Upload
lakshmi-narayan-r
View
76
Download
12
Tags:
Embed Size (px)
DESCRIPTION
Congenital Talipes Equinovarus
Citation preview
CONGENITAL TALIPES EQUINOVARUS
Sriram Venkitaraman
INTRODUCTION
Most common congenital foot disorder
Males more commonly affected
Incidence : 1.2 per 1000 live births.
TYPESOsseous: tibia, fibula absent
Muscular : Arthrogryposis congenita or multiple cong. Contractures
Neuropathic: spina bifida etc.
Idiopathic (most common)
PATHOLOGYBone changesCalcaneum : varus positionTalus : medial, plantar displacementNavicular: medial displacement and rotation
Cuboid: medial displacement and articulates with non-articular surface of calcaneum (cuboid sign/locked cuboid)
Metatarsals: medial deviation at T-MT jTalocalcaneal joint: dislocatedTibia: medial torsion (rarely lateral)
Soft tissue contracturesMedial side:
MusclesLigamentsCapsules ofAbHLDeltoidSubtalarTPSpringTarsalFHLPlantarT-MT
Posterior side:
Anterior side:
MusclesLigamentsCapsules ofTPTalofibularAnkle j.Tendo-achillesCalcaneo-fibularsubtalar
MusclesligamentsCapsules ofTA inserted abnormallySup. Peroneal retcalcaneo-cuboid
CLINICAL FEATURES
Primary deformitiesEquinusVarusCavusForefoot adductionInternal tibial torsion
Secondary deformities
Foot size dec. by 50%Medial border concave, lateral-convexForefoot plantarflexed upon hindfootSkin stretched upon dorsumCallosities over dorsumStumbling gaitHypotrophic Anterior Tibial arteryAtrophied muscles of ant.and post. compartments
Late changes
Degeneration of jointsFusion of joints
CLINICAL TESTSDorsiflexion testPlumbline test
Scratch testMedial scratch testLateral scratch test
RADIOGRAPHYA-P viewTalocalcaneal (TC) angle reduced (N=30-35)Talometatarsal angle zero or ve (N=5-15)Talocalcaneal index (TCI) reducedTCI=TC angle AP view + Lat view(N is atleast 40)
Lateral viewTC angle reduced (N=25-50)Tibiocalcaneal angle ve (N=5-15)
MANAGEMENTFirst 6 weeks: serial manipulation + above knee casting weeklyUpto 6 months: repeat fortnightly
Order of correction of deformity
AD AD duction of forefoot corrected
V V arus of heel corrected
E E quinus of hindfoot corrected
RB to prevent R ocker B ottom foot
If correction achieved in 6 months:6 to 18 monthsPhelps brace dayDenis Browne splint night
18m to 4 yrsBelow-knee walking calipers
Follow-up till skeletal maturity
Surgical managementindications:No response to conservative treatment after 6m.Rigid club-foot. Relapse.Recurrent club-foot (muscle imbalance)Resistant club-foot.
Methods:A) Turcos procedure-posteromedial release:
Posteriorly:Z-plasty of tendo-achilles - lengthening
Post. Capsulotomy - ankle and subtalar j.
Release post. talofibular, calc.fibular lig.
MediallyLengthen TP, FHL and FDL muscles.
Release talonavicular, spring, superficial part of deltoid lig.
Release interosseous talocalcaneal lig.
Release naviculocuneiform, 1st metatarso-cuneiform joint capsules.
Plantar sideRelease plantar fascia
Release AbH, FDB
B) Mc-Kays procedure:For severe deformities. Posteromed. and posterolat. release
Surgeries in older children:A) Triple arthrodesis:Lateral closed wedge osteotomy thru subtalar and midtarsal joints.all 3 j. fused (subtalar, TN, CC)B) Talectomy:salvage procedure for severe clubfootin uncorrected and unsuccessful corressctionsuncorrectable CTEV
Recurrent club-foot (muscle imbalance)Garceaus method: transfer TA to middle cuneiform boneModified Garceaus: transfer TA to base of 5th metatarsal
Correction of tibial torsion: Sells criteria- > 15 degree torsionBy derotation osteotomyTo prevent recurrence
External fixators
Ilizarovs method2 types
Joshis External Stabilisation System (JESS)
Advantages of fixators:semi-invasive, bloodless, without tourniquetAvoids surgical complications and post-op scarCorrects bone and soft tissue defectsLess chance of recurrence or relapse
Retention of Correction
Denis Browne splint during nightPhelps brace during daytimeBelow-knee walking calipersCTEV shoes