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Ctev

This document provides an overview of clubfoot (CTEV), including: 1. The historical aspects and key figures in the development of clubfoot treatment methods. 2. The anatomy and biomechanics involved in clubfoot deformity. 3. The Ponseti method of non-surgical clubfoot correction, which involves weekly manipulation, casting, and often a percutaneous Achilles tenotomy. 4. Important considerations for casting including proper manipulation technique and ensuring adequate foot abduction prior to tenotomy. 5. Potential complications of casting and the process of cast removal.

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CTEV By Dr Praveen Lisie hospital,kochi
INTRODUCTION TALUS-ANKLE PES-FOOT EQUINO-LIKE A HORSE VARUS- TURNED INWARDS
HISTORICAL ASPECTS - EARLIEST EVIDENCE IN EGYPTIAN PERIOD. - YAJURVEDA ADVISED TO MASSAGE TO CORRECT DEFORMITY. - HIPPOCRATES FIRST DESCRIBED CLUB FOOT. - SCARPA(1803) FIRST DESCRIBED PATHOLOGIC ANATOMY.
- KITE (1930) DESCRIBED NON OPERATIVE TREATMENT WITH SEVERAL MANIPULATION AND PLASTER CAST APPLICATION. - DENNIS BROWN (1934) DEVISED SPLINT FOR MAINTENANCE OF CLUBFOOT CORRECTION. - IGNACIO PONSETI (1950) DEVELOPED METHOD CORRECTION.
DEFINITION CONGENITAL DYSPLASIA OF MUSCULOSKELETAL TISSUES DISTAL TO KNEE JOINT IN THE FORM OF DEFORMITY OF FOOT AND ANKLE.
Biology • Clubfoot is not an embryonic malformation. • Developmental deformation • Rarely detected with USG before the 16th week of gestation
• Excessive pull of the tibialis posterior abetted by the gastrosoleus and the long toe flexors • The ligaments of the posterior and medial aspect of the ankle and tarsal joints are very thick and taut
• Excessive collagen synthesis in the ligaments, tendons, and muscles may persist until the child is 3 or 4 years of age and might be a cause of relapses. • The bundles of collagen fibers display a wavy appearance known as crimp.
Kinematics • Talus: most deformed and least displaced. Head & neck deviated medially & plantarward Body rotated externally in the ankle mortise, superior articular surface escapes from mortice. Talar neck is short and medially deviated. Smaller than normal, disturbance of vascular supply, ossification centre eccentrically placed.
• Navicular: Medially displaced Close to medial malleolus Articulates with medial surface of head of talus • calcaneus is – adducted and – inverted under the talus
• Cuboid Displaced medially on the dysmorphic distal end of the calcaneus
Tibio-talar plantar flexion Medially displaced navicular Adducted and inverted calcaneus Medially displaced cuboid
• Correction of the extreme medial displacement and inversion of the tarsal bones in the clubfoot necessitates a simultaneous gradual lateral shift of the navicular, cuboid, and calcaneus before they can be everted into a neutral position
Lateral displacement (abduction) of the calcaneus will correct the heel varus deformity of the clubfoot
The bones and joints remodelling with each cast change-- demonstrated by Pirani
• The tendo Achillis, unlike the tarsal ligaments that are stretchable, is made of non-stretchable, thick, tight collagen bundles with few cells.
• Most cases of clubfoot are corrected after five to six cast changes and, in many cases, a tendo Achillis tenotomy needed.
1.MECHANICAL FACTORS- HIPPOCRATES Oligohydramnios Abnormal fetal positioning Unstretched uterus Placental insufficiency Constriction bands 2.PRIMARY GERM PLASM DEFECT 3.ARRESTED FOETAL DEVELOPMENT
4.HEREDITARY- AD 5.MUSCULOLIGAMENTOUS FIBROSIS 6. VASCULAR HYPOTHESIS- 90% of CTEV limbs showed hypoplasia / absence of anterior tibial artery.
SECONDARY CLUBFOOT 1.PARALYTIC DISORDERS - evertors and dorsiflexors are weak. Ex- Polio , Spina Bifida, Myelodysplasia, Friedreich Ataxia. 2.SYNDROMES -Arthogryposis Multiplex Congenita Downs Syndrome, Larsen Syndrome.
• IN UPPER MOTOR NEURON – Cerebral palsy – Friedreich ataxia – Syringomyelia
• In nerve root – Spina bifida – Spinal dysraphism • In the nerve-neuropathy(leprosy) • In myoneural junction-myasthenia gravis • In foot muscles – Muscular dystrophy – Arthrogryposis Multiplex Congenita
INCIDENCE- 1 to 2 in 1000 livebirths. SEX – MALE >FEMALE BILATERAL IN MORE THAN 50 % . FAMILY HISTORY- 5-50% POSITIVE.
Classifying the clubfoot • The classification of a clubfoot may change with time depending on management Typical clubfoot • Classic clubfoot and is found in otherwise normal infants • It generally corrects in five casts, and with Ponseti management the long-term oucome is usually good or excellent.
• Positional clubfoot – deformity is very flexible – due to intrauterine crowding – Correction is often achieved with one or two castings. • Delayed treated clubfoot-beyond 6 months of age. • Alternatively treated typical clubfoot – treated by surgery or non-Ponseti casting.
• Recurrent typical clubfoot – may occur whether the original treatment was by Ponseti management or other methods. – Relapse is much less frequent after Ponseti management and is usually due to a premature discontinuation of bracing. – The recurrence is most often supination and equinus that is first dynamic but may become fixed with time.
Atypical clubfoot usually associated with other problems Start with Ponseti management Correction usually is more difficult
Rigid or resistant atypical clubfoot • severe plantarflexion of all metatarsals, • a deep crease just above the heel and across the sole of the midfoot • a short hyperextended big toe.
Manipulation
• Do not abduct more than 30 degrees. After 30 degrees abduction is achieved, change emphasis to correction of the cavus and equinus. • Casting Always apply casts with the above- knee portion in 110 degrees flexion to prevent slippage. Up to 6–8 casts can be needed to correct deformity
• Tenotomy – A tenotomy is necessary in most cases. – At least 10 degrees dorsiflexion is necessary – change casts at weekly intervals after the tenotomy if sufficient dorsiflexion is not achieved immediately after the tenotomy.
• Bracing Reduce abduction on the affected side to 30 degrees in the foot abduction brace. The follow-up management remains the same.
• Teratologic clubfoot such as congenital tarsal synchondrosis • Neurogenic clubfoot associated with a neurological disorder such as meningomyelocele. • Acquired clubfoot such as Streeter dysplasia.
• Syndromic clubfoot – Syndromic clubfoot are more difficult to treat and sometimes require surgery. Arthrogryposis – Start with standard Ponseti casting. – 9 to 15 casts are often required. – If correction is not achieved, surgery may be required
• Myelodysplasia – Because of sensory loss, casting requires great care to prevent skin ulceration. – Apply more padding and avoid excessive pressure in molding.
Radiology • Plain radiograph: Can be assessed prior to treatment with A-P & Lateral of foot • Foot held in position of best correction, with weight- bearing, or simulated weight-bearing
Anteroposterior view • Talocalcaneal angle • Calcaneal-second metatarsal angle • Talus –first metatarsal angle • Intermetatarsal angle
AP radiograph: Talo-Calcaneal angle • Lines drawn through center of the long axis of talus (parallel to medial border) and through the long axis of calcaneum (parallel to lateral border), and they usually subtend an angle of 30-45°. • decreased in a varus foot and increased in a valgus hindfoot
Axis of the second metatarsal diaphysis Axis of the calcaneus 15Âş : Normal value > 15Âş : Pes adductus
Talus –first metatarsal angle
Intermetatarsal angle(<5)
Lateral view • The lateral talocalcaneal angle • Meary angle • Hibb angle • Calcaneal pitch
Talocalcaneal angle Angle between the mid-talar axis and calcaneal inclination axis. -normally measure between 30° and 45° -decreased in a varus foot and increased in a valgus hindfoot
Meary angle • B/n long axis of the talus and the long axis of the 1st MT • Normally, these lines are colinear • apex directed dorsally-cavus foot • apex angled plantarward- valgus or flatfeet
Hibb angle • angle between the plantar surface of the calcaneus and the first metatarsal • Normally Hibb angle is greater than 150 degrees
Calcaneal pitch • Angle between the horizontal and the plantar surface of the calcaneus • Important in evaluating a cavus foot or clubfoot • low: 10-20° - indicative of pes planus • medium: 20-30° • high: ≥30° - indicative of pes cavus
SCORING SYSTEMS
• Serial scoring useful in – classifying the clubfoot, – assessing progress, – showing signs of recurrence, and – establishing the prognosis.
Pirani Score • Documents the severity of the Deformity • Sequential scores are an excellent way to monitor progress. • Six parameters : 3 of midfoot and 3 of hindfoot • Each parameter is given a value as follows: 0: normal 0.5: Mildly abnormal 1: severely abnormal
Mid foot score • Curved lateral border [A] • Medial crease [B] • Talar head coverage [C]
Hind foot score • Posterior crease [D] • Rigid equinus [E] • Empty heel [F]
Uses of Pirani’s score • Predicting need for tenotomy • Estimation of probable no. of casts required* • Very good interobserver reliability and reproducibility**
• Scoring of 4 or more is likely to require at least four casts. • Scoring less than 4 will require three or fewer • A foot with a hindfoot score of 2.5 or 3 has a 72% chance of requiring a Tenotomy.
DimĂŠglio A.Equinus deviation B. Varus deviation C. Derotation D. Adduction.
Reducibility( degrees) Score Additional parameters Score 90-45 4 Marked posterior crease 1 45-20 3 Marked medio tarsal crease 1 20-0 2 Cavus 1 0 t0 -20 1 Poor muscle condition 1
Grade Type Score Reducibility i Benign 1-4 >90% ii Moderate 5-9 >50%, soft-stiff, reducible, partially resistant iii Severe 10-14 >50%, stiff-soft, resistant, partially reducible iv Very severe 15-20 <10% stiff- stiff,resistant
Aims of treatment • Achieve a – plantigrade , – pliable, – cosmetically accepted foot in shortest possible time and with least disruption of family and child life.
PRINCIPLES OF TREATMENT Soft tissue contractures should be stretched out in order to restore normal tarsal relationship. Once achieved correction should be maintained in till tarsal bones remoulds stable articular surfaces.
TWO OPTIONS – 1. NON OPERATIVE- immediately after birth 2. OPERATIVE
Clubfoot treatment brace used in 1806
Thomas Wrench
KITES METHOD  Correction of each component separately and in order.  Avg time 6 months  Fulcrum – calcaneocuboid joint.  Order 1.Forefoot adduction 2.Heel varus 3.equinus
Kite method • Believed heel varus would correct simply by everting calcaneus • Did not realize calcaneus can evert only when it is abducted (i.e., laterally rotated) under the talus • Forefoot overcorrected into mild flatfoot • Calcaneus is rolled out of inversion by placing plantar surface of a slipper cast on glass plate to flatten the sole • Dorsiflexion of foot with wedging casts
Reasons for poor results in kites method 1. FULCRUM- prevents abduction of calcaneum and thereby eversion of calcaneum. 2. Pronation of forefoot worsens cavus.
Common errors(Kite errors) • No manipulation • Pronation/eversion of 1st metatarsal • Premature dorsiflexion of heel • Counterpressure at calcaneocuboid joint • Below knee casts • Short splints
Ponseti Cast Correction
• weekly manipulation and cast application to hold correction • Percutaneous tenotomy of tendo achilles for “hind foot stall” • Once foot corrected, an abduction foot orthosis worn full time for 12 weeks, and then at nights and naps, up to age of four.
• Order- cavus adduction varus equinus
Setup
Exactly locate the head of the talus
Manipulation • Start as soon after birth as possible • Abduction of the foot beneath the stabilized talar head. • All components of clubfoot deformity, except for the ankle equinus, are corrected simultaneously
• Metatarsus adductus and hindfoot varus are simultaneously corrected
Reduce the cavus -requires only elevating the first ray of the forefoot to achieve a normal longitudinal arch of the foot -The cavus is almost always corrected with the first cast -At the first session the forefoot is simultaneously supinated and abducted
• First, forefoot abduction should be performed with the foot in slight supination • Second, the heel should not be constrained by premature dorsiflexion • Third, care is taken to locate the fulcrum for counterpressure on the lateral head of the talus
Steps in cast application Preliminary manipulation The heel is not touched to allow the calcaneus to abduct with the foot
Applying the padding
Plaster at toes Below knee pop
• press and release talar head repetitively to avoid pressure sores of the skin. • Mold the plaster over the head of the talus while holding the foot in the corrected position • The calcaneus is never touched during the manipulation or casting.
Molding Extension upto the thigh
Plantar support to toes Final appearance
Casts and foot
Characteristics of adequate abduction • Confirm that the foot is sufficiently abducted to safely bring the foot into 0 to 5 degrees of dorsiflexion before performing tenotomy. • The best sign-ability to palpate the anterior process of the calcaneus as it abducts out from beneath the talus
• Abduction of approximately 60 degrees in relationship to the frontal plane of the tibia is possible. • Neutral or slight valgus of os calcis is present. This is determined by palpating the posterior os calcis. • The correction is accomplished by abducting the foot under the head of the talus. The foot is never pronated.
The final outcome • At the completion of casting, the foot appears to be over-corrected into abduction with respect to normal foot appearance during walking.
Complications of casting • Tight cast • Rocker bottom deformity • Crowded toes • Flat heel pad • Superficial sores • Deep sores • Pressure sores
Cast removal Cast knife removal Soaking and unwrapping
• Equinus is the last deformity that is corrected, and correction should be attempted when the hindfoot is in neutral to slight valgus and the foot is abducted 70 degrees relative to the leg. • By progressively dorsiflexing the foot -by applying pressure under the entire sole of the foot