Paediatric foot and ankle disorders

18 Nov Paediatric foot and ankle disorders

Congenital talipes equinovarus deformity (CTEV)

• An idiopathic deformity of foot usually presents in Neonatal age.
• Not a packaging disorder
• Forefoot in adduction and supination and hind foot in equines and varus
• Most common birth defect 1:1000 caucasians and 3:1000 Polynesians, High prevalence in Hawaiians
• Male:female ratio 2:1
• 50% bilateral and 80% CTEV is an isolated deformity.

Pathophysiology

• Muscle contracture leads to deformity
  • cavus due to tight FHL, FDL and intrinsics
  • Adductus of forefoot due to tight Tibialis posterior
  • Varus due to tight tendoachilles, tibialis posterior and tibialis anterior
  • Equinus due to tight tendoachilles.
• Bony deformity consists of medial spin of mid foot and forefoot relative to hindfoot
• Genetics
  • familial occurence iin 255 patients
  • recent link to PITX1 gene
• Neurogenic imbalance deformity defect in nerve supply(spina bifida)
• Associated condition
  • Arthrogryposis
  • diastrophic dysplasia
  • tibial hemimelia

Examination and imaging

• Midfoot cavus
• forefoot adduction
• hind foot varus and equinus
• Pirani score maximum score 6
  • hindfoot
    • posterior crease
    • rigid equinus
    • degree of emptiness of heel
  • midfoot
    • severity of medial crease
    • coverage of lateral head of talus
    • curvature of lateral foot
• Radiograph
  • Lateral
    • Talo-calcaneal angle < 25⁰
    • Tibio-calcaneal angle <90⁰
  • AP
    • Talo-calcaneal angle (Kites angle) < 20⁰
  • Dorsiflexion lateral view ( turcos view) shows parallelism between talus and calcaneus.

Treatment

• aim is to have a functional plantigrade foot without need of orthotics
• Ponseti casting
  • 90% success
  • starts at 5th day to 7 day
  • Can be used in children upto 10 years
  • 6 to 8 weeks of casting
  • above knee casting in 90⁰ flexion
  • 90% patients require tendoachilles release
  • Post reduction abduction splint required for 23 hrs per day for 3 months followed by 12 hrs per day until 5 years
  • Denis brown splint or Mitchell boot can be used.
  • ponseti technique is better then kites in short term(Cochrane)
• Surgery
  • Posteromedial soft tissue release in rocker bottom foot due to serial casting or syndromic club foot
• Delayed presentation > 1-2 years of age
  • Posteromedial release
  • calcanea slide osteotomy
  • medial opening and lateral closing osteotomy