Wednesday, March 13, 2013

Congenital Talipes Equinovarus(Clubfoot)



The term talipes is derived from of the Latin words for ankle(talus) & foot (pes).

The term refers to the gait of severely affected
patients, who walked on their ankles.
  • Clubfoot  is a severe fixed deformity of the foot characterized by fixed ankle plantar flexion (equinus), inversion of the subtalar (talocalcaneal) joint (varus), and medial subluxation of the talonavicular and calcaneocuboid joints (adductus)
Etiopathogenesis 
  • Idiopathic majority , some  secondary to muscle pathology 
  • All the tissues of the foot i.e. bone, joint,ligaments and muscles have developmental abnormality
  • Bone: smaller in size, neck of talus is angulated so that head of talus is directed downwards  and medially. Calcaneum is small and concave  medially
  • Joints: equinus deformity  occurs primarily at ankle joint. Inversion deformity occur  in subtalar joint. Adduction occurs in midtarsal joints
  • Muscles and tendons: muscles of calf are underdeveloped.
  • Capsule and ligament: all the ligamentous structure on the postero-medial side of the foot shortened
  • Skin shows adaptive change
  • Callosities and bursae over  bony prominences on the lateral side
Congenital Talipes Equinovarus
  • Bilateral in 60%. 
  • General examination to rule out other deformities
  • Normally, the foot of newborn can be dorsiflexed until the dorsum touches the anterior aspect of shin of tibia
  • Components of the deformity:
  • Equinus.
  • Varus.
  • Adduction.
X-ray
  • AP view and a lateral view in a position of maximum dorsiflexion. 
  • Kite angle is the angle subtended by the long axes of the calcaneus and the talus on the AP view. 
  • This angle is normally between 20 and 40 degrees. 
  • In the clubfoot, this angle is less than 20 degrees with relative parallel alignment of the talus and calcaneus. 
  • The relationship of the talus and calcaneus should also be assessed on the lateral view. Again, in the clubfoot, this shows relative parallel alignment compared with the normal foot



Treatment 
Nonoperative :
  • Best results are achieved with early manipulation.
  • (as early as first week of life) and serial casting (changed every 2 week).  Adduction deformity is corrected first followed by inversion and then equinus deformity. If this sequence is not followed rocker bottom foot may result 



Wearing Of Dennis-Browne(DB) splints for maintenance.


Good results may be achieved if previous technique is applied.


Operative Technique :
  • In less than 3 years only soft tissue release may be sufficient while older children require  bony operations.
  • Indicated for manipulation failure cases, recurrence and neglected cases
  • Posteromedial soft tissue release (PMSTR)
  • Tendon transfer
  • Dwyer’s osteotomy- open wedge osteotomy  of calcaneus
  • Dilwyn-Evan’s procedure : PMSTR with calcaneo-cuboid fusion
  • Wedge tarsectomy
  • Triple arthrodesis

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