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Congenital Talipes Equino-Varus (Congenital Clubfoot)

Congenital Talipes Equino-Varus (Congenital Clubfoot). Dr. Mazloumi MD Associate Professor Pediatric Orthopedic Surgeon. THE NORMAL FOOT. Complex organ that is required to be Stable: for supporting the body weight in standing Resilient: for walking and running

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Congenital Talipes Equino-Varus (Congenital Clubfoot)

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  1. Congenital Talipes Equino-Varus(Congenital Clubfoot) Dr. Mazloumi MD Associate Professor Pediatric Orthopedic Surgeon

  2. THE NORMAL FOOT Complex organ that is required to be • Stable:for supporting the body weight in standing • Resilient: for walking and running • Mobile:to accommodate variations of surface • Cosmetic

  3. CLUB FOOT Gross deformity of the foot that is giving it the stunted lumpy appearance

  4. CLUB FOOT Definitions Talipes: Talus = ankle Pes = foot Equinus:(Latin = horse) Foot that is in a position of planter flexion at the ankle, looks like that of the horse. Calcaneus:Full dorsiflexion at the ankle

  5. CLUB FOOT Planus: flatfoot Cavus:highly arched foot Varus: heal going towards the midline Valgus:heel going away from the midline Adduction:forefoot going towards the midline Abduction:forefoot going away From the midline Forefoot Hind foot

  6. CLUB FOOT Postural : Calcaneo-ValgusEquino-Varus Look for DDH Minor and correctable

  7. CLUB FOOT Types Idiopathic (Unknown Etiology) : • Congenital TalipesEquino-VarusCTEV Acquired, Secondary to : • CNS Disease : Myelomenegocel • Arthrogryposis • Absent Bone : fibula / tibia

  8. Congenital Talipes Equino-VarusCTEV Congenital clubfoot or CTEV occurs typically in an otherwise normal child.

  9. Congenital Talipes Equino-VarusCTEV Etiology • Polygenic • Multifactorial although many of these factors are speculative

  10. Congenital Talipes Equino-VarusCTEV Etiology Some of these factors are : • Abnormal intrauterine forces • Arrested fetal development • Abnormal muscle and tendon insertions • Abnormal rotation of the talus in the mortise • Germ plasm defects

  11. Congenital TalipesEquino-VarusCTEV Incidence • Occurs approximately in one of every 1000 live birth • In affected families, clubfeet are about 30 times more frequent in offspring • Male are affected in about 65% of cases • Bilateral cases are as high as 30 – 40 %

  12. Congenital Talipes Equino-VarusCTEV Basic Pathology • Abnormal Tarsal Relation Congenital Dislocation / Subluxation TaloCalcaneoNavicular Joint • Soft Tissue Contracture Congenital Atresia

  13. Congenital Talipes Equino-VarusCTEV

  14. Congenital Talipes Equino-VarusCTEV Adaptive Changes • Bony : Change in the shape of tarsal and metatarsal bones especially after walking • Soft Tissue : Shortening ? Contracture in the Concave Side 1- Muscles 2- Tendons 3- Ligaments 4- Joints Capsule 5- Skin 6- Nerves & Vessels

  15. Congenital Talipes Equino-VarusCTEV

  16. Congenital Talipes Equino-VarusCTEV Diagnosis General Examination : Exclude • Neurological lesion that can cause the deformity “Spina Bifida” • Other abnormalities that can explain the deformity “Arthrogryposis, Myelodysplasia” • Presence of concomitant congenital anomalies “Proximal femoral focal deficiency” • Syndromatic clubfoot “Larsen’s syndrome, Amniotic band Syndrome”

  17. Congenital Talipes Equino-VarusCTEV Diagnosis Spina Bifida = Paralytic TEV

  18. Congenital Talipes Equino-VarusCTEV Diagnosis Characteristic Deformity : Hind foot • Equinus (Ankle joint) • Varus (Subtalar joint) Fore foot • Adduction (Med tarsal joint) • Supination fore foot • Cavus

  19. Congenital Talipes Equino-VarusCTEV Diagnosis

  20. Congenital Talipes Equino-VarusCTEV Diagnosis “ Hind foot “ “ Fore foot “ Equinus, Varus Adduction, Supination, Cavus

  21. Congenital Talipes Equino-VarusCTEV Diagnosis

  22. Congenital Talipes Equino-VarusCTEV Diagnosis • Short Achilles tendon • High and small heel • No creases behind Heel • Abnormal crease in middle of the foot • Foot is smaller in unilateral affection • Callosities at abnormal pressure areas • Internal torsion of the leg • Calf muscles wasting • Deformities don’t prevent walking

  23. Congenital Talipes Equino-VarusCTEV Diagnosis

  24. Congenital Talipes Equino-VarusCTEV Diagnosis X-Rayneeded to assess progress of treatment

  25. Congenital Talipes Equino-VarusCTEV Treatment The goal of treatment for clubfoot is to obtain a plantigrade foot that is functional, painless, and stable over time A cosmetically pleasing appearance is also an important goal sought by the surgeon and the family

  26. Congenital Talipes Equino-VarusCTEV Treatment Non surgical treatment should begin shortly after birth • Gentle manipulation • Immobilization - POP or synthetic cast

  27. Congenital Talipes Equino-VarusCTEV Treatment Non surgical treatment should begin shortly after birth • Splints to maintain correction - Ankle-foot orthosis - Dennis Brown splint

  28. Congenital Talipes Equino-VarusCTEV Treatment Manipulation and serial casts • Validity, up to 6 months ! • Technique “Ponseti” • Avoid false correction • When to stop ? • Maintaining the correction • Follow up to watch and avoid recurrence

  29. Congenital Talipes Equino-VarusCTEV Treatment Ponseti technique • Always use long leg casts, change weekly. • First manipulation raises the 1st metatarsal to decrease the cavus • All subsequent manipulations include pure abduction of forefoot with counter-pressure on neck of talus. • Never pronate ! • Never put counter pressure on calcaneus or cuboid.

  30. Congenital Talipes Equino-VarusCTEV Treatment Ponseti technique (cont.) • Cast until there is about 60 degrees of external rotation (about 4-6 casts) • Percutaneous tendo Achilles tenotomy in cast room under local anesthesia, followed by final cast (3 weeks) • After final cast removal, apply Normal last shoes with Denis Browne bar set at 70 degrees external rotation (40 degrees on normal side) • Denis Browne splint full time for two months, then night time only for two-four years. • 35% need Anterior Tibialis tendon transfer at age 2-3

  31. Congenital Talipes Equino-VarusCTEV Surgical Treatment Indications • Late presentation, after 6 months of age ! • Complementary to conservative treatment • Failure of conservative treatment • Residual deformities after conservative treatment • Recurrence after conservative treatment

  32. Congenital Talipes Equino-VarusCTEV Surgical Treatment Soft tissue operations • Release of contractures • Tenotomy • Tendon elongation • Tendon transfer • Restoration of normal bony relationship

  33. Congenital Talipes Equino-VarusCTEV Surgical Treatment

  34. Congenital Talipes Equino-VarusCTEV Surgical Treatment

  35. Congenital Talipes Equino-VarusCTEV Surgical Treatment Bony operations • Indications • Usually accompanied with soft tissue operation • Types: - Osteotomy, to correct foot deformity or int. tibial torsion - Wedge excision - Arthrodesis (usually after bone maturity) one or several joints - Salvage operation to restore shape

  36. Congenital Talipes Equino-VarusCTEV Surgical Treatment

  37. Congenital Talipes Equino-VarusCTEV Surgical Treatment

  38. Congenital Talipes Equino-VarusCTEV Surgical Treatment

  39. Congenital Talipes Equino-VarusCTEV Surgical Treatment

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