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 changes

Calcaneum : varus position

Talus : medial, plantar displacement

Navicular: 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 j

Talocalcaneal joint: dislocated

Tibia: medial torsion (rarely lateral)

Soft tissue contractures

Medial side:

Muscles Ligaments Capsules of

AbHL Deltoid Subtalar

TP Spring Tarsal

FHL Plantar T-MT

Posterior side:

Anterior side:

Muscles Ligaments Capsules of

TP Talofibular Ankle j.

Tendo-achilles

Calcaneo-fibular

subtalar

Muscles ligaments Capsules of

TA inserted abnormally

Sup. Peroneal ret

calcaneo-cuboid

CLINICAL FEATURES

Primary deformities

1. Equinus

2. Varus

3. Cavus

4. Forefoot adduction

5. Internal tibial torsion

Secondary deformities

1. Foot size dec. by 50%2. Medial border concave, lateral-convex3. Forefoot plantarflexed upon hindfoot4. Skin stretched upon dorsum5. Callosities over dorsum6. Stumbling gait7. Hypotrophic Anterior Tibial artery8. Atrophied muscles of ant.and post.

compartments

o Late changes

1. Degeneration of joints

2. Fusion of joints

CLINICAL TESTSDorsiflexion test

Plumbline test

Scratch testMedial scratch testLateral scratch test

RADIOGRAPHYA-P view

1. Talocalcaneal (TC) angle reduced (N=30-35)

2. Talometatarsal angle zero or –ve (N=5-15)

3. Talocalcaneal index (TCI) reduced

TCI=TC angle AP view + Lat view

(N is atleast 40)

Lateral view

1. TC angle reduced (N=25-50)

2. Tibiocalcaneal angle –ve (N=5-15)

MANAGEMENTo First 6 weeks : serial manipulation +

above knee casting weekly

o Upto 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 months

Phelp’s brace – day

Denis Browne splint – night

18m to 4 yrs

Below-knee walking calipers

Follow-up till skeletal maturity

Surgical management

indications:

1. No response to conservative treatment after 6m.

2. Rigid club-foot.

3. Relapse.

4. Recurrent club-foot (muscle imbalance)

5. Resistant club-foot.

Methods:

A) Turco’s procedure-posteromedial release:

Posteriorly:

1. Z-plasty of tendo-achilles - lengthening

2. Post. Capsulotomy - ankle and subtalar j.

3. Release post. talofibular, calc.fibular lig.

Medially

1. Lengthen TP, FHL and FDL muscles.

2. Release talonavicular, spring, superficial part of deltoid lig.

3. Release interosseous talocalcaneal lig.

4. Release naviculocuneiform, 1st metatarso-cuneiform joint capsules.

Plantar side

1. Release plantar fascia

2. Release AbH, FDB

B) Mc-Kay’s 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 clubfoot

in uncorrected and unsuccessful corerctions

uncorectable CTEV

Recurrent club-foot (muscle imbalance)

1. Garceaus method: transfer TA to middle cuneiform bone

2. Modified Garceaus: transfer TA to base of 5th metatarsal

Correction of tibial torsion:

Sell’s criteria- > 15 degree torsion

By derotation osteotomy

To prevent recurrence

External fixators

Ilizarov’s method

2 types

Joshi’s External Stabilisation System (JESS)

Advantages of fixators:

1. semi-invasive, bloodless, without tourniquet

2. Avoids surgical complications and post-op scar

3. Corrects bone and soft tissue defects

4. Less chance of recurrence or relapse

Retention of Correction

1. Denis Browne splint – during night

2. Phelp’s brace – during daytime

3. Below-knee walking calipers

4. CTEV shoes