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CONGENITAL TALIPES EQUINO VARUS

Oleh : Hanum Maftukha Ahda

Bagian Ilmu Ortopedi dan Traumatologi


RS Panembahan Senopati Bantul
Profesi Dokter FKIK UMY
DEFINITION
Congenital talipes equinovarus, usually
known as ‘clubfoot’ is a congenital
deformity consisting of hindfoot
equinus, hindfoot varus and forefoot
varus.

The term talipes is derived from a


contraction of Latin words for ankle,
talus,and foot, pes.

Equinus : Foot that is in a position of


plantar flexion at the ankle

Clubfoot Repair Series – Normal Anatomy. ADAM. http://www.adamimages.com


Greene, W. B. (Ed.). (2006). Netter's orthopaedics. Saunders Elsevier.
Anatomy

Forefoot

Midfoot

Hindfoot
Tarsal Bones Anatomy Skeletal System Review - Anatomy And Physiology With Snow At -
Anatomy Organ(2017). http://anatomyorgan.com
Anatomy of Outer Ankle Foot.http://annahamilton.me
EPIDEMIOLOGY

• Most common musculoskeletal birth defect


• Overall incidence 1: 1000
• Male : female ratio approximately 2:1
• Half of cases are bilateral

Kay,Robert.2018.Clubfoot.Orthobullets.Web.
https://www.orthobullets.com/pediatrics/4062/clubfoot-congenital-talipes-equinovarus#
PATHOPHYSIOLOGY

• Muscle contractures contribute to the characteristic


deformity that include CAVE :
• Midfoot Cavus (high arch)
• Forefoot Adductus (tight tibialis posterior)
• Hindfoot Varus (tight tendoachilles, tibialis posterior,
tibialis anterior or inverted)
• Hindfoot Equinus ( plantar flexion - tight
tendoachilles)

Kay,Robert.2018.Clubfoot.Orthobullets.Web.
https://www.orthobullets.com/pediatrics/4062/clubfoot-congenital-talipes-equinovarus
PATHOLOGICAL ANATOMY

Apley,G.A. & Solomon,Luis.2010.Apley’s System of Orthopedics and Fractures :


Ed.9.HodderArnold UK.
TYPES OF CLUBFOOT

• FIXED/RIGID
Flexible or resisten
• POSTURAL OR POSITIONAL CLUBFOOT
The affected foot maybe more flexible with a condition
known as positional clubfoot. Caused by the baby’s
prenatal position in the uterus.

Cahyono, B. C. (2012). Congenital Talipes Equino Varus (CTEV). CDK-191, 39(4), 178-181.
ETIOLOGY

• Idiopathic
• Germ defect
• Otogenic theory : Form of arrested development
• Neurological disorder
• Neural tube defect
• Tighpacking in an overcrowded uterus (postural)
• Association with arthrogryposis

Kay,Robert.2018.Clubfoot.Orthobullets.Web.
Cahyono, B. C. (2012). Congenital Talipes Equino Varus (CTEV). CDK-191, 39(4), 178-181.
CLINICAL FEATURE
• The foot is both turned and twisted inward
• Ankle equinus
• Heel is inverted
• Forefoot adducted and supinated
• High medial arch
• Talus on dorsolateral surface of the foot
• Heel is small and high
• Deep creases appear posteriorly and medially
• Abnormal thin calf
• Always examined for associated disorders such as
congenital hip dislocation and spina bifida.
Apley,G.A. & Solomon,Luis.2010.Apley’s System of Orthopedics and Fractures :
Ed.9.HodderArnold UK.
X-rays

Apley,G.A. & Solomon,Luis.2010.Apley’s System of Orthopedics and Fractures :


Ed.9.HodderArnold UK.
TREATMENT

• OPERATIVE
• NON OPERATIVE
Non operative

• Serial manipulative and casting (possetti’s method)


• French method

Kay,Robert.2018.Clubfoot.Orthobullets.Web.
Cahyono, B. C. (2012). Congenital Talipes Equino Varus (CTEV). CDK-191, 39(4), 178-181.
Ponsetti’s Method

• Order of correction CAVE


• Midfoot cavus
• Forefoot Adductus
• Hindfoot Varus
• Hindfoot Equinus

Goldstein, Rachel & Ryan, Deirdre.2018.Ponseti Technique in The Treatment of


Clubfoot.Orthobullets.Web. https://www.orthobullets.com/
Cavus deformity Correction

• Supinated the pronated foot


• Elevate the first metatarsal
• Place a well molded plaster cast with the forefoot
supinated and mold under the first metatarsal

Goldstein, Rachel & Ryan, Deirdre.2018.Ponseti Technique in The Treatment of


Clubfoot.Orthobullets.Web. https://www.orthobullets.com/
Forefoot Adductus and Hindfoot Varus
Correction
Manipulate the fore foot
• abduct the forefoot against counterpressure on the head of the talus
• make sure the counterpressure is not on the fibula or the calcaneocuboid
joint
• this will correct the metatarsus adductus by reduction of the metatarsals
and the navicular on the head of the talus and the cuboid on the
calcaneus
• with further casting the calcaneus will begin to evert and abduct under
the talus
• the hindfoot will then begin to convert from varus to neutral or valgus
• it is critical to perform abduction with the foot in with the forefoot in
supination and the foot in equinus so that the calcaneus can evert and
abduct underneath the talus

Goldstein, Rachel & Ryan, Deirdre.2018.Ponseti Technique in The Treatment of


Clubfoot.Orthobullets.Web. https://www.orthobullets.com/
Perform serial manipulation and casting
perform weekly manipulations and castings with the
forefoot in supination and with the foot in equinus until
full correction of forefoot adduction and hindfoot varus
is obtained

Goldstein, Rachel & Ryan, Deirdre.2018.Ponseti Technique in The Treatment of


Clubfoot.Orthobullets.Web. https://www.orthobullets.com/
Equinus Correction

• Bringing the heel down and dorsiflexing the foot.


• It may be necessary to perform heel cord tenotomy

Goldstein, Rachel & Ryan, Deirdre.2018.Ponseti Technique in The Treatment of


Clubfoot.Orthobullets.Web. https://www.orthobullets.com/
Post operative treatment
Place the child in a foot abduction orthosis after correction
• This consists of two shoes that are attached to a bar that
maintains the foot in external rotation
• Keep the feet at shoulder width
• the shoes are placed in the degree of external rotation that
was achieved in the last cast
• If this is unilateral correction, the unaffected foot is placed
into 35 degrees of external rotation
• Return to the clinic at intervals of 1 month, 3 months 6
months and 12 months from final cast removal
• Maintain patient in FAO full time x3 months, followed by
nighttime/naptime until 3 years old

Goldstein, Rachel & Ryan, Deirdre.2018.Ponseti Technique in The Treatment of


Clubfoot.Orthobullets.Web. https://www.orthobullets.com/
Manipulation and stapping The lizarov fixation

Apley,G.A. & Solomon,Luis.2010.Apley’s System of Orthopedics and Fractures :


Ed.9.HodderArnold UK.
FRENCH METHOD
• Performed by an experienced physical therapist and
the correction is held with elastic tapping.
Derotation of the calcaneopedal block, correction of
forefoot adduction through massage of the Achilles
tendon and gastrocnemius muscle

Kay,Robert.2018.Clubfoot.Orthobullets.Web.
https://www.orthobullets.com.
FRENCH METHOD

Forefoot Massage Distraction

Derotation Hindfoot valgus


Kay,Robert.2018.Clubfoot.Orthobullets.Web.
https://www.orthobullets.com.
Serial casting Dennis Browne boots
(foot abduction orthosis)

Apley,G.A. & Solomon,Luis.2010.Apley’s System of Orthopedics and Fractures :


Ed.9.HodderArnold UK.
OPERATIVE

• Posteromedial tissue release and tendon lenghtening


• Medial opening or lateral column shortening
osteotomy or cuboidal decancellation
• Triple arthrodesis
• Tallectomy

Kay,Robert.2018.Clubfoot.Orthobullets.Web.
https://www.orthobullets.com.
Clubfoot Repair Series – Normal Anatomy, procedure, Aftercare. ADAM.
http://www.adamimages.com
Complication

Nonoperative OPERATIVE
• Deformity relapse • Residual cavus
• Dynamic supination • Pes planus
• Overcorrection : rocker • Under correction
bottom defect • Intoeing gait
• Osteonecrosis talus
• Dorsal bunion

Kay,Robert.2018.Clubfoot.Orthobullets.Web.
https://www.orthobullets.com.
THANK YOU