Congenital Talipes Equino Varus Club foot

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USMLE
Club foot AIPGMEE PG Medical Entrance AIIMS

‘Club foot’ –  CongenitalTalipesEquinoVarus (CTEV).

    • Surgical anatomy
      • The joints of the foot  (MCQ)
        • ankle joint between the tibia and the talus
        • subtalar joint between the talus and the calcaneum
        • talo-navicular joint
        • calcaneo-cuboid joint
    • Foot is divided into hindfoot,Midfoot, forefoot  (MCQ)
      • hindfoot
        • talo-calcaneal (subtalar) and calcaneo-cuboid joints.
      • Midfoot
        • talonavicular and naviculo-cuneiform joints.
      • forefoot
        • metatarsal and other joints beyond it.
    • Ligaments
    • Deltoid ligament: (MCQ)
      • medialcollateralligament of the ankle
      • It has a superficial and adeep component.
    • Spring ligament: (MCQ)
      • This is a ligament which joinsthe anterior end of the calcaneum to thenavicular.
    • Interosseous ligament:
      • This ligament is betweenthe talus and calcaneum, joining their apposingsurfaces.
    • Capsular ligaments:
      • The thickened portions ofthe capsule of the talo-navicular, naviculo-cuneiform, and cuneiform-metatarsal joints,termed as the capsular ligaments
      • Importantstructures in pathology of CTEV.
    • Plantar ligaments:
      • These are ligaments extending from the plantar surface of the calcaneumto the foot, giving rise to the longitudinal arch of the foot. (MCQ)
    • Tibiaiis posterior (MCQ)
      • This is the most important muscle related to pathology of clubfoot. (MCQ)
      • The tendon immediately behind the medial malleolus is that of the tibiaiis posterior.
      • The tibiaiis posterior tendon has its main insertion on the navicular (MCQ)
    • More posteriorly are the flexor digitorumlongus tendon, posterior tibial artery and nerve, and flexor hailucislongus tendon.
    • Nomenclature
      • Equinus: (MCQ)
        • ‘equine’ means a horsewho walks on toes)
        • This is a deformity wherethe foot is fixed in plantar-flexion,
      • Calcaneus (reverse of equinus): (MCQ)
        • This is adeformity where the foot is fixed in dorsiflexion.
      • Varus:
        • The foot is inverted and adducted atthe mid-tarsal joints so that the sole ‘faces’inwards.
      • Valgus:
        • The foot is everted and abducted atthe mid-tarsal joints so that the sole ‘faces’outwards.
      • Cavus
        • The logitudinal arch of the foot isexaggerated.
      • Planus:
        • The longitudinal arch is flattened.
      • Splay:
        • The transverse arch is flattened.
        • Congenital Foot deformities
      • commonest being equino-varus
    • secondmost common is calcaneo-valgus.
    • Causesof secondary clubfoot:
      • Paralytic disorders: (MCQ)
          • In a case where there is a muscle imbalance i.e., the invertors and plantar flexorsare stronger than the evertors and dorsiflexors,an equino-varus deformity will develop.
          • This occurs in paralytic disorders such as polio, spina bifida, myelodysplasia and Freidreich’s ataxia. (MCQ)
      • Arthrogryposis multiplex congenita(AMC): (MCQ)
          • a disorder of defective development of the muscles.
          • The muscles are fibroticand result in foot deformities, and deformities at other joints.
    • Pathoanatomy
      • Bones:
        • Bones of the foot are smaller than normal. (MCQ)
        • Neck of the talus is angulated so that the head of the talus faces downwards and medially. (MCQ)
        • Calcaneum is small, and concave medially. (MCQ)
      • Joints:
        • Equinus deformity occurs primarily at the anklejoint. (MCQ)
        • Inversion deformity occurs primarily at thesubtalar joint. (MCQ)
        • The inverted calcaneum takesthe whole foot with it so that the sole facesmedially. (MCQ)
        • Forefoot adduction deformity occurs at the mid-tarsal joints, mainly at talonavicularjoint. (MCQ)
        • Forefoot cavus deformity is the result of excessivearching of the foot at the midtarsal joints. (MCQ)
      • Muscles and tendons:
        • Muscles of the calf are underdeveloped. (MCQ)
        • As a result, the following muscles-tendon units are contracted: (MCQ)
          • Posteriorly- Tendoachilles
          • Medially-Tibialisposterior ,Flexor digitorumlongus , Flexor hallucislongus
      • Capsule and ligaments:
        • All the ligamentous structures on the postero-medial side of the foot are shortened.
        • Posterior
          • Posterior capsule of theankle joint
          • Posterior capsule of the subtalarjoint
          • Posterior talo-fibular   andcalcaneo-fibular ligaments
        • Medial      (MCQ)
          • Talo-navicular ligament
          • Spring ligament
          • Deltoid ligament
      • Plantar
        • Plantar fascia
        • Plantar ligaments
      • Skin
        • skin develops adaptive shortening on the medial side of the sole. (MCQ)
        • There are deep creases on the medial side. (MCQ)
        • There are dimples on the lateral aspect of the ankle and midfoot. (MCQ)
    • Clinical features
      • Normally, the foot of anewborn child can bedorsiflexed until thedorsum touches the anterior aspect of the shin of the tibia  (MCQ)
        • This is a good screening test for detecting the milder variety of clubfoot.
      • Bilateral foot deformity in 60 per cent cases.
      • Size of the foot smaller (in unilateral cases). (MCQ)
      • Foot is in equinus, varus and adduction.
      • This canbe judged by the inability to bring the foot inthe opposite direction (MCQ)
      • In late cases, in addition,cavus of the foot may also be present. (MCQ)
      • Heel is small in size; the calcaneum may be feltwith great difficulty. (MCQ)
      • Deep skin creaseson the back of the heel and onthe medial side of the sole.
      • Bony prominencesfelt on the lateral side of thefoot, the head of the talus and lateral malleolus. (MCQ)
      • Outer side of the footis gently convex. (MCQ)
      • There aredimples on the outer aspect of the ankle. (MCQ)
      • On attempted correction, one can feel the tight structures posteriorly (tendoachilles) and plantar-wards (plantar fascia). (MCQ)
      • A child presenting late may have callosities over the lateral aspect of the foot.
      • The calf muscles are wasted. (MCQ)
      • A patient of residual polio may present with equino-varus deformity, which may mimic clubfoot, but there will be paralysis of some other part of the limb. (MCQ)
    • Diagnosis
      • X-rays of the foot
        • talo-calcaneal angle (MCQ)
          • angle between long axis of talus and calcaneum
          • also called as Kite’s angle.
          • done in both, AP and lateral views (MCQ)
          • in a normal foot are more than 35 (MCQ)
          • in CTEV these are reduced  (MCQ)
      • A child presenting late may have callosities over the lateral aspect of the foot. (MCQ)
      • The calf muscles are wasted. (MCQ)
    • Treatment
      • Non-operative methods:
        • Manipulation alone:
          • In a newborn, the mother istaught to manipulate the footafter every feed.
          • The foot is dorsiflexedand everted (MCQ)
          • While manipulating, sufficient pressureshould be applied by the person so as to blanchher own fingers.
          • This pressure should bemaintained for about 5 seconds, and this isrepeated several times, over a period of roughly5 minutes.
          • Minor deformities are usuallycorrected by this method alone.
          • For majordeformities, further treatment by correctiveplaster casts is required.
        • Manipulation and PoP
          • In this method, thesurgeon manipulates the foot after sedatingthe child.
          • The foot is then held in the correctedposition with plaster casts.
          • Kite’s philosophy:
            • foot is treated by manipulation and PoP, beginning at the age of 1 month (MCQ)
            • The deformities are corrected sequentially
            • Adduction deformity is corrected first followed by inversion deformity and then equinus deformity. (Remember: AIpgmEE-Adduction,Inversion, Equinus) (MCQ)
            • A below-knee plaster cast is usually sufficient.
            • The casts are changed every 2 weeks, and are continued until it is possible to ‘overcorrect’ all the deformities. (MCQ)
            • Once this happens, the foot is kept in a suitable maintenance device
            • By this method, correction is achieved in 30% of cases, over a period of 6-9 months. The rest need surgical correction. (MCQ)
          • Ponsetti’s philosophy:
            • According to Ponsetti, the calcaneo-cuboid-navicular complex is internally rotated (adducted) under the plantarflexed talus,(MCQ)
            • Hence, the deformity can be corrected by bringing the complex back under the talus by gradually stretching the tight structures (MCQ)
            • This is done by putting thumb pressure over the talus head(and not over calcaneo-cuboid joint as in Kite’s method). (MCQ)
            • By doing this, the calcaneo-cuboid-navicular complex is externally rotated under the talar head.
            • Treatment is started within 1st week of life. (MCQ)
            • All componentsof the deformity are corrected simultaneously. (MCQ)
            • After every manipulation, an above-knee PoP cast is applied, which is changed every 5-7 days.(MCQ)
            • It is usually possible to correct all components of the deformity within 6 weeks (MCQ)
            • The equinus deformity often remains undercorrected, and can be treated by percutaneous tenotomy of tendoachilles.
            • The cut tendoachilles regenerates spontaneously.
    • Operative methods:
      • Soft tissue release operations may be sufficient in younger children (younger than 3 years)
      • Bony operations are required in older children.
      • Postero-medial soft tissue release (PMSTR):(MCQ)
        • This operation consists of releasing the tight soft tissue structures (tendons, ligaments, capsule etc.) on the posterior and medial side of the foot (MCQ)
        • This can be performed in younger children
        • In older children, an additional bony procedure is required.
        • The following structures are generally released:
          • On the posterior side: (MCQ)
            • Lengthening  of the  tendoachillesis done by Z plasty
            • Release of posterior capsules of the ankleand subtalar joints.
            • Release  of posterior   talo-fibular  andcalcaneo-fibular ligaments.
          • On the medial side: (MCQ)
            • Lengthening of 3 tendons
              • Tibialisposterior
              • flexordigitorumlongus
              • flexorhallucislongus.
            • In addition, theircontracted thickened sheaths are excised.
            • Release of 3 ligaments (MCQ)
              • talo-navicularligament
              • superficial part of the deltoidligament
              • spring ligament.
            • Release of 3 more structures is needed insevere cases. (MCQ)
            • interosseoustalocalcaneal ligament
            • capsules of the naviculocuneiform
            • cuneiform-first metatarsaljoints.
          • On the plantar side:
            • Plantar fascia release.
            • Release of the short flexors of the toes from their origin on the calcaneum. (MCQ)
              • flexordigitorumbrevis
              • abductorhalluces
      • Limited soft tissue release
        • In some cases, the foot remains partially corrected after conservative treatment, and only limited soft tissue release may be sufficient:
          • Forequinus alone –   aposterior release (MCQ)
          • For adduction alone–   a medial release (MCQ)
          • For cavus alone -a plantar release. (MCQ)
      • Tendon transfers:
        • In some cases, the tibialisanterior and tibialis posterior (both invertersof the foot) may exert a deforming forceagainst the weak peronei (evertors). (MCQ)
        • Thismuscle imbalance may be corrected bytransfering the tibialis anterior to the outer sideof the foot, where it acts as an everter.
        • Minimum age for tendon transfers is 5 years. (MCQ)
      • Dwyer’s osteotomy: (MCQ)
        • This is an open-wedgeosteotomy of the calcaneum.,
        • performed inorder to correct varus of the heel
        • Minimum age at which this operation can be performed is 3 years, as prior to this the calcaneum is mainly cartilaginous. (MCQ)
      • Dilwyn Evan’s ‘procedure: (MCQ)
        • This consists of a thorough soft tissue release (PMSTR) with calcaneo-cuboid fusion (MCQ)
        • It is used for a neglected or recurred clubfoot in children between 4-8 years (MCQ)
        • With fusion of the calcaneo-cuboid joint, the lateral side of the footdoes not grow as much as the medial thus resulting in gradual correction of the deformity. (MCQ)
      • Wedge tarsectomy: (MCQ)
        • This consists of removinga wedge of bones from the mid-tarsal area
        • The wedge is cut with its base onthe dorso-lateral side (MCQ)
        • Once the wedge isremoved the foot can be brought to normal(plantigrade) position.
        • This  operation isperformed for neglected clubfeet between theage of 8-11 years. (MCQ)
      • Triple arthrodesis: (MCQ)
        • This consists of the fusion ofthree joints of the foot (subtalar, calcaneo-cuboidand talo-navicular), after taking suitable wedgesto correct the deformity
        • Of the three, talo-navicular joint fusion is most difficult to achieve. (MCQ)
      • llizarov’s technique: (MCQ)
        • Using the principles of llizarov’s technique, different components of the deformity are corrected by gradual stretching, using an external fixator
        • Once correction is achieved, it is maintained by plaster casts
        • llizarov’s technique is indicated in neglected clubfeet, and in those in which it (MCQ)
    • Methods of maintenance of the correction
      • CTEV splints
      • Denis-Brown splint (DB splint): (MCQ)
        • a splint to hold the foot in the corrected position
        • It is used throughout the daybefore the child starts walking.
        • Once he startswalking, a DB splint is used at nightand CTEVshoes during the day.
      • CTEV shoes:
        • These are modified shoes, usedonce a child starts walking.
        • Modifications    are   made   in   the   shoe (MCQ)
          • Straight inner border to prevent forefoot adduction (MCQ)
          • Outer shoeraise to prevent foot inversion.
          • No heel to prevent equinus.
        • These shoes are used until the child is 5 years old. (MCQ)
    • Operative methods -Indications (MCQ)
      • A child who does not respondto non-operative treatment (resistant clubfeet)
        • These feet are generally severely deformed, ‘chubby’
        • These feet are associated with underlying arthrogryposis multiplex congenita (AMC).
      • A child whose deformities have recurred(recurrent clubfeet):
        • This usually happens ifcorrection  is  not  maintained.
        • The firstdeformity to recur is the equinus.
      • A child who has presented late or has not beenadequately treated(neglected clubfeet).

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