congenital talipes equino varus

1. CTEV
By Dr Praveen
Lisie hospital,kochi

2. INTRODUCTION
TALUS-ANKLE
PES-FOOT
EQUINO-LIKE A HORSE
VARUS- TURNED INWARDS

4. HISTORICAL ASPECTS
- EARLIEST EVIDENCE IN EGYPTIAN PERIOD.
- YAJURVEDA ADVISED TO MASSAGE TO
CORRECT DEFORMITY.
- HIPPOCRATES FIRST DESCRIBED CLUB FOOT.
- SCARPA(1803) FIRST DESCRIBED PATHOLOGIC
ANATOMY.

5. - KITE (1930) DESCRIBED NON OPERATIVE
TREATMENT WITH SEVERAL MANIPULATION
AND PLASTER CAST APPLICATION.
- DENNIS BROWN (1934) DEVISED SPLINT FOR
MAINTENANCE OF CLUBFOOT CORRECTION.
- IGNACIO PONSETI (1950) DEVELOPED
METHOD CORRECTION.

6. DEFINITION
CONGENITAL DYSPLASIA OF MUSCULOSKELETAL
TISSUES DISTAL TO KNEE JOINT IN THE FORM OF
DEFORMITY OF FOOT AND ANKLE.

7. Biology
• Clubfoot is not an embryonic malformation.
• Developmental deformation
• Rarely detected with USG before the 16th
week of gestation

9. • Excessive pull of the tibialis posterior abetted
by the gastrosoleus and the long toe flexors
• The ligaments of the posterior and medial
aspect of the ankle and tarsal joints are very
thick and taut

10. • Excessive collagen synthesis in the ligaments,
tendons, and muscles may persist until the
child is 3 or 4 years of age and might be a
cause of relapses.
• The bundles of collagen fibers display a wavy
appearance known as crimp.

11. Kinematics
• Talus: most deformed and least displaced.
Head & neck deviated medially & plantarward
Body rotated externally in the ankle mortise,
superior articular surface escapes from mortice.
Talar neck is short and medially deviated.
Smaller than normal, disturbance of vascular
supply, ossification centre eccentrically placed.

12. • Navicular:
Medially displaced
Close to medial malleolus
Articulates with medial surface of head of talus
• calcaneus is
– adducted and
– inverted under the talus

13. • Cuboid
Displaced medially on the dysmorphic distal end
of the calcaneus

14. Tibio-talar plantar flexion
Medially displaced navicular
Adducted and inverted
calcaneus
Medially displaced
cuboid

15. • Correction of the extreme medial
displacement and inversion of the tarsal
bones in the clubfoot necessitates a
simultaneous gradual lateral shift of the
navicular, cuboid, and calcaneus before they
can be everted into a neutral position

16. Lateral displacement (abduction) of the calcaneus will
correct the heel varus deformity of the clubfoot

17. The bones and joints
remodelling with
each cast change--
demonstrated by
Pirani

18. • The tendo Achillis, unlike the tarsal ligaments
that are stretchable, is made of
non-stretchable, thick, tight collagen bundles
with few cells.

19. • Most cases of clubfoot are corrected after five
to six cast changes and, in many cases, a
tendo Achillis tenotomy needed.

20. 1.MECHANICAL FACTORS- HIPPOCRATES
Oligohydramnios
Abnormal fetal positioning
Unstretched uterus
Placental insufficiency
Constriction bands
2.PRIMARY GERM PLASM DEFECT
3.ARRESTED FOETAL DEVELOPMENT

21. 4.HEREDITARY- AD
5.MUSCULOLIGAMENTOUS FIBROSIS
6. VASCULAR HYPOTHESIS- 90% of CTEV limbs
showed hypoplasia / absence of anterior
tibial artery.

22. SECONDARY CLUBFOOT
1.PARALYTIC DISORDERS - evertors and dorsiflexors
are weak.
Ex- Polio , Spina Bifida, Myelodysplasia,
Friedreich Ataxia.
2.SYNDROMES -Arthogryposis Multiplex Congenita
Downs Syndrome, Larsen Syndrome.

23. • IN UPPER MOTOR NEURON
– Cerebral palsy
– Friedreich ataxia
– Syringomyelia

24. • In nerve root
– Spina bifida
– Spinal dysraphism
• In the nerve-neuropathy(leprosy)
• In myoneural junction-myasthenia gravis
• In foot muscles
– Muscular dystrophy
– Arthrogryposis Multiplex Congenita

25. INCIDENCE- 1 to 2 in 1000 livebirths.
SEX – MALE >FEMALE
BILATERAL IN MORE THAN 50 % .
FAMILY HISTORY- 5-50% POSITIVE.

30. Classifying the clubfoot
• The classification of a clubfoot may change
with time depending on management
Typical clubfoot
• Classic clubfoot and is found in otherwise
normal infants
• It generally corrects in five casts, and with
Ponseti management the long-term oucome is
usually good or excellent.

31. • Positional clubfoot
– deformity is very flexible
– due to intrauterine crowding
– Correction is often achieved with one or two
castings.
• Delayed treated clubfoot-beyond 6 months of
age.
• Alternatively treated typical clubfoot
– treated by surgery or non-Ponseti casting.

32. • Recurrent typical clubfoot
– may occur whether the original treatment was by
Ponseti management or other methods.
– Relapse is much less frequent after Ponseti
management and is usually due to a premature
discontinuation of bracing.
– The recurrence is most often supination and
equinus that is first dynamic but may become
fixed with time.

33. Atypical clubfoot
usually associated with other problems
Start with Ponseti management
Correction usually is more difficult

34. Rigid or resistant atypical clubfoot
• severe plantarflexion of all metatarsals,
• a deep crease just above the heel and across
the sole of the midfoot
• a short hyperextended big toe.

35. Manipulation

36. • Do not abduct more than 30 degrees. After 30
degrees abduction is achieved, change
emphasis to correction of the cavus and
equinus.
• Casting Always apply casts with the above-
knee portion in 110 degrees flexion to
prevent slippage. Up to 6–8 casts can be
needed to correct deformity

37. • Tenotomy
– A tenotomy is necessary in most cases.
– At least 10 degrees dorsiflexion is necessary
– change casts at weekly intervals after the
tenotomy if sufficient dorsiflexion is not achieved
immediately after the tenotomy.

38. • Bracing Reduce abduction on the affected
side to 30 degrees in the foot abduction
brace. The follow-up management remains
the same.

39. • Teratologic clubfoot such as congenital tarsal
synchondrosis
• Neurogenic clubfoot associated with a
neurological disorder such as
meningomyelocele.
• Acquired clubfoot such as Streeter dysplasia.

40. • Syndromic clubfoot
– Syndromic clubfoot are more difficult to treat and
sometimes require surgery.
Arthrogryposis
– Start with standard Ponseti casting.
– 9 to 15 casts are often required.
– If correction is not achieved, surgery
may be required

41. • Myelodysplasia
– Because of sensory loss, casting requires great
care to prevent skin ulceration.
– Apply more padding and avoid excessive pressure
in molding.

42. 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

43. Anteroposterior view
• Talocalcaneal angle
• Calcaneal-second metatarsal angle
• Talus –first metatarsal angle
• Intermetatarsal angle

44. 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 30-45°.
• decreased in a varus foot
and increased in a valgus
hindfoot

45. Axis of the second
metatarsal diaphysis
Axis of the calcaneus
15º : Normal value
> 15º : Pes adductus

46. Talus –first metatarsal angle

47. Intermetatarsal angle(<5)

48. Lateral view
• The lateral talocalcaneal angle
• Meary angle
• Hibb angle
• Calcaneal pitch

49. Talocalcaneal angle
Angle between
the mid-talar
axis and calcaneal
inclination axis.
-normally measure
between 30° and 45°
-decreased in a varus
foot and increased in a
valgus hindfoot

51. Meary angle
• B/n long axis of the talus and the long axis of
the 1st MT
• Normally, these lines are colinear
• apex directed dorsally-cavus foot
• apex angled plantarward- valgus or flatfeet

55. Hibb angle
• angle between the plantar surface of the
calcaneus and the first metatarsal
• Normally Hibb angle is
greater than
150 degrees

56. Calcaneal pitch
• Angle between the horizontal and the plantar
surface of the calcaneus
• Important in evaluating a cavus foot or
clubfoot
• low: 10-20° - indicative of pes planus
• medium: 20-30°
• high: ≥30° - indicative of pes cavus

58. SCORING SYSTEMS

59. • Serial scoring useful in
– classifying the clubfoot,
– assessing progress,
– showing signs of recurrence, and
– establishing the prognosis.

61. Pirani Score
• Documents the severity of the Deformity
• Sequential scores are an excellent way to
monitor progress.
• Six parameters : 3 of midfoot and 3 of hindfoot
• Each parameter is given a value as follows:
0: normal
0.5: Mildly abnormal
1: severely abnormal

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

64. Hind foot score
• Posterior crease [D]
• Rigid equinus [E]
• Empty heel [F]

65. Uses of Pirani’s score
• Predicting need for tenotomy
• Estimation of probable no. of casts required*
• Very good interobserver reliability and reproducibility**

66. • Scoring of 4 or more is likely to require at least
four casts.
• Scoring less than 4 will require three or fewer
• A foot with a hindfoot score of 2.5 or 3 has a
72% chance of requiring a Tenotomy.

67. Diméglio
A.Equinus deviation B. Varus deviation C. Derotation D. Adduction.

68. Reducibility(
degrees)
Score Additional
parameters
Score
90-45 4 Marked posterior
crease
1
45-20 3 Marked medio tarsal
crease
1
20-0 2 Cavus 1
0 t0 -20 1 Poor muscle
condition
1

69. Grade Type Score Reducibility
i Benign 1-4 >90%
ii Moderate 5-9 >50%, soft-stiff,
reducible, partially
resistant
iii Severe 10-14 >50%, stiff-soft,
resistant, partially
reducible
iv Very severe 15-20 <10% stiff-
stiff,resistant

70. Aims of treatment
• Achieve a
– plantigrade ,
– pliable,
– cosmetically accepted foot
in shortest possible time and with least disruption of
family and child life.

71. PRINCIPLES OF TREATMENT
Soft tissue contractures should be stretched
out in order to restore normal tarsal
relationship.
Once achieved correction should be
maintained in till tarsal bones remoulds stable
articular surfaces.

72. TWO OPTIONS –
1. NON OPERATIVE- immediately after birth
2. OPERATIVE

73. Clubfoot treatment brace used in 1806

74. Thomas Wrench

75. KITES METHOD
 Correction of each
component separately
and in order.
 Avg time 6 months
 Fulcrum –
calcaneocuboid joint.
 Order
1.Forefoot adduction
2.Heel varus
3.equinus

76. 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
• Forefoot overcorrected into mild flatfoot
• Calcaneus is 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

77. Reasons for poor results in kites method
1. FULCRUM- prevents abduction of calcaneum
and thereby eversion of calcaneum.
2. Pronation of forefoot worsens cavus.

78. Common errors(Kite errors)
• No manipulation
• Pronation/eversion
of 1st metatarsal
• Premature
dorsiflexion of heel
• Counterpressure at
calcaneocuboid joint
• Below knee casts
• Short splints

79. Ponseti Cast Correction

80. • weekly manipulation and cast application to hold
correction
• 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.

81. • Order- cavus
adduction
varus
equinus

82. Setup

83. Exactly locate the head of the talus

84. Manipulation
• Start as soon after birth as possible
• Abduction of the foot beneath the stabilized
talar head.
• All components of clubfoot deformity, except
for the ankle equinus, are corrected
simultaneously

85. • Metatarsus adductus and hindfoot varus are
simultaneously corrected

86. Reduce the cavus
-requires only elevating
the first ray of the forefoot
to achieve a normal
longitudinal arch of the
foot
-The cavus is almost
always corrected with the
first cast
-At the first session the
forefoot is simultaneously
supinated and abducted

87. • First, forefoot abduction should be
performed with the foot in slight supination
• Second, the heel should not be constrained
by premature dorsiflexion
• Third, care is taken to locate the fulcrum for
counterpressure on the lateral head of the
talus

88. Steps in cast application
Preliminary manipulation
The heel is not touched to
allow the calcaneus to
abduct with the foot

89. Applying the padding

90. Plaster at toes Below knee pop

91. • press and release talar head repetitively to
avoid pressure sores of the skin.
• Mold the plaster over the head of the talus
while holding the foot in the corrected
position
• The calcaneus is never touched during the
manipulation or casting.

92. Molding Extension upto the thigh

93. Plantar support to toes Final appearance

94. Casts and foot

95. Characteristics of adequate abduction
• Confirm that the foot is sufficiently abducted
to safely bring the foot into 0 to 5 degrees of
dorsiflexion before performing tenotomy.
• The best sign-ability to palpate the anterior
process of the calcaneus as it abducts out
from beneath the talus

96. • Abduction of approximately 60 degrees in
relationship to the frontal plane of the tibia is
possible.
• Neutral or slight valgus of os calcis is present.
This is determined by palpating the posterior
os calcis.
• The correction is accomplished by abducting
the foot under the head of the talus. The foot
is never pronated.

97. The final outcome
• At the completion of casting, the foot appears
to be over-corrected into abduction with
respect to normal foot appearance during
walking.

98. Complications of casting
• Tight cast
• Rocker bottom deformity
• Crowded toes
• Flat heel pad
• Superficial sores
• Deep sores
• Pressure sores

99. Cast removal
Cast knife removal Soaking and unwrapping

100. • Equinus is the last deformity that is
corrected, and correction should be
attempted when the hindfoot is in neutral to
slight valgus and the foot is abducted 70
degrees relative to the leg.
• By progressively dorsiflexing the foot -by
applying pressure under the entire sole of the
foot

101. Tenotomy
• Indicated to correct equinus when cavus,
adductus, and varus fully corrected but ankle
dorsiflexion remains less than 10 degrees
above neutral

102. • to facilitate more rapid correction,
subcutaneous heel cord tenotomy is performed-
entire Achilles tendon is transected
• Performed in children up to 1 year of age
without the occurrence of overlengthening or
weakness

105. • Foot is held by an assistant in maximum
dorsiflexion
• select a site about 1.5 cm above the
calcaneus for the tenotomy
• The blade enters the skin along the medial
border of the Achilles tendon.
• Successful tenotomy -palpable pop and
ability for further dorsiflexion of about 15 to
20 degrees

106. Post-tenotomy cast
• Foot abducted 60 to 70 degrees with respect
to the frontal plane of the ankle, and 15
degrees dorsiflexion.
• for 3 weeks
• Usually the last cast

107. • An alternative to percutaneous heel cord
tenotomy -suggested by Alvarez and
colleagues
• Botulinum A toxin is injected into the triceps
surae muscle .
• Very short-term success with this approach

108. Foot Abduction braces
• Shoes mounted to bar in
position of 60- 70° of ER and
5-10° of dorsiflexion in B/L
cases and in case of U/L cases
30 to 40° of ER in normal side,
• Heels of the shoes are at
shoulder width
• Knees left free, so the child
can kick them “straight” to
stretch gastrosoleus tendon

109. • The bar should be bent 5 to 10 degrees with
the convexity away from the child, to hold the
feet in dorsiflexion.

110. Bracing protocol
• Worn 24 hours each day for first 3-4 months.
• Afterward it is worn at nap and nighttime for 2 to 4
years.
• Noncompliance with bracing protocol – the most
common cause of recurrence in children on Ponseti
regimen
.

111. • Occasionally, a child will develop excessive
heel valgus and external tibial torsion while
using the brace. In such instances, the
physician should reduce the external rotation
of the shoes on the bar from approximately
70 degrees to 40 degrees.

112. Mitchell brace Dobbs dynamic brace

113. Dennis brown Romanus

114. 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

115. Results of Ponseti method
• Cooper and Dietz published long-term results
from Iowa in 1995.
• In this retrospective review, 45 patients with 71
clubfeet were evaluated an average of 34 years
later.
• Results compared with NORMAL CONTROLS
– Thirty of the 71 feet required tibialis anterior
transfer.
– 62% of clubfeet were normal,
– 16% were good, and
– 15% were poor.

116. • Physical examination documented very good
strength and decreased foot motion in
comparison to those whose contralateral foot
was normal.
• Radiographs showed :feet not completely
corrected, but functioned well despite this

117. The French method
Bensahel/Dimeglio regime
 Daily manipulations by a skilled physiotherapist and
temporary immobilisation with elastic and non-
elastic adhesive taping .
 GOAL- reduce talonavicular joint, stretch out medial
tissues, correct deformities squentially.

118. • Mobilization during the hours of sleep with
CPM machine.
• Successful in 51% of cases ( of which 9% req
TA tenotomy) ;
• 49% Required extensive soft tissue release
– 29% post release and
– 20% comprehensive posteromedial release**.

119. Follow up protocol
• 2 weeks: to check for compliance of full-time bracing.
• 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

120. RESULTS OF NON OPERATIVE
TREATMENT
OVERALL – 19% TO 95%.
KITES METHD- 80%.
PONSETI – 95%

121. Surgery in clubfoot
INDICATIONS
• Resistant clubfoot
• Persistently deformed clubfoot
• Relapsed clubfoot
• Neglected clubfoot
( no treatment given till age of 2 yrs)
one of the more complicated procedures
performed in all of orthopaedics

122. General Principles
• Goal: address all pathoantomic structures.
• Type of surgery depend on age and deformity.
• Soft tissue release for upto 2 years
• 2-4 years-Dwyer calcaneal osteotomy
• 8-10 years-calcaneocuboid fusion
• After that-triple arthrodesis

123. Timing of the Procedure
• before the age of 12 months
• There is therefore little advantage to
performing the surgery before 9 to 10 months
• Ensure that the child will be weight bearing
when the postoperative cast immobilization is
completed

124. Approaches
Turco (postero medial incision)
Cincinnati (postero medial and
postero lateral )

125. Caroll’s two incision technique
Medial incision - straight oblique incision from
first metatarsal, across medial malleolus to
Achilles tendon
Straight lateral incision along the lateral
subtalar joint antr to distal fibula

126. TURCOS ONE STAGE RELEASE
• First complete one-stage posteromedial release
• curved posteromedial incision
• complete subtalar release
• release of the calcaneofibular ligaments
• posterior tibialis tendon being lengthened or
released
• The Achilles tendon and long toe flexors are
lengthened and repaired

127. • talonavicular joint opened dorsally, medially,
and inferiorly, and the calcaneonavicular
spring ligament released
• The talonavicular joint is reduced and pinned
• Turco immobilized his patients for a total of 4
months and removed the K-wires at 6 weeks
• Night splints were used for an additional year
after the end of cast immobilization

129. • emphasized plantar fascial release and
capsulotomy of the calcaneocuboid joint
because forefoot adduction and supination
(actual cavus) were not addressed by Turco's
procedure

131. McKay and Simons
• Cincinnati incision
• A medial and lateral circumferential
talocalcaneal release is performed
• Complete release of the talonavicular and
calcaneocuboid is included, and both these
structures are pinned

132. Suggested Operative Technique
• Prone/supine position
• Cincinnati incision
• exposure is key
• posterolateral corner of the ankle
• precise and complete release of the
calcaneofibular and lateral subtalar ligaments
• Achilles tendon Z-lengthening

133. Transverse circumferential (Cincinnati) incision
as described by Crawford et al.

139. • Posterior and medial release of the subtalar
and tibiotalar joints
• The neurovascular bundle is mobilized and
protected with a Penrose drain
• Posterior tibialis ,flexor digitorum longus,
flexor hallucis longus sheaths are also incised
for retraction or lengthening, or both

140. • Talonavicular release -talonavicular
capsulotomy is performed medially, dorsally,
and plantarward
• calcaneocuboid joint, which is incised and
mobilized
• If cavus is a significant component -plantar
fascia should be divided transversely
• The talonavicular joint is now reduced and
pinned

141. The lateral column remains too long.
Lateral column shortening is indicated.

142. • Skin closure
• above-knee cast
• Immobilization

143. 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

144. 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

145. TENDON TRANSFERS
• INDICATION –PASSIVELY CORRECTABLE FOOT
RESULTING FROM MUSCLE IMBALANCE.
• NEVER A PRIMARY PROCEDURE
• THREE TYPES-
• 1.TIBIALIS ANTERIOR
• 2.TIBIALIS POSTERIOR
• 3.SPLIT ANTERIOR TIBIALIS TENDON
TRANSFER

146. TIBIALIS ANTERIOR TRANSFER
• Indicated when there is dynamic inversion or
supination of the midfoot, especially in swing
phase.
• The goal is to eliminate the supinated
position for the initiation of stance.

147. • Split transfer-lateral arm reinserted in the
cuboid or lateral cuneiform.
• Entire tendon transfer-the insertion should
be moved to the midline or just slightly
lateral to midline.
• Anterior tibialis transfer with lengthening-as
part of revision for a postoperative dorsal
bunion when the first ray is excessively
dorsiflexed

148. Transfer for Insufficient Triceps Surae
(Calcaneus Gait)
• Plantar flexion weakness is universal
following tendoachillies lengthening.
• Diagnose plantar flexion weakness as early as
possible.
• Muscles available-peroneus ,tibialis posterior
and long toe flexors

150. • Foot is passively held in equinus and
immobilized for 6 to 8 weeks
• Thereafter, a solid ankle-foot orthosis with
dorsiflexion stopped at neutral should be
continued for an additional 4 months in an
attempt to prevent the transfers from
stretching out, and active plantar flexion
exercises should be performed non–weight
bearing with the brace off.

151. Dilwyn Evans Osteotomy
• Posteromedial release
• Calcaneocuboid wedge resection and arthrodesis
• Shortens lateral column
• Stiffness at subtalar and midfoot joints
• Preferred in older children (4-8 yrs)
• standard technique for recurrent clubfoot deformity
in which the midfoot is clearly in varus

153. Litchblau procedure
• IND – hind foot includes
varus and residual internal
deformity of calcaneum
with long lateral column.
AGE – min 3 years.
• Lateral closing wedge
osteotomy of calcaneus
along with medial soft
tissue release .
• Shortens the lateral column.
• Complication- skew foot.

154. • calcaneocuboid arthroplasty
• can be used whenever the lateral column is
too long

160. Fowler's procedure
• Older than 6 years with a varus forefoot
position
• lateral column shortening has been combined
with medial column lengthening

162. Bony procedures
Dwyer calcaneal osteotomy
Age 3-4 years
IND- persistent varus
deformity.
 Medial Opening wedge
Calcaneal osteotomy to
increase the length and
height of calcaneus
 Osteotomy held open by a
wedge of bone taken from
tibia with k wire.
 Cast for 3 months.

164. Supramalleolar Osteotomy
• If the toe-in gait persists for 2 years after
clubfoot surgery.
• Reserved only for rotational correction.

166. Salvage procedures
Triple arthrodesis
• Salvage procedure for painful stiff foot.
• Correction of large degrees of deformity in
neglected clubfeet.
• After the age of 10 years
• Not performed before advanced skeletal maturity
• 3 Joints fused
– 1.Subtalar joint.
– 2.Talonavicular joint.
– 3.Calcaneo cuboid joint.

167. Talectomy
 Originally done for syndromic
clubfoot.
 Now done for severe
untreated club foot.
 Age – 6years.
 Complete excision of talus .
 Derotate foot and displace
calcaneum into ankle mortise
untill navicular abuts anterior
edge of tibial plafond.

168. Complications- limb length discrepancy.
limitation of ankle
movements.

169. 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

170. JOSHI EXTERNAL STABILISATION SYSTEM
• DR.B.B. JOSHI, MUMBAI.
• Principle –tension stress applied in physiological
doses by mechanical device have shown to stimulate
histiogenesis.

171. 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

172. JESS
• 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.

173. ADVANTAGES OF JESS
1. Causes lengthening of all contracted tissues
and prevent further scarring by surgery.
2. Magnitude of correction can be controlled by
distraction.
3. Resultant foot are supple in contrast to foot
in surgery.

174. 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.

175. 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

176. • Flattening and breaking of the talar head
• Undercorrection/ Overcorrection.
• Forefoot adductus
• Hindfoot varus
• Severe scarring
• Stiff joints
• Weakness of the plantar flexors of the ankle

177. 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

178. Thank you