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Clubfoot

Congenital Talipes Equino Varus (CTEV)


Disusun Oleh:
dr. Akbar Rihansyah
dr. Puja Indah Anggraeni
dr. Soraya Febriananda

Pendamping :
dr. Hesti S. Wardani

Pembimbing :
dr. Adijayansyah, Sp.OT

PROGRAM INTERNSIP DOKTER INDONESIA


KEMENTERIAN KESEHATAN INDONESIA
DAN DINAS KESEHATAN PEMERINTAH KOTA BANJARBARU
RSUD BANJARBARU 2016-2017
Definition

Twisting of the scaphoid, os calcis and


cuboid around the astragalus
Congenital Talipes Equino Varus or club foot
has 4 basic deformation:
1. fore foot : adduction
2. hind foot : inversion or varus
3. hind foot : equinus
4. mid foot : cavus
Incidence : - (1-2) per 1000
births
- male : female =
7:5
Incidence : of CTEV- in
50%various races
bilateral

Race Cases per


thousand birth

Chinese 0.39
Japanese 0.53
Malay 0.68
Filipino 0.76
Caucasian 1.12
Puerto Rican 1.36
Indian 1.51
South African black 3.50
Polynesian 6.81
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

Otogenic theory (arrest theory)


arrest of development
related to a change in genetic factor known as cronon
Cronon : guide the precise time of the progressive
modification every structure during development
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
PATHOANATOMY

Major deformity
Inward rotation of the whole foot on the talus
Rotation primarily takes place in :
talocalcaneal joint
talonavicular joint
calcaneocuboid joint
PATHOANATOMY

Talocrural (ankle ) joint :


Talus in equinus
Talus in mortise = external rotation (horizontal breach)
Posterior = capsule & ligament contracted
Horizontal breach according to the concept of Swann,
Lloyd-Roberts, and Catterall
PATHOANATOMY

TALUS
Constriction encasement

Head & neck : medial & plantar deviation


PATHOANATOMY

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)
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

In mild & moderate CTEV : a.dorsalis pedis = normal

In severe CTEV : a.dorsalis pedis = 6.7% absent


MECHANISM of the CTEV
Fetal posture abnormality :
foot in equinovarus
Muscle imbalance : tib.
post. contracted
Factors determine the
severity of the CTEV

Intrauterine position. The hips are


always flexed and externally rotated,
while the knees are usually flexed and
the feet turned inward
PATHOANATOMY

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

1. Non rigid type (packing syndrome)


2. Rigid type :
Moderate
Severe
3. Resistance rigid type :
AMC
Myelomeningocele
Constriction band
DIFFERENTIAL DIAGNOSIS

1. Constriction bands (Streeter disease)


2. A.M.C
3. Myelomeningocel
4. Sacral agenesis
5. Tibial agenesis
6. Charcot-Marie disease
Constriction bands
Arthrogryposis Multiplex Congenita
Spina bifida
Sacral agenesis
Tibial agenesis
Charcot-Mary disease
TREATMENT

The goal of treatment :


Realign the os calcis, scaphoid and cuboid
around the astragalus by correcting the varus,
adduction, varus and equinus
Maintain the correction until stable
normal function, no pain, plantigrade, good
mobility, no callus formation, wearing normal
shoe
TREATMENT

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

Three magic words for the successful and


enthusiasm carrying out his
treatment : knowledge,patience andenthusiasm
Ponseti

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
COMPARISON KITE and PONSETI treatment

Clubfoot

1. Adduction
2. Varus
3. Equinus

KITE PONSETI

Correction by serial plastering :


4 Cavus and pronation
Correction by serial plastering :
Fulcrum : calcaneo cuboid
Fulcrum : head talus
1. Adduction Abduction 4. Cavus and pronation (realign cavus by supination)
2. Varus valgus to unlock subtalar movement
1. Adduction Abduction 600-750
2. Varus : will be corrected by 4 & 1
weeks
Rigid 3 Equinus 6 weeks
tenotomy 3 Equinus Rigid
close tenotomy 90%

Surgery no yes
no =5% yes=95% Surgery

plastering
plastering

(10-11) months Shoe


Shoe
Denis-Brown
splint
splint

(3-4) years Evaluation


(3-4) years Evaluation
Kite
Clubfoot correction

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

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
TAL
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
Common errors
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
BK plastering High heel
Post posterior release ATL & capsulotomy
Plaster correction complication
1. Neuromuscular
2. Pressure necrosis
Plaster correction complication
3. Rocker bottom foot
Plaster correction complication
4. Flat top talus
Plaster correction complication
5. Increase cavus deformity
6. Longitudinal breach
7. Stiff joint
Operative treatment

Indication
1. Conservative Txfail 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