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Clubfoot

Congenital Talipes Equino Varus


(CTEV)
Definition

Twisting of the scaphoid, os calcis and


cuboid around the astragalus
Congenital Talipes Equino Varus or club foot
has 4 basic deformation:
1. fore foot : adduction
2. hind foot : inversion or varus
3. hind foot : equinus
4. mid foot : cavus
Incidence : - (1-2) per 1000 births
- male : female = 7:5
- 50% bilateral

Incidence : of CTEV in various races

Race Cases per


thousand birth

Chinese 0.39
Japanese 0.53
Malay 0.68
Filipino 0.76
Caucasian 1.12
Puerto Rican 1.36
Indian 1.51
South African black 3.50
Polynesian 6.81
Tachjian, The child foot
ETIOLOGY

 Chromosomal theory
 Embryonic theory
 Otogenic theory
 Fetal theory
 Neurological theory
 Muscular theory
ETIOLOGY
Chromosomal theory
defect : in unfertilized germ cell (defect exists
before fertilization)
ETIOLOGY
Embryonic theory
defect : within fertilized germ cell
Occurs : between conception-12 weeks (Irani,
Sherman and Settle)
ETIOLOGY

Otogenic theory (arrest theory)


arrest of development
related to a change in genetic factor known as “cronon”
Cronon : guide the precise time of the progressive
modification every structure during development
ETIOLOGY

Neurologic theory
Muscular theory
ETIOLOGY
Fetal theory (packing syndrome)
Intrauterine packing (mechanical factors)
Schematic illustration of the critical periods in human development. During the first two weeks development, of the embryo is
usually not susceptible to teratogens. During these pre-embryonic stages, a teratogen either damages all or most of the cells,
resulting in its death, or damages only a few cells, allowing the conceptus to recover and the embryo to develop without birth
defects. Red denotes highly sensitive periods when major defects may be produced (e.g. amelia, absence of limbs). Yellow
indicates stages that are less sensitive to teratogens when minor defects may be induced (e.g. hypoplastic thumbs)
Ponseti : genetic, embryonic malformation, collagen
over production in ligament, collagen
Etiology fibres wavy arranged, dense, many cells

Week
0 5 8 12 20 30 TERM

Otogenic theory -- arrest theory


- chromosomal theory
- Cronon : genetic factor which
polygenic (multi factorial) Intra uterine pressure
determine the precise time for
- defect in unfertilized primary muscle (packing syndrome)
progression modification during
germ cell : abnormality?
development
- in family
- Cronon may be changed by certain
- race (palynesia-Maori)
element (teratogen)  abnormal
development of the limb
- Embryonic theory
- growth arrest : permanent, temporair,
(0-12) weeks
slowed growth permanent deformity
defect occurs during
temporary CTEV, slow – steroid
fertilized germ cell
- occur during (7-8) week  marked CTEV
- occur during (9-12) week  moderate
to mild CTEV
Specification defect (Hoofnick)
limb specification at 5 month (teratogen)
- neuromuscular
- vascular CTEV : post
- bone specification defect
PATHOANATOMY

 Major deformity
• Inward rotation of the whole foot on the talus
 Rotation primarily takes place in :
• talocalcaneal joint
• talonavicular joint
• calcaneocuboid joint
PATHOANATOMY

Talocrural (ankle ) joint :


• Talus in equinus
• Talus in mortise = external rotation (horizontal breach)
• Posterior = capsule & ligament contracted
“Horizontal breach” according to the concept of Swann,
Lloyd-Roberts, and Catterall
PATHOANATOMY

TALUS
 Constriction encasement

 Head & neck : medial & plantar deviation


PATHOANATOMY

TALOCALCANEAL JOINT:
Calcaneus :
rotation in 3 dimensions :
• Sagittal
• Coronal
• Horizontal
Pathomechanics of talipes
equinovarus
A. Posterolateral view of the
calcaneus and talus of normal foot. B.
Lateral rotation of the talus, C. The
anterior part of the calcaneus is
pressed by the head of the talus and
forced into plantar
flexion, rotation, and varus position.
(From Carroll, N., Murphy, R, and
Leete, S.F. : The pathoanatomy of
congenital clubfoot, Orthop.Clin.N.
Amer., 9 : 227, 1978)
The articular relationship of the calcaneus to the talus as seen from the front in the left foot.
Pathoanatomy

Talonavicular joint :
 Navicular : displaced medial & plantarward
 Tib.posterior tendon
 Tibio-navic. Ligament (deltoid lig.)
 Calcaneo-navic.lig. (spring lig.)
 Talo-navic. Ligament contracted
 Bifurcate ligament
 Cubonavic. Oblique ligament
 All navicular ligament
PATHOANATOMY

Calcaneo-cuboid joint:
 Cuboid displaced medially on calcaneus and under navicular &
cuneiform
 All ligaments : contracted
 Forefoot : supination and adduction
 Calcaneo-cuboid joint corrected nicely if other 2 subtalar
complex are corrected except in resistant CTEV
PATHOANATOMY

Muscles
 Imbalance between agonist and antagonist
 Muscles tonus determined by the amount of muscle
fibres type I & II
 All muscle below knee in CTEV fibre Type I > II [similar
with L.M.N lesion : AMC, sacral agenesis, Charcot-
Marie, post poliomyelitis]
 Some CTEV tendency to be recurrent
PATHOANATOMY
Vascular
By Doppler Technique :
 In normal population : a.dorsalis pedis 2.2.% absent

 In mild & moderate CTEV : a.dorsalis pedis = normal

 In severe CTEV : a.dorsalis pedis = 6.7% absent


MECHANISM of the CTEV

 Fetal posture abnormality :


foot in equinovarus
 Muscle imbalance : tib.
post. contracted
 Factors determine the
severity of the CTEV

Intrauterine position. The hips are always


flexed and externally rotated, while the knees
are usually flexed and the feet turned inward
EXAMINATION

 History
 Physical examination
 Radiologic examination
Radiology : age more than (4-5) months

N : AP : talo-calcaneal angle :
(200-400), CTEV < 200
Lat : talo-calcaneal angle :
(350-500), CTEV<350
DIAGNOSIS

1. Non rigid type (packing syndrome)


2. Rigid type :
• Moderate
• Severe
3. Resistance rigid type :
• AMC
• Myelomeningocele
• Constriction band
DIFFERENTIAL DIAGNOSIS

1. Constriction bands (Streeter disease)


2. A.M.C
3. Myelomeningocel
4. Sacral agenesis
5. Tibial agenesis
6. Charcot-Marie disease
Constriction bands
Arthrogryposis Multiplex Congenita
Spina bifida
Sacral agenesis
Tibial agenesis
Charcot-Mary disease
TREATMENT

The goal of treatment :


• Realign the os calcis, scaphoid and cuboid
around the astragalus by correcting the varus,
adduction, varus and equinus
• Maintain the correction until stable
 normal function, no pain, plantigrade, good
mobility, no callus formation, wearing normal
shoe
HISTORY
 Egyptian : tomb painting
 India (1.000 BC) : Tx
 Hippocrates (400 BC) : manipulative Tx,
early Tx
 Indian (Aztecs) Pre Columbian American
Tx : splint with cactus leaves
HISTORY : 20th century

Hugh Owen Thomas (1834 -1891)

Wrench
W.H. Trethewan (1882-1934) :

Thomas Wrench is a barbarous weapon


TREATMENT

1. Conservative
2. Operative
Conservative treatment

Golden period:
• 1st week
• laxity :estrogen

1. Serial plastering
2. Stretching  Dennis Brown splint
3. Adhesive strapping
4. Physiotherapy
HIRAM KITE :
Brought Hippocrates’ view info focus :
Stressing slow, gentle, manipulative correction of
the adduction, varus and equinus with minimal
surgery

Three magic words for the successful and


enthusiasm carrying out his
treatment : knowledge,patience andenthusiasm
Ponseti :
Concept biomechanical
understanding

SURGERY is the wrong approach for the treatment of the clubfoot.


Ponseti
Ponseti
Based on kinematic of the subtalar joint.
1st concept : the whole foot moves under the talus “calcaneo-
pedis block”
2nd concept : fore foot and hind foot are corrected
simultaneously by abduction
Equinus correction :
• mostly close tenotomy
• tendo achilles non stretchable collagen, thick and
stiff
COMPARISON KITE and PONSETI treatment

Clubfoot

1. Adduction
2. Varus
3. Equinus

KITE PONSETI

Correction by serial plastering :


4 Cavus and pronation
Correction by serial plastering :
Fulcrum : calcaneo cuboid
Fulcrum : head talus
1. Adduction  Abduction 4. Cavus and pronation (realign cavus by supination)
2. Varus  valgus to “unlock” subtalar movement
1. Adduction  Abduction 600-750
2. Varus : will be corrected by 4 & 1
12 weeks
Rigid 3 Equinus 6 weeks
tenotomy 3 Equinus Rigid
close tenotomy 90%

Surgery no yes
no =5% yes=95% Surgery

plastering
plastering

(10-11) months Shoe


Shoe
Denis-Brown
splint
splint

(3-4) years Evaluation


(3-4) years Evaluation
Kite
Clubfoot correction

Abduction of fore foot in pronation the cavus becomes more severe, calcaneus
locked (jammed) under the head of talus; mid foot and forefoot are twisted  eversion
Kite
Kite

Calcaneo-cuboid is used as fulcrum which is pressed medial ward while fore foot
is moved lateral ward (abduction); calcaneus will not move lateral ward (no
abduction) that is why the varus will not be corrected; only naviculare and fore foot
will move lateral ward. To press the posterior part of calcaneus to correct varus is
a big mistake
Ponseti
Clubfoot correction

a. realign cavus : forefoot supinated (3,4)


b. fulcrum : caput tali – stabilisator (5)
c. forefoot in supination – abduction (6)
d. maximal abduction of forefoot (7)
e. dorso flexion of the ankle (+TAL)

Process of a,b,c,d (5-6) x each (5-7) days.


Plaster cast above knee (groin), knee
flexion 900
Ponseti (Clubfoot correction)
Ponseti
TAL
 After 6x plastering
 TAL (close), local anaesthesia
 Plaster 3 weeks
 bracing for 3 months (24hours)
 (2-4) hours day time, 12 hours at
nigh
 (3-4) years night splint
 Ponseti success = 90%
Pre ATL
Pre ATL
Daffa pre ATL
Daffa Post ATL
Daffa
Common errors
1. Forefoot still in pronation
during correction of
adduction to abduction
2. Not using head of talus
as fulcrum
3. Calcaneus is pressed
lateral ward to correct
varus
4. Equinus is corrected
before adduction and
varus are corrected 
Rocker bottom foot
5. Plaster immobilisation
below knee
BK plastering High heel
Post posterior release ATL & capsulotomy
Plaster correction complication
1. Neuromuscular
2. Pressure necrosis
Plaster correction complication
3. Rocker bottom foot
Plaster correction complication
4. Flat top talus
Plaster correction complication
5. Increase cavus deformity
6. Longitudinal breach
7. Stiff joint
Operative treatment

Indication
1. Conservative Tx—fail Ponseti + 10%
2. Neglected
Postero medial release (Turco)
Cincinati
Ilizaroff
Tripple arthrodesis (adult)
Surgical complication
1. Infection
2. Bad scar
3. Stiff joint
4. Over/under correction
5. Navicular dislocation
6. Flattening or beaking talar head
7. Talar necrosis
8. Weakening of the muscles
9. Skew foot (severe valgus of the heel and adduction
of the fore foot)
10. Main artery injury  foot necrosis
Out patient clinic

RSUD.Dr.Soetomo