club foot

1. CTEV-ETIOLOGY ,PATHOANATOMY
,CLASSIFICATION ,IMAGING
Dr.Sushil Pokhrel (ms ortho resident

2. Congenital club foot
-Rigid deformity present at birth characterized
by ankle equinus , hind foot varus ,midfoot
cavus, forefoot adduction,usually calf muscle
underdevelopment

3. History of club foot
• Club foot – was first described in Egyptian
tomb painting
• First written description of club foot given by
Hippocrates in 400 B.C.

4. Epidemology
- 1-2 per 1000 birth
- Male> female
- 50 % cases are bilateral
- In unilateral cases –right>left foot
- Single parent affected have 3-4% while both
affected parent 30 % chance of club foot
- Certain ethnicities such as the Hawaiians and
Maori more affected and lowest in Chinese

5. Etiology
Etiology of idiopathic clubfoot is multifactorial
and modulated significantly by developmental
aberrations early in limb bud development
Primary germplasm defect :
- defect at germplasm cartilaginous talar
anlage produces the dysmorphic neck and
navicular subluxation < 7 weeks

6. Developmental delay :Bohm et al.
-arrest in fetal foot development
-characteristic dysmorphic talar head and the
medial dislocation of the navicular have never
been observed at any stage of normal fetal
development

7. Intra-uterine enviromental causes :
smoking increase 1.5x for light smoker
3.9 x heavy smoker
more in who smoked in first trimester
- many factors have been associated :

8. Environmental
factor
•Early amniocentesis or CVS
•Amniotic fluid leakage and
oligohydramnios
•Cigratte smoking
•Seasonal viral infections
•Elevated maternal homocysteine
•Methylenetetrahydrofolate
reductase (MTHFR) gene
polymorphisms

9. Conclusions: Smoking, maternal obesity, family history, amniocentesis, and some
selective serotonin reuptake inhibitor exposures are the most clinically relevant
exposures associated with increased odds of clubfoot, with family history representing
the greatest risk

10. Neuromuscular unit abnormalitis :
-alter musculotendinous position and pressure on
tarsal bone relative to each other
-congenital fiber type disproportion with atrophy of type
I fibers found in both peroneal and triceps surae
histopathologic specimens
- supported by fact that increase incidance : peripheral
neuropathy ,myelopathic abnormalitis ,central cerebral
lesion

11. Heredity :
- autosomal dominant with incomplete
penetrance
-first degree relative has 20-30 times higher
incidance than in normal popupation
-in twin study ,monozygotic twins has
concordance rate of 33% as compared to
dizygotic twin has 3%

12. Gene and molecular abnormalitis:
- missense mutation in number of gene have
been idetified :
N-acetylation genes, NAT1 and NAT2
CYP1A1,
HOXA, HOXD, and IGFBP3,
CAND2 and WNT7a,
TBX4,caspases genes
Transcription factor PITX1

13. Retractin fibrosis
Zimny et .-identified myofibroblast like cells
in medial ligamentous complex and tibialis
posterior tendon insertion
- myofibroblast like cells seemed to create
disorder of ligaments resembling fibromatosis
-Ippolito and Ponseti, who identified an increase in
collagen fibers and fibroblastic cells in the
ligaments and tendons of a clubfoot.

14. Syndromic
•Arthrogryposis
•Diastrophic dysplasia
•Streeter dysplasia (constriction
band syndrome)
•Freeman-Sheldon syndrome
•Möbius syndrome
•Chromosomal deletion
•Autosomal trisomy
•Smith-Lemli-Opitz syndrome
•Larsen syndrome
•TARP syndrome
•Chondrodysplasia punctata
•Myotonic dystrophy
•Spinal muscular atrophy
•Neural tube defect

15. Pathoanatomy
• Scarpa in 1803 reported medial and plantar
displacement of the navicular, cuboid, and
calcaneus around talus
• Scarpa, Adams in 1866,and Elmslie in 1920,
emphasized the midtarsal subluxation -
navicular and cuboid displaced medially,with
plantar and medial rotation of the calcaneus

16. -Talonavicular subluxation and dislocation of
the head of the talus out of“socket”
(acetabulum pedis)
• Finally Ponseti, in defining clubfoot, has
emphasized the cavus component which is
due to pronation of forefoot in relation to
hindfoot

17. Talus (astragalus)
1.Head and neck deviated medially
and plantarward
1
2
2.Short neck , small body,head –
neck to body angle is decreased
3.Body of talus at superior
articular surface at ankle is
obliquely positioned into
equinous
3
Anterior part of talus displaced
from ankle joint onto dorsum

18. 4.Radiographic appearance of the
ossification center of the talus is
delayed
6
6 Articular surface of head
articulates with medially displaced
navicular
Anterior and medial facets of the
subtalar joint are absent,fused, or
significantly misshapen
4
Herzenberg and colleagues, commented that the body of the
talus appeared to be externally rotated within the mortise
Talus is inverted ,plantarflex and adducted

19. Os calcis(calcaneus)
Altered position, small
Planterflexed into equinus,
also inverted to varus
Anterior articular surface is
medially deviated and
deformed
Calcaneus slips beneath the
head and neck of the talus
anterior to the ankle joint
Sustentaculum tali is
usually underdeveloped

20. Cuboid
-cuboid is displaced
medially on the
anterior end of the
calcaneus
Navicular
-Positioned medially and plantarward
-Medial tuberosity of the navicular
may be hypertrophied
Cueiforms and MT
-abnormal positioning is due to altered
position of navicular ,os calcis and talus

22. First MTP Joint
Metatarsal I is more in Plantar flexion than the
rest of the Metatarsals.

23. Resisting Talocalcaneal joint realignment
Posterior talocalcaneal
Peroneal tendon seath
Calcaneofibular
Superior peroneal retinaculum

24. Resisting realignment of TN joint
- posterior tibial tendon
-deltoid ligament (tibial navicular)
-calcaneonavicular ligament (spring ligament)
-Talonavicular capsule
- dorsal talonavicular ligament
-bifurcated (Y) ligament
-inferior extensor retinaculum,
- cubonavicular oblique ligament.
Bifurcate ligament

25. IR of the CalcaneoCuboid joint
• causes contracture of
-bifurcated (Y) ligament
- long plantar ligament
-plantar calcaneocuboid ligament
-navicular cuboid ligament
-inferior extensor retinaculum
-dorsal calcaneocuboid ligament
-cubonavicular ligament
Bifurcate ligament
Due to contarcture

26. Kinematic coupling
• Subtalar joint axis is mobile oblique axis
• Movements of one tarsal bone affects
movements of other
• Calcaneal adduction,inversion and flexon
occur together
• Calcaneal abduction ,eversion and extension
occur together
• Fore foot abduction causes calcaneal
abduction around talus

27. Calcaneo-Pedis Block
The entire forefoot moves with the calcaneus
around talus
 Abduction pressure on forefoot,
causes movement of calcaneum
into abduction
 As abduction is coupled with
eversion and extension of
calcanaeum :hind foot deformity correct

29. Clinical features

31. Types of club foot
1.Idiopathic club foot
isolated , unilateral or bilateral deformity
no underlying neuromuscular disorder
2.Newborn neuromuscular club foot
congenital myelopathy ,myelo-meningocele
3.Club foot with arthrogryposis
at least one other joint contracture should be present
4.Syndromal club foot
Mutliple connective tissue abnormalities eg diastrophic
dysplasia

32. Carroll et al . 2012 based on etiology
classified
• Postural
bening ,resolves with streching ,full pasive ROM
• Idiopathic
congenital club foot with variable severity
• Neurogenic –actually neuromuscular
associated with underlying neurologic or muscular disorder
• Syndromal
Skeletal dysplasia and connective tissue disorder tend to be
very rigid

33. Classification of clubfoot
based on management (ponsetti)
• Typical clubfoot:
1-Positional clubfoot
2-Delayed treated clubfoot
3-Recurrent typical clubfoot
4-Alternatively treated typical clubfoot

34. • Atypical clubfoot
1-Rigid or resistant atypical clubfoot:
stiff, short, chubby, with a deep crease in the sole of the foot and behind the ankle, and
have shortening of the first metatarsal with hyperextension of the metatarsal
phalangeal joint
2-Syndromic clubfoot
3-Neurogenic club foot
4-Acquired clubfoot
5-Teratologic clubfoot
-congenital tarsal synchondrosis

36. Differential diagnosis

37. Clinical index of severity
Harrold and walker (1983)
Grade I
foot could held at or beyond neutral position
Garde II
foot couldn’t be manually reduced to neutral but fixed
equinous or angle of varus was 20 or less
Garde III
fixed deformity more than 20 equinous or varus

38. Pirani score
• Consists of
- Midfoot contracture score (MFCS)-max 3
- Hindfoot contracture score (HFCS)-max 3
• Documentation on
- initial visit
- changing cast
- seperately for each foot
• Prognostic value , severity and monitor progress
of treatment

39. Mid foot contracture score(MFCS)

40. Hind foot contracture score(HFCS)

44. Conclusions: Higher Pirani scores were associated with late relapses, but HFCS is a
stronger predictor of potential late relapse. Close follow-up is advised for patients at risk.

45. Dimeglio’s Adduction

46. Muscle condition

47. Ponseti and Smoley Classification
Ankle
Dorsiflexion
(degrees)
Heel
Varus(Degrees)
Adduction of
fore part of
foot (degrees)
Tibial
Torsion(degrees)
Result
>10 0 0-10 0 Good
0-10 0-10 10-20 Moderate Acceptable
0 >10 >20 Severe Poor

48. Catterall’s system
Tendon contracture criteria

49. Imaging
• X ray : atypical, global neurologic or genetic,
resistant to non operative treatments
• In non ambulatory : simulated weight bearing
AP and stress dorsiflexion lateral both feet
• For older standing AP and Lateral
• Talocalcaneal angle decreases on both views
with increase in severity, on lateral parallel

50. • -
Fig: talocalcaneal angle on AP
Normal-30-55°Club foot
Fig talocalcaneal angle in stress dorsiflexon lateral
Club foot Normal-20-50°

51. • Tibiocalcaneal
angle : negative
Normal:10-40°
Talus–first metatarsal
angle : negative
Normal-5-15

52. Ultrasound
Prenatal assesment
-upto 86 %
between 20-23 weeks
Post natal assesment
-assessing medial malleolar navicular dsiatance
and calcaneo cuboid relationship
- used for post tenotomy tendon healing

53. Approch

55. Summary
• Club foot has equinus,varus,cavus and adduction deformity
• Mutiple etiology ,retraction fibrosis (crimp) latest accepetd theory
• Rotatory subluxation of TCN joint complex with talus in plantar flexon and
at subtalar complex in medial rotataion and inversion
• Calnaneal abduction is kinameticaly coupled with eversion
• Abduction of forefoot is associated with abduction and eversion of hind
foot around talus (calacneo pedal block)
• Typical – classic club foot can be unilateral or b/l otherwise normal infant
• Atypical club foot –associated with other problem.
• Rigid club foot have stiff, short ,chubby ,deep posterior and medial crease
with extenion of 1st MTP joint and small 1st MT in otherwise normal infant
• Pirani score consists of HFCS and MFCS ,higher score associated with
increase no.cast and high tenotomy rate

56. Referances
• Pediatric orthopedic deformities vol 2 springer
• Cambell 13 e
• Tachdjian pediatric orthopaedics 4e
• Ponseti method manual 3e
• Related articles ,internet