Gross deformity of the foot that is giving it

the stunted lumpy appearance

 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
Planus: flatfoot

Cavus: highly arched foot

Varus: heel going towards

the midline
Valgus: heel going away
from the midline
Adduction: forefoot going
towards the midline Forefoot Hind foot
Abduction: forefoot going away
From the midline
 Types

Postural :


Calcaneo-Valgus Equino-Varus
Look for CDH Minor and
correctable
 Types
Idiopathic (Unknown Etiology) :
Congenital Talipes Equino-Varus CTEV
Acquired, Secondary to :
CNS Disease : Spina bifida, Poliomyelitis

Arthrogryposis
Absent Bone : fibula / tibia
Congenital clubfoot or CTEV occurs
typically in an otherwise normal child.
 Etiology

Polygenic
Multifactorial
although many of these factors are speculative
 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
 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 %
 Geographic Distribution

Middle East , KSA common

Mediterranean Coast & North Africa
White race
 Basic Pathology
Abnormal Tarsal Relation
Congenital Dislocation / Subluxation
Talo Calcaneo Navicular Joint
Soft Tissue Contracture
Congenital Atresia
 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
Larsens syndrome, Amniotic band Syndrome
 Diagnosis

Spina Bifida = Paralytic TEV

 Diagnosis
Characteristic Deformity :
Hind foot
Equinus (Ankle joint)
Varus (Subtalar joint)
Fore foot
Adduction (Med tarsal joint)
Supination fore foot
Cavus
Diagnosis
 Diagnosis

Hind foot Fore foot

Equinus, Varus Adduction, Supination,
Cavus
Diagnosis
 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 dont prevent walking
Diagnosis
 Diagnosis
X-Ray needed to assess progress of treatment
 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
Golden period:
1st week
laxity :estrogen

1. Serial plastering
2. Stretching Dennis Brown splint
3. Adhesive strapping
4. Physiotherapy
 Treatment
Non surgical treatment should begin shortly after
birth
1. Gentle manipulation

2. Immobilization
- Strapping
- POP or synthetic cast
 Treatment
Non surgical treatment should begin shortly after
birth
3. Splints to maintain correction
- Ankle-foot orthosis
- Dennis Brown splint
 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
 Treatment
Ponseti technique
1. Always use long leg casts, change weekly.
2. First manipulation raises the 1st metatarsal
to decrease the cavus
3. All subsequent manipulations include pure
abduction of forefoot with counter-pressure
on neck of talus.
4. Never pronate !
5. Never put counter pressure on calcaneus
or cuboid.
Ponseti
(Clubfoot correction)
Ponseti
 Treatment
Ponseti technique (cont.)
6. Cast until there is about 60 degrees of external
rotation (about 4-6 casts)
7. Percutaneous tendo Achilles tenotomy in cast room
under local anesthesia, followed by final cast (3
weeks)
8. After final cast removal, apply Normal last shoes with
Denis Browne bar set at 70 degrees external rotation
(40 degrees on normal side)
9. Denis Browne splint full time for two months, then
night time only for two-four years.
10. 35% need Anterior Tibialis tendon transfer at age 2-3
 Dennis Brown Brace- used when long leg
cast is removed after 3 weeks of treatment.
The bar is fit shoulder width apart and worn
full time for the 1st 2months
 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
 Surgical Treatment
Types (soft tissue and bony operations)
Time of surgery
Selection of the procedure and the
incision
Post operative care
Follow up
Complications
 Surgical Treatment
Soft tissue operations
1. Release of contractures
2. Tenotomy
3. Tendon elongation
4. Tendon transfer
5. Restoration of normal bony relationship
Surgical Treatment
Surgical Treatment
 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
Surgical Treatment
Surgical Treatment
Surgical Treatment
Surgical Treatment
1. Difficult to position the foot
2. The ossific nuclei do not represent the true shape
3. In the first year of life, only the talus, calcaneus, and
metatarsals may be ossified
4. Failure to hold the foot in the position of
best correction makes the foot look worse than it is
 The foot should be held in the position of best
correction, with weight-bearing, or, if an infant is being
examined, with simulated weight-bearing
Focused on the hindfoot (about 30 from the vertical
for AP view)
Lat. View: transmalleolar with the fibula overlapping
the posterior half of the tibia
 normal CTEV

AP Talo 20 -50 deg <20 deg

calcaneal
angle
Tarsal-1st MT Upto 30 deg Varus
angle valgus anglulation
cuboid os. medial
center w.r.t displacement
calcaneal axis
 Normal foot: 20`-50` CTEV:<20 deg
 normal CTEV

Talo 25 to 50 <25 deg

calcaneal deg
angle
Tarsal-1st hyperflexio
MT angle n
 Lateral view: Talo-Calcaneal
angle
Normal foot : 25` to CTEV: <25 `
50`
Hindfoot equinus is plantar flexion of
the anterior calcaneus (similar to a
horse's hoof) such that the angle
between the long axis of the tibia
and the long axis of the calcaneus
(tibiocalcaneal angle) is greater
than 90
On the lateral view, instead of having
the normal overlapped appearance,
the metatarsals are arranged in a
ladder like configuration, with the first
being most dorsal
SUMMARY OF
RADIOLOGICAL
FINDINGS
1. Conservative
2. Operative
Golden period:
1st week
laxity :estrogen

1. Serial plastering
2. Stretching Dennis Brown splint
3. Adhesive strapping
4. Physiotherapy
Concept biomechanical
understanding

SURGERY is the wrong approach for the treatm

Based on kinematic of the subtalar joint.
1st concept : the whole foot moves under the talus calcaneo-
pedis block
2nd concept : fore foot and hind foot are corrected
simultaneously by abduction
Equinus correction :
mostly close tenotomy
tendo achilles non stretchable collagen, thick and stiff
Ponseti

a. realign cavus : forefoot supinated (3,4)

b. fulcrum : caput tali stabilisator (5)
c. forefoot in supination abduction (6)
d. maximal abduction of forefoot (7)
e. dorso flexion of the ankle (+TAL)

Process of a,b,c,d (5-6) x each (5-7) days.

Plaster cast above knee (groin), knee flexion
900
Ponseti
(Clubfoot correction)
Ponseti
 After 6x plastering
TAL (close), local anaesthesia
Plaster 3 weeks
bracing for 3 months (24hours)
(2-4) hours day time, 12 hours at nigh
(3-4) years night splint
Ponseti success = 90%
Pre ATL
Pre ATL
Daffa pre ATL
Daffa Post ATL
Daffa
1. Forefoot still in pronation
during correction of
adduction to abduction
2. Not using head of talus as
fulcrum
3. Calcaneus is pressed
lateral ward to correct
varus
4. Equinus is corrected
before adduction and
varus are corrected
Rocker bottom foot
5. Plaster immobilisation
below knee
High heel
1. Neuromuscular
2. Pressure necrosis
3. Rocker bottom foot
4. Flat top talus
5. Increase cavus deformity
6. Longitudinal breach
7. Stiff joint
Indication
1. Conservative Txfail Ponseti + 10%
2. Neglected
Ilizaroff
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