CONGENITAL TALIPES EQUINOVARUS (CTEV)
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
Comments