Congenital
talipes equinovarus describes a deformity noted at the birth and includes idiopathic as well as non-idiopathic talipes equino
varus. In non idiopathic group it is a manifestation of a systemic skeletal syndrome; the associated skeletal anomalies are due to the same
etiological factor that caused failure of the normal development as in:
1)
From muscle imbalance e.g. neuromuscular disorders.
2)
From fibrosis of soft tissue as in Arthrogryphosis
3) From bone and
joint anomalies.
Theories to explain idiopathic CTEV
1.
Mechanical pressure in utero e.g.: Oligohydraminos
2.
Neuromuscular defect
— Spina bifida
— Weak peroneal muscles
3.
Germ cell defect
4.
Intrauterine arrest of the growth.
5.
Hereditary.
6.
Multifactorial.
Non-idiopathic
causes:
—
Arthrogryphosis
—
Nail patella syndrome
—
Streeter syndrome
—
Muscular dystrophy
—
Myelomeningocele, Spina bifida, Spinal cord defects.
EPIDEMOLOGY
· 1 in 1000 birth
· M: F: 2.5:1
· Incidence:
· Polynesian > Caucasian> Orientals.
· 50% Bilateral
· 20 - 30 times common if one child affected
· 1 - 4% if one parent affected
· 15 - 20% if both parents affected
· 32% in case of monozygotic twins
· 3% in case of dizygotic twins.
Pathological
Anatomy:
The
clubfoot deformity is due to the abnormal relation ship of the tarsal bones: the navicular and calcaneus are displaced around
the
tarsus.
Correction of this abnormal tarsal relationship is resisted by pathological contracture of the associated softer parts the
severity of the deformity depends on the degree of displacement, whereas the resistance to the treatment is determined by
the rigidity of the soft tissue structures. Two laws used for understanding are:
Wolf’s
law: every change in
the use of the static function of the bone causes a change in the internal form as well as the architecture and also the external
form and function according to mathematical law.
Davis law: When ligaments and soft tissue in lax state they will shorten.
Components
of the deformity.
1. Equinus - At
the ankle joint plantar flexion
of the forefoot.
2.
Varus - primary at sub talar joint but
entire tarsus rotated except talus.
3.
Adduction - talo navicular and tarso metatarsal joint
4.
Cavus - forefoot plantar flexion.
Anatomical
region wise involvement:
Posterior
contracture: Tend Achilles, Tibiotalar
capsule, talo calcaneal capsule, posterior talo fibular ligament, calcaneo fibulas ligament. These structures resist equinus
correction.
Medial:
Most important and most resistant
structures Tibialis posterior, deltoid, talo navicular capsule and spring ligament.
Subtalar: Talo calcaneal interosseous ligament, bifurcated
Y ligament.
Plantar
contractures: Abductor Hallucis,
intrinsic flexors, quadratus plantae, plantar aponeurosis.
Clinical
Examination
•
Smaller stubby feet with shortened first metatarsal ray.
•
Equinus deformity with inversion of the heel, adduction and varus of
the fore foot.
•
Medial border of the foot is concave and elevated, its plantar surface face up ward.
•
Lateral border of the foot is convex and depressed down.
•
The posterior tuberosity of the heel is upwards, invested difficult to palpate and less visible, there is absent skin crease
on posterior aspect.
•
Callosity on the dorsal aspect of the fifth metatarsal.
•
Boney prominence visible and palpable over the dorsolateral aspect of the foot represents the head and neck of the talus which
are partially uncovered be cause the navicular and
Osseous
deformity
•
Overall size of all the tarsal bones is decreased
•
Both legs are usually equal in the length.
1.Talus:
•
While talus is the least displaced, it undergoes the most changes.
•
Anterior extrusion of the body of talus.
•
External rotation of the body of Talus in the ankle mortise.
•
Equinus of talus.
•
Medial and plantar deviation of the talar neck.
•
Lack of normal construction in the neck with overgrowth of the anterior trochlea.
2. Calcaneum - Equinus and medial rotation.
3. Navicular - Medical subluxation.
4.
Cuboid - Minimal changes.
5.
Cuneiform and metatarsal - Adduction, supination & cavus.
Muscles
•
Atrophy of peroneals
•
Contracture of Tibialis posterior, Tendoachilles, F.DL, F.H.L.
•
Thickening of tendon sheath esp. Tib. Post.
Joint
Capsule
•
Contracture of ankle, Subtalar, talonavicular and calcaneocuboid capsules.
Fascia
•
Contracture of fascial planes & plantar fascia
Ligaments:
Contracture of following ligaments:
•
Calcaneo fibular ligament
•
Talofibular ligament
•
Deltoid ligament
•
long and short plantar ligaments
•
Spring ligament.
Skin:
-
Stretched out, thinned & atrophic; may have deep cleft on the medical plantar surface.
Knee:
- Hyperextension
because of fixed equinus
-
Genu valgus as a compensatory
mechanism in severe deformity to place the more deformed foot in plantigrade position.
Tibia:
-
Internal tibial torsion.
Ankle:
-
Normal external rotation of the Mortise is increased the lateral malleolus is palpable more posteriorly. medial
malleolus anteriorly and usually under developed.
•
Examine the LS spine for spina bifida occulta or apperta.
•
Examine for other deformities like congenital bands, contractures.
X-rays:
1 Simulated
weight bearing A-P view
•
Tibio calcaneal angle normal range 20-40 degrees,
abnormal if less than 20 degrees.
•
Talo 1st metatarsal angle.
2.
Lateral film in maximum dorsiflexion:
•
Talocalcaneal angle normal range 25-50 degrees, abnormal if less than 25 degrees.
•
Tibio calcaneal angle normal range 5-15 degrees, abnormal if less than 5 degrees or negative.
Kites
view: AP view with toot
flexed 30 degrees
and tube angled 30 degree anteriorly in sagittal plane. Importance of x-ray on follow-up
- Clinically the heel varus many appear to be corrected because manipulation may have displaced the heel pad laterally, but
x-ray will demonstrate on abnormal tarsal relationship between talus and calcaneus confirming whether one is dealing with
spurious correction.
•
Rocker bottom foot - An iatrogenic deformity that results from vigorous attempts to dorsiflex and evert the foot in
absence of unyielding soft tissue contractures. There is fore foot abduction and dorsiflexion with a breech at the tarso metatarsal
level causing the hyper mobility at lisfranc joint. The lateral x-ray confirms that there
is
no dorsiflexion of the calcaneum and that talus is more plantar flexed than usual.
•
Flat top talus - Overgrowth of the anterior body and failure to develop the construction of the neck of talus contributes
to the equinus deformity by impinging on anterior lip of tibia in dorsiflexion.
Management
of CTEV:
Aims:
•
To correct the deformity early
•
To correct the deformity fully
•
Hold the correction until growth
stops.
Nonoperative
treatment:
•
Manipulation and serial casting
•
Stretching and adhesive strapping
•
Dennis - Browne splinting.
Manipulation
and serial casting:
•
Should begin in nursery ideally but some surgeons prefer to defer for 3 weeks.
• Manipulation
before the cast application is most important part of nonoperative treatment.The objective is to stretch the soft tissue contracture,
the plaster of paris cast serves to maintain the correction obtained by manipulation.
•
The goal is to relocate the navicular in front of the talus and dorsiflex, evert the calcaneum.
•
Classical order of correction is CAVE: Cavus, Adduction, Varus, equinus
•
Mother is taught to correct with each and breast-feed. pressure applied till toes blanch, kept for 2-5 sec; continued for
up to six weeks after which serial cast correction.
Method
of Casting:
a.
Kites - Each component of deformity corrected in the cave sequence. Kite believed that heel varus would correct simply
by everting the heel.
Ponsetti
however felt that calcaneus could evert only when it is abducted i.e. laterally rotated under the talus.
b.
Ponsetti - All component of the deformity must be corrected simultaneously, not in the sequence except for equinus,
which should be corrected last. The cavus, which arises from the pronation of the forefoot in relation to the hind foot is
corrected by supinating the fore foot in proper alignment with the hind foot. With the arch well molded, the entire foot can
be gently and gradually abducted under the talus, which is secured against rotation, in the ankle mortise by applying counter
pressure with thumb against the lateral part of the talus. Heel varus will get corrected when the entire foot is entirely
abducted. Finally equinus is corrected by dorsiflexing the foot, which can be facilitated by simple percutaneous tenotomy
of the tend Achilles. Well molded plaster cast applied after manipulation is complete.
Frequency
of cast change – ideally
weekly but practically done fortnightly.
Reassessment at 3 months:
• Clinically
- by observing the posterior tuberosity, which can be seen as well as palpated to be moving downward as the foot is dorsiflexed,
in
contrast to spurious correction where no vertical movement occurs.
•
Radiologically on stress dorsiflexion lateral view, no dorsi flexion of the calcaneum indicates spurious correction.
On
reassessment at 3 months:
A.
If completely corrected: Maintain in maximally corrected position for total of 6-8 months, after 6- 8 months Dennis Browne
bar with attached tarso pronator shoe for 24 hrs checked at routine intervals
for
recurrence, mother also taught to look for heel cord shortening.
One
walking age attained only tarso pronator shoe with the Dennis Browne splint at night.Night time splinting continued till 7
years of age.
B.
Partially corrected or no correction – observed for further 3 months with manipulation and casting. If no correction,
static deformity may require surgery at 6 months.
Denis
Browne Splint - A dynamic splint
in which the kicking movement of each leg exerts a corrective force on the counter part.
Relapsed
foot - The deformity recurred after
Fair correction.
Resistant
foot- foot is considered
resistant when the deformity shows no evidences of further improvement with manipulation the radiograph and the X rays confirming the persistence of equinovarus deformity.
OPERATIVE
MANAGEMENT
Indications:
•
When a plateau has been reached in non operative treatment.
•
The child is old enough for the anatomy of foot to be recognized usually by six months.
Complete
Subtalar release:
A.
Incision:
· L shaped or hockey stick.
· Transverse circumferential (Mc Kay’s, Cincinnati).
· Two incision technique of Carroll: Curvilinear medial incision and a posterolateral
incision.
B:
Identify and isolate the neurovascular bundle and the sural nerve. Take care to preserve the medial calcaneal branch
of
the
posterior tibial nerve.
C.
Identify and expose Tibialis Posterior, FDL, FHL, tendoachilles.
D.
Transect the master knot of Henry- which is hypertrophied thickening of the tendon sheaths of long toe flexors functioning
as suspensory ligament that holds FDL & FHL close to the plantar surface of the navicular. Excision is necessary to completely
mobilize the navicular and permit transection of the spring ligament.
E.
Posterior release: Done first as it facilitates the exposure of medial plantar and subtalar contractures.
i.
Tendo - Achilles lengthening:
•
Z lengthening in the sagittal plane
•
Detaching medial half of the insertion on
calcaneum
thereby eliminating the inversion force of the T.A.
•
Lengthen enough to permit immobilization at 90 degrees.
ii.
Capsulotomy of the tibio-talar joint.
iii.
Capsulotomy of the tibio-calcaneal joint.
iv.
Transection of the posterior talofibular
ligament.
v.
Transection of the calcaneofibular ligament.
vi.
Posterior portion of the deltoid ligament
on
capsule cut.
F.
Medial Plantar Release:
i.
Lengthening of Tibialis posterior.
ii.
Division of FHL, FDL.
iii.
Transection of superficial Deltoid &
spring
ligament.
iv.
Cutting the talonavicular capsule
v.
Mobilization of navicular.
vi.
Capsulotomy of subtalar joint.
G. Subtalar Release
•
Division of talo calcaneo interosseous
ligament:
limited to the amount necessary to unlock calcaneum
•
Y ligament bifurcated
H.
Internal fixation with k wire of
•
Talo calcaneal.
•
Talo navicular
After
6 weeks K- wire removed and cast given.
Potential
Complications:
•
Infection and wound breakdown
•
AVN of talus
•
Overcorrection
Residual
deformity: Must ensure that there
is no neurologic cause. The residual deformity may be:
a.
Dynamic -
If unable to actively evert the foot. Consider SPLATT (Split ant. Tibialis transfer).
b.
Fixed - Look for the uncorrected component and treat accordingly.
1 Metatarsus
adductus – after 5 year MT osteotomy
2 Hind
foot varus:
<
2-3 year - Repeat soft tissue procedure
preferably
complete subtalar release (McKay’s)
3-10
year
•
Dwyer’s procedure - later closed wedge
or
medial open edge osteotomy of calcaneum.
•
For long lateral column
•
Cuboid decancellation
•
Litchblau's procedure: lateral close
wedge
osteotomy of calcaneum or cuboid
enucleation.
3 Equinus:
•
TA lengthening with posterior
Capsulectomy
of ankle, Subtalar joint.
•
Lambrunidi’s triple arthrodesis.
4.
All three deformities severe, resistant: Triple arthrodesis
Talectomy-
neglected severe cases of Arthrogryphosis.
Use
of Jess fixator in CTEV (Joshi’s
External Stabilizing
System)
Principle
- Controlled differential distraction
Main indications:
•
Dropout of conservative treatment
•
Recurrence after earlier surgical release.
•
Known resistant cases like AMC, streeter's
syndrome
•
Late presentation for treatment
• Adjunct
to soft tissue, surgical procedure for realignment of skelton to minimize bone resection and shortening of the foot.
Cure
of CTEV: The CTEV deformity
is considered cured when there is no deformity, there is below on the dorsum of foot, passive movement to full calcaneovalgus.
Position and the child is able to evert and dorsiflex the foot voluntarily to about the right angle.
Follow
up and success of treatment by a particular method is audited by using Pirani's classification whose scoring is based
on:
•
The curvature of lateral border
•
Severity of the medial crease
•
Severity of the posterior crease
•
Palpation of the lateral part of the head
of
the talus
•
Emptiness of the heel.
•
Rigidity of Equinus.
