2. Definition
īDevelopmental deformation of the foot characterized by
rotational subluxation of the talocalcaneonavicular joint
complex with Talus in plantar flexion and Subtalar complex
in medial rotation and inversion
4. Multifactorial causation
īEstablished by genetic epidemiologic research by Idelberger
ī32.5% concordance rate among monozygotic twins as
compared to 2.9% among dizygotic twins
īgenetic heritability of 80% .
Idelberger K. et al 1939; 33:272â276.
5. GENETIC FACTORS
īA major gene effect (inherited in recessive manner) with
additional polygenes and environmental factors
īcomplex segregation analyses of idiopathic clubfoot
populations. (de Andrade M ,1998)
ī deletion on Chromosome 2 (2q31-33) related to the
CASP10 gene.
Heck AL et al. J Pediatr Orthop 2005;25:598-602
7. Pressure theory
īConclusively disproved by Wynne-Davies
īconcordance between dizygotic twins was identical to the
non-twin sibling rate
īDizygotic twins âcrowdedâ into a single uterus did not
demonstrate a higher concordance with respect to non-twin
siblings.
8. Infective pathogens (enteroviruses)
īSeasonal variation with significant increase in CTEV
incidence was seen in the winter (DecemberâMarch ) in
some studies*
īInfective pathogens exhibiting seasonal activity
postulated as potential causes
īConflicting evidence âCarney et al (2005)**
* Barker SL. J Pediatr Orthop B 2002; 11:129â133.
** Carney BT. J Pediatr Orthop 2005;25:351-2.
9. Toxins and electromagnetic
radiation
īMaternal alcohol
consumption
(Halmesmaki et al. 1985)
īMaternal smoking
(Alderman et al.)
īPaternal smoking
(HONEIN M ,2000)
īHigh-power radio
transmitters
īThe results are
preliminary, and further
work is required
Irgens LM, et al.Teratology 1998;
57:34.
10. Drugs:
īSalicylate use in first
trimester
īPrenatal exposure to
barbiturates.
Chung C et al. Hum Hered. 1969;19:321-42
Maternal disorders
īMaternal anaemia
īMaternal hyperemesis
īThyroid disorders
Byron-Scott R, et al. Paediatr Perinat Epidemiol
2005;19:227-37.
11. Neuromuscular theory
īGray et al (1981) : increase in % of type I fibres in the soleus
muscle; suggested defective neural influence.
īRecent study**: no evidence of type I fiber grouping
** Milan B MD et al. Journal of Pediatric Orthopedics. 26(1):91-93, January/February
2006.
12. Vascular theory
īhypoplasia or absence of the anterior tibial
artery in majority of CTEV patients*
īabsence of the dorsalis pedis pulse in the
parents of children with clubfoot**
*Sodre H et al. J Pediatr Orthop. 1990;10:101-4.
**Muir L et al. J Bone Joint Surg Br. 1995;77:114-6.
13. Generalized disorder of development of
the limb
ī Lower limb in unilateral CTEV
- Redn in calf and thigh girth
- Significant shortening, most prominent
at ankle and least at femur
Shimode K, Myagi N, Majima T, Yasuda K, Minami A. J Pediatr Orthop [B] 2005;14:280-4.
16. Pathoanatomy of soft tissues
1. The plantar calcaneonavicular
ligament.
2. The tibionavicular ligament
3. The superior, medial and plantar
parts of the talonavicular capsule
4. The posterior tibial tendon
5. The master knot of Henry
6. The calcaneofibular ligament
7. The superior
peroneal(calcaneofibular)
retinaculum
8. The posterior talocalcanel ligament
9. The posterior capsule of the
tibiotalarjoint
10. The tendo Achillis
11. The interosseous ligament
12. The long toe flexors
17. Micro architecture
īincrease of collagen fibers and
cells in the ligaments.
īThe bundles of collagen fibers
display a wavy appearance
known as crimp.
īcrimp allows the ligaments to be
stretched.
īThe crimp reappears a few days
later, allowing for further
stretching
īTA : non-stretchable, thick,
tight collagen bundles with few
cells
18. Bony abnormalities
ī The tarsal bones, which are mostly
made of cartilage, are in the most
extreme positions of flexion,
adduction, and inversion at birth
ī The talus: severe plantar flexion, neck
medially and plantarly deflected, and
head wedge shaped.
ī Navicular: severely medially displaced,
close to the medial malleolus, and
articulates with the medial surface of the
head of the talus.
ī The Calcaneus adducted and inverted.
anterior portion of the Calcaneus lies
beneath the head of theTalus.
19. BIOMECHANICAL FACTORS
īTarsal joints are functionally interdependent. The
movement of each tarsal bone involves simultaneous shifts in
the adjacent bones.
īNo single axis of rotation
īNecessiates SIMULTANEOUS correction of adduction,
varus and inversion.
21. īA standardized examination initially and after each interval of
treatment
īreference posn, usually the knee in 90° of flexion, chosen.
īAll deformities assessed in relation to the next most proximal
segment
īExmn of the entire child to look for associated anomalies, esp the
spine.
22.
23. īFoot shorter and wider than
normal.
īTransverse plantar creases or
clefts at the midfoot and
posterior part of the ankle.
ī Atrophy of the calf
24. Assessment of equinus
ī posterior aspect of the calcaneus
must be palpated carefully when the
equinus is measured
īEquinus assessed with the knee
both in extension and in flexion.
īequinus with knee extended
-The true contractureof the
gastro-soleus muscle complex.
īThe difference between the
equinus in knee flex and extn
indicates the amount of stiffness
in the ankle joint.
25. ī heel is in varus but the forefoot is well
aligned with the heel.There is no
supination of the forefoot on the
hindfoot.
īThe varus of the heel at rest
and in the position of best
correction
īPosn of forefoot in relation
to midfoot
īPalpation of the lateral
column with the foot in
dorsiflexion
īTibial torsion
27. Congenital vs Acquired
CongenitalCongenital AcquiredAcquired
HistoryHistory Since birthSince birth Appears laterAppears later
BilateralBilateral In >50%In >50% Usually unilateralUsually unilateral
DeformityDeformity īĩEquinovarusEquinovarus
īĩForefoot adductionForefoot adduction
īĩCavusCavus
EquinovarusEquinovarus
Congenital grooveCongenital groove PresentPresent Not presentNot present
HeelHeel SmallerSmaller Usually maintainsUsually maintains
shapeshape
CalfCalf Cylindrical and toughCylindrical and tough NormalNormal
28. Classification Systems
TypeType
I(Extrinsic)I(Extrinsic)
Non RigidNon Rigid
TypeType
II(Intrinsic)II(Intrinsic)
RigidRigid
Foot sizeFoot size NormalNormal SmallerSmaller
HeelHeel īĩNormal sizeNormal size
īĩCan be broughtCan be brought
down with easedown with ease
īĩMinimal varusMinimal varus
īĩSmall , elevatedSmall , elevated
īĩCannot be broughtCannot be brought
down with easedown with ease
īĩMarked varusMarked varus
CreasesCreases More or less normalMore or less normal Deep medial,Deep medial,
posterior and lateralposterior and lateral
creasescreases
Reduced creasesReduced creases
laterallylaterally
TelescopingTelescoping NegativeNegative PositivePositive
29. Differential diagnosis
īClub foot like appearance in cong. absence or hypoplasia of
tibia and in cong. dislocation of ankle
īCareful palpation of Anatomical relationship and Radiograph
will establish the diagnosis
32. Limitations
1. Difficult to position the foot
2. The ossific nuclei do not represent the true shape
3. In the first year of life, only the talus, calcaneus, and
metatarsals may be ossified
4. Failure to hold the foot in the position of
best correction makes the foot look worse than it is
33. Plain radiograph
īThe foot should be held in the position of best correction,
with weight-bearing, or, if an infant is being examined, with
simulated weight-bearing
īFocused on the hindfoot (about 30° from the vertical for AP
view)
īLat. View: transmalleolar with the fibula overlapping the
posterior half of the tibia
34. AP Radiograph
normalnormal CTEVCTEV
AP TaloAP Talo
calcanealcalcaneal
angleangle
20 -50 deg20 -50 deg <20 deg<20 deg
Tarsal-1Tarsal-1stst
MTMT
angleangle
Upto 30 degUpto 30 deg
valgusvalgus
VarusVarus
anglulationanglulation
cuboid os.cuboid os.
center w.r.tcenter w.r.t
calcaneal axiscalcaneal axis
medialmedial
displacementdisplacement
40. ANTENATAL DIAGNOSIS
īIdeally done at 20 to 24 weeks
īRecent reports*: positive predictive value of 83% with a
false positive rate of 17%.
ī26% no Rx reqd; 61% reqd Sx
* Baron E, Mashiach R, Inbar O, et al. J Bone Joint Surg [Br] 2005;87-B:990-3.
41. Research tool
1. Recent study: to describe the morphological changes in a
comparative study of treatment methods
2. Used for demonstrating complete healing of TA at 3 wks
foll. Percutaneous tenotomy
43. ROLE OF MRI
īNOT used in routine clinical practice
īImportant tool in research studies
44. PIRANIâS MRI PROTOCOL
īSagittal images perpendicular to the bimalleolar axis
īOblique axial images perpendicular to the talonavicular joint
īOblique axial images perpendicular to the calcaneocuboid
joint
īOblique coronal images perpendicular to the subtalar joint
46. Oblique axial images perpendicular to the
talonavicular joint
īmedial talar neck
inclination,
ī medial talonavicular
displacement,
ī the wedge-shaped head of
the talus, and navicular
47. Oblique axial images perpendicular to the
calcaneocuboid joint
īthe wedge-shaped distal calcaneus
īMedial calcaneocuboid displacement
48. Oblique coronal images perpendicular to the
subtalar joint
īThe inverted and adducted calcaneus
īThe abnormal facets of the subtalar joint
50. Piraniâs severity scoring
īSix parameters 3 of midfoot and 3 of hindfoot taken into
account
īEach parameter is given a value as foll:
0 normal
0.5 moderately
abnormal
1 severely
abnormal
53. Uses of Piraniâs score
īAssessment of progress by serial plotting of the score
īPredicting need for tenotomy (hs>1& ms<1)
īEstimation of probable no. of casts reqd*
īvery 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
55. ICFSG
īIntroduced by Bensahel et al in 2003
īFound to have good interobserver reliability and
reproducibility**
īMorhological (12 pts), functional (24 pts) & radiological
(12 pts) parameters
īMaximum of 60 for most deformed and 0 for normal feet
**Celebi L et al J Pediatr Orthop B. 2006;15:34-36.
60. Aims of treatment
īStrong, painless, plantigrade and supple foot by conservative
management
īPlantigrade, painless foot that can wear shoes by surgical
means if conservative regimen fails
61. PONSETIâS METHOD
īDR. IGNACIO PONSETI
īIntroduction of Ponsetiâs
method and its wide spread
use over the last decade
following the publication of
long-term results has been
the most significant event in
the history of CTEV
62. Outline of Ponseti regimen
īSerial casting of the lower limb using a strictly defined
technique and weekly change of casts
īPercutaneous tenotomy of the tendo achilles for âhind
foot stallâ
īOnce the foot is corrected, an abduction foot orthosis
worn full time for 12 weeks, and then at nights and naps,
up to the age of four.
īTransfer of the tibialis anterior tendon for dynamic
supination deformity
63. Cavus correction
īCavus results from pronation of the forefoot in relation
to the hindÂfoot ââ THE PRONATION TWIST â
īAttempting to correct the supination of hindfoot before
correction of varus results in an iatrogenic increase in
cavus
īcavus corrected first by supinating the forefoot to place
it in proper alignment with the hindfoot.
64.
65. Varus, inversion, and adduction
correction
īvarus, inversion, and adduction of the hindfoot are corrected
after correction of cavus
īCorrection of all three components done simultaneously
as the tarsal joints are in a strict mechanical interdependence
70. Correction of equinus
īNo direct attempt at equinus correction is made until the
heel varus is corrected
īThe equinus deformity gradually improves with correction of
adductus and varus- calcaneus dorsiflexes as it abducts under
the talus
īResidual equinus- manipulation and casting +/-
percutaneous tenotomy
71. Percutaneous TA tenotomy
īTenotomy of the tendo Achillis is an integral step in the Ponseti
technique
īTenotomy is indicated when HS > 1, MS < 1(Piraniâs hindfoot
and midfoot scores resp.), and the head of the talus is covered
īThe best sign of sufficient abduction is the ability to palpate the
anterior process of the calcaneus as it abducts out from beneath
the talus .
72. 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
74. Complications of tenotomy
īHealing of ruptured tendon:
. Barker et al* used USG studies to demonstrate complete
healing of TA BY 3 weeks
. Bleeding:
Dobbs MB et al ** reported a 2% incidence of serious
bleeding following tenotomy
* Barker SL et al. J Bone Joint Surg [Br] 2006;88-B:377-9.
** Dobbs MB et al. J Pediatr Orthop 2004;24:353-7.
75. Bracing protocol
īApplied immediately after the last cast is removed, 3 weeks
after tenotomy
īThe brace consists of open toe high-top straight last shoes
attached to a bar
78. Bracing protocol
īworn full time (day and night) for the first 3 months after the
last cast is removed.
īAfter that, for 12 hours at night and 2 to 4 hours in the middle
of the day for a total of 14 to16 hours during each 24-hour
period.
īcontinued until the child is 3 to 4 years of age.
79. Significance of bracing
Haft et al**: noncompliance with bracing protocol â 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, 2007.487â493
80. Atypical clubfoot
ī2-3% Feet highly resistant to correction
īDeep skin creases, rigid and severe deformities, fibrotic
muscles
ī60 deg supination in 1st
cast.
īAK casts with knee in 120 deg flexn
īTenotomy after correction of hyperflexion of
metatarsals
īPost tenotomy casts changed every5 days
81. Follow up protocol
ī 2 weeks: to troubleshoot compliance
issues.
ī 3 months: to graduate to the nights-and-
naps protocol.
ī every 4 months: until age 3 years to monitor
compliance and check for relapses
ī every 6 months: until age 4 years.
ī every 1 to 2 years: until skeletal maturity
83. Treatment of relapse
īEquinus relapse: corrective casting +/- percutaneous
tenotomy in child < 2 yrs;
TA lengthening in older children
īVarus relapse: recasting and restitution of bracing
84. Dynamic supination deformity
ī persistent varus and supination during walking
ī thickening of lateral plantar skin.
ī Will require anterior tibialis tendon transfer
ī fixed deformity corrected by casts before
transfer.
ī best performed when the child is between 3
and 5 years of age.
ī delayed till radiographs show ossification of
lateral cuneiform.
ī No bracing is necessary after the procedure.
85. Results of Ponsetiâs method
ī The key paper by Cooper and Dietz in 1995.
ī reviewed a group of 45 adults, with 71 clubfeet, who had been managed with
the Ponseti method, 30 years after treatment.
ī The results were compared with NORMAL CONTROLS.
ī Based on structured examination, radiographs, electrogoniometry and
measurements using a pedobarography.
ī Using the Laaveg and Ponseti score, the results in the normal controls and in
those with treated clubfeet were the same.
ī Radiographs showed that the feet were not completely corrected, but
functioned well despite this.
Cooper DM, Dietz FR. J Bone Joint Surg [Am] 1995;77-A:1477-89.
86. Results of Ponsetiâs method..
īstudy from Iowa (2004) described the short-term results of a
more recent series of 256 feet.
īCorrection obtained in 98% with one to seven casts.
ī 2.5% required extensive corrective surgery.
īPercutaneous tenotomy in 86%.
ī The mean angle of dorsiflexion : 20° (0° to 35°).
ī Minor cast complications in 8%
īRate 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.
87. OUTCOME AFTER CORRECTIVE SURGERY â
A STARK CONTRAST
īLaaveg and Ponseti scores: 0% excellent, 33% good, 20% fair and
47% poor results.
īsignificantly reduced scores in physical functioning, role physical,
general health, vitality, social functioning and physical components
īsimilar to those with pain in the cervical spine with
radiculopathy,Parkinsonâs,haemodialysis, CHF and those awaiting
CABG
ī Dobbs MB, Nunley R, Schoenecker PL. Long term follow up of patients with clubfeet treated with extensive soft-tissue release. J Bone
Joint Surg [Am] 2006;88-A:986- [on 73 feet in 45 patients after a minimum follow-up of 25 years ]
88. Ponseti regime Vs surgical correction
īCT at skeletal maturity
īmanipulation and serial casting, followed by posteromedial release
for the resisting feet vs modified Ponseti regime [open z-
lengthening of TA]
īPonseti group: better correction of cavus, supination and
adduction
Ippolito et al. J Bone Joint Surg [Br] 2004;86-B:574-80
89. Ponseti Vs Kite technique
PonsetiPonseti KiteKite
Mean followMean follow
upup
(months)(months)
2929 5454
ResidualResidual
deformitydeformity
6%6% 44%44%
Need forNeed for
surgerysurgery
6%6% 57%57%
Segev E, Keret D, Lokiec F, et al. Early experience with the Ponseti method for the treatment of congenital
idiopathic clubfoot. Isr Med Assoc J 2005;7:307-10.
90. Modifications of Ponsetiâs method
ACCELERATED PONSETI PROTOCOL
īMorcuende et al , (2005) 7 day Vs 5 day interval
īAverage time to tenotomy: 16 days in 5 day group and
24 days in 7 day group
Morcuende JA, Abbasi D, Dolan LA, Ponseti IV. Results of an accelerated Ponseti protocol for clubfoot. J
Pediatr Orthop 2005;25:623-6
91. Botulinum toxin injection into the
gastrocsoleus
īAlvarez et al (2005)*: alternative to Achilles tenotomy
producing satisfactory results with less skin scarring and deep
tissue fibrosis
īprospective RCT(Cummings et al,2005)**:NO significant
difference between injections of a placebo or Botulinum
toxin.
* Alvarez CM, Tredwell SJ, Keenan SP, et al. J Pediatr Orthop 2005;25:229-35.
** Cummings RJ, Shanks DE. POSNA Annual Meeting,
92. Paramedical staff-delivered Ponseti
service
īGood results can be achieved by trained physiotherapists and
orthopedic clinical officers
īenables many families in rural and remote areas to receive
treatment which would otherwise have been inaccessible and
unaffordable.
Shack N, Eastwood DM.. J Bone Joint Surg [Br] 2006;88-B:1085-9.
Tindall AJ et al.J Pediatr Orthop 2005;25:627
93. Application in neglected club foot
īLourenco et al,2007: retrospective study on 17 children (24
feet) presenting after walking age (mean age 3.9 years)
īCorrection in 66.67% with ponsetiâs method alone.
ī A. F. Lourenço, MD et al. Journal of Bone and Joint Surgery - British Volume,2007. Vol 89-B, Issue 3, 378-
381.
94. The French method
īBensahel/Dimeglio regime
īdaily manipulations by a skilled physiotherapist and temporary
immobilisation with elastic and non-elastic adhesive taping
īmobilisation during the hours of sleep with CPM machine
īSuccessful 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.
95. Custom AFOâs
īManipulation and appln of
adjustable hinged orthosis
īDyanmic splinting
īCorrection reported in
76% of cases with mild to
severe CTEV **
**Adnan A.Faraj et al.Foot and Ankle Surgery.Volume 10,Issue 2,
2004,Pages 57-58
96. Dennis Browne splint
ī The childâs âphysiological motionsâ
are used to correct the deformity
ī Application of corrective shoes
attached to a bar allowing
progressive external rotation of the
foot
ī Constant kicking by the infant
stretches the contracted tissues
correcting the deformity
..
99. RELAPSED VS NEGLECTED CTEV
Relapsed CTEV
īInitial correction done and
susequent deformity less
severe
īPost surgical: extensive
scarring and stiff foot
Neglected CTEV
īDeformity severe and
worsens as child starts
walking
īLateral skin callosities and
fissures- prone to infection
100. Surgical correction
ī2-4 years :
īSoft tissue release
ī4 â 11 years :
īSoft tissue release with
īOsteotomy performed according to the deformities
ī>11 years :Salvage procedures:
īTriple arthrodesis
īTalectomy (astragalectomy)
102. EXTENT OF RELEASE
ī"Ã LA CARTE" approach [Bensahel]
-Full posteromedial plantar lateral release only if All
components of deformity present
-postr release: persistent isolated equinus
īTurcoâs âone size fits allâ approach
103. TIMING OF SURGERY
ī3-6 months: high remodelling potential in 1st
yr of life
ī9-12 months: pathoanatomy clearer and surgery easier to
perform
īSimons: size of foot >8 cm.
104. Incisions
ī TURCOâS APPROACH
ī hockey-stick posteromedial type of
incision
ī Crosses the skin creases on the
medial side of the foot and ankle.
ī more difficult to reach the
posterolateral structures, origin of
plantar fascia
106. Carollâs two incision technique
īmedial incision - straight
oblique incision from the
first metatarsal, across the
medial malleolus to the
Achilles tendon
107. īA second short, straight
lateral incision made
along the lateral subtalar
joint antr to distal fibula
108. Medial Plantar Release
īposterior and medial subtalar joint capsule (leaving the
interosseous ligaments intact),
ī talonavicular joint capsulotomy (including the spring
ligament and bifurcate Y ligament),
īmedial calcaneocuboid joint capsulotomy,
īknot of Henry,
īthe abductor hallucis,
īlengthening of posterior tibial tendon
īThe plantar fascia, if cavus is present
109. Structures preserved
īThe dorsal structures-
tibialis anterior and
extensor tendons,
īneurovascular bundle,
īthe deep deltoid ligament
110. Posterior release
īrelease of the posterior capsule of the ankle and subtalar joint
īopen Achilles tendon lengthening.
īThe posterior talofibular ligament
113. Soft tissue release
īFollow up :
īWound inspection done under sedation at 1 week
īFoot held in neutral, plantigrade position and cast applied â
above knee
īCast kept for 4 â 6 weeks
īCast removed along with any K wires, if applied during surgery
for stabilisation
īAFO given for 6 months
115. Osteotomies
īSoft tissue release alone may not fully correct the deformity
because of secondary bony deformity.
īThe combination of this soft tissue release with midfoot
osteotomy is usually required in children between
approximately 4 and 12 years of age
116. Correction of Adductus
ībony lateral column is longer than the medial column,
īrelative lengthening of the lateral portion of the anterior
process of the calcaneus
īobliquity of the calcaneocuboid joint
īShortening through the distal calcaneus to make the
calcaneocuboid joint transverse.
117. Litchblau procedure
īexcision of the anterior
process of calcaneus
īCalcaneocuboid
Pseudoarthrosis
īStiffness minimized
īPreferred in younger
children
118. Dilwyn Evans Osteotomy
īcalcaneocuboid wedge resection
īArthrodesis of the joint
īReduced risk of relapse
īStiffness at subtalar and midfoot joints
īPreferred in older children
119. TRANS-MIDTARSAL OSTEOTOMY
īKÃļse et al., in 1999, described trans-midtarsal osteotomy
for>6yr olds
īopening-wedge osteotomy of the medial cuneiform and
īdorsal, truncated wedge osteotomies of the middle and
lateral cuneiforms
īBetter correction of rotational and cavus deformities
120. Correction of Equinus
īadequacy of release of the lateral tether
īlateral column shortening
īexcision of a portion of the head of the talus or
naviculectomy.
īfinal resort is to consider adding a distal tibial dorsiflexion
osteotomy.
121. Correction of Calcaneal Varus
īCalcaneal varus corrects as
the foot abducts after medial
soft tissue release.
īPersistent calcaneal varus: a
lateral slide osteotomy of the
calcaneus is performed
ī Alternative: Dwyer lateral
closing wedge osteotomy
122. Correction of CAVUS
īSteindlerâs release of plantar fascia
īJapas âVâ osteotomy
īPatients >6 years
īRigid cavus
īAllows midfoot correction without foot shortening
īAkron midtarsal Osteotomy :
īCorrection at midfoot
īA dome shaped osteotomy for dorsoplantar and varus / valgus control
123. Salvage procedures
TRIPLE ARTHRODESIS
īSalvage procedure for pain after previous surgical correction.
īCorrection of large degrees of deformity in neglected
clubfeet.
īNot performed before advanced skeletal maturity, at age 10
to 12.
124.
125. TRIPLE ARTHRODESIS
ī Modification of the classic
lambrinudi triple arthrodeses
ī Resection through the talus should
be minimized because of its
tenuous blood supply and
ī Most of the correction made
through the calcaneus.
ī Recent study in Uganda: 92%
patients happy with the procedure
126. TRIPLE ARTHRODESIS
TWO STAGE :
īextensive posteromedial
release + triple arthrodesis
īminimizes bone rescection
īrisk of AVN talus
SINGLE STAGE
ARTHRODESIS:
ī less time consuming
ī reduced risk of AVN
Penny, John Norgrove 2005.Uganda
128. Ilizarov
1) Correction slow enough to protect soft tissues;
2) correction at the focus of deformity,
3) simultaneous three-dimensional, multilevel correction;
4) deformity correction without shortening the foot;
129. Ilizarov
īRings are fixed to the tibia connected to half rings for the
calcaneus and the forefoot.
īAsymmetric distraction corrects the various deformities
ībony deformity not severe,(<8 yr): unconstrained frame
īSevere deformities,(>8 yrs): distraction osteogenesis
through osteotomies using constrained frame with hinges
133. Results with Ilizarov
īgood 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
īRecent 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
135. JESS
ī2 to 4 transfixing wires in
prox tibia
īMetatarsal segt:
Transfixing wire throâ
I &V MT; Medial half pin
throâI, II, III MT; Lat half pin
throâ IV, V MT
ī2 transfixing and 1 axial wire
thro calcaneum
136. JESS
īFractional, differential distraction used to Sequentially
correct deformities.
īDistraction continued until approximately 20 degrees of
dorsiflexion and overcorrection of the forefoot
deformities was achieved
īmaintained in this overcorrected position for twice as
long as the distraction phase by casts/braces
137. Results with JESS
īGood or excellent results reported by Joshi in 84% of his
patients
īRecommended in all who have not responded to serial
plaster casting methods.
īSimilar good results have been reported by other authors**
**Suresh et al,2003. Journal of Orthopaedic Surgery 2003: 11(2): 194â201
138. Advantages over Ilizarov
īThe wires are not tensioned
īstability depends on the placement of the wires, the use of
half pins and pre-tensioning.
īHinges are not used in this method.Thus the corrective
forces are not directed along a single axis, instead, the soft
tissue envelope in conjunction with the shape of the
articulating surfaces guide the correction.
ī frame is less bulky, is less expensive, and more simple to
apply
139. Complications of surgery
īWound infection
īSkin dehiscence
īSevere scarring
īStiff joints
īOver/under correction
īDislocation of the navicular
īFlattening and breaking of the talar head
īAVN of the talus
īWeakness of the plantar flexors of the ankle
140. Skin dehiscence
īCincinnati incision, neglected clubfeet
īleft in partly corrected posn in post op cast & remanipulation
done at 1 to 2 weeks .
īLocal rotation flap from the dorsum of the foot (Mittal,1987)
īPosterior V-Y advancement flap.
141. Rotation flap
īFlap taken superficial to
venous plexus
īLarge proximal base
ensures adequate blood
supply
142. conclusion
īProper understanding of the pathology and kinematics of
clubfoot, meticulous application of therapeutic methods,
laying stress on parental education to ensure compliance and
resorting to surgery only as the last resort, and is essential to
successful therapy of this complex condition