More Related Content
Similar to CTEV PPT.pptx
Similar to CTEV PPT.pptx (20)
Recently uploaded
Recently uploaded (20)
CTEV PPT.pptx
- 1. PRESENTOR : DR. SREEHARI SREEDHAR Junior resident orthopedics(2018) MODERATOR:DR.SIBIN SURENDRAN Associate prof orthopedics Govt. Medical college, Kozhikode
- 2. Terminology Epidemiology Classification Deformities Pathoanatomy Kinematics Clinical examination Radiography Non op treatment Operative treatment Treatment of recurrence Atypical clubfoot
- 3. T erms • Talipes – ankle and foot • Equinus –foot pointed downwards • Varus- turned inwards
- 4. Neglected –over 2 years/weight bearing Corrected –by ponsetti mgmt. Relapsed/recurrent –supination /equinus after initial good corrctn Resistant/rigid –uncorrected with ponsetti/asso with syndromes Atypical/complex
- 5. Epidemiology • 1-2 in 1000 live births • MC congenital ortho condition requiring intensive treatment • Boys affected twice as often as girls • 50% of cases bilateral • Genetic cause strongly suggested in idiopathic cases
- 6. classification Idiopathic-MC Secondary Osseous-absence of tibia ,fibula Neuromuscular-spina bifida Syndromic
- 7. Syndromic ARTHROGRYPOSIS STREETER DYSPLASIA MOBIUS SYNDROME LARSEN SYNDROME FREEMAN SHELDON SYNDROME DIASTROPHIC DYSPLASIA
- 8. THEORIES Primary germplasm defect in talus Primary soft tissue abnormality Vascular cause Genetic Development arrest inutero
- 10. Secondary deformities Decrease foot size Internal tibial torsion Stretched skin Callosities Stumbling gait Atrophy of muscles
- 11. Deformities Hindfoot / ankle Or inversion at subtalar joint complex Plantar flexion of forefoot on the hindfoot Forefoo t on midfoot
- 12. PATHOANATOMY
- 14. • Talar neck deformity (shortened ,internal rotated & plantar deviation) • So the body of talus appears externally rotated DEFORMITIES
- 15. *Navicular displaced medially and plantarward on the talar head and has false articular relationship to the medial malleolus *Cuboid displaced medially on the anterior end of calcaneus *Calcaneus -Plantar and medial rotated especially its posterior segment
- 16. SOFT TISSUE CONTRACTURES Medial side Muscles-AHL,TP,FHL Ligaments-deltoid,spring,plantar Capsules-subtalar,tarsal,tarsometatarsal joints Posterior Muscles-TP,TA Ligaments-talofibular,calcaneofibular Capsules-ankle joint,subtalar joint
- 17. KINEMATICS Supination pronation Inversion eversion Adduction abduction Plantar flexion dorsiflexion Hindfoot varus hindfoot valgus
- 18. Dorsi flexion test Clinical examination
- 19. Lack of correctability seperates a true clubfoot from milder postural clubfoot Search for associated anomalies and neuromuscular conditions
- 20. PLUMBLINE TEST A plumb line drawn from the tip of patella through tibial tubercle should cut the foot at 1st or 2nd intermetatarsal space. In ctev it deviates laterally
- 21. SCRATCH TEST Detect muscle imbalance Medial scratch-everts-peroneals Lateral scratch-inverts-invertors
- 23. Curved Lateral Border MIDFOOT SCORES
- 24. Medial Crease
- 27. Empty Heel
- 28. Rigid Equinus
- 29. • Midfoot Score = Medial Crease +Lateral Head of Talus+ + Curved Lateral Border • Hindfoot Score = Posterior Crease + Rigid Equinus + Empty Heel. • Total Score Hindfoot & midfoot score. • measurement of overall deformity from 0 [no deformity] to 6 [severe deformity]
- 30. • Dimeglio et al Each major component of club foot is graded clinically from 4 ( most severe) to 1(most mild) - EQUINUS - HEEL VARUS - MEDIAL ROTATION OF CALCANEOPEDAL BLOCK - FOREFOOT ADDUCTUS Assessment of club foot by severity
- 32. • If clubfoot deformity is atypical imaging evaluation included • AP and lateral talocalcaneal angles • Tibiocalcaneal angle • Talus-first metatarsal angle RADIOGRAPHIC EVALUATION
- 33. Kite angle/talocalcaneal angle • Mid-talar line should pass through (or just medial to) the base of the 1st metatarsal • Mid-calcaneal line should pass through the base of the 4th metatarsal. • angle should measure between 30 and 55 degrees • usually <20° in a clubfoot
- 35. Lateral talo calcanealangle • Angle between mid tarsal axis and calcaneal inclination axis • Normal 25-50 degree • Decrease in ctev according to severity to an angle of 0 degree -parallelism
- 36. Tibio calcaneal angle Normal:5-15 Indicates extend of equinus Negative in ctev
- 37. Talar1st metatarsalangle • Angle between axis of the talus and 1st metatarsal • Usualy 5 to 15 degrees • Ctev:0 to negative
- 38. The goal of treatment To achieve a functional,pain free,plantigrade foot with good mobility and without calluses
- 39. Principle Soft tissue contractures should be stretched out in order to restore normal tarsal relationship. Once achieved correction should be maintained till tarsal bones remoulds stable articular surfaces. TWO OPTIONS – 1. NON OPERATIVE 2. OPERATIVE
- 40. HISTORY AND EVOLUTION Hippocrates 400BC–manipulation and bandaging Thomas(1834-1891)-forceful manipulations to correct the deformity SURGICAL MANAGEMENT-1970,80,90 PMR Correct the deformity at first .long term-stiff,painful,arthritis Kite method-1930 French method Ponsettis method
- 41. Non- operative • J.H Kite from 1924 to 1960 > 800 pts at Atlanta Scottish Rite Hospital • These outcomes were not reproducible in further studies Kite corrected each component of clubfoot deformity separately Fulcrum – calcaneocuboid joint. Order 1.adduction 2.varus 3.equinus
- 42. • He was adamant that one could not proceed to correct the next deformity until the previous one has been corrected. • Reason for failure of kites method-anatomically inaccurate method of manipulation, use of below knee cast • Kites method also required high numbers of castings
- 43. FRENCH METHOD(functional) Daily manipulation and stretching of foot Stimulation of underactive muscles particularly peroneal Strapping of the foot to hold in position Carried out by physiotherapist Higher level of input and cost required
- 44. Ignacio Ponceti • In 1960 s, he developed his non operative approach for club foot • At university of lowa,USA • After studying extensively anatomy of foot and ankle • Was slow to catch,accepted widely within the last decade
- 46. • Fulcrum-head of talus • Protocol- Stretching & manipulating the foot & applying holding casts & the correction maintained for 5 to 7days • 5 to 6 cast changes are sufficient to correct most clubfoot
- 47. Two phases-treatment and maintenance Treatment phase begun as early as possible Order of correction 1.Forefoot cavus 2.forefoot/midfoot adduction 3.Heel varus 4.Hindfoot equinus
- 48. 1st cast-corrects cavus deformity Further cast –abducting the foot around head of talus First bkc and then extended above knee upto groin Percutaneous tenotomy of tendoachilles done to correct equines deformity rapidly After tenotomy foot in the cast 70 degree abduction and 15 deg dorsiflexion –for 3 weeks
- 69. Complications of casting • Tight cast • Rocker bottom deformity • Crowded toes • Flat heel pad • Sores • Injury to distal tibial physis
- 70. T enotomy Indicated to correct equinus when cavus, adductus and varus fully corrected but ankle dorsiflexion remains < 10 degrees from neutral
- 71. • Foot held in maximum dorsiflexion • Tenotomy done 1.5cm above calcaneal insertion • Additional 25 to 30 degree dorsi flexion is required
- 72. Maintenance phase Final cast is removed and infant placed in a brace maintaining the foot in corrected position The brace(foot abduction orthosis)-shoes mounted in a bar 70 deg er,15 deg dorsiflexion In b/l case-nl leg 30-40 ER Distance between shoes 1 inch wider than width of shoulder Brace worn 23 hours each day –first 3 months Then while sleeping 3-4 years
- 76. Follow up protocol 2weeks-to troubleshoot compliance issues 3months-nights and naps protocol every4months-upto3yrs compliance and relapse every6months-until4yrs every1-2yrs-until skeletal maturity
- 77. SURGICAL Turcos Postero medial soft tissue release(<3yrs) • Posterior side: • Lengthen tendoachilles by Z- plasty • Release posterior capsule of ankle and subtalarjoint • Release posterior talo fibular and calcaneo fibular ligament
- 78. Medial side 3 tendons • Tibialis posterior • Flexor digitorum longus •Flexor hallucis longus 3ligaments • Talo- navicular • Superficial part of deltoid ligament • Springligament(calca neonavicular lig)
- 79. • 3 more structures • Interosseous talo-calcaneal ligament • Capsules of naviculo-cuneiform • Cuneiform-first metatarsal joints
- 80. Plantar side • Plantar fascia release • Flexor digitorum brevis and abductor hallucis release
- 81. Management of recurrence Recurrence due to non adherence with bracing Early recurrences treated with manipulation and casting Surgery after 18months Achilles tendon lengthening,plantar fascia release if dorsiflexion insufficient Anterior tibial tendon transfer if persistant dynamic inversion-3yrs Posteromedial release-2-3years Onestage extensile soft tissue release
- 82. Anterior tibialis transfer Tibialis anterior transferred from medial to lateral And fixed onto third cuneiform
- 83. • Limited soft tissue release • Mckay extensile release • Tendon transfers • Dwyer’s osteotomy • Dilwyn Evan’sprocedure • Litchblau procedure • Mubarak and van valin procedure • Wedge tarsectomy • Triple arthrodesis • jess • Ilizarov’stechnique
- 84. Extensive release includes posterolateral ligament complex-McKay Allows correction of internal rotation deformity of calcaneus Modified McKay –through a transverse circumfrential (CINCINNATI) incision
- 85. Lateral side • Release peroneal tendons • Incise calcaneofibular ligament • Incise lateral talocalcaneal ligament and lateral capsule of talocalcaneal joint • In more resisitant cases origin of extensor digitorum brevis,cruciate crural ligaments,dorsal calcaneocuboid lig,cubonavicular lig dissected off calcaneus to allow anterior portion of calcaneus to move laterally
- 86. Transverse cicinnati incision Begin from medial aspect naviculocuneiform Joint Carry incisison posteriorly transversely over Tendoachilles Curve over lateral malleolus and end it just Distal and medial to sinus tarsi Extend the incisison as required
- 87. Post op *Long leg cast with foot in plantarflexion for 2 weeks *At 2 weeks foot placed in corrected position 6 weeks cast removed *Ankle foot orthosis applied for maintenance
- 88. Treatment of resistant or residual clubfoot in older child *One of the most difficult problems in pediatric orthopaedics *Each child evaluated carefully *Prior surgical procedure causing scarring of foot noted *Most deformities due to undercorrection at the time of primary operation *Functional ability of child,severity of symptoms,likelihood of progression if untreated to be considered *Repeat manipulation and casting considered-part of the deformity corrected lessen degree of surgery required
- 89. *Surgery-soft tissue release and bony osteotomies *Depends on age,severity of deformity,pathological process involved *2-3years-modified mckay procedure *But if stiffness,avn talus,skin contractures-osteotomy *>5yrs-requires osteotomy *Common components of resistant clubfoot- Adduction+-supination of forefoot Short medial column/long lateral column Internal rotation and varus of calcaneus equinus
- 90. Forefoot adduction –multiple metatarsal osteotomy/combined medial cuneiform and lateral cuboid osteotomies Isolated heel varus + mild forefoot supination-dwyer osteotomy with lateral closing wedge osteotomy of calcaneum(ideal 3-4yrs) Hindfoot varus +residual IR calcnm+long lateral column of foot- Litchblau procedure(ideal 3+years) Residual midfoot deformities-talonavicular arthrodesis All three deformities >10years-triple arthrodesis Ilizarov method/jess-3D deformity correction- rigid,relapsed,untreated clubfoot
- 91. Dwyer osteotomy • Osteotomy of calcaneus • Opening wedge medial osteotomy to increase the length and height of calcaneus • Bone taken from tibia • For isolated heel varus • Modified method uses lateral incisions kwire fixn
- 92. Dilwyn Evan’sprocedure • For recurrent/ neglected cases between 4- 8 years old • PMSTR + calcaneo-cuboid wedge • Resection and fusion • Shortens lateral column • Long term stiffness of hind foot
- 93. Litchblauprocedure • Alternative to calcaneocuboid arthrodesis • Lateral closing wedge osteotomy of distal calcaneus along with medial soft tissue release • Shortens the lateral column
- 94. MUBARAK AND VAN VALIN SELECTIVE JOINT SPARING OSTEOTOMIES Rigid cavus and cavovarus Ankle/foot instability,pain,fractures Stepwise correction of deformity Closing wedge osteotomy 1st metatarsal Opening plantar wedge osteotomy med cuneiform Closing wedge osteotomy cuboid Osteotomy 2nd 3rd metatarsal Osteotomy calcaneus Plantar fasciotomy
- 96. Triple arthrodesis • Salvage sx for uncorrected clubfoot in older ,adolescent • For painful stiff foot • Correction of large degrees of deformity in neglected clubfeet • Lateral closing wedge osteotomy subtalar,midtarsal jts(cc,tn) • Post op stiffness but functional improvement
- 97. • TALECTOMY • Syndromic clubfoot • Severe untreated club foot • Uncorrectable by other techniques • Complete excision of talus • Derotate foot & displace calcaneum into ankle mortise until navicular abuts anterior edge of tibial plafond.
- 98. EXTERNAL FIXATORS JESS For difficult cases Rate of relapse/recurrence less Options of surgery always open
- 100. • COMPLICATIONS OF SURGERY • Neurovascular injury • Skin dehiscence • Wound infection • AVN talus • Dislocation of the navicular • Flattening and breaking of the talar head • Dorsal bunion
- 101. • Undercorrection/Overcorrection. • Forefoot adductus • Hindfoot varus • Severe scarring • Stiff joints • Weakness of the plantar flexors of the ankle
- 102. ATYPICAL/COMPLEX CLUBFOOT *Refractory to usual corrective manipulation *Rigid equinus,severe plantar flexion of all metatarsals,talus,calcaneus *Deep crease above heel,transverse crease in the sole *Short hyperextended first toe *High cavus *Normal neurologic examination *2/3rd –anterolateral bowing of tibia *Xray –talocalcaneal angle parallel both ap and lateral
- 104. TREATMENT *Modified ponsetti method *Increased no. of cast,relapse,surgical release *Place thumb over talar head,index finger over posterior aspect LM *Abduct the foot *Forefoot adduction is corrected *Plantarflexion of metatarsal corrected by-grasping the ankle with both hands and dorsiflexing the foot with both thumb under metatarsal *Knee casted in 110deg flexion *Percutaneous achilles tenotomy after plantarfl of mt corrected *2nd tenotomy may be required *Once 5def dorsiflexion and 40deg abduction-bracing
- 106. THANK YOU