CONGENITAL TALIPES EQUINOVARUS (CTEV)

Monday, November 24, 2008


 

DEFINISI


 

Deformitas kongenital pada kaki yang terdiri dari:

  • Aduksi & supinasi forefoot
  • Varus pada tumit
  • Equines
  • Deviasi medial kaki


     

INCIDENCE

  • Incidence :    2 : 1000 live births
  • Bilateral involvement : 50 %
  • Side : right > left
  • Sex :     male : female = 2 : 1


 

ETIOLOGY

GENETIC FACTORS

  • Siblings : 30 fold increase in risk.
  • Monozygotic twins : 32,5 %
  • Family history : + in 24,4 %

    HISTOLOGIC ANOMALIES

  • Increased of type I : II muscle-fiber ratio

    7 : 1 (N 1 : 2)

  • Primary germ plasm defect of bone : talus never develop into normal size & shape
  • Increased collagen synthesis

    VASCULAR ANOMALIES

  • Hypoplasia or absence of anterior tibial artery

    ANOMALOUS MUSCLES

  • Anomalous flexor muscle in the calf
  • Accessory soleus muscle

    INTRAUTERINE FACTORS

  • Interruption in development of normal foot.
  • Oligohydramnion
  • Mechanical theory : deformed posture in utero

    NEUROMUSCULAR THEORY

  • Deformity is sequelae of neuromuscular imbalance
  • PHYSICAL EXAMINATION

    GENERAL

  • Examine entire body for other associated anomalies     orthopaedic check list
  • Associated anomalies : dwarfism, spina bifida, myelomeningocele, arthrogryposis
  • Performed : initially & on evaluation
  • Position : knee in 90 of flexion
  • Inspection : torsional alignment, varus/valgus, overall size & shape of leg, ankle, foot.


 

PHYSICAL EXAMINATION

DEFORMITIES

  • Affected foot is shorter & wider.
  • Ankle        equines
  • Heel        inverted
  • Forefoot    adducted & supinated
  • Atrophy of calf muscles
  • Medial displacement of navicular & calcaneus
  • Talus : head & neck deviated medially
  • Rotation of talocalcaneal joint
  • Bean-shaped at plantar
  • Varus/valgus position of heel
  • Forefoot supination : in relation to midfoot

RADIOLOGY

Difficult, because

  • Difficult to position the foot
  • Ossific nuclei do not represent the true shape
  • Only talus, calcaneus & metatarsal are ossified (< 1 yo)
  • Rotation distorts the measured angle
  • Position : foot in weight-bearing (AP view) ; foot in maximum dorsiflexion (lateral view)

CLASSIFICATION

By etiology

  • Neurologic
  • Teratologic
  • Idiopathic

By severity :

  • mild, moderate, severe.
  • flexible, rigid, resistant.


 

NON OPERATIVE TREATMENT

  • Principle : stretching & manipulation
  • Basis : correction of deformity through production of plastic deformation of shortened ligaments & tendons
  • By serial manipulation & cast immobilization
  • Correction by gentle stretching & place the shortened tissues under tension
  • Technique :
    • Kite & Lovell technique
    • Ponseti technique
    • Longitudinal traction to the foot.
    • Reduction of talonavicular joint
    • Correction of forefoot adduction
    • Correction of heel varus
    • Correction of hindfoot equines

IMMOBILIZATION & INTERVAL

  • Cast : above/below knee, foot is in external rotation
  • Cast change & remanipulation : weekly
  • Duration of correction : 2 – 4 months
  • Post correction : casting for 2 – 4 weeks
  • Then : bracing
  • Kite & Lovell : Phelps splint until 10 yo.
  • Ponseti : Denis Browne bar until 2 –4 yo


 

OPERATIVE TREATMENT

PREOPERATIVE ASSESSMENT

  • To determine residual deformity.
  • If all components (+) : full posteromedial plantar lateral release.
  • Persistent equinus : posterior release.

AGE

  • Two options
    • Early : 3 – 6 mo.
    • Late : 9 – 12 mo.

EARLY

  • Great deal of growth in foot
  • Lot of remodelling potential

LATE

  • Pathoanatomy is more obvious & components are larger        surgery is easier to perform
  • Start to walk        early WB to prevent recurrence of deformity

SIZE OF FOOT (SIMONS) : > 8 cm


 

COMPLICATIONS

  • Recurrence
  • Overcorrection
  • Stiffness
  • Pain


 

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