2. CONGENITAL TALIPES

CONGENITAL TALIPES















































1

LEARNING OBJECTIVE










1. Senaraikan 2 jenis talipes



2. Menyatakan karektor talipes




3. Terangkan patologi talipes



4. Menyatakan etiologi talipes




5. Nyatakan pengurusan konservatif & surgikal untuk


klien talipes









2

RELEVANT ANATOMY










The joint of the foot :









i. the ankle joint between tibia and talus



ii. the subtalar joint between talus and calcaneum




iii. the talo-navicular joint



iv. the calcaneo-cuboid joint








3

JOINTS OF THE FOOT















































4

RELEVANT ANATOMY












• The foot is divided into hindfoot,midfoot and


forefoot.



• The hindfoot is the part comprising of talo-calcaneal



(subtalar) and calcaneo-cuboid joints (calcaneus


and talus).




• Midfoot comprise of talo-navicular and naviculo-


cuneiform joints (cuboid,navicular and three


cuneiform bones).



5
• The forefoot is fourteen phalanges and five


metatarsal.

6

RELEVANT ANATOMY












The ligaments related to the etiology of clubfoot:



i. Deltoid ligament : the medial collateral ligament


of the ankle. It has a superficial and a deep



component.



ii. Spring ligament(calcaneonavicular) : which is



joins the anterior end of the calcaneum to the


navicular.




iii. Plantar ligaments : extending from the plantar

7
surface of the calcaneum to the foot,giving rise to


the longitudinal arch of the foot.

RELEVANT ANATOMY.












iv. Interosseus ligament : between the talus and


calcaneum,joining their apposing surfaces.









v. Capsular ligamnet : the thickened portions of the


capsular of the talonavicular,Naviculo-cuneiform



and cuneiform-metatarsal joints, termed as the


capsular ligaments are important structure in


pathology of CTEV.



8

9

TYPE OF TALIPES










This slide describe about 2 types










1. CONGENITAL TALIPES EQUINOVARUS



(CTEV)





2. CONGENITAL TALIPES


CALCANEOVALGUS (CTCV)







10

CONGENITAL TALIPES





EQUINOVARUS (CTEV)






























11

CONGENITAL TALIPES


EQUINOVARUS/CLUB FOOT








• The term talipes is derived from talus (Latin =


ankle bone) and pes (Latin = foot).




• Equinovarus is one of several different talipes


deformities; others are talipes calcaneus and


talipes valgus




• 0riginal meaning – A deformity that cause the


patient to walk on the ankle.







12

13

PATHOANATOMY






All the tissues of the foot : the bones,joints,ligaments and muscle


have developmental abnormality.



i. Bones



• Smaller than normal


• Neck of talus is angulated so that the head of talus faces


downwards and medially.



• Calcaneum is small and concave medially.








ii. Joints



• Deformities occur from the malpositioning of different joints 14

PATHOANATOMY










• Equinus deformity occurs primarily at the ankle joint.



• Inversion deformity occurs primarily at the subtalar joint.


The inverted calcaneum takes the whole foot with it so


that the sole faces medially.



• Forefoot adduction deformity occurs at the mid tarsal


joints mainly at talo navicular joint.



• Forefoot cavus deformity is the result of exercise arching


of the foot at mid tarsal joints.




15

PATHOANATOMY









iii. Muscle and Tendons : muscle of the calf underdeveloped. As

the result, the following muscles-tendon units are contracted :



• Posteriorly - Tendoachilles



• Medially - Tibialis posterior


- Flexor digitorum longus



- Flexor hallucis longus


iv. Capsule and Ligaments : Postero medial ligament shortened.










16

PATHOANATOMY












• Posterior - capsule of the ankle joint



- capsule of the subtalar joint




- talo fibular and calcaneo fibular ligament




• Medial - talo navicular ligament



- spring ligament




- deltoid ligament





17

PATHOANATOMY












• Plantar - plantar fascia



- plantar ligaments




• Others - interosseous ligament between talus and


calcaneum


















18

PATHOANATOMY









v. Skin : develops adaptive shortening on the medial side


of sole. Deep crease on the medial side and dimples on

the lateral aspect of the ankle and midfoot.








vi. Secondary changes : occur in the foot if child starts


walking on the deformed feet. Weight bearing


exaggerates the deformity.Callositiesand bursae

develop over the bony prominence on lateral side of


foot.




19

PHATOLOGICAL CHANGES










Deformity primarily affects the hindfoot and midfoot.


• The pathological changes seen include



1. abnormally small calcaneus, talus, and navicular


2. contracted ligaments between the hindfoot and midfoot.

3. plantarflexion deformity of the ankle (talocrural) joint


4. medial subluxation of the talonavicular and calcaneocubid joints


5. inversion and adduction of the calcaneus, navicular, and cuboid.











20

PHATOLOGICAL CHANGES










• Deformity can extent


1. distally to the forefoot plantar flexion (“equinus”)


2. inversion (“varus”) of the metatarsals


3. proximally to the calf, with atrophy, fibrosis and shortening of the

muscle-tendon units of the posteromedial leg muscles seen.




















21

CTEV





















































22

ETIOLOGY










• The exact cause of congenital club foot is



unknown.










• Most infant who have clubfoot have no



identifiable genetic/syndromal/extrinsic



cause.








23

CLINICAL FEATURES









• The deformity usually obvious at birth, the foot is both


turned and twisted inwards so the sole faces

posteromedially.



• The ankle is equinus,the heel is inverted and the forefoot


adducted and supinated but sometimes also has high


medial arch(cavus) and the talus may protrude on the

dorsolateral surface of the foot.



• The heel is usually small and high; the calcaneum may be


felt with great difficulty.




24

CLINICAL FEATURES










• Deep skin crease on the back of the heel and



on the medial side of the sole.










• Bony prominences felt on the lateral side of



the foot, head of talus and lateral malleolus.











• Outer side of the foot is gently convex. There
25

are dimples on the outer aspect of the ankle.

DIAGNOSIS /





INVESTIGATION






























26

DIAGNOSIS









• Clubfoot is easily diagnosed during a physical


examination, but an x-ray of the foot will also be


taken. The condition can often be diagnosed


before birth during an ultrasound examination.








• X-rays are used for documentation of the


deformities and a method for assessment of


correction after treatment.






27

DIAGNOSIS










X-RAYS



• Anteroposterior film is taken with the foot 30° plant


flexed and the tube likewise angled 30° perpendicular.



• Lateral film with the foot held in maximal dorsi-flexion.



• The talo-calcaneal angles in both AP and lateral views,in


a normal foot are more than 35° but in CTEV these are


reduced.








28

MANAGEMENT






























29

TREATMENT










• Principles of treatment :Treatment consist of


correction of the deformity and its maintenance.



• Correction can be achieved by non-operative or



operative methods.



• Maintenance is continue until the foot (and its bone)



grow to reasonable size so that the deformity does


not recurrent.







30

METHODS OF CORRECTION


DEFORMITY







1. Non-operative



i. Manipulation alone


• Treatment should begin early, preferably within a day


or two of birth.


• In newborn, the mother is taught to manipulate the foot

after every feed. The foot is dorsiflexed and everted.



• While manipulating, sufficient pressure should be

applied by the person so as to blanch her own fingers.








31

METHODS OF CORRECTION


DEFORMITY








• This pressure should be maintained for about 5


seconds and this is repeated several times over a


period of roughly 5 minutes.




• Minor deformities are usually corrected by this


method alone.




• For major deformities further treatment by


corrective plaster cast is required.







32

METHODS OF CORRECTION


DEFORMITY








ii. Manipulation and cast



• The foot is held in the corrected position with


plaster cast.




• 1 or 2 weekly changes for 3 months



• There two methods of treatment of clubfoot :



Ponsetti’s and Kite’s method.



• The common and practical is Ponsetti’s method.





33

PONSETTI’S METHODS









The Ponseti technique combines conservative techniques


of manipulation and casting and a small surgery in the form

of an Achilles tenotomy.



1. Correct the cavus first



2. Abduct the forefoot around the head of the talus



3. Correct the equinus with achilles tendon tenotomy after


50° adduction.










34

PONSETTI METHODS

















































35

PONSETTI METHODS












Forefoot adduction equines deformity small heel

































36

PONSETTI METHODS












Application of orthoban

































37

PONSETTI METHODS












Apply above knee cast

































38

39

40

iii.Splintage > To maintenace the correction.



• Denis Brown splint :Is a splint to hold the foot in the


corrected position.




• It is used throughout the day before the child starts


walking.




• Once starts walking, Denis Brown splint is used at


night and CTEV shoes during the day.




• CTEV shoes > These are modified shoes used once 41


a child starts walking.

DENNIS BROWN SPLINT

















































42

CTEV SHOES










43

OPERATIVE METHODS









When to operate?





➢When a plateau has been reached in



non operative treatment/failed



conservative treatment.





➢When the child is of sufficient size to



enable anatomy to be recognized.







44

TREATMENT BY AGE











➢Less than 5 years correction can be achieved by soft


tissue procedures (Posterior-medial release)




➢More than 5 years requires bony reshaping,example


dorso-lateral wedge exercision of the calcaneo cuboid


joint (Evans procedur) or Osteotomy of the calcaneum to



correct varus.



➢More than 10 years lateral wedge Tarsectomy or triple if



the foot is mature (Salvage procedure)
45

CTEV SURGERY


I. POSTERO-MEDIAL RELEASE













































46

II.ILLIZAROV FIXATOR

















































47

iii. Tendon Transfer




The muscle imbalance


may be corrected by

transfering the tibialis

anterior to the outer

side of the foot where

it acts as an everter.





Minimun age for

tendon transfer is 5

years.
















48

IV.WEDGE TARSECTOMY










➢Removing a wedge of bones from the mid-tarsal


area.



➢Once the wedge is removed the foot can be brought



to normal (plantigrade) position.



➢This operation performed for neglected clubfoot



more than 5 years old.











49

PRE-OP MANAGEMENT










1) Psychological preparation



-Explain to the parent regarding the operation




-Show to the parent other patient who have same


diagnosis and had done same operation.



-Inform to the parent, patient able to walk after



successfully surgery.



-Teach parent regarding post op care.





50