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Club foot

  1. 1. CLUBFOOT  VAGUETERM USEDTO DESCRIBE A NUMBER OF DIFFERENTABNORMALITIES INTHE SHAPE OFTHE FOOT  NOW IT HAS COMETO BE SYNONYMOUS WITH THE COMMONEST CONGENITAL FOOTABNORMALITY i.e., CTEV
  2. 2. ANATOMY
  3. 3. ANATOMY-JOINTS  ANKLE JOINT :TIBIA ANDTALUS  SUBTALAR JOINT :TALUS AND CALCANEUM  TALONAVICULAR JOINT  CALCANEO- CUBOID JOINTS
  4. 4. ANATOMY  TENDONS  TIBIALIS POST  FLEXOR DIG. LONGUS  FLEXOR HALLUSIS LONGUS
  5. 5. ANATOMY  LIGAMENTS  DELTOID L. : MEDIAL COLLATERAL LIG. OF ANKLE  SPRING L. : CALCANIUM – NAVICULAR  CAPSULAR L. :T – N , N – C , C – M  PLANTAR L. :LONGITUDINAL ARCH OF FOOT
  6. 6. NOMENCLATURE Planus: flatfoot Cavus: highly arched foot Varus: heal going towards the midline Valgus: heel going away from the midline Adduction: forefoot going towards the midline Abduction: forefoot going away From the midline
  7. 7. CLUB FOOT
  8. 8. CLUB FOOT Definitions Talipes: Talus = ankle Pes = foot Equinus: (Latin = horse) Foot that is in a position of planter flexion at the ankle, looks like that of the horse. Calcaneus: Full dorsiflexion at the ankle
  9. 9. CLUB FOOT Types  Idiopathic (Unknown Etiology) :  CongenitalTalipes Equino-Varus CTEV  Acquired, Secondary to :  CNS Disease : Spina bifida, Poliomyelitis  Arthrogryposis Multiplex Congenita  Absent Bone : fibula / tibia
  10. 10. CTEV  MOST COMMON CONGENITAL FOOT DISORDER  MALES  1/1000 LIVES BIRTHS
  11. 11. TYPES  OSSEOUS : absent tibia / fibula  MUSCULAR : AMC  NEUROPATHIC : spina bifida  IDIOPATHIC  CLASSIFICATION : Ponsetti  Supple  Rigid  Teratologic
  12. 12. CLASSIFICATION  EXTRINSIC  FLEXIBLEWITH ABNORMAL BONE RELATION  WITHOUT MARKED FIBROSIS  CONSERVATIVETREATMENT  INTRINSIC  RIGIDWITH ABNORMAL BONE RELATION  MARKED FIBROSIS  OPERATIVETREATMENT
  13. 13. THEORIES OF CTEV  TURCO’S : medial displacement of navicular and calcaneous around talus  BROCKMAN’S : congenital atresia of theT – N joint  Mc- KAY’s :3-D bony deformity of the subtalar complex  INTRAUTERINE:compression by malpositon of fetus in utero  Germ plasm theory  Soft tissue theory  Prenatal muscle imbalance theory
  14. 14. PATHO-ANATOMY  BONES AND JOINTS  CALCANEUS : INVARUS POSITION  TALUS : DISPLACED MEDIAL AND PLANTARWARDS  NAVICULAR : MEDIALLY DISPLACED AND ROTATED  CUBOID : DISPLACED MEDIALLY AND ARTICULATES WITHTHE NON-ARTICULAR SURFACE OF CALCANEUM ( CUBOID SIGN / LOCKED CUBOID )  METATARSALS : DEVIATES MEDIALLY ATT-M JOINTS  DISLOCATION OFTALOCALCANEAL ARTICULATION  TIBIA – MEDIALTORSION
  15. 15. PATHO-ANATOMY  BONESAND JOINTS  EQUINUS - ANKLE JOINT  INVERSION - SUBTALAR JOINT  FOREFOOT ADDUCTION - MIDTARSAL JOINTS  FOREFOOT CAVUS – EXCESSIVE ARCHING AT MIDTARSAL JNTS
  16. 16. PATHO-ANATOMY  MUSCLES CAPSULESAND LIGAMENTS STRCTURES CONTRACTED ONTHE MEDIAL SIDE 3 MUSCLES • AHL • TP • FHL 3 LIGAMENTS • DELTOID • SPRING • PLANTAR 3 CAPSULES OF • SUBTALAR • TARSAL • TARSOMETATARSAL
  17. 17. 2 MUSCLES • TIBIALIS POST. • TENDO-ACHILLES 2 LIGAMENTS • TALOFIBULAR • CALCANEOFIBULAR 2 CAPSULES OF • ANKLE JNT • SUBTALAR JNT PATHO-ANATOMY  MUSCLES CAPSULESAND LIGAMENTS STRCTURES CONTRACTED ONTHE POSTERIOR SIDE
  18. 18. 1 MUSCLE • TIBIALIS ANT. 1 LIGAMENT • SUPERIOR PARONEAL RETINACULA 1 CAPSULES • CALCANEO- CUBOID JNT PATHO-ANATOMY  MUSCLES CAPSULESAND LIGAMENTS STRCTURES CONTRACTED ONTHE ANTERIOR SIDE
  19. 19. PATHO-ANATOMY  SKIN  Adapts shortening on the medial side  Deep creases on the medial side  Dimples on the lateral aspect  SECONDARY CHANGES  Occurs when the child starts walking-exaggerates the deformity  Callosities and bursae
  20. 20. CLINICAL FEATURES  COMMON PRESENTATIONS  Detected at birth  Infancy and early child hood  Late childhood
  21. 21. CLINICAL FEATURES  Short Achilles tendon  High and small heel  No creases behind Heel  Abnormal crease in middle of the foot  Foot is smaller in unilateral affection  Callosities at abnormal pressure areas  Internal torsion of the leg  Calf muscles wasting  Deformities don’t prevent walking
  22. 22. CLINICAL FEATURES  Seek a detailed family history of clubfoot or neuromuscular disorders, and perform a general examination to identify any other abnormalities.  Similar deformities are seen with myelomeningocele and arthrogryposis.Therefore, always examine for these associated conditions.
  23. 23. CLINICAL FEATURES  DORSIFLEXION TEST :  PLUMBLINETEST : tibial torsion  child is made to sit on a table with both LL hanging from the edge.  Line drawn from the centre of the patella to the tibial tubercle when extended down should cut the foot at 1st or 2nd intermetatarsal space normally.- PLUMBLINE  In CTEV , with medial rotation of tibia it cuts through 4th or 5th space  SCRATCHTEST – INFANTS  MEDIAL SCRACTHTEST : FOOT EVERTS - PERONEALS  LATERAL SCRACTHTEST: FOOT INVERTS - INVERTORS
  24. 24. INVESTIGATIONS  RADIOGRAPHY  APVIEW :angle formed b/w  talus and calcaneum ( NORMAL 30-35) REDUCED  Talus and metatarsals ( NORMAL 5 -15 )  -VE Helps to asses angle of varus and forefoot adduction
  25. 25. RADIOGRAPHY  LATERALVIEW - ANGLE FORMED B/W  TIBIA AND CALCANEUM ( NORMAL 5- 15 )  -VE  TALUS AND CALCANEUM ( NORMAL 20- 50)  TO KNOWTHE EXTENTOF EQINUSANDVARUS DEFORMITY  CT , MRI , ARTHROGRAPHY
  26. 26. MANAGEMENT The goal of treatment for clubfoot is to obtain a plantigrade foot that is functional, painless, and stable A cosmetically pleasing appearance is also an important goal  CONSERVATIVE  SURGICAL  EXTERNAL FIXATORS
  27. 27. CONSERVATIVE  INFANTS (< 6 MONTHS)  1ST 6WEEKS : SERIAL MANIPULATION AND CASTING  Corrective casting  First correction of adductus of midfoot  Folowed by correction of inversion  Finally correction of the equinus
  28. 28. Conservative management Weekly serial manipulation and casting Every weekly for 1st 6 week Fortnightly till 6 months Correction acheived Correction not achieved Splint day time Phelp’s Brace night time Dennis Brown Splint For 6 – 18 mothhs CTEV shoes ( upto 4 years ) SURGERY EXT. FIXATOR <4YRS STR >4YRS STR+BONY PROCEDURE
  29. 29. SURGICAL TRATMENT Indications  Late presentation, after 6 months of age  Complementary to conservative treatment  Failure of conservative treatment  Residual deformities after conservative treatment  Recurrence after conservative treatment
  30. 30. SURGICAL TREATMENT  Soft tissue operations  Release of contractures  Tendon elongation  Tendon transfer  Restoration of normal bony relationship  Bony operations Usually accompanied with soft tissue operation Types:  - Osteotomy, to correct foot deformity or int. tibial torsion  - Wedge excision  - Arthrodesis (usually after bone maturity)  one or several joints  - Salvage operation to restore shape
  31. 31. P M S R POSTERO MEDIAL SOFTTISSUE RELEASE ( 6-12 months )  TURCO’S PROCEDURE  On the posterior Side  Z- plasty of tendo – Achilles  Posterior capsulotomy of ankle and subtalar jnt  Release of posterior talo-fibular and calcaneo-fibular lig  On the medial side  Lenghtening ofTP , FHL, FDL  Release of talonavicular lig., spring lig., superficial part of deltoid lig.  Release of interossious talocalcaneal lig, capsules of naviculo- cuniform and 1st metatarsao-cuniform jnts
  32. 32. P M S R  On the plantar side  Plantar fascia release  Release of AH , FDB  Post – op regimen  Change cast at 2 weeks  Remove K wire at 6 weeks  Long leg cast for 3 months  Ankle foot orthoses for 6- 9 months
  33. 33. LIMITED SOFT TISSUE RELEASE  When only one component present  Equinus – posterior release  Adduction – medial release  Cavus – plantar release
  34. 34. CIRCUMFERENTIAL RELEASE  McKAY’s  All structures on PMSR + lateral structures  Superior peroneal retinaculam  Inferior extensor retinaculam  Dorsal calcaneo-cuboid lig.  12 – 36 months  Passively correctable deformity resulting from muscle imbalance
  35. 35. RESISTANT CLUBFOOT • >5YR. METATARSAL OSTEOTOMY METATARSUS ADDUCTUS • <2- 3YR .modified McKey”s procedure • 3- 10 yr • Dwyer osteotomy • Dilwyn –Evans operation • 10-12 yr tripple arthrodesis HIND FOOT VARUS • TendoAchillus lengthening + posterior capsulotomy sub talar and ankle joint • Lambrunidis triple arthrodesis EQINUS
  36. 36. OPERATIONS  TRIPPLE ARTHRODESIS(>10YRS)  Lateral closed wedge osteotomy through subtalar and midtarsal joints is done to fuse  SUBTALAR  TALONAVICULAR  CALCANEOCUBOID  TALECTOMY  Severe uncorrected club-foot  SURGERY FOR CORRECTION OFTIBIALTORSION  >15deg should be corrected by derotation osteotomy
  37. 37. DILWYN-EVANS OPERATION  Soft tissue release and calcaneocuboid fusion  1st three stages : extensive soft tissue release  Finally calcaneaocuboid wedge is excised  Neglected or recurred foot in children of 4-8 yrs
  38. 38. EXTERNAL FIXATORS  ILIZAROV’S EXTERNAL FIXATOR FRAME  JOSHI’S EXTERNAL FIXATOR FRAME  Allows gradual distraction  Transfixing wires through  Tibia, calcaneum ad metatarsals  Distractors positioned  Posteriorly, medially and laterally  Frame completed by interconnecting the components
  39. 39. TREATMENT IN ADULT PATIENT  CUNIFORMTARSECTOMY  Vertical wedge of bone , with its base laterally is removed from  Calcaneus – behind the metatarsal joints  Cuboid – infront of the joint  Curved wedge , with its base upwards and laterally  from head and neck of talus
  40. 40. RETENSION OF CTEV CORRECTION  DENIS BROWN SPLINT  PHELP’S BRACE  BELOW KNEEWALKING CALIPERS  CTEV SHOES

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