Ctev

WHATISCTEV?
• ROTATORY SUBLUXATION OF TALOCALNOENAVICULAR JOINT
(SUBTALAR) COMPLEX WITH TALUS IN PLANTAR FLEXION
AND SUBTALAR COMPLEX IN MEDIAL ROTATION AND
INVERSION.
• ALSO REFFERED AS CLUBFOOT.
• TALIPES DERIVED FROM TERM: TALUS- ANKLE &
PES - FOOT
• EQUINOVARUS DERIVED FROM WORD EQUINO - LIKE A
HORSE &

DEFORMITIES:
• 4 CLINICAL COMPONENTS: CAVE
• C- CAVUS- EXAGGERATED MEDIAL LONGITUDINAL ARCH
AT MIDFOOT
• A- ADDUCTION- FOREFOOT IN ADDUCTION
AT TARSOMETATARSAL JUNCTION
• V- VARUS- HINDFOOT ROTATED INWARD AT
TALONAVICULAR JOINT
• E- EQUINUS- FOOT FIXED IN PLANTAR FLEXION ATANKLE

EPIDEMIOLOGY:
• INCIDENCE- 1-2 PER 1000 LIVE BIRTH
• INCIDENCE IN MALE:FEMALE- 2.5:1
• LATERALITY- >50% CASES ARE
BILATERAL
• IN UNILATERAL AFFLICTION- RIGHT>
LEFT

ETIOLOGY:
• MOST COMMON CAUSE OF
CTEV IS
IDIOPATHIC.
• OTHER THAN IDIOPATHIC
IS
IS
CTEV
WHIC
H WITH
UNDERLYI
NG
SECONDA
RY
ASSOCIAT
ED

IDIOPATHICCTEV:
• ARRESTED FETAL DEVELOPMENT: BOHM PROPOSED ARREST OF FETAL
DEVELOPMENT OF THE LOWER LIMB IN 6-8 WKS SO CALLED CLUB FOOT
EMBRYONIC STAGE. HOWEVER DYSMORPHIC TALAR HEAD AND MEDIAL
DISPLACEMENT OF NAVICULAR IS NOT SEEN IN ANY STAGE OF NORMAL FETAL
DEVELOPMENT.
• MECHANICAL FACTOR IN UTERO: OLDEST THEORY PROPOSED BY HIPPOCRATES
SUGGESTING FOOT WAS HELD IN EQUINO VARUS BY EXTERNAL UTERINE
COMPRESSION. SOME INVESTIGATOR OPINE DIMINUTION OF AMNIOTIC FLUID
AS CAUSE OF CLUB FOOT.
• VASCULAR HYPOTHESIS: KEITH SUGGESTED TEMPORARY CESSATION OF

IDIOPATHICCTEV:
• MUSCULOLIGAMENTOUS FIBROSIS: IPPOLITO AND PONSETI FOUND
CONSIDERABLE INCREASE IN COLLEGEN FIBRES AND FIBROBLASTIC CELLS IN
LIGAMENTS AND TENDONS OF CLUBFOOT. THEY CONSIDERED TO BE PRIMARY
DEFECT, CARTILAGINOUS AND BONY CHANGES BEING SECONDARY.
• PRIMARY GERM PLASMA DEFECT: WAISBROD SUGGESTED DEFECT IN
PRIMARY GERM PLASMA OF CARTILAGINOUS TALAR ANALGE RESULTING IN
DYSMORPHIC TALAR NECK AND NAVICULAR SUBLUXATION.
• HEREDITARY: WYNNE- DAVIES SUGGESTED CLUB FOOT ARE PART OF
NUMEROUS SYNDROMES FOLLOWING MANDELIAN PATTERN OF EITHER
AUTOSOMAL DOMINANT OR AUTOSOMAL RECESSIVE INHERITANCE.

SECONDARYCTEV:
• ASSOCIATED WITH NEUROMUSCULAR OR SYNDROMIC
ETIOLOGIES-
 ARTHROGRYPOSIS MULTIPLEX CONGENITA
 DIASTROPHIC DYSPLASIA
 STREETER SYNDROME (CONSTRICTION BAND SYNDROME)
 FREEMAN SHELDON SYNDROME
 MOBIUS SYNDROME
 NAIL PATELLA SYNDROME
 DIASTROPHIC DWARFISM
• ASSOCIATED WITH PARALYTIC DISORDER-
 POLIOMYELITIS
 SPINA BIFIDA
 MYELODYSPLESIA
 FREIDRICH’S ATAXIA

SECONDARYCTEV:
• GENETIC CAUSES-
N- ACETYLATION GENES NAT1 AND NAT2
XENOBIOTIC METABOLISM GENES CYP1A1
LIMB AND MUSCLE MORPHOGENESIS GENE HOXA, HOXD
AND IGF BP3
GENE FOR LOWER EXTREMITY DEVELOPMENT- CAN D2
AND WNT 7A
GENE FOR CONTACTILE PROTEIN OF SKELETAL
MYOFIBRES- TBX4

PATHOLOGICALANATOMY:
1. BONES-
• TALUS-
HEAD AND NECK DEVIATED MEDIALLY AND DOWNWARD.
MEDIAL AND PLANTAR DEVIATION OF NAVICULAR
ARTICULATION.
BODY ROTATED EXTERNALLY AND IS IN EQUINUS OF
NECK IN ANKLE
MORTISE.
BODY EXTRUDED ANTERIORLY
SMALLER THAN NORMAL
NECK- BODY ANGLE IS 90-110* (NORMAL- 150*)
DISLOCATION OF HEAD OF TALUS OUT OF ITS SOCKET.

• NAVICULAR-
MEDIALLY AND
PLANTAR
DISPLACEMENT
CLOSE TO MEDIAL MALLEOLUS
ARTICULATES WITH MEDIAL
SURFACFE
OF DYSMORPHIC TALUS
TALONAVICULAR JOINT
SUBLUXATION

• CALCANEUM-
OFTEN SMALL IN SIZE
MEDIALLY ROTATED
ANTERIOR PORTION LIES BENEATH
THE HEAD OF TALUS CAUSING VARUS
AND EQUINUS OF HEEL.
SUSTENTACULUM TALI IS
UNDERDEVELOPED.
• CUBOID-
MEDIAL
LY
HEAD
SUBLUXAT
ED
OVE
R
CALCANE
UM

• MUSCLES AND TENDONS-
ATROPHY OF PERONEAL GROUP OF
MUSCLES
CONTRACTURE OF TRICEP
SURAE,TIBIALIS
POSTERIOR,FLEXOR DIGITORUM
LONGUS AND FLEXOR HALLUCIS
LONGUS.
NUMBER OF FIBRES IN MUSCLE IS
NORMAL BUT ARE SMALLER IN SIZE.
THICKENING AND CONTRACTURE OF
TENDON SHEATHS ESPECIALLY OF

• LIGAMENTS-
THICKENING AND CONTRACTURES
ARE SEEN IN
 CALCANEOFIBULAR LIGAMENT
 TALOFIBULAR LIGAMENT
 DELTOID LIGAMENT
 LONG AND SHORT PLANTAR LIGAMENT
 SPRING LIGAMENT
 BIFURCATE LIGAMENT
 INTEROSSEOUS TALO CALCANEUM
LIGAMENT
 MASTER KNOT OF HENRY

• JOINTS CAPSULE AND FASCIA-
CONTRACTURES ARE SEEN IN
POSTERIOR ANKLE CAPSULE
SUBTALAR CAPSULE
TALONAVICULAR JOINT CAPSULE
CALCANEOCUBOID JOINT CAPSULE
PLANTAR FASCIA CONTRACTURE ARE SEEN WHICH IS
RESPONSIBLE CAVUS DEFORMITY

• SKIN CHANGES-
DEEP CREASE ON MEDIAL SIDE
DIMPLES IN LATERAL ASPECT OF ANKLE AND
MID FOOT.
SHORTENING ON MEDIAL SIDE OF SOLE
CALLOSITIES AND BURSA ON LATERAL SIDE
OF FOOT
• VASCULAR CHANGES-
HYPOPLASIA OR ABSENCE OF DORSALIS
PAEDIS AND ANTERIOR TIBIAL ARTERY

CLINICALFEATURES:
• HEEL IS SMALL AND IN EQUINUS
• FOOT INVERTED ON END OF TIBIA
• DEEP CREASES ON MEDIAL AND POSTERIOR
ASPECT
• ABNORMAL THIN CALF
• VARYING DEGREE OF RESISTANCE/ FIXED
DEFORMITY WHEN TRY TO DORSIFLEX AND EVERT
THE FOOT.
• LACK OF CORRECTABILITY
• OTHER JOINT ABNORMALITY
• ASSOCIATED ANOMALIES
AND CONDITION.
NEUROMUSCU
LAR

CLASSIFICATION:
1. IDIOPATHIC AND NON-IDIOPATHIC
2. CUMMIN CLASSIFICATION
3. PONSETI AND SMOLEY CLASSIFICATION- BASED ON EXTENT OF
DEFORMITY
4. HARROLD AND WALKER CLASSIFICATION- BASED ON
ABILITY TO CORRECT THE DEFORMITY.
5. BROWNE’S CLASSIFICATION- BASED ON TYPE OF DEFORMITY
6. DIMEGLIO ET AL SCORING SYSTEM BASED ON SEVERITY OF THE
DEFORMITY

CUMMINCLASSIFICATION
• SUPPLE: FOOT CAN BE BROUGHT TO NORMAL POSITION AND
ALL JOINTS ARE MOBILE.
• NEGLECTED: NO TREATMENT FOR 1 YR.
• RELAPSED: CORRECTED DEFORMITIES APPEARS AGAIN.
• RECCURENT: TYPE OF RELAPSE DUE TO MUSCLE IMBALANCE
• RESISTANT: NO CORRECTION AFTER CONSERVATIVE
MANAGEMENT.
• RIGID: AFTER CONSERVATIVE TREATMENT
FOREFOOT DEFORMITY CORRECTED AND
HINDFOOT DEFORMITY REMAIN UNCORRECTED.

PIRANISCORINGSYSTEM:
• SIMPLE AND RELIABLE SYSTEM TO DETERMINE SEVERITY AND MONITOR PROGRESS IN THE
ASSESSMENT AND
TREATMENT OF CLUBFOOT.
• SIX “SIGNS” ARE ASSESSED
• 3 SIGNS IN MIDFOOT
• 3 SIGNS IN HINDFOOT
• BASED ON 6 WELL-DESCRIBED CLINICAL SIGNS OF CONTRACTURE CHARACTERIZING A SEVERE
CLUBFOOT:
• IF THE SIGN IS SEVERELY ABNORMAL IT SCORES 1
• IF IT IS PARTIALLY ABNORMAL IT SCORES 0.5
• IF IT IS NORMAL IT SCORES 0
• TOTAL SCORE (TS) VARIES FROM 0 TO 6 AND IS THE SUM OF MIDFOOT AND HINDFOOT
CONTRACTURE SCORES

RADIOGRAPHICEVALUATION:
• FOR NON AMBULATORY CHILD-
 ANTEROPOSTERIOR
 STRESS DORSIFLEXION LATERAL
VIEW
• FOR OLDER CHILD-
 STANDING ANTEROPOSTERIOR
 STANDING LATERAL
• IMPORTANT ANGLE WE MEASURE-
 TALOCALCANEAL ANGLE ON AP AND
LAT VIEW
 TIBIOCALCANEAL ANGLE ON LAT VIEW
 TALUS- FIRST METATARSAL ANGLE

RADIOGRAPHIC
EVALUATION:
TALOCALCANEAL ANGLE-
• ON AP VIEW-
 1ST LINE THROUGH THE CENTRE OF
LONG AXIS OF TALUS (PARALLEL TO
MEDIAL BORDER)
2ND LINE THROUGH LONG AXIS
OFCALCANEUM (PARALLEL TO
LATERAL BORDER)
 NORMAL 25-40*
• ON LATERAL VIEW-
 1ST LINE MIDPOINT OF HEAD AND
BODY OF TALUS
 2ND LINE ALONG BOTTOM OF
CALCANEUM
 NORMAL 35-50*

RADIOGRAPHICEVALUATION
• RADIOLOGICAL FINDING SEEN-
• ON LATERAL VIEW-
 DECREASED TALOCALCANEAL ANGLE (TALOCALCANEAL PARALLELISM)
 DISRUPTED TALAR FIRST METATARSALANGLE
 LONG AXIS OF TALUS AND CALCANEUM PASSES INFERIOR TO CUBOID (NORMALLY
CROSSES CUBOID)
• ON ANTEROPOSTERIOR VIEW-
 INCREASED TALOCALCANEAL ANGLE
 INCREASED TALAR FIRST METATARSALANGLE
 LONG AXIS OF TALUS DEVIATE LATERALLY AND PASSES ALONG 3RD OR 4TH
METATARSALBONE

TREATMENT:
• GOAL: TO ACHIEVE
PLANTIGRADE FOOT
FLEXIBILTY
COSMETICALLY ACCEPTABLE FUNCTIONAL AND PAIN FREE FOOT IN SHORTEST
TREATMENT TIME
• PRINCIPLES:
SOFT TISSUE CONTRACTURE RELEASE OR STRETCHING TO
RESTORE NORMAL TARSAL RELATIONSHIP.
ONCE NORMAL TARSAL RELATIONSHIP ATTAINED, CORRECTION SHOULD BE
MAINTAINED TILL TARSAL BONES REMOULDS STABLE ARTICULAR SURFACE.

NONOPERATIVETREATMENT:
• SEVERAL REGIME HAVE BEEN PROPOSED INCLUDING SPLINTING
TAPING AND CASTING.
• KITE’S METHOD:
 CORRECTION OF EACH COMPONENT SEPARATELY
 CORRECTION WAS DONE IN FOLLOWING ORDER
 PRONATION/ EVERSION OF 1ST METATARSAL.
 PREMATURE DORSIFLEXION OF HEEL.
 USED CALCANEOCUBOID JOINT AS FULCRUM THAT BLOCKS ABDUCTION OF CALCANEUS ,
THERBY PREVENTS EVERSION OF CALCANEUS.
FOREFO
OT
ADDUCTI
ON
 KITE’S
ERRORS:
HEEL VARUS
EQUINU
S

NONOPERATIVETREATMENT:
• PONSETI TECHNIQUE:
2 PHASE- TREATMENT AND MAINTENANCE PHASE
TREATMENT PHASE-
BEGINS AS EARLY AS POSSIBLE. DURING FIRST WEEK OF LIFE ONLY
MANIPULATION IS CARRIED OUT BUT CAST IS NOT APPLIED.
ORDER OF CORRECTION-
TALUS HEAD IS USED AS FULCRUM.
5-6 SERIAL CASTING WITH MANIPULATION IS GENERALLY ENOUGH TO CORRECT
THE DEFORMITY. MAXIMUM UPTO 1O CASTING CAN BE DONE.
CAVU
S
ADDUCTION
WITH
VARUS
EQUINU
S

PONSETITECHNIQUE:
• CORRECTION OF CAVUS
DEFORMITY:
CORRECTED BY FOREFOOT
SUPINATION RELATIVE TO
HINDFOOT ALONG WITH
ADDUCTION OF FOREFOOT.
TENDS TO EXAGGERATE FOOT
INVERSION.
PRONATION OF FOREFOOT
SHOULD NOT BE DONE AS
IT INCREASES CAVUS
DEFORMITY BECAUSE 1ST
METATARSAL IS FURTHER
PLANTAR FLEXED.
E- RIGHT MANEUVER TO CORRECT CAVUS
DEFORMITY
F- WRONG MANEUVER TO CORRECT CAVUS

PONSETITECHNIQUE
A: THUMB IS POSITIONED OVER LATERAL ASPECT OF HEAD OF TALUS AND FINGER
CORRECT THE FOREFOOT.
B: CAVUS AND ADDUCTION ARE CORRECTED BY SLIGHT SUPINATION OF FOREFOOT IN

PONSETITECHNIQUE
• CORRECTION OF VARUS AND ADDUCTION:
CORRECTION OF CAVUS BRINGS METATARSAL, CUNIEFORM,
NAVICULAR, AND CUBOID IN SAME PLANE OF SUPINATION.
NOW FOOT IS ABDUCTED AND HELD IN FLEXION AND
SUPINATION TO ACCOMMODATE THE INVERSION OF TARSAL
BONES WHILE COUNTER PRESSURE IS APPLIED WITH THUMB
ON LATERAL ASPECT OF HEAD OF TALUS.
THIS MANEUVER NECESSITATES PROLONG STRETCHING OF
MEDIAL TARSAL LIGAMENTS AND TENDONS.

PRESSURE EXERTED ON METATARSALAND COUNTERPRESSURE ON LATERALASPECT
OF HEAD OF TALUS. FURTHER ABDUCTION OF FOOT HELD IN FLEXION AND
SUPINATION.

FOOT IS
FURTHER
ABDUCTE
D AND
SUPINATI
ON
DECREAS
ED BUT
WITHOUT
PRONATIN
G THE
FOOT

PONSETITECHNIQUE
• CORRECTION OF EQUINUS:
• SHOULD BE ATTEMPTED WHEN HINDFOOT
IS IN NEUTRAL POSITION TO SLIGHT
VALGUS AND FOOT IS ABDUCTED 70* RELATIVE TO LEG.
• EQUINUS IS COORECTED BY PROGRESSIVE DORSIFLEXING
THE FOOT.
• TO FACILITATE RAPID CORRECTION SUBCUTANEOUS
TENOTOMY IS DONE.
• CARESHOULDBE TAKEN WHILE DORSIFLEXING FOOTBY

FOOT IS FURTHER ABDUCTED UPTO 70*
TO
STRETCH TO STRETCH MEDIAL TARSAL
LIGAMENT.
NOTE: HEEL IS NOT GRASPED BY HAND
THUS ALLOWING CALCANEUS TO
ABDUCT WITH FOOT AND HEEL VARUS
TO CORRECT

EQUINUS CORRECTED
BY SUBCUTANEOUS
SECTION OF TENDO
ACHILLES

PERCUTANEOUSTENOTOMY
FOOT HELD IN DORSIFLEXION AND
TENDON IS FELT
BLADE OF 11 SIZE ENTERS PARALLEL TO MEDIAL
BORDER OF
TENDOACHILLES 1CM ABOVE INSERTION AT
CALCANEUM.
BLADE IS PUSHED MEDIAL TO TENDON AND
ROTATED 90* UNDERNEATH IT. TENDON IS CUT
FROM MEDIAL TO LATERAL DIRECTION.
"POP" IS FELT AND CAST IS APPLIED IN
MAXIMAL

PERCUTANEO
US ACHILLES
TENOTOMY
FROM MEDIAL
TO LATERAL

PONSETITECHNIQUE
• MAINTENANCE PHASE:
• AFTER REMOVAL OF CAST INFANT IS PLACED IN FOOT ABDUCTION
ORTHOSIS.
• BRACE IS WORN FOR 23HRS PER DAY FOR FIRST 3 MONTH THEN
ONLY WHILE SLEEPING FOR 3-4 YEARS.
• FREQUENT FOLLOW UP IS IMPORTANT TO DETECT EARLY
RECCURENCE.
• IT PREVENT RECURRENCE OF DEFORMITY
• IT FAVORS REMODELLING OF JOINTS WITH THE BONES IN PROPER
ALINGMENT AND TO INCREASE LEG AND FOOT MUSCLE STRENGTH.

FOOTABDUCTION
ORTHOSIS
• ALSO KNOWN AS DENIS BROWN
SPLINT.
• CONSIST OF SHOES MOUNTED TO
CROSSBAR IN POSITION OF 70*
EXTERNAL ROTATION AND 15*
DORSIFLEXION.
• DISTANCE BETWEEN SHOES IS SET
AT ABOUT 1INCH WIDER THAN THE
WIDTH OF INFANT’S SHOULDER.
• IN UNILATERAL CASES NORMAL
FOOT SHOULD IN 40* OUTWARD

CTEVSHOES
• MODIFIED SHOES
FOR CHILD WHO
START WALKING.
• THESE SHOES ARE
USE UNTILL 5
YEARS OF AGE.
• SPECIAL FEATURES:
STRAIGHT INNER
BORDER
OUTER SHOE RISE

NONOPERATIVETREATMENT
• STRETCHING AND ADHESIVE STRAPPING(ROBERT JONES):
PRINCIPLE- APPLY EVERSION CORRECTION FORCE ON FOOT
WITH HELP OF ADHESIVE STRAPPING.
• FRENCH TECHNIQUE:
GOAL IS TO REDUCE TALONAVICULAR JOINT, STRETCH OUT
MEDIAL TISSUES AND THEN SEQUENTIALLY CORRECT FOREFOOT
ADDUCTION, HINDFOOT VARUS AND EQUINUS OF CALCANEUM.

COMPLICATIONSOFNONOPERATIVETREATMENT
• ROCKER BOTTOM FOOT
• BEAN SHAPED FOOT
• FRACTURES
• PRESSURE SORES
• FLAT TOP TALUS
• FAILURE OF CORRECTION
• RECCURENCE OR RELAPSE OF
DEFORMITY

SURGICALTREATMENT
• INDICATION:
 IN CASE OF NEGLECTED CTEV, RELAPSED CTEV, RECCURENT CTEV,
RESISTANT CTEV, RIGID CTEV.
• CHOICE OF SURGERY:
1-4 YEARS-
 SOFT TISSUE RELEASE
4-11 YEARS-
 SOFT TISSUE RELEASE WITH
 OSTEOTOMY PERFORMED ACCORDING TO THE DEFORMITIES
>11YRS- SALVAGE PROCEDURES
 TRIPLE ARTHRODESIS
 TALECTOMY

SOFT TISSUE RELEASEOPERATION
TURCO’S OPERATION- IT IS ONE STAGE POSTEROMEDIAL RELEASE. HE
EMPHASIZED ON SUBTALAR
RELEASE ALONG WITH CALCANEOFIBULAR LIGAMENT.
CAROLL’S INCISION- CAROLL EMPHASIZED ON PLANTAR FASCIA RELEASE AND
CAPSULOTOMY OF
CALCANEOCUBOID JOINT. IT INCLUDE 2 INCISIONS, MEDIAL AND POSTERO-
LATERAL INCISION.
CINCINATTI INCISION- IT IS DONE FOR POSTEROMEDIAL AND POSTEROLATERAL
SOFT TISSUE RELEASE. PREFFERED TECHNIQUE FOR INITIAL SURGICAL
MANAGEMENT OF CLUB FOOT.
TENDOACHILLES TENDON RELEASE WITH POSTERIOR CAPSULOTOMY- TO
CORRECT RESIDUAL

TURCOOPERATION
• MEDIAL INCISION GIVEN
• EXPOSE TIBIALIS POSTERIOR, FDL,FHL, TENDOACHILLES AND POSTERIOR NEUROVASCULAR BUNDLE.
• DIVIDE MASTER KNOT OF HENRY.
• DIVIDE CALCANEONAVICULAR LIGAMENT AND ABDUCTOR HALLUCIS FROM TIBIALIS POSTERIOR
TENDON,NAVICULAR TUBEROSITY AND 1ST METATARSAL.
• POSTERIOR RELEASE- BY DOING Z-PLASTY OF TENDO ACHILLES, INCISING POSTERIOR CAPSULE OF ANKLE
JOIN, SUBTALAR JOINT AND DIVIDING TALOFIBULAR LIGAMENT AND CALCANEOFIBULAR LIGAMENT.
• MEDIAL PLANTAR RELEASE- DIVIDE TIBIALIS POSTERIOR, SUPERFICIAL DELTOID LIGAMENT, TALONAVICULAR
CAPSULE AND SPRING LIGAMENT.
• SUTALAR RELEASE- DIVIDE MEDIAL PART OF TALOCALCANEAL INTERROSEOUS LIGAMENT AND BIFURCATION OF Y
LIGAMENT.
• AFTER REDUCING NAVICULAR BONE TRANSFIX TALONAVICULAR JOINT BY K-WIRE AND SUBTALAR JOINT BY 2ND K-
WIRE.

CINCINATTIINCISION
• TRANSVERSE CIRCUMFERENTIAL
INCISION

ACHILLESTENDON
LENTHENINGAND
POSTERIORCAPSULOTOMY
• TO CORRECT RESIDUAL HINDFOOT
EQUINUS
• Z-PLASTY IS DONE TO LENGTHEN
THE ACHILLES TENDON.
• RELEASING MEDIAL HALF DISTALLY
AND LATERAL HALF PROXIMALLY.
• POSTERIOR CAPSULOTOMY OF
ANKLE AND SUBTALAR JOINT TO
RELEASE CAPSULE CONTRACTURE.

TENDONTRANSFER
• INDICATION- PASSIVELY
CORRECTABLE DEFORMITY
RESULTING FROM MUSCLE
IMBALANCE.
• ANTERIOR TIBIALIS TENDON
TRANSFER- TENDON IS
TRANSFERRED EITHER TO
MIDDLE CUNIEFORM OR TO BASE
OF 5TH METATARSAL.
• SPLATT (SPLit ANTERIOR TIBIALIS
TENDON TRANSFER)- LATERAL

DWYER
OSTEOTOMY
• INDICATION- PERSISTENT
VARUS DEFORMITY OF
HEEL WHEN SOFT TISSUE
SURGERIES ARE
CONTRAINDICATED.
• AGE- 3-4YRS
• DONE BY MEDIAL OPEN
WEDGE OSTEOTOMY OR
BY LATERAL CLOSED
WEDGE OSTEOTOMY

LATERALCOLUMNSHORTENINGPROCEDURE
• INDICATION- RECURRENCE OF CLUBFOOT
DEFORMITY
AFTER SURGICAL RELEASE IS MOSTLY DUE
TO DISPARITY BETWEEN MEDIAL AND
LATERAL BORDER OF FOOT. ANY ATTEMPT
TO CORRECT DEFORMITY IS RESISTED BY
MEDIAL CONTRACTURE AND EXCESSIVE
LENGTH OF LATERAL COLUMN.
• DIFFERENT PROCEDURE TO DO SHORTEN
LATERAL COLUMN ARE-
 DILLWYNN EVANS PROCEDURE
 LICHTBLAU PROCEDURE

LATERALCOLUMNSHORTENINGPROCEDURE
DILLWYN EVANS PROCEDURE LICHTBLAU
PROCEDURE
AGE- 4-8 YRS
INDICATION- MIDFOOT IN VARUS
DUE TO TALONAVICULAR AND
CALCANEOCUBOID SUBLUXATION
AGE- 3-4 YRS
INDICATION- HEEL VARUS & RESIDUAL
INTERNAL DEFORMITY OF CALCANEUS
WITH LONG LATERAL COLUMN

FOWLER
PROCEDURE
• INDICATION- SUFFICIENT
SCARRING THAT MEDIAL SOFT
TISSUE AND SUBTALAR RELEASE
WOULD BE IN EFFECTIVE.
• AGE- 6-8 YEARS
• PROCEDURE- LATERAL COLUMN
SHORTENING COMBINING WITH
MEDIAL
COLUMN LENGTHING BY
REMOVING
WEDGE FROM
CUBOI
D
AN
AN
D
OPENIN
G
TRANSFERING IT
TO
WEDGE.

SALVAGEPROCEDURE
• INDICATION-
 UNCORRECTED CLUBFOOT OR WITH RESIDUAL DEFORMITY AFTER THE
AGE OF 10 YRS.
 PAINFUL STIFF FOOT WITH POOR FUNCTION
 DIFFICULT TO ACCOMMODATE TO FOOT WEAR
• GOAL-
 CORRECT RESIDUAL DEFORMITY WHICH IS RESISTANT TO SOFT
TISSUE RELEASE.
 TO ATTAIN FUNCTIONALLY AND COSMETICALLY ACCEPTABLE FOOT.
• PROCEDURE-
 TRIPLE ARTHRODESIS
 TALECTOMY

TRIPLE
ARTHRODESIS
• INDICATION-
PAINFUL STIFF FOOT WITH POOR
FUNCTION
DIFFICULT TO
ACCOMMODATE TO
FOOT WEAR
ALL OTHER CORRECTION FAILED
• AGE – 10 – 12 YEARS
• PROCEDURE-
 OSTEOTOMY FOLLOWED BY
FUSION OF TALONAVICULAR,

TALECTOMY
• INDICATION-
 RESERVEDFOR
SEVERE CLUBFOOT
• AGE - <6 YEARS
• PROCEDURE-
UNTREAT
ED
 COMPLETE EXCISION OF TALUS
 DEROTATE THE FOOT AND
DISPLACE THE CALCANEUS
POSTERIORLY INTO ANKLE
MORTISE UNTIL NAVICULAR ABUTS
THE ANTERIOR EDGE OF TIBIAL
PLAFOND.
• COMPLICATION-

EXTERNALFIXATOR
• INDICATION-
IN CASE OF NEGLECTED AND RECCURENT DEFORMITY WITH
SEVERE SCARRING
• MODALITIES-
ILLIZAROV’S EXTERNAL FIXATOR
JESS (JOSHI EXTERNAL STABILIZING SYSTEM)
• ADVANTAGE-
PREVENT CRUSHING OF THE TISSUES ON CONVEX SIDE
LENGHTENS THE LIMB
EFFECTIVELY CORRECT THE DEFORMITY AT SAME TIME

ILLIZAROV’SEXTERNAL
FIXATOR
• PRINCIPLE- FRACTIONAL DISTRACTION
• INDICATION- SEVERE DEFORMITIES
WITH SEVERE SCARING OR TROPHIC
ULCERS WHICH MAKE OPERATIVE
INTERVENTION CONTRAINDICATION
BECAUSE OF RISK OF TISSUE
NECROSIS.
• STEPS OF CORRECTION-
ANGULAR CORRECTION
OF HINDFOOTCORRECTION OF
FOREFOOT
SUPINATION
CORRECTION OF
FOOT
EQUINUS

JESS
• PRINCIPLE- DIFFERENTIAL
DISTRACTION
• ADVANTAGE-
 LENTHENS ALL CONTRACTED
TISSUES PREVENTING
HISTIOGENESIS AND THUS
AVOID CUTTING OF THESE
IMMINENT SCARRING.
 POSSIBLE TO CONTROL
MAGNITUDE
OF CORRECTION.
 NO FURTHER SHORTHENING
OF FOOT
 RESULTANT FEET IS VERY

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