CTEV

PRESENTER-DR.RAGHAVENDRA RAJU
MODERATOR-DR.SAMEER WOOLY
 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.

 IT IS A DEVELOPMENTAL DISORDER.
 ETIOLOGY-IDIOPATHIC

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, friedrichs
ataxia.
2.SYNDROMES -arthogryposis multiplex congenita,
downs syndrome, larsen syndrome.
INCIDENCE- 1 to 2 in 1000 livebirths.
SEX – MALE >FEMALE
LATERALITY- BILATERAL IN MORE THAN 50 % .
FAMILY HISTORY- 5-50% POSITIVE.
COMPONENTS OF CTEV
 BONY CHANGES

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
 Anterior portion lies beneath
the head of talus causing
varus and equinus of heel
 In equinus
 Rotated medially
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
 Soft tissue changes

 Posterior structures :
 Tendo achilles
 Post. capsule of ankle
joint & subtalar joint
 Post. talo fibular
 Calcaneo-fibular
ligaments
MEDIAL-
 Tibialis posterior
 FHL,FDL, Master Knot of
Henry
 Talonavicular ligament
 Calcaneo-navicular ligament
 Deltoid ligament
 Interossseus talo calcaneal
ligaments
 Capsules of naviculo
cuneiform & cuneiform first
metatarsal
Plantar wards :
Plantar fascia

Plantar ligaments
Flexor digitorum brevis & a bductor hallucis

Laterally
Calcaneofibular ligament
Bifurcated ligament

Calcaneocuboid joint capsule

 EXAMINATION

1.DORSIFLEXION TEST-
2. PLUMB LINE TEST-
 CLASSIFICATION

1. IDIOPATHIC AND NON IDIOPATHIC-

2. CUMMIN CLASSIFICATION
3. a. supple –foot can be brought to normal position.
b.rigid - forefoot can be corrected but not the hind foot
by conservative management.
c. neglected- not received treatment for one year.
d.relapsed- deformity reappear after correction.
e.recurrent- type of relapse, due to muscle imbalance.
f. resistant- cannot be corrected by conservative
treatment.
3. Browne s classification-
a.first degree- only forefoot adduction present.
b.second degree- inversion and equinus is present
along adduction.
c.Third degree- toes pointing upwards, sole is in
contact with medial surface of tibia. Equinus
component is not present.
 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
AP view: Taken with foot in 30° of plantar flexion and tube
at 30° from vertical
Lat. View: Transmalleolar with the fibula overlapping the
posterior half of the tibia; foot in 30° of plantar flexion
Anteroposterior view
Talocalcaneal angle

Calcaneal-second
metatarsal angle

Talus –first metatarsal

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 25-
40°.
Any angle less than 20°
considered abnormal
Lateral view
 Talocalcaneal view
 Calcaneal-first metatarsal
view
 Tibiocalcaneal
 Talus-first metatarsal
angle
 Talocalcaneal index
(Kite's angles from AP and
Lateral views added)
 Pirani’s severity scoring

Six parameters : 3 of midfoot and 3 of hindfoot

Each parameter is given a value as follows:
 0: normal
 0.5: moderately abnormal
 1: severely abnormal

Pirani s et al. A method of evaluating virgin clubfoot with substantial interobserver reliability. Annual
meeting of Pediatric orthopaedic society of North America 1995
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

Assessment of progress by serial plotting of the score

Predicting need for tenotomy

Estimation of probable no. of casts reqd*

Very 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
Classification of clubfoot severity by Diméglio A.Equinus
deviation B. Varus deviation C. Derotation D. Adduction.
Reducibility( Score Additional Score
degrees) parameters
90-45 4 Marked posterior 1
crease
45-20 3 Marked 1
mediotarsal
crease
20-0 2 Cavus 1
0 t0 -20 1 Poor muscle 1
condition
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
 KITES METHOD

 Correction of each
component separately
and in order.
 Avg time 6 months
 Fulcrum –
calcaneocuboid joint.
 Order
1.adduction
2.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
 Outline of Ponseti regimen
Serial casting of lower limb
using a strictly defined
technique and weekly
change of casts

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.
 Reasons for poor results in kites method
1. FULCRUM- prevents abduction of calcaneum and
thereby eversion of calcaneum.
2. Pronation of forefoot worsens cavus.
 Manipulation and cast application

1.Manipulation
Manipulation: start as soon
after birth as possible

Setup for casting includes

calming the child with a bottle
or breast feeding

Assistant holds the foot while

the manipulator performs the
correction

.
Order- cavus
adduction
varus
equinus
2. Correction of cavus
Cavus results from pronation of
the forefoot in relation to
hindfoot “ THE PRONATION
TWIST “
Attempting to correct the
supination of hindfoot before
correction of varus results in an
iatrogenic increase in cavus
Corrected by supinating the
forefoot to place it in proper
alignment with the hindfoot.
 Cast application
Manipulation Padding
Plaster at toes Below knee pop
Molding Extension upto the thigh
Plantar support to toes Final appearance
Casts and foot Adequate abduction

Best sign of sufficient

abduction: ability to
palpate the anterior
process of the calcaneus
as it abducts out from
beneath talus
Abduction of approx.70
degrees in relationship to
the frontal plane of the
tibia possible
 Complications of casting

Tight cast
Rocker bottom deformity
Crowded toes
Flat heel pad
Superficial sores
Deep sores
Pressure sores
Injury to distal tibial physis
Common errors(Kite errors)

No manipulation
Pronation/eversion of
1st metatarsal
Premature dorsiflexion
of heel
Counterpressure at
calcaneocuboid joint
Below knee casts
Short splints
 Rocker bottom deformity

Dorsiflexion via midfoot

before correction of
hindfoot varus
Dorsal dislocation of
navicular on talus
Fixed equinus of
calcaneus
 Correction of equinus and tenotomy

No direct attempt at equinus correction is made

until heel varus is corrected
Equinus deformity gradually improves with
correction of adductus and varus- calcaneus
dorsiflexes as it abducts under talus
Residual equinus- manipulation and casting +/-
percutaneous tenotomy
Tenotomy : Indicated to correct equinus when cavus,
adductus, and varus fully corrected but ankle
dorsiflexion remains less than 10 degrees above
neutral
 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.
Cast with the foot abducted 60 to 70 degrees with
respect to the frontal plane of the ankle, and 15
degrees dorsiflexion for 3 weeks
 Foot Abduction braces

Shoes mounted to bar in

position of 70° of ER and 15°
of dorsiflexion in B/L cases
and incase of U/L cases 30
to 40° of ER in normal side,
distance between shoes set
at about 1˝ wider than width
of shoulders

Knees left free, so the child

can kick them “straight” to
stretch gastrosoleus tendon
 Bracing protocol

Worn 24 hours each day for first 3 months.

For 12 hours at night and 2 to 4 hours in middle of day for

a total of 14 to 16 hours during each 24-hour period.

Continued until the child is 3 to 4 years of age.

Noncompliance with bracing protocol – the most common

cause of recurrence in children on Ponseti regimen

.
Mitchell brace Dobbs dynamic brace
Dennis brown Romanus
 CTEV Splint

Straight inner border to

prevent forefoot adduction
Outer shoe raise to prevent
fooot inversion
No heel to prevent equinus
Slight(1/8”) lateral sole raise
Inner iron bar
Outer t trap
Walking age to 5 yrs of age
 The French method

Bensahel/Dimeglio regime
Daily manipulations by a skilled physiotherapist and
temporary immobilisation with elastic and non-elastic
adhesive taping .

GOAL- reduce talonavicular joint, stretch out medial

tissues, correct deformities squentially.

Mobilisation during the hours of sleep with CPM machine.

Successful in 51% of cases ( of which 9% req TA tenotomy) ;

49% Reqd extensive soft tissue release -29% post release
and 20% comprehensive posteromedial release**.
 Follow up protocol

2 weeks: to troubleshoot compliance issues

3 months: to graduate to the nights and naps protocol

Every 4 months: until age 3 years to monitor compliance

and check for relapses

Every 6 months: until age 4 years.

Every 1 to 2 years: until skeletal maturity

RESULTS OF NON OPERATIVE TREATMENT

 OVERALL – 19% TO 95%.

 KITES METHD- 80%.
 PONSETI – 95%
 Surgery in clubfoot
INDICATIONS
Resistant clubfoot( non-responsive to serial casting and
manipulation)
Persistently deformed clubfoot(non-operative correction
inadequately done with/without compliant bracing)
Relapsed clubfoot( initially satisfactorily corrected that
recurs in part or whole)
Neglected clubfoot( no treatment given till age of 2 yrs)
 General Principles

Goal: address all pathoantomic structures.

Type of surgery depend on age and deformity.

 Approaches
Turco (postero medial Cincinnati (postero medial and
incision) postero lateral )
 Caroll’s two incision technique
Medial incision - straight oblique incision
Straight lateral incision along the lateral
from first metatarsal, across medial
subtalar joint antr to distal fibula
malleolus to Achilles tendon
 TURCOS ONE STAGE RELEASE

AGE 9- 12 MONTHS

RELEASING OF IDENTIFY AND

MEDIAL, PLANTAR, AND MOBILISE-
POSTERIOR ASPECTS OF 1.TIBIALIS POSTERIOR
FOOT.
2. FDL
3.FHL
4.NV BUNDLE
5.ACHILLES TENDON
Medial tibial navicular
ligament, dorsal
talonavicular ligamnet,
and plantar
calcaneonavicular
ligament cut
Capsule of T-N cut all the
way around
 Bifurcated ligament cut
 Complete release of
talocalcaneal joint ligaments
except interosseous
ligaments
 Detach origin of quadratus
plantae muscle from
calcaneus
 Roll talus back into ankle
koint, if not incise post.
talofibular ligament, post.
Portion of deep deltoid
ligament
Line up medial side of
head and neck of talus
with medial side of
cuneiforms, medially push
calcaneus post. to ankle
joint
K wire through
talonavicular
,talocalcaneal joints
Check for proper position
of foot
Longitudinal plane of foot
85-90° to bimalleolar
ankle plane, heel under
tibia in slight valgus
Suture all tendons with
foot in 20° dorsiflexion
Wound closure
Follow up :
 Wound inspection done under sedation at 1 week
 Foot held in neutral, plantigrade position and cast applied –
above knee
 Cast kept for 4 – 6 weeks
 Cast removed along with any K wires, if applied during surgery
for stabilisation
 AFO given for 6 months
 Residual deformities

Residual hindfoot equinus : Achilles tendon

lengthening and posterior capsulotomy of ankle and
subtalar joints
Dynamic metatarsus adductus : Transfer of anterior
tibial tendon, either as split transfer or entire tendon
 Resistant clubfoot

Metatarsus adductus : >5 yrs metatarsal osteototomy

Hindfoor varus : <2-3 yrs modified Mckay procedure
3- 10 yrs
Dwyer osteotomy ( isolated heel varus)
Dilwyn Evans procedure (short medial column)
Lichtblau procedure( long lateral column)
10-12 yrs triple arthrodesis
Equinus : Achilles tendon lengthening and posterior
capsulotomy of subtalar joint, ankle joint / Lambrinudi procedure

All three deformities >10 yrs triple arthrodesis

 TENDON TRANSFERS

INDICATION –PASSIVELY CORRECTABLE FOOT

RESULTING FROM MUSCLE IMBALANCE.
NEVER A PRIMARY PROCEDURE
THREE TYPES-
1.TIBIALIS ANTERIOR
2.TIBIALIS POSTERIOR
3.SPLIT ANTERIOR TIBIALIS TENDON
TRANSFER
 TIBIALIS ANTERIOR TRANSFER

AGE 3- 6 YEARS

Weakness of
muscle(peroneus).
Garceaus- middle
Cuneiform.
Mod gerceaus- 5 th
metatarsl base.
SPLATT

Indicated for dynamic

foot deformity.
Lateral part on to
cuboid
 TIBIALIS POSTERIOR TRANSFER

AGE- 8 YEARS.
PRINCIPLE- eliminate the deforming force of tibialis
posterior and use it corrective force when there is toe
in gait, cavus ,weak peroneals, forefoot equinus.
Through interroseous membrane to lateral cuneiform.
 Bony procedures
Dwyer calcaneal osteotomy
Age 3-4 years
IND- persistent varus
deformity.
Opening wedge medial
osteotomy to increase the
length and height of calcaneus
 Osteotomy held open by a
wedge of bone taken from
tibia with k wire.
Cast for 3 months.
 Litchblau procedure

IND – hind foot includes

varus and residual internal
deformity of calcaneum
with long lateral column.
AGE – min 3 years.
Lateral closing wedge
osteotomy of calcaneus
along with medial soft
tissue release .
• Shortens the lateral
column.
• Complication- skew foot.
 Dilwyn Evans Osteotomy

Posteromedial release
Calcaneocuboid wedge
resection and
arthrodesis of the joint
Shortens lateral column
Stiffness at subtalar and
midfoot joints
Preferred in older
children (4-8 yrs)
 Dilwyn Evans Osteotomy

PRINCIPLE- basic deformity is at mid tarsal joint

and all other deformities are adaptive.
Age – 4 years- 8 years. Staged procedure.
Lateral foot shortened by closed wedge osteotomy.
Medial soft tissue release and closed tenotomy of
plantar fascia.
Posterior capsulotomy and soft tissue release.
Calcaneo – cuboid fusion.
 Salvage procedures

Triple arthrodesis
Salvage procedure for painful stiff foot.
Correction of large degrees of deformity in neglected
clubfeet.
Not performed before advanced skeletal maturity, at
age 10 to 12 years.
3
Joints fused 1. subtalar joint.
2. talonavicular joint.
3. calcaneo cuboid joint.
 Talectomy

 Originally done for

syndromic clubfoot.
 Now done for severe
untreated club foot.
 Age – 6years.
 Complete excision of talus .
 Derotate foot and displace
calcaneum into ankle
mortise untill navicular
abuts anterior edge of tibial
plafond.
 Complications- limb length discrepancy.
limitation of ankle movements.
 Ilizarov

Correction slow enough

to protect soft tissue
Correction at the focus
of deformity
Simultaneous three-
dimensional, multilevel
correction
Deformity correction
without shortening the
foot
JOSHI EXTERNAL STABILISATION SYSTEM

DR.B.B. JOSHI, MUMBAI.

Principle –tension stress applied in physiological

doses by mechanical device have shown to
stimulate histiogenesis.
 JOSHI EXTERNAL STABILISATION
SYSTEM

DR.B.B. JOSHI, MUMBAI

2 to 4 transfixing wires in
prox tibia
Metatarsal
Transfixing wire through
I &V MT; Medial half pin
through I, II, III MT; Lat
half pin thro’ IV, V MT
2 transfixing and 1 axial
wire through calcaneum
 JESS

Distraction used to Sequentially correct deformities

(Medial- 0.25 mm every 6 hours ,Lateral- 0.25 mm every 12
hours).

Distraction continued until approximately 20 degrees of

dorsiflexion and overcorrection of the forefoot deformities
was achieved .

Maintained in this overcorrected position for twice as long

as the distraction phase by casts/braces.
 ADVANTAGES OF JESS

1. Causes lengthening of all contracted tissues and

prevent further scarring by surgery.
2. Magnitude of correction can be controlled by
distraction.
3. Resultant foot are supple in contrast to foot in
surgery.
 Results with JESS

Good or excellent results reported by Joshi in 84% of

his patients
Recommended in all who have not responded to
serial plaster casting methods.
 Complications of surgery

Neurovascular injury
Loss of foot (10% have atrophic dorsalis pedis artery bundle)
Skin dehiscence
Wound infection
AVN talus
Dislocation of the navicular
Flattening and breaking of the talar head
Undercorrection/ Overcorrection.
Forefoot adductus
Hindfoot varus
Severe scarring
Stiff joints
Weakness of the plantar flexors of the ankle
 Conclusion

Proper understanding of the patho-anatomy a must

Ponseti method is now the standard treatment
method
Indications of surgery limited but well defined
Turco’s posteromedial soft tissue release remains the
treatment of choice in most cases amenable to
surgical treatment
THANK YOU
HAPPY BIRTHDAY
MANJUNATH