Rima Melati Anne Kristina Riri Zalita EW Raspati C Roosmalia P Ferra

LITERATURE READING Orthopaedics 17/03/2004 1

Congenital talipes equinovarus (CTEV)

Talipes, literally "ankle-foot", refers to the talus Equinovarus refers to the position of the clubfoot, in equinus and varus or adductus
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Congenital deformity 1 of 1000 babies One or both feet boy : girl = 2 : 1 1st trimester of pregnancy The foot pointing downwards and twisted inwards Club, "kidney shaped", with a prominent medial crease along the plantar aspect of the foot
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Clubfoot does not cause pain in the infant It gets worse over time, with secondary bony changes developing over years

An uncorrected clubfoot in the older child or adult is very unsightly, and worse, very crippling The patient walks on the outside of his foot which is not meant for weight-bearing The skin breaks down, and develops chronic ulceration and infection

Two variations: 1) positional deformities caused by the position of the foot in the womb 2) structural malformations where bones, joints, muscles, and blood vessels are malformed

Whether positional or structural, there are four common types of clubfoot

 Clubfoot can be recognized in the infant by examination The foot is inturned, stiff and cannot be brought to a normal position Children with the condition should be referred to an orthopedic surgeon for complete evaluation and treatment of the deformity
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Treatment
very important to treat clubfoot as early as possible (i.e. shortly after birth) to prevent disability and problems with walking when the child gets older

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CASTING
The first step is taping/casting of the foot The physician holds the foot in the proper position and then puts tape or cast on to hold it in place One-third of feet, usually the ones more mildly affected, will respond to this therapy During the immediate postnatal period, the cast or tapings are changed every day

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child will be seen frequently by the pediatric orthopedic surgeon: every one to two weeks Initial treatment is provided by a series of casts to the affected foot
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Infants are placed in casts covering the entire limb(s) The severity of child's deformity will determine the number of casts required The casts will need to be kept dry
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After multiple serial castings are completed (2-3 months), special shoes with or without a bar may be needed

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SURGERY
Achilles lengthening procedure If cast treatment fails, surgery is necessary This is not performed until the child is between four and eight months of age The Pediatric Orthopaedic Surgeon lengthens several of the tendons (structures which connect muscle to bone) which allows to foot to adopt a normal position 15

The Operation patient is anesthetized positioned prone a tourniquet applied to the proximal limb the limb is surgically scrubbed and draped releases and reductions one or two K-wires are inserted by drill, to hold the reduced and corrected position, to fixate the talonavicular and calcaneocuboid joints then are shortened and bent externally This makes for easy removal, and eliminates danger of migration
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Steri-strips and a dressing are applied and a plaster of Paris backslab long leg splint is applied Most surgeons do not splint the foot in the completely corrected position initially This is to allow for expected postoperative soft tissue swelling and to prevent ischemia of the foot The limb is then elevated The hospital stay is commonly just one night Pain and circulation status must be under control before discharge
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One week after surgery under general anesthetic or sedation, the splint is removed the foot is examined
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a circumferential long leg cast is applied in the over-corrected position of heel dorsiflexion, pronation of the foot and external rotation of the ankle The knee is placed at 90 degrees of flexion

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Sometimes orthotic fitting is done at this time for a kneeankle-foot orthotic (KAFO) OR an ankle-foot orthotic (AFO) The device will be worn for months

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If a KAFO is used, it will eventually be replaced by an AFO to allow the baby to walk. These are worn inside shoes

Bilateral AFO orthotics

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