Orthopedic topic

1. CONGENITAL TALIPES
EQUINO VARUS
CTEV

2. ● Children with physical
disabilities are often
socially and
economically
disadvantaged
● Importance of
Clubfoot – easily
diagnosed, easily
treated

3. ● CTEV – congenital
talipes equino-varus
Talipes - 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. 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

6. INCIDENCE
● About 1 in 1000 live
births
● Most cases sporadic
● Sometimes
Autosomal dominant
trait with incomplete
penetrance

7. ● More common in boys than girls
● 50 % cases are bilateral
● In unilateral cases right side is more often
involved

8. Types According To Cause
● 1) Idiopathic
● 2) Secondary
● 3) Postural / Positional

9. 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

10. Theories regarding cause
● Primary germ plasm
defect of talus
● Contractile
myofibroblastic tissue
in the
musculotendinous
units

11. 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

12. Congenital Talipes Equino-Varus
CTEV
Spina Bifida = Paralytic TEV

13. Syndromes Producing CTEV
● Streeters dysplasia
● Arthrogryposis
● Edwards syndrome – trisomy 18

14. Postural
● Due to abnormal intrauterine position
● Easily corrected by massage by mother or
by 1 or 2 casts

15. Types of Clubfoot According to
Treatment Stage
● Untreated
● Treated
● Resistant
● Recurrent
● Neglected
● Complex

16. ● 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

17. ● Resistant – child has previously untreated
clubfoot and that does not correct with
Ponseti method. This is usually syndromic
and surgery may be necessary

18. ● 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

19. ● 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

20. ● Complex clubfoot – clubfoot treated by
any method other than ponseti technique
- complicated by additional pathology or
scarring

21. Pathological Changes
● Four basic
components are
● midfoot Cavus (tight
intrinsics, FHL, FDL)

22. ● forefoot Adductus
(tight tibialis posterior)

23. ● hindfoot Varus (tight
tendoachilles, tibialis
posterior)

24. ● hindfoot Equinus
(tight tendoachilles )

25. ● The ankle, subtalar and midtarsal joints
are involved
● The severity of deformity varies and is
graded by the pirani score

26. 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

27. Congenital Talipes Equino-Varus
CTEV

29. ● Associated findings- hypotrophic anterior
tibial artery
-atrophy of muscles
around the calf
-abnormal foot is
smaller

30. Soft Tissue Abnormalities
● Talocalcaneal (subtalar) joint realignment
is opposed by-
- calcaneo fibular ligament
- peroneal tendon sheath
- posterior talo calcaneal ligament

31. ● Talo navicular joint realignment is
opposed by- posterior tibial tendon
- deltoid ligament
- spring ligament
- joint capsule
- dorsal talonavicular ligament
- bifurcated Y ligamant

32. ● Calcaneo cuboid joint realignment is
opposed by-bifurcated Y ligament
- long plantar ligament
- plantar calcaneo cuboid
ligament

33. ● 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

34. Radiological Evaluation
● Talocalcaneal angle
- Anteroposterior
view: 30-55 degrees

35. ● Talocalcaneal angle -
Dorsiflexion lateral
view: 25-50 degrees

36. ● Tibiocalcaneal angle
Stress lateral view:
60-90 degrees

37. ● Talus–first metatarsal
angle Anteroposterior
view: 5-15 degrees

38. Treatment
● Non operative – Ponseti technique
Kite technique
French technique
● Surgical–Posteromedial soft tissue
release
Osteotomies
Triple arthrodesis
Achilles tendon lengthening
Ilizarov / JESS

39. 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)

40. ● 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

41. Kite’s technique
● Foot manipulated with calcaneo cuboid
joint as fulcrum
● Casting done after manipulation
● After correction Denis Browne splint
applied

42. French Technique
● Daily manipulation by physical therapist
for 30 mts
● Electrical stimulation of peroneal muscles
done
● Reduction maintained by adhesive taping

43. PMR
● Done at age 1 yr
● Tight structures in
posterior and medial
aspect of the foot is
released or
lengthened

45. ● Osteotomies – for
residual hind foot
varus
● Triple arthrodesis – in
children more than 12
yrs old
● TA lengthening – for
residual equinus

46. ● Ilizarov and JESS are
for older children with
recurrence or residual
deformity

48. THANK YOU