Talipes equino varus in an adult

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Hi All,

I have had a 22y.o male in today with TEV.
Was diagnosed at birth and reports 3 surgical procedures, the last when he was when he was 10y.o.

His deformity looks barely corrected and he reports pain daily as 8/10. He is unable exercise or work in a physical job.

He was under a orthopead surgeon as a child, who reportedly just told his mother he will be in a wheelchair by adulthood? no other treatment option offered :wacko:

He is unable to get the left heel to contact, right is able to.
He is severely inverted with medial forefoot unable to contact ground.
There is barely any pronatory motion available.

Has anybody had experience in addressing this foot type conservatively?

I was hoping to attempt to address with an EVA accomodating device with medial forefoot wedge, and mild lateral heel skive?

Any pointers are much appreciated:drinks

 

Re: talipes equino varus in adult

Hi

I have seen a few similar patients usually older, usually do not want anymore surgery and deformity is fixed.
Clinically I have found the best treatment is reducing the forefoot pressure, most patients are aware the deformity is fixed and are aware treatment will aim to reduce pain and aid everyday activity but will not reduce deformity.
In patients similar to yours I have had success with heel raises to reduce forefoot pressure and often lesions present to lateral metatarsal phalangeal joints so plantar pad of 6-9mm with 4-5th cut outs, again aiming to reduce pressure to painful areas.
I dont think any lateral skive would be beneficial if there is no ROM available personally.
Just my thoughts

Kevin

 

Re: talipes equino varus in adult

I was thinking lateral skive as I was concerned with increasing the risk of inversion sprains?

 

Re: talipes equino varus in adult

I would agree unless the ankle/subtalar joint is fixed in maximal inversion already.
Or you could bevel a mild lateral skive into a heel raise?

Kevin

 

Re: talipes equino varus in adult

What about getting increased lateral stabiltiy built into his shoewear. Ie well made boots. With will take away the problems from pronating a stiff STJ which may develop compression type problems.

 

Need more info. Is there any range of motion at all of the STJ or ankle joints. When trying to weight bear how much distance is there from heel to the floor. How much distance is there from the 1st met to the floor? If you put a heel lift under the foot that can't get its heel to the floor does the other foot have ankle plantar flexion to accommodate an equal lift?

In the frontal plane is the weight bearing part of the foot medial or lateral or directly underneath the leg. If it is to one side this will put a stress on the knee and you need to know this if you try and accommodate the forefoot varus deformity.

There was some talk of a lateral heel skive. This will help to shift the center of pressure more laterally. The question is whether you need this or not. What hurts when he tries to stand? is it the styloid process that takes all the weight. Is there ankle pain? This could be caused by a varus or valgus stress on the ankle. Is there recruvatum pain at the knee in the uncompensated equinous leg. What are his goals?

It may hurt all over, but you need to figure out what stresses make it worse so that you can decrease those stresses.

For example, if the weight bearing point of the foot is under the leg, adding a varus forefoot wedge, (in an attempt even the weight distribution across the met heads) this may shift the center of pressure under the foot medial to the knee or ankle and that would put a varus stress on either of those structures.

Shoe modifications can be helpful. If there is a varus or valgus stress a flare on the sole can shift the center of pressure. A shoe that goes above the ankle can help on ankle stresses.

Good luck,

Eric