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Congenital Talipes Equinovarus

(Clubfoot)

Anatomy/Terminology
3 main sections
1.Hindfoot talus,
calcaneus
2.Midfoot navicular,
cuboid, cuneiforms
3.Forefoot
metatarsals and
phalanges

Anatomy/Terminology
Important joints

1. tibiotalar (ankle) plantar/dorsiflexion


2. talocalcaneal (subtalar) inversion/eversion
Important tendons

1. achilles (post calcaneus) plantar flexion


2. post fibular (navicular/cuneiform) inversion
3. ant fibular (med cuneiform/1st met) dorsiflexion
4. peroneus brevis (5th met) - eversion

Anatomy/Terminology
Varus/Valgus

Talipes Equinovarus (congenitalclubfoot)


- talipes
: Talus (bone), Pes (foot)
- The heel
: inverted
- The forefoot & midfoot : inverted & adducted
(varus)
- The ankle
: equinus
in utero displacement & mal alignment of the
talocalcanealnavicular & calcaneocuboid joint

Talipes Equinovarus (congenital clubfoot)

Incidency
-Varies with race & sex
-Caucasians : 1,2/1000 , : = 2 : 1
-Hawaiians : 4,9/1000
-Maori : 6,5-7,0/1000
-Bilateral : 50%, 1/3 of cases
-Unilateral : right > left

Heredity
-Genetic factors : 10%, others sporadis
-Environmental factors :
Idelberger :
Identical (Monozygotic) twins 32,5%
Fraternal (Dizygotic) twins 2,9%

Etiology
- The exact cause : unknown

1. Intrauterine Mechanical Factors


- The oldest, Hipocrates
- External mechanical forces
equinovarus
posture the ligaments, muscles,
bones
changes articular mal alignment
- Twining, high birth weight, primiparous
uterus, hidramnios

2. Neuromuscular Defect
- White, 1929 : A peroneal N. lesion caused by
pressure at the intrauterine stage
- Middleton, 1934 : Mal development of the
striated muscle
- Flinchum, 1953 : Muscle imbalance due to
dysplasia of the peroneals
- Ritsila : Concluded that primary soft tissue
changes
provoking skeletal deformities

3. Arrest of Fetal Development


- Huter : Result of an arrest of
development of the foot in one of the
physiologic phases of its embryonic life

4. Primary Germ Plasm Defect


- Irani & Sherman : CTEV is the
result of a
defective cartilagineous anlage
produced by a
primary germ plasm defect,
developing in the
first trimester

Pathology

- The foot is plantar flexed at the ankle &

subtalar joints, the hindfoot is inverted &


the mid and forefoot are adducted,
inverted & equinus
Fixed contractures of the related soft
tissue (the ligaments, capsules, muscles,
tendons) maintained articular mal
alignment

A. Bony Deformities
1. The Talus
- Medial & plantar deviation of the anterior end of
the talus
- declination angle : by the long axis of the
head & neck of the talus with the long axis of its
body
- Obliquity the neck of talus : medial tilting of the
anterior part of the talus (adult : 12-32 degrees,
fetus : 35-75 degrees, CTEV : 50-65 degrees)

2. The Calcaneus
- Much less deformed than the talus
- Rotated on its long axis inward &
downward
beneath the talus
- The sustentaculum tali usually
underdeveloped
& in close proximity to the medial
maleolus

3. The Forefoot & Tibia


- Smaller than normal

B. Articular Malalignments
1. Relationship of talus to distal tibia & fibula
- The talus has no muscle attachments, it
is stabilized by the ankle mortis

2. Relationship of navicular to talus

3. Relationship of talus to calcaneus

4. Relationship of
Calcaneus to Cuboid
bone
- The cuboid is
displace medially in
relation to the
anterior end of the
calcaneus

C. Soft-Tissue Changes

- The soft tissues on the medial & posterior

aspect of the foot & ankle are shorten


(ligaments, capsules, muscles, tendons,
vessels, nerves, skin)
In eversion, the navicular & anterior end of
the os calcis move laterally, in inversion
they move medially

Diagnosis
Clinical picture :
- Clublike appearance
- Deep creases at the posterior aspect of the
ankle joint
- Mid & forefoot are adducted, inverted &
equinus
- The navicular bone abuts the anterior & medial
margin of the medial maleolus, on palpation
cant insert a finger between the two bones

Radiographic Assessment
-The purpose is to define precisely the anatomic
relationship of talocalcaneonavicular, tibiotalar,
midtarsal & tarso-metatarso joint
-To assess the degree of subluxation of the
talocalcaneonavicular joint & the severity of the
deformity before treatment
- To provide an accurate guide to progress during the
course of closed non operative treatment
- To assess wether reduction of the talocalcaneonavicular
dislocation & normal articular alignment have been
achieved

Normal range of
roentgenographic angles
Talocalcaneal angle
Anteroposterior view: 30 to 55 degrees
Dorsiflexion lateral view : 25 to 50
degrees

Tibiocalcaneal angle
Stress lateral view : 10 to 40 degrees

Talo-first metatarsal angle


Anteroposterior view : 5 to 15 degrees

Treatment
The objective :
1. To achieve reduction of the dislocation or
subluxation of the talocalcaneonavicular joint
2. To maintain the reduction
3. To restore normal articular alignment of the
tarsus & the ankle
4. To establish muscle balance between the evertors
& invertors, and the dorsiflexors & plantarflexors
5. To provide a mobile foot with normal function &
weight bearing

- Treatment should be started as soon as

possible, immediately following birth


- The first three weeks of life are the golden
period, because the ligamentous tissues
are still lacks under the influences of
maternal sex hormones
- Managements extends until adolescent

Closed Non-Operative Method

- Elongation of the contracted soft tissues by

passive manipulation gentle with a non


irritative adhesive liquid, use gloves
- Shouldnt stretch the midfoot by forced
dorsiflexion of the forefoot rocker bottom
deformity of the foot transversed breech
- The stretched position is maintain to the
count of ten, repeated 20-30 times each
session

Advantage :
- A dynamic corrective
-

force is transmitted to
the foot
In expensive, applied
easily, reapplied at
frequent intervals
Relatively safe
Being least likely to
cause pressure sores

Closed reduction of the medial &


plantar dislocation of
talocalcaneonavicular joint

- The success of reduction confirm by AP &


-

Lat X-ray
AP : The talocalcaneal angle should be
>20, the talo-first metatarsal angle <15
Lat : The talocalcaneal angle should be 3045

Retention of reduction

- Above knee cast to maintain the reduction


- Three persons
- The cast should extend from the toes to the
groin with the knee flexed at 60-80 to
control the heel & prevent the cast from
slipping
- Proper & carefull molding of the cast :
calcaneocuboid area, back of the heel, the
midtarsal joint area to prevent a rocker
bottom deformity

- The cast is change at 2-3 weeks


- intervals 3 months

polypropylene above knee splint


(hold the hindfoot in 15-20 of
eversion, the midfoot & forefoot in
20 of abduction, the ankle at 0-5
of dorsiflexion, the knee flexed
60) the splint is worn only at
night & at nap times

- A pre walker clubfoot shoes is worn

during the day


- When the child begins to walk
wear outflare (tarsal pronator )
shoes, with outer lateral side heel &
sole wedges to encourage walking in
eversion & abduction
- X-ray periodically, if there is no
reccurents of deformity after 2 years
normal shoes

Treatment of resistant
clubfoot
Metatarsus adductus
>5yr : metatarsal osteotomy

Hindfoot varus

<2-3yr : modified McKay procedure


3-10yr :
Dwyer osteotomy (isolated heel varus)
Dillwyn-Evans proc (short medial column)
Lichtblau proc (long lateral column)
10-12yr : triple arthrodesis

Equinus
Tendo calcaneus lengthening plus
posterior capsulotomy of subtalar joint,
ankle joint (mild to moderate deformity)
Lambrinudi procedure (severe deformity,
skeletal immaturity)

All three deformities :


>10yr : triple arthrodesis

Talipes Equinovarus (congenital clubfoot)