PATHOLOGICAL ANATOMY of club foot, treatment of CTEV and clubfoot, pirani score of CTEV, surgical procedures of club foot

1. CTEV / CLUB FOOT
By :- Dr. Surya Vijay Singh
Central institute of orthopaedics,
VMMC and SJH, New Delhi
Moderator : Dr. Ravi Sreeniwasan
Faculty, C. I.O, VMMC and SJH,
New Delhi

2. OUTLINE
• What is CTEV?
• EPIDEMIOLOGY
• ETIOLOGY
• PATHOLOGICAL ANATOMY
• CLINICAL FEATURES
• CLASSIFICATION
• RADIOGRAPHIC EVALUATION
• TREATMENT
• SUMMARY

3. WHAT IS CTEV?
• Congenital Talipes Equino Varus or
club foot
• TALUS- ankle, PES- Foot, EQUINO- like a
horse, VARUS- turned inward.
• Club foot is congenital deformity of the
foot and ankle characterised by 4 basic
deformity
1. fore foot(TM joint) : adduction
2. Hind foot(SUBTALAR joint) : inversion
or varus
3. Hind foot(ankle joint) : equinus
4. Mid foot(TN, CC joint) : cavus

4. DEFORMITIES
• 4 Clinical components CAVE
• C - CAVUS : Exaggerated Medial
Longitudinal arch at midfoot
• A - ADDUCTION : Forefoot in
adduction in tarsometatarsal
junction
• V - VARUS : Hind foot rotated
inward at talocalcaneonavicular
joint
• E - EQUINUS : Foot fixed in plantar
flexion at ankle joint

5. EPIDEMIOLOGY
• Relatively common I 1-2 per 1000 Births
• Incidence in 1st degree relative =2%
• Incidence IN 2nd degree relative in = 0.6%
• Incidence in MALE:FEMALE- 2.5:1
• LATERALITY- >50% CASES ARE BILATERAL
• IN UNILATERAL AFFLICTION- RIGHT> LEFT

6. ETIOLOGY
• MOST COMMON CAUSE OF CTEV IS IDIOPATHIC (PRIMARY)
• OTHER THAN IDIOPATHIC IS SECONDARY CTEV WHICH IS ASSOCIATED
WITH UNDERLYING CAUSE.

7. IDIOPATHIC CTEV
• PRIMARY GERM PLASMA DEFECT: WAISBROD SUGGESTED DEFECT IN
PRIMARY GERM PLASMA OF CARTILAGINOUS TALAR ANALGE
RESULTING IN DYSMORPHIC TALAR NECK AND NAVICULAR
SUBLUXATION.
• 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.

8. IDIOPATHIC CTEV
• OTOGENIC THEORY / ARRESTTHEORY : ARREST OF DEVELOPMENT
RELATED TO A CHANGE IN GENETIC FACTOR KNOWN AS “ CRONON”.
CRONON MAY CHANGED BY CERTAIN ELEMENTS ( TERATOGENIC) LEADS TO A
NORMAL DEVELOPMENTOF LIMBS.
• VASCULARHYPOTHESIS: KEITH SUGGESTED TEMPORARY CESSATION OF
CIRCULATION IN DEVELOPINGFETUS RESULTED IN CONTRACTURESOF
SOFT TISSUES AND DEFECTIVE DEVELOPMENTOF CARTILAGE.
• MUSCULOLIGAMENTOUS FIBROSIS:IPPOLITOAND PONSETI FOUND
CONSIDERABLEINCREASEIN COLLEGEN FIBRES AND FIBROBLASTIC CELLS IN
LIGAMENTSAND TENDONS OF CLUBFOOT.
THEY CONSIDERED TO BE PRIMARY DEFECT, CARTILAGINOUSAND BONY
CHANGES BEING SECONDARY.

9. IDIOPATHIC CTEV
• MECHANICAL FACTOR IN UTERO: OLDEST THEORY PROPOSED BY
HIPPOCRATES SUGGESTING FOOT HELD IN EQUINO VARUS BY
EXTERNAL UTERINE COMPRESSION. SOME INVESTIGATOR OPINE
DIMINUTION OF AMNIOTIC FLUID AS CAUSE OF CLUB FOOT.
• HEREDITARY: WYNNE- DAVIES SUGGESTED CLUB FOOT ARE PART OF
NUMEROUS SYNDROMES FOLLOWING MANDELIAN PATTERN OF
EITHER AUTOSOMAL DOMINANT OR AUTOSOMAL RECESSIVE
INHERITANCE.

10. SECONDARY CTEV:
• ASSOCIATEDWITH NEUROMUSCULAROR SYNDROMIC ETIOLOGIES-
1. ARTHROGRYPOSISMULTIPLEX CONGENITA
2. DIASTROPHICDYSPLASIA
3. STREETER SYNDROME(CONSTRICTION BAND SYNDROME)
4. FREEMAN SHELDON SYNDROME(whistling face)
5. MOBIUS SYNDROME
6. NAIL PATELLA SYNDROME
7. DIASTROPHICDWARFISM
• ASSOCIATEDWITH PARALYTIC DISORDER-
1. POLIOMYELITIS
2. SPINA BIFIDA
3. MYELODYSPLESIA
4. FREIDRICH’SATAXIA
MOBIUS SYNDROME

12. SECONDARY CTEV
• GENETIC CAUSES-
1. N- ACETYLATION GENES NAT1 AND NAT2
2. XENOBIOTIC METABOLISMGENES CYP1A1
3. LIMB AND MUSCLE MORPHOGENESISGENE HOXA, HOXD AND IGF BP3
4. GENE FOR LOWER EXTREMITY DEVELOPMENT- CAN D2 AND WNT 7A
5. GENE FOR CONTACTILE PROTEIN OF SKELETAL MYOFIBRES- TBX4

13. PATHOLOGICAL ANATOMY

14. PATHOLOGICAL ANATOMY:
1. BONES-
• TALUS-
• HEAD AND NECK DEVIATED MEDIALLY AND
DOWNWARD.
• MEDIAL AND PLANTARDEVIATION OF
NAVICULAR ARTICULATION.
• BODY ROTATED EXTERNALLY AND IS IN EQUINUS
OF NECK IN ANKLE MORTISE.
• BODY EXTRUDED ANTERIORLY
• SMALLER THAN NORMAL
• NECK- BODY ANGLE IS 90-110* (NORMAL- 150*)
• DISLOCATION OF HEAD OF TALUS OUT OF ITS
SOCKET.

15. PATHOLOGICAL ANATOMY
• NAVICULAR-
• MEDIALLYAND PLANTAR
DISPLACEMENT
• CLOSE TO MEDIALMALLEOLUS
• ARTICULATESWITH MEDIAL SURFACFE
OF DYSMORPHICTALUS
• TALONAVICULAR JOINT SUBLUXATION

16. PATHOLOGICAL ANATOMY
• CALCANEUM-
• OFTEN SMALL IN SIZE
• MEDIALLY ROTATED
• ANTERIOR PORTION LIES BENEATHTHE
HEAD OF TALUS CAUSING VARUS AND
EQUINUSOF HEEL.
• SUSTENTACULUMTALI IS
UNDERDEVELOPED.
• CUBOID-
• MEDIALLY SUBLUXATED OVER
CALCANEUM HEAD

17. PATHOLOGICAL ANATOMY

18. PATHOLOGICAL ANATOMY

19. PATHOLOGICAL ANATOMY

20. PATHOLOGICAL ANATOMY

21. PATHOLOGICAL ANATOMY

22. PATHOLOGICAL ANATOMY
2. MUSCLES AND TENDONS-
• ATROPHY OF PERONEAL GROUP OF MUSCLES
• CONTRACTURE OF TRICEP SURAE,TIBIALIS
POSTERIOR,FLEXOR DIGITORUM LONGUS AND
FLEXOR HALLUCIS LUNGUS.
• NUMBER OF FIBRES IN MUSCLE IS NORMAL BUT
ARE SMALLER IN SIZE.
• THICKENING AND CONTRACTURE OF TENDON
SHEATHSESPECIALLY OF TIBIALIS POSTERIOR
AND PERONEAL.

24. PATHOLOGICAL ANATOMY
3. LIGAMENTS-
THICKENING AND CONTRACTURES ARE
SEEN IN
• CALCANEOFIBULARLIGAMENT
• TALOFIBULAR LIGAMENT
• DELTOID LIGAMENT
• LONG AND SHORT PLANTARLIGAMENT
• SPRING LIGAMENT
• BIFURCATE LIGAMENT
• INTEROSSEOUSTALO CALCANEUM LIGAMENT
• MASTER KNOT OF HENRY

27. PATHOLOGICAL ANATOMY
4. JOINTS CAPSULE AND FASCIA-
• CONTRACTURES ARE SEEN IN
• POSTERIOR ANKLE CAPSULE
• SUBTALAR CAPSULE
• TALONAVICULAR JOINT CAPSULE
• CALCANEOCUBOID JOINT CAPSULE
• PLANTAR FASCIA CONTRACTURE ARE
SEEN WHICH IS RESPONSIBLE CAVUS
DEFORMITY

28. PATHOLOGICAL ANATOMY
5. SKIN CHANGES-
DEEP CREASE ON MEDIAL SIDE
DIMPLES IN LATERAL ASPECT OF ANKLE AND MID
FOOT.
SHORTENING ON MEDIAL SIDE OF SOLE
CALLOSITIES AND BURSA ON LATERAL SIDE OF FOOT
6. VASCULAR CHANGES-
HYPOPLASIA OR ABSENCE OF DORSALIS PAEDISAND
ANTERIOR TIBIAL ARTERY

29. CLINICAL FEATURES OF CLUB FOOT
HEEL IS SMALL AND IN EQUINUS
• FOOT INVERTED ON END OF TIBIA
• DEEP CREASES ON MEDIAL AND POSTERIOR ASPECT
• ABNORMAL THIN CALF MUSCLES WASTING
• VARYING DEGREE OF RESISTANCE/FIXED DEFORMITY WHEN
TRY TO DORSIFLEX AND EVERT THE FOOT.
• LACK OF CORRECTABILITY
• OTHER JOINT ABNORMALITY
• ASSOCIATEDANOMALIES AND NEUROMUSCULAR
CONDITION AND SPINA BIFIDA.

30. CLASSIFICATION
1. IDIOPATHIC AND NON-IDIOPATHIC
2. CUMMIN CLASSIFICATION
3. PONSETI AND SMOLEYCLASSIFICATION- BASED EXTENT OF DEFORMITY
4. HARROLDAND WALKER CLASSIFICATION-BASED ON ABILITY TO CORRECT
THE DEFORMITY.
5. BROWNE’SCLASSIFICATION- BASED ON TYPE OF DEFORMITY
6. DIMEGLIO ET AL SCORING SYSTEM BASED ON SEVERITY OF THE DEFORMITY
7. PIRANI SCORING SYSTEM

31. CUMMINCLASSIFICATION
• 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.

32. DIMEGLIOSCORING
SYSTEM

33. PIRANI SCORING SYSTEM:
• SIMPLE AND RELIABLE SYSTEM TO DETERMINE SEVERITY AND MONITOR
PROGRESS IN THE ASSESSMENT AND
TREATMENTOF CLUBFOOT.
• SIX “SIGNS” ARE ASSESSED
• 3 SIGNS IN MIDFOOT
• 3 SIGNS IN HINDFOOT
• BASED ON 6 WELL-DESCRIBEDCLINICALSIGNS OF CONTRACTURE
CHARACTERIZINGA SEVERE CLUBFOOT:
• IF THE SIGN IS SEVERELY ABNORMALIT SCORES 1
• IF IT IS PARTIALLYABNORMALIT 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

34. PIRANI SCORE

37. RADIOGRAPHIC EVALUATION:
• FOR NON AMBULATORY CHILD-
ANTEROPOSTERIOR
STRESS DORSIFLEXION LATERAL VIEW
• FOR OLDER CHILD-
STANDINGANTEROPOSTERIOR
STANDINGLATERAL
• IMPORTANT ANGLE WE MEASURE-
• TALOCALCANEALANGLE ON AP AND LAT VIEW
• TIBIOCALCANEALANGLE ON LAT VIEW
• TALUS- FIRST METATARSALANGLE

38. RADIOGRAPHIC EVALUATION:
TALOCALCANEALANGLE-
• ON AP VIEW-
• 1ST LINE THROUGH THE CENTRE OF LONG
AXIS OF TALUS (PARALLEL TO MEDIAL
BORDER)
• 2ND LINE THROUGH LONG AXIS OF
CALCANEUM (PARALLEL TO LATERAL
BORDER)
• NORMAL 25-50*
• ON LATERAL VIEW-
• 1ST LINE MIDPOINT OF HEAD AND BODY OF
TALUS
• 2ND LINE ALONG BOTTOM OF CALCANEUM
• NORMAL 35-50*

39. RADIOGRAPHIC EVALUATION:
• RADIOLOGICAL FINDINGSEEN-
• ON LATERAL VIEW-
• DECREASED TALOCALCANEAL ANGLE
(TALOCALCANEAL PARALLELISM)
• DISRUPTED TALAR FIRST METATARSAL ANGLE
• LONG AXIS OF TALUS AND CALCANEUM PASSES
INFERIOR TO CUBOID (NORMALLY CROSSES CUBOID)
• ON ANTEROPOSTERIOR VIEW-
• INCREASED TALOCALCANEAL ANGLE
• INCREASED TALAR FIRST METATARSAL ANGLE
• LONG AXIS OF TALUS DEVIATE LATERALLY AND PASSES
ALONG 3RD OR 4TH METATARSAL BONE

41. TREATMENT:
• GOAL: TO ACHIEVE
• PLANTIGRADE FOOT
• FLEXIBILTY
• COSMETICALLY ACCEPTABLE FUNCTIONALAND PAIN FREE FOOT IN SHORTEST
TREATMENTTIME
• PRINCIPLES:
• SOFT TISSUE CONTRACTURE RELEASE OR STRETCHING TO RESTORE NORMAL TARSAL
RELATIONSHIP.
• ONCE NORMAL TARSAL RELATIONSHIP ATTAINED,CORRECTION SHOULD BE
MAINTAINEDTILL TARSAL BONES REMOULDS STABLE ARTICULAR SURFACE.

42. NONOPERATIVE TREATMENT:
• SEVERAL REGIME HAVE BEEN PROPOSED
INCLUDING SPLINTING TAPING AND CASTING.
• KITE’S METHOD:
1. CORRECTIONOF EACH COMPONENT
SEPARATELY
2. CORRECTIONWAS DONE IN FOLLOWING
ORDER
• KITE’S ERRORS:
• PRONATION/ EVERSIONOF 1ST METATARSAL.
• PREMATURE DORSIFLEXION OF HEEL.
• USED CALCANEOCUBOIDJOINT AS FULCRUM
THAT BLOCKS ABDUCTION OF CALCANEUS ,
THERBY PREVENTS EVERSIONOF
CALCANEUM.
FOREFOOT
ADDUCTION
HEEL VARUS EQUINUS

44. NONOPERATIVE TREATMENT:
CAVUS
ADDUCTION
WITH VARUS
EQUINUS
• PONSETI TECHNIQUE:
• 2 PHASE- TREATMENT AND
MAINTENANCE PHASE
• TREATMENT PHASE-
• BEGINS AS EARLY AS POSSIBLE. DURINGFIRST
WEEK OF LIFE ONLY MANIPULATION IS CARRIED
OUT
BUT CAST IS NOT APPLIED.
• ORDER OF CORRECTION-
• TALUS HEAD IS USED AS FULCRUM.
• 5-6 SERIAL CASTING WITH MANIPULATIONIS
GENERALLY ENOUGH TO CORRECTTHE
DEFORMITY.
MAXIMUM UPTO 1O CASTING CAN BE DONE.

47. • PONSETI TECHNIQUE:
A) • CORRECTION OF CAVUS
DEFORMITY:
• CORRECTED BY FOREFOOT SUPINATION
RELATIVE TO HINDFOOT ALONG WITH
ADDUCTION OF FOREFOOT.
• TENDS TO EXAGGERATEFOOT INVERSION.
• PRONATION OF FOREFOOT SHOULD NOT BE
DONE AS IT INCREASES CAVUS DEFORMITY
BECAUSE 1ST METATARSALIS FURTHER
PLANTARFLEXED.

48. • PONSETI TECHNIQUE:
B) • CORRECTION OF VARUS AND
ADDUCTION:
• CORRECTION OF CAVUS BRINGS METATARSAL,
CUNIEFORM, NAVICULAR, AND CUBOID IN SAME
PLANE OF SUPINATION.
• NOW FOOT IS ABDUCTED AND HELD IN FLEXION
AND SUPINATIONTO ACCOMMODATE THE
INVERSION OF TARSALBONES WHILE COUNTER
PRESSURE IS APPLIED WITH THUMB ON LATERAL
ASPECT OF HEAD OF TALUS.
• THIS MANEUVER NECESSITATESPROLONG
STRETCHING OF MEDIAL TARSAL LIGAMENTS AND
TENDONS.

50. C) • CORRECTION OF EQUINUS:
• SHOULD BE ATTEMPTEDWHEN
HINDFOOT IS IN NEUTRAL POSITION TO
SLIGHT VALGUS AND FOOT IS ABDUCTED
70* RELATIVE TO LEG.
• EQUINUSIS COORECTED BY
PROGRESSIVE DORSIFLEXING THE FOOT.
• TO FACILITATE RAPID CORRECTION
SUBCUTANEOUSTENOTOMY IS DONE.
• CARE SHOULD BE TAKENWHILE
DORSIFLEXING FOOT BY APPYLING
PRESSURE UNDER ENTIRE SOLE AND NOT
UNDER METATARSALHEADS.
• PONSETI TECHNIQUE:

51. PERCUTANEOUS TENOTOMY
FOOT HELD IN DORSIFLEXION AND TENDON FELT
BLADE OF 11 SIZE ENTERS PARALLEL TO MEDIAL BORDER
OF TENDOACHILES 1CM ABOVE INSERSION AT CALCANEUM
BLADE IS PUSHED MEDIAL TO TENDON AND ROTATED 90* UNDERNEATHIT.
TENDON IS CUT FROM MEDIAL TO LATERAL DIRECTION.
“POP” IS FELT AND CAST IS APPLIED IN MAXIMUM DORSIFLEXION AND 70*
ABDUCTION FOR 3-4 WEEKS.

53. PONSETI CAST

54. • PONSETI TECHNIQUE:
• Ponseti claims to avoid open surgery in 89% of cases by using his
technique of manipulation, casting, and limited surgery.
(Ethiop J Health Sci. 2012 Jul; 22(2): 77–84.PMCID:PMC3407829,PMID: , Sharma Pulak1 and MKS
Swamy1)

55. • 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.
• FREQUENTFOLLOW 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.

57. 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 1INCHWIDER THAN THE WIDTHOF
INFANT’S SHOULDER.
• IN UNILATERAL CASES NORMAL FOOT
SHOULD IN 40* OUTWARD ROTATION.

58. CTEV SHOES
• MODIFIED SHOES FOR
CHILD WHO START
WALKING.
• THESE SHOES ARE USE
UNTILL 5 YEARS OF AGE.
• SPECIAL FEATURES:
• STRAIGHT INNER BORDER
• OUTER SHOE RISE
• NO HEEL

59. COMPLICATIONS OF NONOPERATIVE TREATMENT
• ROCKER BOTTOM FOOT
• BEAN SHAPED FOOT
• FRACTURES
• PRESSURE SORES
• FLAT TOP TALUS
• FAILURE OF CORRECTION
• RECCURENCE OR RELAPSE OF DEFORMITY

60. SURGICAL TREATMENT OF CTEV
• INDICATION:
• IN CASE OF NEGLECTED CTEV, RELAPSED CTEV, RECCURENT CTEV, RESISTANT CTEV, RIGID
CTEV.
• CHOICE OF SURGERY:
1-4 YEARS-
• SOFT TISSUE RELEASE
4-11 YEARS-
• SOFT TISSUE RELEASE WITH
• OSTEOTOMY PERFORMED ACCORDINGTO THE DEFORMITIES
>11YRS- SALVAGE PROCEDURES
• TRIPLE ARTHRODESIS
• TALECTOMY

61. SOFT TISSUE RELEASE OPERATION
• TURCO’S OPERATION- IT IS ONE STAGE POSTEROMEDIAL RELEASE. HE
EMPHASIZED ON SUBTALAR RELEASE ALONG WITH CALCANEOFIBULAR
LIGAMENT.
• CAROLL’S INCISION- CAROLL EMPHASIZED ON PLANTAR FASCIA RELEASE
AND CAPSULOTOMY OF CALCANEOCUBOID JOINT. IT INCLUDE 2
INCISIONS, MEDIAL AND POSTERO-LATERAL INCISION.
• CINCINATTI INCISION- IT IS DONE FOR POSTEROMEDIAL AND
POSTEROLATERAL SOFT TISSUE RELEASE. PREFFERED TECHNIQUE FOR
INITIAL SURGICAL MANAGEMENT OF CLUB FOOT.
• TENDOACHILLES TENDON RELEASE WITH POSTERIOR CAPSULOTOMY- TO
CORRECT RESIDUAL HIND FOOT EQUINUS

62. TURCO OPERATION
• MEDIAL INCISION GIVEN
• EXPOSE TIBIALISPOSTERIOR, FDL,FHL, TENDOACHILLESAND POSTERIOR NEUROVASCULAR BUNDLE.
• DIVIDEMASTER KNOT OF HENRY.
• DIVIDECALCANEONAVICULAR LIGAMENT AND ABDUCTOR HALLUCIS FROM TIBIALISPOSTERIOR
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 VIDING TALOFIBULAR LIGAMENT AND CALCANEOFIBULAR
LIGAMENT.
• MEDIAL PLANTAR RELEASE- DIVIDETIBIALISPOSTERIOR, SUPERFICIAL DELTOID LIGAMENT,
TALONAVICULAR CAPSULE AND SPRING LIGAMENT.
• SUTALAR RELEASE- DIVIDEMEDIAL PARTOF TALOCALCANEAL INTERROSEOUSLIGAMENT AND
BIFURCATIONOF Y LIGAMENT.
• AFTER REDUCINGNAVICULAR BONE TRANSFIX TALONAVICULAR JOINT BY K-WIRE AND SUBTALAR JOINT
BY 2ND K-WIRE.

65. CINCINATTI INCISION
• TRANSVERSE CIRCUMFERENTIAL INCISION

73. SALVAGE PROCEDURE
• INDICATION-
• UNCORRECTED CLUBFOOT OR WITH RESIDUAL DEFORMITY AFTER THE AGE OF 10 YRS.
• PAINFUL STIFF FOOT WITH POOR FUNCTION
• DIFFICULT TO ACCOMMODATE TO FOOT WEAR
• GOAL-
• CORRECT RESIDUAL DEFORMITY WHICH IS RESISTANT TO SOFT TISSUE RELEASE.
• TO ATTAIN FUNCTIONALLY AND COSMETICALLY ACCEPTABLE FOOT.
• PROCEDURE-
• TRIPLE ARTHRODESIS
• TALECTOMY

76. EXTERNAL FIXATOR
• INDICATION-
• IN CASE OF NEGLECTED AND RECCURENT DEFORMITY WITH SEVERE
SCARRING
• MODALITIES-
• ILLIZAROV’S EXTERNAL FIXATOR
• JESS (JOSHI EXTERNAL STABILIZING SYSTEM)
• ADVANTAGE-
• PREVENT CRUSHING OF THE TISSUES ON CONVEX SIDE
• LENGHTENS THE LIMB
• EFFECTIVELY CORRECT THE DEFORMITY AT SAME TIME

77. JESS (JOSHI EXTERNAL stabilisation system)
• PRINCIPLE- DIFFERENTIAL DISTRACTION
• ADVANTAGE-
• LENTHENS ALL CONTRACTED TISSUES
• PREVENTING HISTIOGENESISAND
THUS AVOID CUTTING OF THESE
IMMINENT SCARRING.
• POSSIBLE TO CONTROL MAGNITUDE
OF CORRECTION.
• NO FURTHER SHORTHENING OF FOOT
• RESULTANTFEET IS VERY SUPPLE.

78. ILLIZAROV’S 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
• CORRECTIONOF
FOREFOOT SUPINATION
• CORRECTIONOF FOOT
EQUINUS

79. Indianauthorsassociatedwithworkin CTEV
• Dr R. L. Mittal- local rotational skin flap for naglected club foot and
extensive soft tissue release for posteromedial contracture.
• Dr. B. B Joshi- JESS
• Prof B Mukhopadhyaya- neglected clubfoot “Patna procedure”.

80. Dr R. L. Mittal Procedure for extreme
deformity in clubfoot
Heterogeneous skin contractures, congenital
with/without scars, were discovered as the primary
cause with cramped deeper tissues and evolved,
evidence based, 3D enlargement of skin chamber by
triple expanding incisions:
• GRADE I: DOrso-LAteral Rotation skin flap (DOLAR-
acronym),
• GRADE II: DOLAR + Z-plasty (DOLARZ) and
• GRADE III: DOLAR + Z + VY-plasty (DOLARZ-E) , E
means Extended.
Trimorphic extreme clubfoot deformities and their management by triple
surgical skin expanders- DOLAR, DOLARZ and DOLARZ-E(evidence based
mega-corrections without arthrodesis)
Authors
Rattan L. Mittal

81. SUMMARIZING
PLAN OF TREATMENT

86. Thank you
3rd June