Club foot

Club Foot (CTEV)

Overview

Outline

• Clubfoot
  • Types
  • Causes
  • Management
  • Case example

Mamoun Kremli

Nomenclature

• Clubfoot: foot shaped like a club
• Talipes: Latin: talus (ankle) + Pes: (foot)
• Equino: Equine: horse
  • Ankle plantar flexed like foot of horse
• Varus: towards midline
• Congenital Talipes Equinovarus (CTEV):
  • Ankle and foot directed down and inwards

Clinical Types

There are two main variations of clubfoot:

• Talipes Equinovarus: most common
  • The foot and ankle turn downward (equinus), and inward (varus)

&

• Talipes Calcaneovalgus:
  • The foot and ankle turn upward (calcaneous), and outward (valgus)
  • Associated with DDH

&

Types of Clubfeet

• Idiopathic (Unknown Etiology):

  • Positional
  • Congenital Talipes Equino-Varus CTEV

• Acquired, Secondary to:

  • CNS Disease: Spina bifida, Poliomyelitis
  • Arthrogryposis
  • Absent Bone: fibula / tibia

http://www.clubfeet.net/

Types of CTEV

• Positional:

  • Held in a deformed position in utero
  • Flexible on examination (correctable)
  • Needs manipulation – corrects spontaneously

• Congenital: (CTEV)

  • Multifactorial inheritance, environmental
  • Fixed (Rigid) deformity, not flexible (not easily correctable)
  • Needs treatment

Epidemiology

• Congenital Talipes Equino Varus typically occurs in an otherwise normal child
• Incidence: 1/1000 live birth
• Positive family history: 30X more frequent in offspring
• Males: 65% of cases
• Bilateral: 30–40%

Pathological Features

CTEV DeformitiesZ

• Hindfoot:

  • Equinus: plantar flexion of ankle
  • Varus: medially tilted subtalar joint
  • Empty heel pad

• Forefoot:

  • Adduction of midtarsal joint
    • Transverse medial crease
  • Pronation
  • Cavus

• Wasted calf

Management

The Ponseti Technique

• Serial manipulation and change of cast

  • (every week) – for 4-6 weeks

• Followed by tenotomy of Achilles Tendon

  • (teno): tendon, (otomy): cutting

Serial Casting Process

• Serial manipulation and change of cast

Week 1 → Week 2 → Week 3 → Week 4 → Week 5

Ponseti Technique Stages

• Serial manipulation and change of cast
• Tenotomy of Achilles tendon

Clubfoot Treatment Over 4-6 Weeks

Stage 1 → Stage 2 → Stage 3 → Stage 4 → Stage 5

Tenotomy of Achilles Tendon

• Complete cut of the Achilles Tendon
• With knife, under anesthesia

Before tenotomy → Local anesthesia → Tenotomy → Full correction

Ponseti Method Outcomes

After casting Still tight Achilles Tendon Can not dorsiflex ankle

After Tenotomy Tightness released Can dorsiflex ankle

Post-Treatment Management

• After tenotomy of Achilles tendon, cast is applied again for 3 weeks
• Followed by special splint
  • (Dennis-Brown shoes)
    • Initially most of the time
    • Later at night (for 4 years)

• Long-term follow-up is needed, with possible need for splints or later surgery

Surgical Management

• In severe or resistant cases, surgery is performed
  • Lengthening of tight tendons
  • Correcting joints, and bone

Clinical Cases

Mamoun Kremli

Summary

• Definition and Types of club feet
• Treatment of CTEV
  • Positional: manipulation
  • CTEV: serial casting & tenotomy

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