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CONGENITAL TALIPES�EQUINOVARUS

Issah J. kiswagala

(M.B.B.S)

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INTRODUCTION

  • Congenital Talipes Equinovarus
  • Talipes Equinovarus comes from the following: “Tali” means Ankle, “Pes” means Foot “Equinus” means foot pointing down (like a horse’s foot)“Varus” means deviated towards midline
  • A birth defect in which the foot is twisted out of shape or position (rotate inward and downward) and looks like as if it’s upside down. Also called Clubfoot.
  • CTEV is developmental deformation of the foot characterized by rotational subluxation of the talocalcaneonavicular joint complex with Talus in plantar flexion and Subtalar complex in medial rotation and inversion

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EPIDEMIOLOGY

Demographics

      • most common musculoskeletal birth defect
      • overall incidence 1:1,000, though some populations 1:250
      • highest prevalence in Hawaiians and Maoris
      • Male : Female ratio approximately 2:1

Location

      • half of cases are bilateral

In 80%, clubfoot is an isolated deformity

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PATHOPHYSIOLOGICAL ANATOMY

  • Muscle contractures contribute to the characteristic deformity that includes (CAVE)
        • Cavus (tight intrinsics, FHL, FDL)
        • Adductus of forefoot (tight tibialis posterior)
        • Varus (tight tendoachilles, tibialis posterior, tibialis anterior)
        • Equinus (tight tendoachilles)
  • Bony deformity consists of medial spin of the midfoot and forefoot relative to the hindfoot
        • talar neck is medially and plantarly deviated
        • calcaneus is in varus and rotated medially around talus
        • navicular and cuboid are displaced medially

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  • The talus: severe plantar flexion, neck medially and plantarly deflected, and head wedge shaped.
  • Navicular: severely medially displaced, close to the medial malleolus, and articulates with the medial surface of the head of the talus.

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CAUSES

  • Intrinsic (genetic) factors
  • Genetic heritability of 80%
  • 32.5% concordance rate among monozygotic twins as compared to 2.9% among dizygotic twins
  • A major gene effect (inherited in recessive manner) with additional polygenes and environmental factors
  • Deletion on Chromosome 2 (2q31-33) related to the CASP10 gene.

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CONT.....

  • Extrinsic (intrauterine) factors
  • Pressure theories: Oligohydramnios, Abnormal fetal positioning and Unstretched uterus
  • Placental insufficiency
  • Constriction bands
  • Toxins
  • Infective pathogens (enteroviruses)
  • Drugs (including abortifacients)
  • Radiation

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CONDITIONS ASSOCIATED WITH CTEV

  • Spinal bifida myelomeningocele
  • Sacral agenesis
  • Arthrogyposis
  • Congenital myopathy
  • Dystrophic dwarfism
  • Down syndrome
  • Fetal alcohol syndrome
  • Constriction band syndrome(streeter dysplasia)

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CLINICAL FEATURES

  • Foot shorter and wider than normal.
  • Transverse plantar creases or clefts at the midfoot and posterior part of the ankle.
  • Atrophy of the calf
  • foot deformities
      • hindfoot in equinus and varus
      • midfoot in cavus
      • forefoot in adduction

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Congenital

  • History :Since birth
  • Bilateral: In >50%
  • Deformity: Equinovarus, Forefoot adduction, Cavus
  • Congenital groove: Present
  • Heel Smaller
  • Calf : Cylindrical and tough

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Acquired

  • Appears later
  • Usually unilateral
  • Equinovarus
  • Not present
  • Usually maintains shape
  • Normal

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DIFFERENTIAL DIAGNOSES

  • Congenital absence of ankle joint
  • Hypoplasia of tibia
  • Congenital dislocation of ankle

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INVESTIGATIONS

  • Radiographs
      • Often not taken
      • Recommended views, if taken are
        1. Dorsiflexion lateral (Turco view)
        2. AP
  • Ultrasound
      • clubfoot sometimes diagnosed in utero through Obs USS

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TREATMENT

  • Conservative option
  • Operation method

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CONSERVATIVE TREATMENT

  • Manipulation non-operative treatment
      • Kite’s Method:
      • Ponseti Technique: The MOST preferred procedure
      • Percutaneous Tenotomy
      • Foot Abduction Orthosis
  • Ponseti method
  • Series of correction and Casting- 5 casts in 5 weeks - goal is to rotate foot laterally around a fixed talus and order of correction is (CAVE) i.e. Cavus, Adductus, Varus, Equinus
  • Tenotomy then 6Th cast which last for 3 weeks. Heel cord tenotomy needed in at least 80-90% of children in most series

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PIRANI SCORE

  • The Pirani Score is a simple and reliable system to determine severity and monitor progress in the Assessment and Treatment of Clubfoot
  • This Scoring System uses the different views of the foot to help visualize the issues in the underling soft tissue and bony anatomy. A foot can be assessed in less than a minute and no technical equipment is required
  • During Ponseti Management of Clubfoot, the Pirani Score Record shows whether the deformity is correcting normally or whether there is a problem, and the degree of correction of each component of the clubfoot.
  • The Pirani Score is also utilized to assist in determining when to perform the Tenotomy.

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METHODS OF USE

  • The Pirani Score key features:
  • Six “Signs” are Assessed
        • Scored depending on Severity - 0, 0.5, or 1
              • 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
        • 3 Signs in Midfoot
        • 3 Signs in Hindfoot
  • Total Score (TS) varies from 0 to 6 and is the sum of Midfoot and Hindfoot Contracture Scores

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MID-FOOT (left) AND HINDFOOT(Right)

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1.Manipulation by parents- 1-2 days post birth

�2.Manipulation and strapping

�3.Serial corrective

      • Casting Forefoot adduction
      • Heel Varus
      • Equinus

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SURGICAL TREATMENT

  • Indication
  • In case of neglected CTEV, relapsed CTEV, recurrent CTEV, resistant CTEV, rigid CTEV.
  • Choice of surgery
      • 1-4 years- soft tissue release
      • 4-11 years- soft tissue release with osteotomy performed according to the deformities
      • >11yrs- salvage procedures like triple arthrodesis�and talectomy

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COMPLICATIONS

Complications with nonoperative treatment

  • Deformity relapse
  • Dynamic supination
      • anterior tibial tendon transfer
  • Rocker bottom deformity
      • dorsiflexion occurs through midfoot instead of through hindfoot.

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Complications with surgical treatment

  • Residual cavus
      • result of insufficient plantar release
  • Pes planus
      • results from overcorrection, often from extensive subtalar capsular release
  • Undercorrection
  • Intoeing gait
      • commonly due to internal tibial torsion
  • Osteonecrosis of talus
      • results from vascular insult to talus resulting in osteonecrosis and collapse
  • Dorsal bunion
      • caused by dorsiflexed first metatarsal

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