RECENT ADVANCES IN CTEV Definition — Developmental deformation of the foot characterized by rotational subluxation of the talocalcaneonavicular joint complex with Talus in plantar flexion and Subtalar complex in medial rotation and inversion Etiological factors

Extrinsic (intrauterine) factors Intrinsic (genetic) factors Multifactorial causation — Established by genetic epidemiologic research by Idelberger — 32.5% concordance rate among monozygotic twins as compared to 2.9% among dizygotic twins — genetic heritability of 80% .

Idelberger K. et al 1939; 33:272–276. GENETIC FACTORS — A major gene effect (inherited in recessive manner) with additional polygenes and environmental factors — complex segregation analyses of idiopathic clubfoot populations. (de Andrade M ,1998) — deletion on Chromosome 2 (2q31-33) related to the CASP10 gene. Heck AL et al. J Pediatr Orthop 2005;25:598-602 Extrinsic factors (intrauterine environment)

— Pressure theories: Oligohydramnios Abnormal fetal positioning Unstrctched uterus — Placental insufficiency — Constriction bands — Tox i n s — Te m p e r at u re — Infective pathogens (enteroviruses) — Drugs (including abortifacients) — Electromagnetic radiation Pressure theory

— Conclusively disproved by Wynne-Davies — concordance between dizygotic twins was identical to the non-twin sibling rate — Dizygotic twins “crowded” into a single uterus did not demonstrate a higher concordance with respect to non-twin siblings. Infective pathogens (enteroviruses) — Seasonal variation with significant increase in CTEV incidence was seen in the winter (December–March ) in some studies* — Infective pathogens exhibiting seasonal activity postulated as potential causes — Conflicting evidence –Carney et al (2005)**

* Barker SL. J Pediatr Orthop B 2002; 11:129–133. ** Carney BT. J Pediatr Orthop 2005;25:351-2. Toxins and electromagnetic radiation — Maternal alcohol — High-power radio consumption transmitters (Halmesmaki et al. 1985) — The results are preliminary, — and further work is Maternal smoking required (Alderman et al.) — Paternal smoking Irgens LM, et al.Teratology 1998; (HONEIN M ,2000) 57:34. Drugs: Maternal disorders

— Salicylate use in first — Maternal anaemia trimester — Prenatal exposure to — Maternal hyperemesis barbiturates. — Thyroid disorders

Chung C et al. Hum Hered. 1969;19:321-42 Byron-Scott R, et al. Paediatr Perinat Epidemiol 2005;19:227-37. Neuromuscular theory — Gray et al (1981) : increase in % of type I fibres in the soleus muscle; suggested defective neural influence.

— Recent study**: no evidence of type I fiber grouping

** Milan B MD et al. Journal of Pediatric Orthopedics. 26(1):91-93, January/February 2006. Vascular theory — hypoplasia or absence of the anterior tibial artery in majority of CTEV patients*

— absence of the dorsalis pedis pulse in the parents of children with clubfoot**

*Sodre H et al. J Pediatr Orthop. 1990;10:101-4. **Muir L et al. J Bone Joint Surg Br. 1995;77:114-6. Generalized disorder of development of the limb — Lower limb in unilateral CTEV - Redn in calf and thigh girth - Significant shortening, most prominent at ankle and least at femur

Shimode K, Myagi N, Majima T, Yasuda K, Minami A. J Pediatr Orthop [B] 2005;14:280-4. Conditions associated with CTEV BIOLOGY OF CTEV

THE BASIS OF PONSTEI’S METHOD Pathoanatomy of soft tissues

1. The plantar calcaneonavicular ligament. 2. The tibionavicular ligament 3. The superior, medial and plantar parts of the talonavicular capsule 4. The posterior tibial tendon 5. The master knot of Henry

6. The calcaneofibular ligament 7. The superior peroneal(calcaneofibular) retinaculum 8. The posterior talocalcanel ligament 9. The posterior capsule of the tibiotalarjoint 10. The tendo Achillis 11. The interosseous ligament 12. The long toe flexors Micro architecture

— increase of collagen fibers and cells in the ligaments. — The bundles of collagen fibers display a wavy appearance known as crimp. — crimp allows the ligaments to be stretched. — The crimp reappears a few days later, allowing for further — TA : non-stretchable, thick, stretching tight collagen bundles with few cells Bony abnormalities

— The talus: severe plantar flexion, neck medially and plantarly deflected, and head wedge shaped. — Navicular: severely medially displaced, close to the medial malleolus, and articulates with the medial surface of the head of the talus. — The Calcaneus adducted and inverted. anterior portion of the Calcaneus lies beneath the head of the Talus. — The tarsal bones, which are mostly made of cartilage, are in the most extreme positions of flexion, adduction, and inversion at birth BIOMECHANICAL FACTORS — Tarsal joints are functionally interdependent. The movement of each tarsal bone involves simultaneous shifts in the adjacent bones.

— No single axis of rotation

— Necessiates SIMULTANEOUS correction of adduction, varus and inversion. Clinical features — A standardized examination initially and after each interval of treatment — reference posn, usually the knee in 90° of flexion, chosen. — All deformities assessed in relation to the next most proximal segment — Exmn of the entire child to look for associated anomalies, esp the spine.

— Foot shorter and wider than normal. — Transverse plantar creases or clefts at the midfoot and posterior part of the ankle. — Atrophy of the calf Assessment of equinus

— Equinus assessed with the knee both in extension and in flexion. — equinus with knee extended - The true contractureof the gastro-soleus muscle complex. — The difference between the equinus in knee flex and extn indicates the amount of stiffness in the ankle joint.

— posterior aspect of the calcaneus must be palpated carefully when the equinus is measured — The varus of the heel at rest and in the position of best correction — Posn of forefoot in relation to midfoot — Palpation of the lateral column with the foot in dorsiflexion

— Tibial torsion — heel is in varus but the forefoot is well aligned with the heel. There is no supination of the forefoot on the hindfoot. Awkward gait Congenital vs Acquired

Congenital Acquired History Since birth Appears later

Bilateral In >50% Usually unilateral

Deformity uEquinovarus Equinovarus uForefoot adduction uCavus Congenital groove Present Not present

Heel Smaller Usually maintains shape Calf Cylindrical and tough Normal Classification Systems

Type Type I(Extrinsic) II(Intrinsic) Non Rigid Rigid Foot size Normal Smaller Heel uNormal size uSmall , elevated uCan be brought uCannot be brought down with ease down with ease uMinimal varus uMarked varus Creases More or less normal Deep medial, posterior and lateral creases Reduced creases laterally Telescoping Negative Positive Differential diagnosis — Club foot like appearance in cong. absence or hypoplasia of tibia and in cong. dislocation of ankle — Careful palpation of Anatomical relationship and Radiograph will establish the diagnosis IMAGING Plain radiography Limitations 1. Difficult to position the foot 2. The ossific nuclei do not represent the true shape 3. In the first year of life, only the talus, calcaneus, and metatarsals may be ossified 4. Failure to hold the foot in the position of best correction makes the foot look worse than it is Plain radiograph — The foot should be held in the position of best correction, with weight-bearing, or, if an infant is being examined, with simulated weight-bearing — Focused on the hindfoot (about 30° from the vertical for AP view) — Lat. View: transmalleolar with the fibula overlapping the posterior half of the tibia AP Radiograph

normal CTEV

AP Talo 20 -50 deg <20 deg calcaneal angle Tarsal-1st MT Upto 30 deg Varus angle valgus anglulation cuboid os. medial center w.r.t displacement calcaneal axis AP radiograph: Talo-Calcaneal angle

— Normal foot: 20`-50` — CTEV:<20 deg AP Radiograph: convergence of base of MT Lateral radiograph

normal CTEV

Talo 25 to 50 <25 deg calcaneal deg angle Tarsal-1st hyperflexio MT angle n Lateral view: Talo-Calcaneal angle u Normal foot : 25` u CTEV: <25 ` to 50` Ultrasonogram ANTENATAL DIAGNOSIS — Ideally done at 20 to 24 weeks

— Recent reports*: positive predictive value of 83% with a false positive rate of 17%.

— 26% no Rx reqd; 61% reqd Sx

* Baron E, Mashiach R, Inbar O, et al. J Bone Joint Surg [Br] 2005;87-B:990-3. Research tool

1. Recent study: to describe the morphological changes in a comparative study of treatment methods 2. Used for demonstrating complete healing of TA at 3 wks foll. Percutaneous tenotomy MRI ROLE OF MRI

— NOT used in routine clinical practice

— Important tool in research studies PIRANI’S MRI PROTOCOL — Sagittal images perpendicular to the bimalleolar axis — Oblique axial images perpendicular to the talonavicular joint — Oblique axial images perpendicular to the calcaneocuboid joint — Oblique coronal images perpendicular to the subtalar joint SAGITTAL IMAGES

— Tibiotalar plantarflexion — Inferior talar neck inclination, and — Inferior talonavicular displacement Oblique axial images perpendicular to the talonavicular joint — medial talar neck inclination, — medial talonavicular displacement, — the wedge-shaped head of the talus, and navicular Oblique axial images perpendicular to the calcaneocuboid joint

— the wedge-shaped distal calcaneus — Medial calcaneocuboid displacement Oblique coronal images perpendicular to the subtalar joint

— The inverted and adducted calcaneus — The abnormal facets of the subtalar joint EVALUATION SYSTEMS Pirani’s severity scoring — Six parameters 3 of midfoot and 3 of hindfoot taken into account — Each parameter is given a value as foll:

0 normal

0.5 moderately abnormal

1 severely abnormal Mid foot score

— Curved lateral border [A]

— Medial crease [B]

— Talar head coverage [C] Hind foot score — Posterior crease [D]

— Rigid equinus [E]

— Empty heel [F] Uses of Pirani’s score — Assessment of progress by serial plotting of the score — Predicting need for tenotomy (hs>1& ms<1) — Estimation of probable no. of casts reqd* — very good interobserver reliability and reproducibility** * J. Dyer et al Journal of Bone and Joint Surgery - British Volume, Vol 88-B, Issue 8, 1082-1084P. ** Flynn JM, Donohoe M, Mackenzie WG. J Pediatr Orthop 1999;18:323-7 International Clubfoot Study Group (ICFSG) score. ICFSG

— Introduced by Bensahel et al in 2003 — Found to have good interobserver reliability and reproducibility** — Morhological (12 pts), functional (24 pts) & radiological (12 pts) parameters — Maximum of 60 for most deformed and 0 for normal feet

**Celebi L et al J Pediatr Orthop B. 2006;15:34-36. MORPHOLOGICAL PARAMETERS FUNCTIONAL PARAMETERS RADIOLOGICAL PARAMETERS Treatment Aims of treatment — Strong, painless, plantigrade and supple foot by conservative management — Plantigrade, painless foot that can wear shoes by surgical means if conservative regimen fails PONSETI’S METHOD

— Introduction of Ponseti’s method and its wide spread use over the last decade following the publication of long-term results has been the most significant event in the history of CTEV

— DR. IGNACIO PONSETI Outline of Ponseti regimen — Serial casting of the lower limb using a strictly defined technique and weekly change of casts — Percutaneous tenotomy of the tendo achilles for “hind foot stall” — Once the foot is corrected, an abduction foot orthosis worn full time for 12 weeks, and then at nights and naps, up to the age of four. — Transfer of the tibialis anterior tendon for dynamic supination deformity Cavus correction — Cavus results from pronation of the forefoot in relation to the hindfoot –“ THE PRONATION TWIST “ — Attempting to correct the supination of hindfoot before correction of varus results in an iatrogenic increase in cavus — cavus corrected first by supinating the forefoot to place it in proper alignment with the hindfoot.

Varus, inversion, and adduction correction — varus, inversion, and adduction of the hindfoot are corrected after correction of cavus

— Correction of all three components done simultaneously as the tarsal joints are in a strict mechanical interdependence Stabilise the talus abducting the foot in supination

Correction of equinus

— No direct attempt at equinus correction is made until the heel varus is corrected — The equinus deformity gradually improves with correction of adductus and varus- calcaneus dorsiflexes as it abducts under the talus — Residual equinus- manipulation and casting +/- percutaneous tenotomy Percutaneous TA tenotomy

— Tenotomy of the tendo Achillis is an integral step in the Ponseti technique

— Tenotomy is indicated when HS > 1, MS < 1(Pirani’s hindfoot and midfoot scores resp.), and the head of the talus is covered

— The best sign of sufficient abduction is the ability to palpate the anterior process of the calcaneus as it abducts out from beneath the talus . Percutaneous tenotomy under LA

* Foot held in max dorsiflexion by an assistant * Tenotomy done 1.5 cm above calcaneal insertion * additional 25-30 deg dorsiflexion obtained POST TENOTOMY CAST WITH FOOT IN 60- 70 DEG ABDN Complications of tenotomy

— Healing of ruptured tendon: . Barker et al* used USG studies to demonstrate complete healing of TA BY 3 weeks . Bleeding: Dobbs MB et al ** reported a 2% incidence of serious bleeding following tenotomy

* Barker SL et al. J Bone Joint Surg [Br] 2006;88-B:377-9. ** Dobbs MB et al. J Pediatr Orthop 2004;24:353-7. Bracing protocol

— Applied immediately after the last cast is removed, 3 weeks after tenotomy — The brace consists of open toe high-top straight last shoes attached to a bar 5 to 10 deg

Bracing protocol

— worn full time (day and night) for the first 3 months after the last cast is removed. — After that, for 12 hours at night and 2 to 4 hours in the middle of the day for a total of 14 to16 hours during each 24-hour period. — continued until the child is 3 to 4 years of age. Significance of bracing Haft et al**: noncompliance with bracing protocol – the most common cause of recurrence in children on Ponseti regimen

**Haft, Geoffrey F. MD; Walker, Cameron G. PhD; Crawford,Haemish A. FRACS.J Bone Joint Surg Am, Volume 89- A(3).March 1, 2007.487–493 Atypical clubfoot — 2-3% Feet highly resistant to correction — Deep skin creases, rigid and severe deformities, fibrotic muscles — 60 deg supination in 1st cast. — AK casts with knee in 120 deg flexn — Tenotomy after correction of hyperflexion of metatarsals — Post tenotomy casts changed every5 days Follow up protocol — 2 weeks: to troubleshoot compliance issues.

— 3 months: to graduate to the nights-and- naps protocol.

— every 4 months: until age 3 years to monitor compliance and check for relapses

— every 6 months: until age 4 years.

— every 1 to 2 years: until skeletal maturity Examine the toddler walking

— Look for heel varus Look for supination Treatment of relapse

— Equinus relapse: corrective casting +/- percutaneous tenotomy in child < 2 yrs; TA lengthening in older children — Varus relapse: recasting and restitution of bracing Dynamic supination deformity

— persistent varus and supination during walking — thickening of lateral plantar skin. — Will require anterior tibialis tendon transfer — fixed deformity corrected by casts before transfer. — best performed when the child is between 3 and 5 years of age. — delayed till radiographs show ossification of lateral cuneiform. — No bracing is necessary after the procedure. Results of Ponseti’s method — The key paper by Cooper and Dietz in 1995. — reviewed a group of 45 adults, with 71 clubfeet, who had been managed with the Ponseti method, 30 years after treatment. — The results were compared with NORMAL CONTROLS. — Based on structured examination, radiographs, electrogoniometry and measurements using a pedobarography. — Using the Laaveg and Ponseti score, the results in the normal controls and in those with treated clubfeet were the same. — Radiographs showed that the feet were not completely corrected, but functioned well despite this.

Cooper DM, Dietz FR. J Bone Joint Surg [Am] 1995;77-A:1477-89. Results of Ponseti’s method.. — study from Iowa (2004) described the short-term results of a more recent series of 256 feet. — Correction obtained in 98% with one to seven casts. — 2.5% required extensive corrective surgery. — Percutaneous tenotomy in 86%. — The mean angle of dorsiflexion : 20° (0° to 35°). — Minor cast complications in 8% — Rate of relapse: 10%.

Morcuende JA, Dolan LA, Dietz FR, Ponseti IV. Radical reduction in the rate of extensive correctivesurgery for clubfoot using the Ponseti method. Pediatrics 2004;113:376-80. OUTCOME AFTER CORRECTIVE SURGERY – A STARK CONTRAST

— Laaveg and Ponseti scores: 0% excellent, 33% good, 20% fair and 47% poor results. — significantly reduced scores in physical functioning, role physical, general health, vitality, social functioning and physical components — similar to those with pain in the cervical spine with radiculopathy,Parkinson‘s,haemodialysis, CHF and those awaiting CABG

— Dobbs MB, Nunley R, Schoenecker PL. Long term follow up of patients with clubfeet treated with extensive soft-tissue release. J Bone Joint Surg [Am] 2006;88-A:986- [on 73 feet in 45 patients after a minimum follow-up of 25 years ] Ponseti regime Vs surgical correction — CT at skeletal maturity

— manipulation and serial casting, followed by posteromedial release for the resisting feet vs modified Ponseti regime [open z- lengthening of TA]

— Ponseti group: better correction of cavus, supination and adduction

Ippolito et al. J Bone Joint Surg [Br] 2004;86-B:574-80 Ponseti Vs Kite technique

Ponseti Kite

Mean follow 29 54 up (months) Residual 6% 44% deformity

Need for 6% 57% surgery Segev E, Keret D, Lokiec F, et al. Early experience with the Ponseti method for the treatment of congenital idiopathic clubfoot. Isr Med Assoc J 2005;7:307-10. Modifications of Ponseti’s method ACCELERATED PONSETI PROTOCOL

— Morcuende et al , (2005) 7 day Vs 5 day interval — Average time to tenotomy: 16 days in 5 day group and 24 days in 7 day group

Morcuende JA, Abbasi D, Dolan LA, Ponseti IV. Results of an accelerated Ponseti protocol for clubfoot. J Pediatr Orthop 2005;25:623-6 Botulinum toxin injection into the gastrocsoleus — Alvarez et al (2005)*: alternative to Achilles tenotomy producing satisfactory results with less skin scarring and deep tissue fibrosis — prospective RCT(Cummings et al,2005)**:NO significant difference between injections of a placebo or Botulinum toxin.

* Alvarez CM, Tredwell SJ, Keenan SP, et al. J Pediatr Orthop 2005;25:229-35. ** Cummings RJ, Shanks DE. POSNA Annual Meeting, Paramedical staff-delivered Ponseti service

— Good results can be achieved by trained physiotherapists and orthopedic clinical officers — enables many families in rural and remote areas to receive treatment which would otherwise have been inaccessible and unaffordable.

Shack N, Eastwood DM.. J Bone Joint Surg [Br] 2006;88-B:1085-9. Tindall AJ et al.J Pediatr Orthop 2005;25:627 Application in neglected club foot — Lourenco et al,2007: retrospective study on 17 children (24 feet) presenting after walking age (mean age 3.9 years) — Correction in 66.67% with ponseti’s method alone.

— A. F. Lourenço, MD et al. Journal of Bone and Joint Surgery - British Volume,2007. Vol 89-B, Issue 3, 378-381. The French method — Bensahel/Dimeglio regime — daily manipulations by a skilled physiotherapist and temporary immobilisation with elastic and non-elastic adhesive taping — mobilisation during the hours of sleep with CPM machine — Successful in 51% of cases ( of which 9% req TA tenotomy) ; 49% Reqd extensive soft tissue release -29% post release and 20% comprehensive posteromedial release**.

** Richards BS, Johnston CE, Wilson H. Nonoperative clubfoot treatment using the French physical therapy method. J Pediatr Orthop 2005;25:98-102. Custom AFO’s

— Manipulation and appln of adjustable hinged orthosis — Dyanmic splinting — Correction reported in 76% of cases with mild to severe CTEV ** **Adnan A. Faraj et al. Foot and Ankle Surgery.Volume 10, Issue 2, 2004, Pages 57-58 Dennis Browne splint — The child’s ‘physiological motions’ are used to correct the deformity — Application of corrective shoes attached to a bar allowing progressive external rotation of the foot — Constant kicking by the infant stretches the contracted tissues correcting the deformity

. Surgical management of CTEV INDICATIONS

— RESISTANT CTEV

— RELAPSE AND RESIDUAL DEFORMITY ESP. AFTER PREVIOUS SURGERY

— NEGLECTED CLUB FOOT RELAPSED VS NEGLECTED CTEV Relapsed CTEV Neglected CTEV — Initial correction done and — Deformity severe and susequent deformity less worsens as child starts severe walking — Post surgical: extensive — Lateral skin callosities and scarring and stiff foot fissures- prone to infection Surgical correction

— 2-4 years : — Soft tissue release — 4 – 11 years : — Soft tissue release with — Osteotomy performed according to the deformities — >11 years :Salvage procedures: — Triple arthrodesis — Talectomy (astragalectomy) SOFT TISSUE RELEASE EXTENT OF RELEASE

— "À LA CARTE" approach [Bensahel] -Full posteromedial plantar lateral release only if All components of deformity present -postr release: persistent isolated equinus — Turco’s ‘one size fits all’ approach TIMING OF SURGERY

— 3-6 months: high remodelling potential in 1st yr of life

— 9-12 months: pathoanatomy clearer and surgery easier to perform

— Simons: size of foot >8 cm. Incisions

— TURCO’S APPROACH — hockey-stick posteromedial type of incision — Crosses the skin creases on the medial side of the foot and ankle. — more difficult to reach the posterolateral structures, origin of plantar fascia Cincinnati approach — Circumferential incision

— problems with the skin edges.

— limited exposure of the Achilles tendon. Caroll’s two incision technique

— medial incision - straight oblique incision from the first metatarsal, across the medial malleolus to the Achilles tendon — A second short, straight lateral incision made along the lateral subtalar joint antr to distal fibula Medial Plantar Release — posterior and medial subtalar joint capsule (leaving the interosseous ligaments intact), — talonavicular joint capsulotomy (including the spring ligament and bifurcate Y ligament), — medial calcaneocuboid joint capsulotomy, — knot of Henry, — the abductor hallucis, — lengthening of posterior tibial tendon — The plantar fascia, if cavus is present Structures preserved

— The dorsal structures- tibialis anterior and extensor tendons,

— neurovascular bundle,

— the deep deltoid ligament Posterior release — release of the posterior capsule of the ankle and subtalar joint

— open Achilles tendon lengthening.

— The posterior talofibular ligament Lateral release

— lateral subtalar joint capsule, — peroneal tendon sheath, and — calcaneofibular ligament Talonavicular joint fixn

— The talonavicular joint, often with the subtalar joint, is routinely pinned with a K-wire Soft tissue release — Follow up : — Wound inspection done under sedation at 1 week — Foot held in neutral, plantigrade position and cast applied – above knee — Cast kept for 4 – 6 weeks — Cast removed along with any K wires, if applied during surgery for stabilisation — AFO given for 6 months AFO Osteotomies — Soft tissue release alone may not fully correct the deformity because of secondary bony deformity. — The combination of this soft tissue release with midfoot osteotomy is usually required in children between approximately 4 and 12 years of age Correction of Adductus — bony lateral column is longer than the medial column, — relative lengthening of the lateral portion of the anterior process of the calcaneus — obliquity of the calcaneocuboid joint — Shortening through the distal calcaneus to make the calcaneocuboid joint transverse. Litchblau procedure — excision of the anterior process of calcaneus — Calcaneocuboid Pseudoarthrosis — Stiffness minimized — Preferred in younger children Dilwyn Evans Osteotomy — calcaneocuboid wedge resection — Arthrodesis of the joint — Reduced risk of relapse — Stiffness at subtalar and midfoot joints — Preferred in older children TRANS-MIDTARSAL OSTEOTOMY

— Köse et al., in 1999, described trans-midtarsal osteotomy for>6yr olds — opening-wedge osteotomy of the medial cuneiform and — dorsal, truncated wedge osteotomies of the middle and lateral cuneiforms — Better correction of rotational and cavus deformities Correction of Equinus — adequacy of release of the lateral tether — lateral column shortening — excision of a portion of the head of the talus or naviculectomy. — final resort is to consider adding a distal tibial dorsiflexion osteotomy. Correction of Calcaneal Varus — Calcaneal varus corrects as the foot abducts after medial soft tissue release. — Persistent calcaneal varus: a lateral slide osteotomy of the calcaneus is performed — Alternative: Dwyer lateral closing wedge osteotomy Correction of CAVUS

— Steindler’s release of plantar fascia — Japas ’V’ osteotomy — Patients >6 years — Rigid cavus — Allows midfoot correction without foot shortening — Akron midtarsal Osteotomy : — Correction at midfoot — A dome shaped osteotomy for dorsoplantar and varus / valgus control Salvage procedures TRIPLE ARTHRODESIS — Salvage procedure for pain after previous surgical correction. — Correction of large degrees of deformity in neglected clubfeet. — Not performed before advanced skeletal maturity, at age 10 to 12.

TRIPLE ARTHRODESIS

— Modification of the classic lambrinudi triple arthrodeses — Resection through the talus should be minimized because of its tenuous blood supply and — Most of the correction made through the calcaneus. — Recent study in Uganda: 92% patients happy with the procedure TRIPLE ARTHRODESIS TWO STAGE : SINGLE STAGE — extensive posteromedial ARTHRODESIS: release + triple arthrodesis — less time consuming — minimizes bone rescection — reduced risk of AVN — risk of AVN talus Penny, John Norgrove 2005.Uganda Ilizarov in CTEV Ilizarov

1) Correction slow enough to protect soft tissues; 2) correction at the focus of deformity, 3) simultaneous three-dimensional, multilevel correction; 4) deformity correction without shortening the foot; Ilizarov — Rings are fixed to the tibia connected to half rings for the calcaneus and the forefoot. — Asymmetric distraction corrects the various deformities — bony deformity not severe,(<8 yr): unconstrained frame — Severe deformities,(>8 yrs): distraction osteogenesis through osteotomies using constrained frame with hinges The construct Correction of adductus Correction of Equinus Results with Ilizarov — good to excellent results reported by various surgeons( Grill et al, Huerta et al, Bradish et al, Heymann et al, Hosny et al) over the last 15 years

— Recent long term follow-up study** by Hari et al (2007):74% good/excellent result **Prem: J. pediatr. orthop., Volume 27(2).March 2007.220-224 JOSHI EXTERNAL STABILISATION SYSTEM

DR.B.B. JOSHI, MUMBAI. JESS — 2 to 4 transfixing wires in prox tibia — Metatarsal segt: Transfixing wire thro’ I &V MT; Medial half pin thro’I, II, III MT; Lat half pin thro’ IV, V MT — 2 transfixing and 1 axial wire thro calcaneum JESS — Fractional, differential distraction used to Sequentially correct deformities. — Distraction continued until approximately 20 degrees of dorsiflexion and overcorrection of the forefoot deformities was achieved — maintained in this overcorrected position for twice as long as the distraction phase by casts/braces Results with JESS — Good or excellent results reported by Joshi in 84% of his patients — Recommended in all who have not responded to serial plaster casting methods. — Similar good results have been reported by other authors** **Suresh et al,2003. Journal of Orthopaedic Surgery 2003: 11(2): 194–201 Advantages over Ilizarov — The wires are not tensioned — stability depends on the placement of the wires, the use of half pins and pre-tensioning. — Hinges are not used in this method. Thus the corrective forces are not directed along a single axis, instead, the soft tissue envelope in conjunction with the shape of the articulating surfaces guide the correction. — frame is less bulky, is less expensive, and more simple to apply Complications of surgery — Wound infection — Skin dehiscence — Severe scarring — Stiff joints — Over/under correction — Dislocation of the navicular — Flattening and breaking of the talar head — AVN of the talus — Weakness of the plantar flexors of the ankle Skin dehiscence — Cincinnati incision, neglected clubfeet — left in partly corrected posn in post op cast & remanipulation done at 1 to 2 weeks . — Local rotation flap from the dorsum of the foot (Mittal,1987) — Posterior V-Y advancement flap. Rotation flap — Flap taken superficial to venous plexus — Large proximal base ensures adequate blood supply conclusion — Proper understanding of the pathology and kinematics of clubfoot, meticulous application of therapeutic methods, laying stress on parental education to ensure compliance and resorting to surgery only as the last resort, and is essential to successful therapy of this complex condition