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Tachjian, The child foot
ETIOLOGY
Chromosomal theory
Embryonic theory
Otogenic theory
Fetal theory
Neurological theory
Muscular theory
ETIOLOGY
Chromosomal theory
defect : in unfertilized germ cell (defect exists
before fertilization)
ETIOLOGY
Embryonic theory
defect : within fertilized germ cell
Occurs : between conception-12 weeks (Irani,
Sherman and Settle)
ETIOLOGY
Neurologic theory
Muscular theory
ETIOLOGY
Fetal theory (packing syndrome)
Intrauterine packing (mechanical factors)
Schematic illustration of the critical periods in human development. During the first two weeks development, of the embryo is
usually not susceptible to teratogens. During these pre-embryonic stages, a teratogen either damages all or most of the cells,
resulting in its death, or damages only a few cells, allowing the conceptus to recover and the embryo to develop without birth
defects. Red denotes highly sensitive periods when major defects may be produced (e.g. amelia, absence of limbs). Yellow
indicates stages that are less sensitive to teratogens when minor defects may be induced (e.g. hypoplastic thumbs)
Ponseti : genetic, embryonic malformation, collagen
over production in ligament, collagen
Etiology fibres wavy arranged, dense, many cells
Week
0 5 8 12 20 30 TERM
Major deformity
• Inward rotation of the whole foot on the talus
Rotation primarily takes place in :
• talocalcaneal joint
• talonavicular joint
• calcaneocuboid joint
PATHOANATOMY
TALUS
Constriction encasement
TALOCALCANEAL JOINT:
Calcaneus :
rotation in 3 dimensions :
• Sagittal
• Coronal
• Horizontal
Pathomechanics of talipes
equinovarus
A. Posterolateral view of the
calcaneus and talus of normal foot. B.
Lateral rotation of the talus, C. The
anterior part of the calcaneus is
pressed by the head of the talus and
forced into plantar
flexion, rotation, and varus position.
(From Carroll, N., Murphy, R, and
Leete, S.F. : The pathoanatomy of
congenital clubfoot, Orthop.Clin.N.
Amer., 9 : 227, 1978)
The articular relationship of the calcaneus to the talus as seen from the front in the left foot.
Pathoanatomy
Talonavicular joint :
Navicular : displaced medial & plantarward
Tib.posterior tendon
Tibio-navic. Ligament (deltoid lig.)
Calcaneo-navic.lig. (spring lig.)
Talo-navic. Ligament contracted
Bifurcate ligament
Cubonavic. Oblique ligament
All navicular ligament
PATHOANATOMY
Calcaneo-cuboid joint:
Cuboid displaced medially on calcaneus and under navicular &
cuneiform
All ligaments : contracted
Forefoot : supination and adduction
Calcaneo-cuboid joint corrected nicely if other 2 subtalar
complex are corrected except in resistant CTEV
PATHOANATOMY
Muscles
Imbalance between agonist and antagonist
Muscles tonus determined by the amount of muscle
fibres type I & II
All muscle below knee in CTEV fibre Type I > II [similar
with L.M.N lesion : AMC, sacral agenesis, Charcot-
Marie, post poliomyelitis]
Some CTEV tendency to be recurrent
PATHOANATOMY
Vascular
By Doppler Technique :
In normal population : a.dorsalis pedis 2.2.% absent
History
Physical examination
Radiologic examination
Radiology : age more than (4-5) months
N : AP : talo-calcaneal angle :
(200-400), CTEV < 200
Lat : talo-calcaneal angle :
(350-500), CTEV<350
DIAGNOSIS
Wrench
W.H. Trethewan (1882-1934) :
1. Conservative
2. Operative
Conservative treatment
Golden period:
• 1st week
• laxity :estrogen
1. Serial plastering
2. Stretching Dennis Brown splint
3. Adhesive strapping
4. Physiotherapy
HIRAM KITE :
Brought Hippocrates’ view info focus :
Stressing slow, gentle, manipulative correction of
the adduction, varus and equinus with minimal
surgery
Clubfoot
1. Adduction
2. Varus
3. Equinus
KITE PONSETI
Surgery no yes
no =5% yes=95% Surgery
plastering
plastering
Abduction of fore foot in pronation the cavus becomes more severe, calcaneus
locked (jammed) under the head of talus; mid foot and forefoot are twisted eversion
Kite
Kite
Calcaneo-cuboid is used as fulcrum which is pressed medial ward while fore foot
is moved lateral ward (abduction); calcaneus will not move lateral ward (no
abduction) that is why the varus will not be corrected; only naviculare and fore foot
will move lateral ward. To press the posterior part of calcaneus to correct varus is
a big mistake
Ponseti
Clubfoot correction
Indication
1. Conservative Tx—fail Ponseti + 10%
2. Neglected
Postero medial release (Turco)
Cincinati
Ilizaroff
Tripple arthrodesis (adult)
Surgical complication
1. Infection
2. Bad scar
3. Stiff joint
4. Over/under correction
5. Navicular dislocation
6. Flattening or beaking talar head
7. Talar necrosis
8. Weakening of the muscles
9. Skew foot (severe valgus of the heel and adduction
of the fore foot)
10. Main artery injury foot necrosis
Out patient clinic
RSUD.Dr.Soetomo