. 61.  When manipulating,index finger should rest over posterior aspect of lateral malleolus while thumb of same hand applies counter pressure over the lateral aspect of the talar head Do not abduct more than 30 degrees After 30 degrees abduction is achieved, change emphasis to correction of the cavus and equinus. All metatarsals are extended simultaneously with both thumbs Above-knee cast in 110 degrees flexion
  62. 62. 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
  63. 63. Surgery in clubfootResistant clubfoot( non-responsive to serial casting and manipulation)Persistently deformed clubfoot(non-operative correction inadequately done with/without compliant bracing)Relapsed clubfoot( initially satisfactorily corrected that recurs in part or whole)Neglected clubfoot( no treatment given till age of 2 yrs)
  64. 64. General PrinciplesGoal: address all pathoantomic structuresDecision regarding timing, extentIndex surgery, the most important“A la carte" approach [Bensahel]Turco’s ‘one size fits all’ approachPosteromedial-plantar-lateral release: all deformities presentPosterior release: straight lateral border, flexible forefoot and hindfoot, and palpable gap between medial malleolus and navicular tuberosity
  65. 65. ApproachesTurco Cincinnati
  66. 66. Caroll’s two incision techniqueMedial incision - straight oblique incision Straight lateral incision along the lateralfrom first metatarsal, across tmedial subtalar joint antr to distal fibulamalleolus to Achilles tendon
  67. 67. Extensile posteromedial and posterolateral releaseModified McKay procedureCincinnati incisionPosterolateral release Z lengthening of the TA Posterior capsulotomy of Ankle joint &Subtalar joint
  68. 68.  Incise superior peroneal retinaculum Cut off calcaneofibular and talofibular ligament Incise talocalcaneal ligament and lateral capsule of talocalcaneal joint EDB, inferior extensor retinaculum and dorsal calcaneocuboid ligamner cut incase of severe clubfoot
  69. 69. Medial release Dissect and protect N-V bundle Master knot of Henry Z-lengthening of the Tibialis Posterior & release of sheath Follow to navicular insertion Capsule of T-N joint released
  70. 70. Medial tibial navicular ligament, dorsal talonavicular ligamnet, and plantar calcaneonavicular ligament cutCapsule of T-N cut all the way around
  71. 71.  Bifurcated ligament cut Complete release of talocalcaneal joint ligaments except interosseous ligaments Detach origin of quadratus plantae muscle from calcaneus Roll talus back into ankle koint, if not incise post. talofibular ligament, post. Portion of deep deltoid ligament
  72. 72. Line up medial side of head and neck of talus with medial side of cuneiforms, medially push calcaneus post. to ankle jointK wire through talonavicular ,talocalcaneal joints
  73. 73. Check for proper position of footLongitudinal plane of foot 85-90° to bimalleolar ankle plane, heel under tibia in slight valgusSuture all tendons with foot in 20° dorsiflexionWound closure
  74. 74. 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
  75. 75. Residual deformitiesResidual hindfoot equinus : Achilles tendon lengthening and posterior capsulotomy of ankle and subtalar jointsDynamic metatarsus adductus : Transfer of anterior tibial tendon, either as split transfer or entire tendon
  76. 76. Resistant clubfoot Metatarsus adductus : >5 yrs metatarsal osteototomy Hindfoor varus : <2-3 yrs modified Mckay procedure 3- 10 yrs Dwyer osteotomy ( isolated heel varus) Dilwyn Evans procedure (short medial column) Lichtblau procedure( long lateral column) 10-12 yrs triple arthrodesis Equinus : Achilles tendon lengthening and posterior capsulotomy of subtalar joint, ankle joint / Lambrinudi procedure All three deformities >10 yrs triple arthrodesis
  77. 77. Neglected clubfootNo / incomplete initial treatment till the age of 2 yearsModerately flexible, moderately stiff, and rigidModified Ponseti*: manipulation for 5-10 mins, two weekly cast change, correction of foot to 30-40° abduction, and AFO for 1 yearExtensive soft tissue release upto 4 yrsDilwyn-Evans, Lichtblau procedureTriple arthrodesisIlizarov/ JESS Lourenco et al . Correction of neglected club foot by ponseti method. JBJS Br. 2007
  78. 78. Bony procedures Dwyer osteotomyOsteotomy of calcaneusOpening wedge medial osteotomy to increase the length and height of calcaneusFor isolated heel varusModified method uses lateral incisions
  79. 79. Litchblau procedureMedial soft tissue releaseLateral closing wedge osteotomy of calcaneusPrevents long term stiffness of hindfootShortens the lateral column
  80. 80. Dilwyn Evans OsteotomyPosteromedial releaseCalcaneocuboid wedge resection and arthrodesis of the jointShortens lateral columnStiffness at subtalar and midfoot jointsPreferred in older children (4-8 yrs)
  81. 81. Salvage proceduresTriple 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Lateral closing wedge osteotomy through subtalar and midtarsal joints
  82. 82. Triple arthrodesisDunn arthrodesis Hoke and kite
  83. 83. TalectomySevere, untreated clubfootPreviously treated clubfoot that is uncorrectable by any other surgical proceduresResistant neuromuscular or syndromic clubfoot
  84. 84. Ilizarov Correction slow enough to protect soft tissue Correction at the focus of deformity Simultaneous three- dimensional, multilevel correction Deformity correction without shortening the foot
  85. 85. 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
  86. 86. JOSHI EXTERNAL STABILISATION SYSTEMDR.B.B. JOSHI, MUMBAI2 to 4 transfixing wires in prox tibiaMetatarsal Transfixing wire through I &V MT; Medial half pin through I, II, III MT; Lat half pin thro’ IV, V MT2 transfixing and 1 axial wire through calcaneum
  87. 87. JESSFractional, differential distraction used to Sequentially correct deformities (Medial- 0.25 mm every 6 hours ,Lateral- 0.25 mm every 12 hours)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
  88. 88. 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
  89. 89. Complications of surgery Neurovascular injury Loss of foot (10% have atrophic dorsalis pedis artery bundle) Skin dehiscence Wound infection AVN talus Dislocation of the navicular Flattening and breaking of the talar head Undercorrection/ Overcorrection (esp with Cincinatti) Forefoot adductus Hindfoot varus Severe scarring Stiff joints Weakness of the plantar flexors of the ankle
  90. 90. ConclusionProper understanding of the patho-anatomy a mustPonseti method is now the standard treatment methodIndications of surgery limited but well definedTurco’s posteromedial soft tissue release remains the treatment of choice in most cases amenable to surgical treatment
  91. 91. THANK YOU