Orthopeadics

1. CONGENITAL TALIPES
EQUINOVARUS
DR SAHIL SARWAL
SENIOR RESIDENT-1
MMIMSR, MULLANA
AMBALA
C/O SARWAL HOSPITAL

2. Defination
 Word talipes made of two latin words reffering to Ankle(talus)
and Foot (pes).
 Development deformation of foot path-anatomically defined
as rotational subluxation of TCN joint complex, with talus in
plantar flexion and subtalar complex in medial rotation and
inversion.
 Incidence is approx. 1 in 1000 live birth, bilateral deformities
occur in 50% of patients. Males are more commly affected than
females.
 It’s a classical presentation.

3.  Deformities are combination of the following
components that may vary in severity.
1. Equinus at ankle:- ankle joint planter flexion,
inversion of TCN joint and plantar flexion of
forefoot.
2. Varus & IR of heel:- occurs at TCN joint when
whole tarsus is rotated inward except talus.
3. Adduction+supination:- forefoot is rotated inward.
4. Cavus:- Relative pronation of forefoot compared to
hindfoot.
5. Internal tibial torsion.

4. ETIOLOGICAL FACTORS
 Extrinsic factors
 Intrinsic factors

5. Genetic factors
 Deletion of chromosome 2 (2q 31-33) realtes CASP
10 gene.
 Trisomy 12,18,21.

7. Neuromuscular defect
 Spina bifida and AMC , based on histopathological
findings.
 Increase in % of collagen fiber type I
 Retracting fibrosis “crimp” .

8. Vascular theory
 Hypoplasia or Absence of anterior tibial artery in
the childrens
 Posterior tibial artery absence in parents.

9.  Germplasm defect
 Anomalous tendon insertion
 3D development bony deformity of subtalar
comples.
 Congenital atresia of talonavicular joint.

10. Biology of developing
clubfoot
 Combination of soft tissue contractures & secondary bone
changes.
 There is excessive pull of tibialis posterior reinforced by
gastrosoleous, tibialis anterior, long toe flexors. Muscles are
also shorter and smaller as compared.
 The “crimp collagen” arises from gastrosoleous and
spreads to whole Tendo-achilles and deep fascia tightening
the structure.
 Size of muscle is inversely proportional to the severity of
deformity.

11.  Ligaments of posterior & medial aspect of the ankle
& tarsal joints are very thick and taut, foot in
equinus,navicular and calcaneum in adduction and
inversion.
 Master knot of henry, B/W FDL & FHL
 Malpostion of tarsal bones and joints which are in
extereme postion of flexion, inversion,adduction

12. Findings
 Absence of dorsiflexion even on application of strong
pressure(dorsiflexion test)
 Characterstic CTEV deformity will have equinus, inversion,
varus, adduction.
 Medial border is concave , elevated and its plantar surface
faces upward.
 Lateral border is convex and depressed downward.
 Post tuberosity of heel is pulled upward, difficult to palpate.
 Skin over post. Tuberosity of calcaneum is smooth and lack
wrinkles.

13.  Boney prominence over dorsolateral aspect of foot
represents head and neck of talus
 Scar and callosities are features of patient walking
on the deformity and are seen in neglected cases.
 Patients with severe deformity have “stumbling
gait”.
 Plumb line test.

14. Radiology
 Ossification center
Calcaneus :- 5-6 months
Talus :- 8 months
Metatarsals :- 10 week of gestration
Cuboid :- at birth
cuneiforms :- 2,3,5 years.
Navicular :- 3-4 years.

15. Plain radiography
LIMIATIONS
 Difficult to position the foot
 The ossific nuclei do not represent the true shapes
 In 1st year of life only talus, calcaneus and
metatarsal may be ossified.
 Faliure to hold the foot in postion of best correction
makes the foot look more worse.

16. Plain radiograph
 The foot should be held in the postion of best correction
with weight-bearing or simulated weight bearing
 Ap view.
 Kites view
Normal Ctev
Ap talo-calcaneal angle 20-50 degree < 20 degree
Talo-1st Metatarsal
angle
Upto 0-20 valgus Varus angulation

17. Lateral view
 Talo-calcaneal angle is 25-50 degree in normal foot
in CTEV it’s <25 degree.

18. Ultrasonography
 Ideally done at 20-24 weeks
 Postive predictive value of 83% with a false postive
rate of 17%.

19. MRI
 NOT used in routine clinical practise.
 Important tool in research studies.
 PIRANI’s MRI Protocol
1. Sagittal images perpendicular to bimalleolar axis.
2. Oblique axial image perpendicular to talonavicular joint
3. Oblique axial image perpendicular to calcaneocuboid
joint.
4. Oblique coronal images perpendicular to subtalar joint.

20. PIRANI’S SEVERITY
SCORE
 6 parameters : 3 of midfoot and 3 of hindfoot taken
into account
 Each parameter is given a value:-
0  normal
0.5  moderately abnormal
1  severely abnormal

21. MID-FOOT SCORE

22. HIND-FOOT SCORE

23. Use of Pirani’s score
 Assesment of progress by serial plotting of score.
 Predictive need for tenotomy.
 Estimation of probale no. of casts required.
 Very good interobserver ability and reproducibility.

24. ATTENBOROUGH
classification in 1966

25. DIMEGLIO’s classification

26. classification

27. Treatment
What should be Goals of treatment to achieve??
1. A plantigrade, pliable, functional and cosmeticaly
acceptable foot.
2. A long lasting correction.

28. OBJECTIVES
 To look good, feel good, move good, measure good.
 Maintain the reduction
 Establish balance muscular acitvity
 Produce normal function and movements

29. NON-SURGICAL
TREATMENT
 Initial management of clubfoot is non-surgical that
should be started as soon as possible.
 Manipulative treatment:- start as soon possible after
birth, assistant hold the foot while manipulator
perform the correction.
 Movement of each tarsal bones involves
simultaneous shift in adjacent bones.

30. Kite’s method of
manipulation
 Adductioninversionvarusequinus.
 Foot is grasped by both hands, thumb tips press
over the lateral bony prominence formed by cuboid
& 5th MT, fingers about heel and MT pull these
structures into abduction and eversion, cast is
applied.
 Cavus is corrected next by pressing the foot on a
glass plate.
 Equinus is corrected last.

31. DRAWBACKS
 Results were not very encouraging & unsatisfactory with this
method.
 Rate of surgical intervention was also very high.
 Error
1. Premature attempted by direct abduction of forefoot locks the
calcaneum beneath the talus and make it immobile.
2. Realtive pronation of forefoot in relation to hindfoot is casue
for cavus deformity.
3. Choosing lat. Prominence instead of talar head for counter
pressure.

32. PONSETI’s METHOD
DR. IGNACIO PONSETI
Introduction of ponseti’s
Method and it’s 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.
• Popular.
• Satisfactory results.
• Low rate of relapse.

33. Outline of Ponseti regimen
 Principle:- kinematic cupping
 Manipulative correction with serial of casting lower
limb using strictly define technique and change of
casts.
CAVUSADDUCTIONVARUSEQUINUS
 Percutaneous tenotomy of tendo achilles and
casting hasten equinus.
 Once corrected. An abduction foot orthosis is worn
fulltime for 12 weeks and night splints is worn.

34. Cast application

38. Complications
 Tight cast
 Rocker bottom deformity
 Crowed toes
 Flat heel pad
 Pressure sores

39. Percutaneous tenotomy
under LA
 Foot held in max dorsiflexion by assistant
 Tenotomy done 1.5 cm above calcaneal insertion
 Additional 25-30 deg dorsiflexion obtained
 Cast with foot abducted 60-70 degree with respect to frontal
plane of ankle and 15 degree dorsiflexion for 3 weeks.

40. FAB
 The width of bar matches the
width of shoulders and feet.
 Shoes mounted to bar in position
of 70 deg of abduction and 15
deg of dorsiflexion in B/L cases,
for U/L cases 30-5- deg of
abduction.
 Knees left free, so the child can
kick straight to stretch
gastrosoleus tendon.

41. Bracing protocol
 Worn 23 hrs each day for 1st 3 months, 1 hr out for
hygeine and toilet.
 After 3 months the FAB is applied only during
sleeping time for minimum of 4 years.
 Frequent change of brace.
 Never attempt to give bracing holidays
 Inspect brace for loosing of screw, straps and foot
structure.

42. BRACING FOR CTEV
 Ankle foot arthrosis
 Wheaton’s type braces(knee ankle foot arthrosis)
 Kessler brace
 Steenbeek brace
 Horton’s click brace
 Dennis browne shoe/bar/splint.

44. Follow up protocol
 2 weeks: To troubleshoot compliance
 3 months: to graduate to the nights and naps
protocol
 Every 4 months: until age 3 years to monitor
compliance and check for relapse
 Evry 6 months: untill age 4 years
 Every 1-2 years: until skeletal maturity

45. SURGICAL
MANAGEMENT
 Soft tissue surgery
 Bony surgery
 Combined soft tissue and boney surgery
 Correction of deformities by ex. Fixation.

46. Soft tissue surgery
 Goal : address all patho-anatomic structures.
 Decision regarding timing, extent
 “A la carte” approach
 Percutaneous tenotomy of TA
 Open Z lengthening of TA
 Tendon transfer(TA, SPLATT)
 Turco “one size fits all” approach(PMR)

47.  TURCO involves release of post, medial,plantar and
subtalar soft tissue contracture in one stage
 Medial release post and medial subtalar joint,
talonavicular capsule, spring ligament, knot of
henry, abductor hallucis
 Post release ankle joint capsule, subtalar joint
capsule, achilles tendon Z- lengthening,
 Lateral release lat. Subtalar joint capsule, peroneal
tendon sheath, EDB,Cacaneocuboid lig.
 After release, surgical correction is temp stabilized
by fix. Talonav and talocal joints with k wires.
 Cast is changed under GA after 3 weeks, wires are
removed at 6 week if full dorsiflexion is possible.

48. Approach

49. Extensile posteriomedial
and posteriolateral release
 Modified Mckay’s procedure
 Cincinnati approach
 Caroll”s two incision procedure utilizes postmedial
incision similar to turco’s and a small lateral insicion
over subtalar joint.

50. BONY PROCEDURE
Done in children above 5 years of age.

53. Talectomy

54. EXTERNAL
DISTRACTION DEVICES
 Wangner’s device
 Joshi’s
 Ilizarov’s apparatus

55. Ilizarov fixator

56. JESS

57. Results with JESS
 Good and excellent result shown in 84% of patients
 Recommended in all who have not responded to
serial plaster casting methods
 Semi-invasive, blood less surgery
 Avoid fibrous tissue formation

58. COMPLICATION WITH
SURGRIES
 NV injury
 Wound infection, Skin dehisence
 ON talus, Disclocation of navicular
 Stiff joints
 Weakness of plantar flexors of ankle
 Loss of correction
 Skewfoot
 Overcorrection
 Undercorrection
 Dorsal bunion

59. Take home message
 Proper understanding of patho-anatomy a must
 Ponsenti method is now the standard treatment
method(given a clubfoot deformity to an orthopedician
will apply cast to the foot before the child is born if it is a
breech delivery)
 Bracing is an important component
 Neglected and long-standing cases need surgical
correction.
 Judge case to case by expert dealing with CTEV for soft
tissue procedure

60. THANK YOU