2. OUTLINE
⢠WHAT IS CTEV?
⢠EPIDEMIOLOGY
⢠ETIOLOGY
⢠PATHOLOGICAL ANATOMY
⢠CLINICAL FEATURES
⢠CLASSIFICATION
⢠RADIOGRAPHIC EVALUATION
⢠TREATMENT
⢠SUMMARY
3. WHAT IS CTEV?
⢠ROTATORY SUBLUXATION OF TALOCALNOENAVICULAR JOINT (SUBTALAR)
COMPLEX WITH TALUS IN PLANTAR FLEXION AND SUBTALAR COMPLEX IN
MEDIAL ROTATION AND INVERSION.
⢠ALSO REFFERED AS CLUBFOOT.
⢠TALIPES DERIVED FROM TERM: TALUS- ANKLE &
PES - FOOT
⢠EQUINOVARUS DERIVED FROM WORD EQUINO - LIKE A HORSE &
VARUS - TURNED INWARD.
4. DEFORMITIES:
⢠4 CLINICAL COMPONENTS: CAVE
⢠C- CAVUS- EXAGGERATED MEDIAL LONGITUDINAL ARCH AT MIDFOOT
⢠A- ADDUCTION- FOREFOOT IN ADDUCTION AT TARSOMETATARSAL
JUNCTION
⢠V- VARUS- HINDFOOT ROTATED INWARD AT TALONAVICULAR JOINT
⢠E- EQUINUS- FOOT FIXED IN PLANTAR FLEXION AT ANKLE JOINT
5.
6. EPIDEMIOLOGY:
⢠INCIDENCE- 1-2 PER 1000 LIVE BIRTH
⢠INCIDENCE IN FIRST DEGREE RELATION- 2%
⢠INCIDENCE IN SECOND DEGREE RELATION- 0.6%
⢠INCIDENCE IN MALE:FEMALE- 2.5:1
⢠LATERALITY- >50% CASES ARE BILATERAL
⢠IN UNILATERAL AFFLICTION- RIGHT> LEFT
7. ETIOLOGY:
⢠MOST COMMON CAUSE OF CTEV IS
IDIOPATHIC.
⢠OTHER THAN IDIOPATHIC IS
SECONDARY CTEV WHICH IS
ASSOCIATED WITH UNDERLYING
CAUSE.
8. IDIOPATHIC CTEV:
⢠ARRESTED FETAL DEVELOPMENT: BOHM PROPOSED ARREST OF FETAL DEVELOPMENT OF THE
LOWER LIMB IN 6-8 WKS SO CALLED CLUB FOOT EMBRYONIC STAGE. HOWEVER DYSMORPHIC
TALAR HEAD AND MEDIAL DISPLACEMENT OF NAVICULAR IS NOT SEEN IN ANY STAGE OF
NORMAL FETAL DEVELOPMENT.
⢠MECHANICAL FACTOR IN UTERO: OLDEST THEORY PROPOSED BY HIPPOCRATES SUGGESTING
FOOT WAS HELD IN EQUINO VARUS BY EXTERNAL UTERINE COMPRESSION. SOME INVESTIGATOR
OPINE DIMINUTION OF AMNIOTIC FLUID AS CAUSE OF CLUB FOOT.
⢠VASCULAR HYPOTHESIS: KEITH SUGGESTED TEMPORARY CESSATION OF CIRCULATION IN
DEVELOPING FETUS RESULTED IN CONTRACTURES OF SOFT TISSUES AND DEFECTIVE
DEVELOPMENT OF CARTILAGE.
9. IDIOPATHIC CTEV:
⢠MUSCULOLIGAMENTOUS FIBROSIS: IPPOLITO AND PONSETI FOUND CONSIDERABLE INCREASE
IN COLLEGEN FIBRES AND FIBROBLASTIC CELLS IN LIGAMENTS AND TENDONS OF CLUBFOOT.
THEY CONSIDERED TO BE PRIMARY DEFECT, CARTILAGINOUS AND BONY CHANGES BEING
SECONDARY.
⢠PRIMARY GERM PLASMA DEFECT: WAISBROD SUGGESTED DEFECT IN PRIMARY GERM PLASMA
OF CARTILAGINOUS TALAR ANALGE RESULTING IN DYSMORPHIC TALAR NECK AND NAVICULAR
SUBLUXATION.
⢠HEREDITARY: WYNNE- DAVIES SUGGESTED CLUB FOOT ARE PART OF NUMEROUS SYNDROMES
FOLLOWING MANDELIAN PATTERN OF EITHER AUTOSOMAL DOMINANT OR AUTOSOMAL
RECESSIVE INHERITANCE.
11. SECONDARY CTEV:
⢠GENETIC CAUSES-
ďN- ACETYLATION GENES NAT1 AND NAT2
ďXENOBIOTIC METABOLISM GENES CYP1A1
ďLIMB AND MUSCLE MORPHOGENESIS GENE HOXA, HOXD AND IGF BP3
ďGENE FOR LOWER EXTREMITY DEVELOPMENT- CAN D2 AND WNT 7A
ďGENE FOR CONTACTILE PROTEIN OF SKELETAL MYOFIBRES- TBX4
12. PATHOLOGICAL ANATOMY:
1. BONES-
⢠TALUS-
ďąHEAD AND NECK DEVIATED MEDIALLY AND DOWNWARD.
ďąMEDIAL AND PLANTAR DEVIATION OF NAVICULAR ARTICULATION.
ďąBODY ROTATED EXTERNALLY AND IS IN EQUINUS OF NECK IN ANKLE
MORTISE.
ďąBODY EXTRUDED ANTERIORLY
ďąSMALLER THAN NORMAL
ďąNECK- BODY ANGLE IS 90-110* (NORMAL- 150*)
ďąDISLOCATION OF HEAD OF TALUS OUT OF ITS SOCKET.
13. PATHOLOGICAL ANATOMY:
⢠NAVICULAR-
ďąMEDIALLY AND PLANTAR
DISPLACEMENT
ďąCLOSE TO MEDIAL MALLEOLUS
ďąARTICULATES WITH MEDIAL SURFACFE
OF DYSMORPHIC TALUS
ďąTALONAVICULAR JOINT SUBLUXATION
14. PATHOLOGICAL ANATOMY:
⢠CALCANEUM-
ďąOFTEN SMALL IN SIZE
ďąMEDIALLY ROTATED
ďąANTERIOR PORTION LIES BENEATH THE HEAD
OF TALUS CAUSING VARUS AND EQUINUS OF
HEEL.
ďąSUSTENTACULUM TALI IS UNDERDEVELOPED.
⢠CUBOID-
ďąMEDIALLY SUBLUXATED OVER CALCANEUM
HEAD
15. PATHOLOGICAL ANATOMY:
⢠MUSCLES AND TENDONS-
ďąATROPHY OF PERONEAL GROUP OF
MUSCLES
ďąCONTRACTURE OF TRICEP SURAE,TIBIALIS
POSTERIOR,FLEXOR DIGITORUM LONGUS
AND FLEXOR HALLUCIS LUNGUS.
ďąNUMBER OF FIBRES IN MUSCLE IS NORMAL
BUT ARE SMALLER IN SIZE.
ďąTHICKENING AND CONTRACTURE OF
TENDON SHEATHS ESPECIALLY OF TIBIALIS
POSTERIOR AND PERONEAL.
16. PATHOLOGICAL ANATOMY:
⢠LIGAMENTS-
ďąTHICKENING AND CONTRACTURES ARE SEEN
IN
ď CALCANEOFIBULAR LIGAMENT
ď TALOFIBULAR LIGAMENT
ď DELTOID LIGAMENT
ď LONG AND SHORT PLANTAR LIGAMENT
ď SPRING LIGAMENT
ď BIFURCATE LIGAMENT
ď INTEROSSEOUS TALO CALCANEUM LIGAMENT
ď MASTER KNOT OF HENRY
17. PATHOLOGICAL ANATOMY:
⢠JOINTS CAPSULE AND FASCIA-
ďąCONTRACTURES ARE SEEN IN
ďPOSTERIOR ANKLE CAPSULE
ďSUBTALAR CAPSULE
ďTALONAVICULAR JOINT CAPSULE
ďCALCANEOCUBOID JOINT CAPSULE
ďąPLANTAR FASCIA CONTRACTURE ARE SEEN WHICH IS RESPONSIBLE CAVUS
DEFORMITY
18. PATHOLOGICAL ANATOMY:
⢠SKIN CHANGES-
ďąDEEP CREASE ON MEDIAL SIDE
ďąDIMPLES IN LATERAL ASPECT OF ANKLE AND MID
FOOT.
ďąSHORTENING ON MEDIAL SIDE OF SOLE
ďąCALLOSITIES AND BURSA ON LATERAL SIDE OF FOOT
⢠VASCULAR CHANGES-
ďąHYPOPLASIA OR ABSENCE OF DORSALIS PAEDIS AND
ANTERIOR TIBIAL ARTERY
19. CLINICAL FEATURES:
⢠HEEL IS SMALL AND IN EQUINUS
⢠FOOT INVERTED ON END OF TIBIA
⢠DEEP CREASES ON MEDIAL AND POSTERIOR ASPECT
⢠ABNORMAL THIN CALF
⢠VARYING DEGREE OF RESISTANCE/ FIXED DEFORMITY WHEN
TRY TO DORSIFLEX AND EVERT THE FOOT.
⢠LACK OF CORRECTABILITY
⢠OTHER JOINT ABNORMALITY
⢠ASSOCIATED ANOMALIES AND NEUROMUSCULAR
CONDITION.
20. CLASSIFICATION:
1. IDIOPATHIC AND NON-IDIOPATHIC
2. CUMMIN CLASSIFICATION
3. PONSETI AND SMOLEY CLASSIFICATION- BASED ON EXTENT OF DEFORMITY
4. HARROLD AND WALKER CLASSIFICATION- BASED ON ABILITY TO CORRECT THE
DEFORMITY.
5. BROWNEâS CLASSIFICATION- BASED ON TYPE OF DEFORMITY
6. DIMEGLIO ET AL SCORING SYSTEM BASED ON SEVERITY OF THE DEFORMITY
7. PIRANI SCORING SYSTEM
21. CUMMIN CLASSIFICATION
⢠SUPPLE: FOOT CAN BE BROUGHT TO NORMAL POSITION AND ALL JOINTS ARE
MOBILE.
⢠NEGLECTED: NO TREATMENT FOR 1 YR.
⢠RELAPSED: CORRECTED DEFORMITIES APPEARS AGAIN.
⢠RECCURENT: TYPE OF RELAPSE DUE TO MUSCLE IMBALANCE
⢠RESISTANT: NO CORRECTION AFTER CONSERVATIVE MANAGEMENT.
⢠RIGID: AFTER CONSERVATIVE TREATMENT FOREFOOT DEFORMITY
CORRECTED AND HINDFOOT DEFORMITY REMAIN UNCORRECTED.
24. PIRANI SCORING SYSTEM:
⢠SIMPLE AND RELIABLE SYSTEM TO DETERMINE SEVERITY AND MONITOR PROGRESS IN THE ASSESSMENT AND
TREATMENT OF CLUBFOOT.
⢠SIX âSIGNSâ ARE ASSESSED
⢠3 SIGNS IN MIDFOOT
⢠3 SIGNS IN HINDFOOT
⢠BASED ON 6 WELL-DESCRIBED CLINICAL SIGNS OF CONTRACTURE CHARACTERIZING A SEVERE CLUBFOOT:
⢠IF THE SIGN IS SEVERELY ABNORMAL IT SCORES 1
⢠IF IT IS PARTIALLY ABNORMAL IT SCORES 0.5
⢠IF IT IS NORMAL IT SCORES 0
⢠TOTAL SCORE (TS) VARIES FROM 0 TO 6 AND IS THE SUM OF MIDFOOT AND HINDFOOT CONTRACTURE SCORES
26. RADIOGRAPHIC EVALUATION:
⢠FOR NON AMBULATORY CHILD-
ď ANTEROPOSTERIOR
ď STRESS DORSIFLEXION LATERAL VIEW
⢠FOR OLDER CHILD-
ď STANDING ANTEROPOSTERIOR
ď STANDING LATERAL
⢠IMPORTANT ANGLE WE MEASURE-
ď TALOCALCANEAL ANGLE ON AP AND LAT VIEW
ď TIBIOCALCANEAL ANGLE ON LAT VIEW
ď TALUS- FIRST METATARSAL ANGLE
27. RADIOGRAPHIC
EVALUATION:
TALOCALCANEAL ANGLE-
⢠ON AP VIEW-
ďś 1ST LINE THROUGH THE CENTRE OF LONG
AXIS OF TALUS (PARALLEL TO MEDIAL
BORDER)
ďś 2ND LINE THROUGH LONG AXIS OF
CALCANEUM (PARALLEL TO LATERAL
BORDER)
ďś NORMAL 25-40*
⢠ON LATERAL VIEW-
ďś 1ST LINE MIDPOINT OF HEAD AND BODY OF
TALUS
ďś 2ND LINE ALONG BOTTOM OF CALCANEUM
ďś NORMAL 35-50*
28. RADIOGRAPHIC EVALUATION
⢠RADIOLOGICAL FINDING SEEN-
⢠ON LATERAL VIEW-
ď DECREASED TALOCALCANEAL ANGLE (TALOCALCANEAL PARALLELISM)
ď DISRUPTED TALAR FIRST METATARSAL ANGLE
ď LONG AXIS OF TALUS AND CALCANEUM PASSES INFERIOR TO CUBOID (NORMALLY CROSSES CUBOID)
⢠ON ANTEROPOSTERIOR VIEW-
ď INCREASED TALOCALCANEAL ANGLE
ď INCREASED TALAR FIRST METATARSAL ANGLE
ď LONG AXIS OF TALUS DEVIATE LATERALLY AND PASSES ALONG 3RD OR 4TH METATARSAL BONE
31. TREATMENT:
⢠GOAL: TO ACHIEVE
ďPLANTIGRADE FOOT
ďFLEXIBILTY
ďCOSMETICALLY ACCEPTABLE FUNCTIONAL AND PAIN FREE FOOT IN SHORTEST TREATMENT TIME
⢠PRINCIPLES:
ďSOFT TISSUE CONTRACTURE RELEASE OR STRETCHING TO RESTORE NORMAL TARSAL
RELATIONSHIP.
ďONCE NORMAL TARSAL RELATIONSHIP ATTAINED, CORRECTION SHOULD BE MAINTAINED TILL
TARSAL BONES REMOULDS STABLE ARTICULAR SURFACE.
32. NONOPERATIVE TREATMENT:
⢠SEVERAL REGIME HAVE BEEN PROPOSED INCLUDING SPLINTING TAPING AND CASTING.
⢠KITEâS METHOD:
ď CORRECTION OF EACH COMPONENT SEPARATELY
ď CORRECTION WAS DONE IN FOLLOWING ORDER
ď KITEâS ERRORS:
ďą PRONATION/ EVERSION OF 1ST METATARSAL.
ďą PREMATURE DORSIFLEXION OF HEEL.
ďą USED CALCANEOCUBOID JOINT AS FULCRUM THAT BLOCKS ABDUCTION OF CALCANEUS , THERBY PREVENTS
EVERSION OF CALCANEUS.
FOREFOOT
ADDUCTION
HEEL VARUS EQUINUS
33.
34.
35. NONOPERATIVE TREATMENT:
⢠PONSETI TECHNIQUE:
ď2 PHASE- TREATMENT AND MAINTENANCE PHASE
ďTREATMENT PHASE-
ďąBEGINS AS EARLY AS POSSIBLE. DURING FIRST WEEK OF LIFE ONLY MANIPULATION IS CARRIED OUT
BUT CAST IS NOT APPLIED.
ďąORDER OF CORRECTION-
ďąTALUS HEAD IS USED AS FULCRUM.
ďą5-6 SERIAL CASTING WITH MANIPULATION IS GENERALLY ENOUGH TO CORRECT THE DEFORMITY.
MAXIMUM UPTO 1O CASTING CAN BE DONE.
CAVUS
ADDUCTION WITH
VARUS
EQUINUS
36. PONSETI TECHNIQUE:
⢠CORRECTION OF CAVUS DEFORMITY:
ďCORRECTED BY FOREFOOT SUPINATION
RELATIVE TO HINDFOOT ALONG WITH
ADDUCTION OF FOREFOOT.
ďTENDS TO EXAGGERATE FOOT
INVERSION.
ďPRONATION OF FOREFOOT SHOULD NOT
BE DONE AS IT INCREASES CAVUS
DEFORMITY BECAUSE 1ST METATARSAL IS
FURTHER PLANTAR FLEXED. E- RIGHT MANEUVER TO CORRECT CAVUS DEFORMITY
F- WRONG MANEUVER TO CORRECT CAVUS DEFORMITY
37. PONSETI TECHNIQUE
A: THUMB IS POSITIONED OVER LATERAL ASPECT OF HEAD OF TALUS AND FINGER CORRECT THE FOREFOOT.
B: CAVUS AND ADDUCTION ARE CORRECTED BY SLIGHT SUPINATION OF FOREFOOT IN RELATION TO HINDFOOT.
38. PONSETI TECHNIQUE
⢠CORRECTION OF VARUS AND ADDUCTION:
ďCORRECTION OF CAVUS BRINGS METATARSAL, CUNIEFORM, NAVICULAR, AND
CUBOID IN SAME PLANE OF SUPINATION.
ďNOW FOOT IS ABDUCTED AND HELD IN FLEXION AND SUPINATION TO
ACCOMMODATE THE INVERSION OF TARSAL BONES WHILE COUNTER
PRESSURE IS APPLIED WITH THUMB ON LATERAL ASPECT OF HEAD OF TALUS.
ďTHIS MANEUVER NECESSITATES PROLONG STRETCHING OF MEDIAL TARSAL
LIGAMENTS AND TENDONS.
39. PRESSURE EXERTED ON METATARSAL AND COUNTERPRESSURE ON LATERAL ASPECT OF HEAD OF TALUS.
FURTHER ABDUCTION OF FOOT HELD IN FLEXION AND SUPINATION.
41. PONSETI TECHNIQUE
⢠CORRECTION OF EQUINUS:
⢠SHOULD BE ATTEMPTED WHEN HINDFOOT IS IN NEUTRAL POSITION TO
SLIGHT VALGUS AND FOOT IS ABDUCTED 70* RELATIVE TO LEG.
⢠EQUINUS IS COORECTED BY PROGRESSIVE DORSIFLEXING THE FOOT.
⢠TO FACILITATE RAPID CORRECTION SUBCUTANEOUS TENOTOMY IS DONE.
⢠CARE SHOULD BE TAKEN WHILE DORSIFLEXING FOOT BY APPYLING
PRESSURE UNDER ENTIRE SOLE AND NOT UNDER METATARSAL HEADS.
42. FOOT IS FURTHER ABDUCTED UPTO 70* TO
STRETCH TO STRETCH MEDIAL TARSAL LIGAMENT.
NOTE: HEEL IS NOT GRASPED BY HAND THUS
ALLOWING CALCANEUS TO ABDUCT WITH FOOT
AND HEEL VARUS TO CORRECT
44. PERCUTANEOUS TENOTOMY
FOOT HELD IN DORSIFLEXION AND TENDON IS FELT
BLADE OF 11 SIZE ENTERS PARALLEL TO MEDIAL BORDER OF
TENDOACHILLES 1CM ABOVE INSERTION AT CALCANEUM.
BLADE IS PUSHED MEDIAL TO TENDON AND ROTATED 90*
UNDERNEATH IT. TENDON IS CUT FROM MEDIAL TO LATERAL
DIRECTION.
"POP" IS FELT AND CAST IS APPLIED IN MAXIMAL
DORSIFLEXION AND 70* ABDUCTION FOR 3-4 WEEKS.
48. PONSETI TECHNIQUE
⢠MAINTAENANCE PHASE:
⢠AFTER REMOVAL OF CAST INFANT IS PLACED IN FOOT ABDUCTION ORTHOSIS.
⢠BRACE IS WORN FOR 23HRS PER DAY FOR FIRST 3 MONTH THEN ONLY WHILE
SLEEPING FOR 3-4 YEARS.
⢠FREQUENT FOLLOW UP IS IMPORTANT TO DETECT EARLY RECCURENCE.
⢠IT PREVENT RECURRENCE OF DEFORMITY
⢠IT FAVORS REMODELLING OF JOINTS WITH THE BONES IN PROPER ALINGMENT AND
TO INCREASE LEG AND FOOT MUSCLE STRENGTH.
49. FOOT ABDUCTION
ORTHOSIS
⢠ALSO KNOWN AS DENIS BROWN SPLINT.
⢠CONSIST OF SHOES MOUNTED TO
CROSSBAR IN POSITION OF 70* EXTERNAL
ROTATION AND 15* DORSIFLEXION.
⢠DISTANCE BETWEEN SHOES IS SET AT
ABOUT 1INCH WIDER THAN THE WIDTH OF
INFANTâS SHOULDER.
⢠IN UNILATERAL CASES NORMAL FOOT
SHOULD IN 40* OUTWARD ROTATION.
50. CTEV SHOES
⢠MODIFIED SHOES FOR
CHILD WHO START
WALKING.
⢠THESE SHOES ARE USE
UNTILL 5 YEARS OF AGE.
⢠SPECIAL FEATURES:
ďSTRAIGHT INNER BORDER
ďOUTER SHOE RISE
ďNO HEEL
51. NONOPERATIVE TREATMENT
⢠STRETCHING AND ADHESIVE STRAPPING(ROBERT JONES):
ďPRINCIPLE- APPLY EVERSION CORRECTION FORCE ON FOOT WITH HELP OF
ADHESIVE STRAPPING.
⢠FRENCH TECHNIQUE:
ďGOAL IS TO REDUCE TALONAVICULAR JOINT, STRETCH OUT MEDIAL TISSUES AND
THEN SEQUENTIALLY CORRECT FOREFOOT ADDUCTION, HINDFOOT VARUS AND
EQUINUS OF CALCANEUM.
52. COMPLICATIONS OF NONOPERATIVE TREATMENT
⢠ROCKER BOTTOM FOOT
⢠BEAN SHAPED FOOT
⢠FRACTURES
⢠PRESSURE SORES
⢠FLAT TOP TALUS
⢠FAILURE OF CORRECTION
⢠RECCURENCE OR RELAPSE OF DEFORMITY
53. SURGICAL TREATMENT
⢠INDICATION:
ď IN CASE OF NEGLECTED CTEV, RELAPSED CTEV, RECCURENT CTEV, RESISTANT CTEV, RIGID CTEV.
⢠CHOICE OF SURGERY:
ďś1-4 YEARS-
ď SOFT TISSUE RELEASE
ďś4-11 YEARS-
ď SOFT TISSUE RELEASE WITH
ď OSTEOTOMY PERFORMED ACCORDING TO THE DEFORMITIES
ďś>11YRS- SALVAGE PROCEDURES
ď TRIPLE ARTHRODESIS
ď TALECTOMY
54. SOFT TISSUE RELEASE OPERATION
ďTURCOâS OPERATION- IT IS ONE STAGE POSTEROMEDIAL RELEASE. HE EMPHASIZED ON SUBTALAR
RELEASE ALONG WITH CALCANEOFIBULAR LIGAMENT.
ďCAROLLâS INCISION- CAROLL EMPHASIZED ON PLANTAR FASCIA RELEASE AND CAPSULOTOMY OF
CALCANEOCUBOID JOINT. IT INCLUDE 2 INCISIONS, MEDIAL AND POSTERO-LATERAL INCISION.
ďCINCINATTI INCISION- IT IS DONE FOR POSTEROMEDIAL AND POSTEROLATERAL SOFT TISSUE
RELEASE. PREFFERED TECHNIQUE FOR INITIAL SURGICAL MANAGEMENT OF CLUB FOOT.
ďTENDOACHILLES TENDON RELEASE WITH POSTERIOR CAPSULOTOMY- TO CORRECT RESIDUAL
HIND FOOT EQUINUS
55. TURCO OPERATION
⢠MEDIAL INCISION GIVEN
⢠EXPOSE TIBIALIS POSTERIOR, FDL,FHL, TENDOACHILLES AND POSTERIOR NEUROVASCULAR BUNDLE.
⢠DIVIDE MASTER KNOT OF HENRY.
⢠DIVIDE CALCANEONAVICULAR LIGAMENT AND ABDUCTOR HALLUCIS FROM TIBIALIS POSTERIOR TENDON,NAVICULAR TUBEROSITY AND
1ST METATARSAL.
⢠POSTERIOR RELEASE- BY DOING Z-PLASTY OF TENDO ACHILLES, INCISING POSTERIOR CAPSULE OF ANKLE JOIN, SUBTALAR JOINT AND
DIVIDING TALOFIBULAR LIGAMENT AND CALCANEOFIBULAR LIGAMENT.
⢠MEDIAL PLANTAR RELEASE- DIVIDE TIBIALIS POSTERIOR, SUPERFICIAL DELTOID LIGAMENT, TALONAVICULAR CAPSULE AND SPRING
LIGAMENT.
⢠SUTALAR RELEASE- DIVIDE MEDIAL PART OF TALOCALCANEAL INTERROSEOUS LIGAMENT AND BIFURCATION OF Y LIGAMENT.
⢠AFTER REDUCING NAVICULAR BONE TRANSFIX TALONAVICULAR JOINT BY K-WIRE AND SUBTALAR JOINT BY 2ND K-WIRE.
58. ACHILLES TENDON
LENTHENING AND
POSTERIOR CAPSULOTOMY
⢠TO CORRECT RESIDUAL HINDFOOT EQUINUS
⢠Z-PLASTY IS DONE TO LENGTHEN THE
ACHILLES TENDON.
⢠RELEASING MEDIAL HALF DISTALLY AND
LATERAL HALF PROXIMALLY.
⢠POSTERIOR CAPSULOTOMY OF ANKLE AND
SUBTALAR JOINT TO RELEASE CAPSULE
CONTRACTURE.
59. TENDON TRANSFER
⢠INDICATION- PASSIVELY CORRECTABLE
DEFORMITY RESULTING FROM MUSCLE
IMBALANCE.
⢠ANTERIOR TIBIALIS TENDON TRANSFER-
TENDON IS TRANSFERRED EITHER TO
MIDDLE CUNIEFORM OR TO BASE OF 5TH
METATARSAL.
⢠SPLATT (SPLit ANTERIOR TIBIALIS TENDON
TRANSFER)- LATERAL PART OF TENDON IS
SPLIT AND INSERTED TO CUBOID.
60. DWYER
OSTEOTOMY
⢠INDICATION- PERSISTENT VARUS
DEFORMITY OF HEEL WHEN
SOFT TISSUE SURGERIES ARE
CONTRAINDICATED.
⢠AGE- 3-4YRS
⢠DONE BY MEDIAL OPEN WEDGE
OSTEOTOMY OR BY LATERAL
CLOSED WEDGE OSTEOTOMY
61. LATERAL COLUMN SHORTENING PROCEDURE
⢠INDICATION- RECURRENCE OF CLUBFOOT DEFORMITY
AFTER SURGICAL RELEASE IS MOSTLY DUE TO
DISPARITY BETWEEN MEDIAL AND LATERAL BORDER
OF FOOT. ANY ATTEMPT TO CORRECT DEFORMITY IS
RESISTED BY MEDIAL CONTRACTURE AND EXCESSIVE
LENGTH OF LATERAL COLUMN.
⢠DIFFERENT PROCEDURE TO DO SHORTEN LATERAL
COLUMN ARE-
ď DILLWYNN EVANS PROCEDURE
ď LICHTBLAU PROCEDURE
ď FOWLER PROCEDURE
62. LATERAL COLUMN SHORTENING PROCEDURE
DILLWYN EVANS PROCEDURE LICHTBLAU PROCEDURE
AGE- 4-8 YRS
INDICATION- MIDFOOT IN VARUS DUE TO
TALONAVICULAR AND CALCANEOCUBOID
SUBLUXATION
AGE- 3-4 YRS
INDICATION- HEEL VARUS & RESIDUAL INTERNAL
DEFORMITY OF CALCANEUS WITH LONG LATERAL
COLUMN
63. FOWLER
PROCEDURE
⢠INDICATION- SUFFICIENT SCARRING THAT
MEDIAL SOFT TISSUE AND SUBTALAR
RELEASE WOULD BE IN EFFECTIVE.
⢠AGE- 6-8 YEARS
⢠PROCEDURE- LATERAL COLUMN
SHORTENING COMBINING WITH MEDIAL
COLUMN LENGTHING BY REMOVING
WEDGE FROM CUBOID AND
TRANSFERING IT TO AN OPENING
WEDGE.
64. SALVAGE PROCEDURE
⢠INDICATION-
ď UNCORRECTED CLUBFOOT OR WITH RESIDUAL DEFORMITY AFTER THE AGE OF 10 YRS.
ď PAINFUL STIFF FOOT WITH POOR FUNCTION
ď DIFFICULT TO ACCOMMODATE TO FOOT WEAR
⢠GOAL-
ď CORRECT RESIDUAL DEFORMITY WHICH IS RESISTANT TO SOFT TISSUE RELEASE.
ď TO ATTAIN FUNCTIONALLY AND COSMETICALLY ACCEPTABLE FOOT.
⢠PROCEDURE-
ď TRIPLE ARTHRODESIS
ď TALECTOMY
65. TRIPLE
ARTHRODESIS
⢠INDICATION-
ďPAINFUL STIFF FOOT WITH POOR FUNCTION
ďDIFFICULT TO ACCOMMODATE TO FOOT
WEAR
ďALL OTHER CORRECTION FAILED
⢠AGE â 10 â 12 YEARS
⢠PROCEDURE-
ď OSTEOTOMY FOLLOWED BY FUSION OF
TALONAVICULAR, TALOCALCANEUM AND
CALCANEOCUBOID JOINT.
66. TALECTOMY
⢠INDICATION-
ď RESERVED FOR SEVERE UNTREATED
CLUBFOOT
⢠AGE - <6 YEARS
⢠PROCEDURE-
ď COMPLETE EXCISION OF TALUS
ď DEROTATE THE FOOT AND DISPLACE THE
CALCANEUS POSTERIORLY INTO ANKLE
MORTISE UNTIL NAVICULAR ABUTS THE
ANTERIOR EDGE OF TIBIAL PLAFOND.
⢠COMPLICATION-
ď LOSS OF LIMB LENGTH
ď LIMITATION OF ANKLE MOVEMENT
67. EXTERNAL FIXATOR
⢠INDICATION-
ďIN CASE OF NEGLECTED AND RECCURENT DEFORMITY WITH SEVERE SCARRING
⢠MODALITIES-
ďILLIZAROVâS EXTERNAL FIXATOR
ďJESS (JOSHI EXTERNAL STABILIZING SYSTEM)
⢠ADVANTAGE-
ďPREVENT CRUSHING OF THE TISSUES ON CONVEX SIDE
ďLENGHTENS THE LIMB
ďEFFECTIVELY CORRECT THE DEFORMITY AT SAME TIME
68. ILLIZAROVâS EXTERNAL
FIXATOR
⢠PRINCIPLE- FRACTIONAL DISTRACTION
⢠INDICATION- SEVERE DEFORMITIES WITH SEVERE
SCARING OR TROPHIC ULCERS WHICH MAKE
OPERATIVE INTERVENTION CONTRAINDICATION
BECAUSE OF RISK OF TISSUE NECROSIS.
⢠STEPS OF CORRECTION-
ANGULAR CORRECTION
OF HINDFOOT
CORRECTION OF
FOREFOOT SUPINATION
CORRECTION OF FOOT
EQUINUS
69. JESS
⢠PRINCIPLE- DIFFERENTIAL DISTRACTION
⢠ADVANTAGE-
ď LENTHENS ALL CONTRACTED TISSUES
PREVENTING HISTIOGENESIS AND
THUS AVOID CUTTING OF THESE
IMMINENT SCARRING.
ď POSSIBLE TO CONTROL MAGNITUDE
OF CORRECTION.
ď NO FURTHER SHORTHENING OF FOOT
ď RESULTANT FEET IS VERY SUPPLE.
71. A. FRESH CASE OF CTEV AT BIRTH
PONSETI
METHOD
TENOTOMY
ALL DEFORMITIES LEFT: PMSTR
ONLY EQUINUS: POSTERIOR RELEASE
ONLY HEEL VARUS: DWYERâS OSTEOTOMY
FOLLOW TILL 10-
12 YEARS OF AGE
TREATMENT SUCCESSFUL
TREAT AS B
72. B. OLD AND NEGLECTED CASES
< 3 YEARS OLD
SOFT TISSUE
RELEASE
4-8 YEARS OLD
SOFT TISSUE
RELEASE
+
OSTEOTOMY
10-12 YEARS OLD
ALREADY OPERATED
TRANSFORMING GROWTH FACTOR â BETA AND PLATELET DERIVED GROWTH FACTOR ARE INCREASED IN THESE CONTRACTED TISSUES.
NAVICULAR BONE SHOULD BE BOUGHT DOWNWARD UNDER MEDIAL MALLEOLUS FROM VERTICAL POSITION AND THEN DISPLACE IT LATERALLY, ABDUCT AND LASTLY EVERT IT
COBOID IS LESS DISPLACED STILL BRING LATERALLY, ABDUCT AND THEN EVERT
SAME FOR CALCANEUM, ABDUCTED IN FLEXION UNDER TALUS THEN EVERTED.