CTEV

CONGENITAL TALIPES
EQUINOVARUS

FARHAT
 HISTORY

 commonly known as clubfoot

 has been a recognized deformity since the
time of the ancient Egyptians and was
described independently by Hippocrates
and the Aztecs.
 the underlying deformity consists of
 a hind foot in equinus (plantar-flexed)
 varus (inverted).
 a cavus (abnormally high arch)
 adductus component to the midfoot
 Classification

 Postural
Postural or positional talipes can be passively
fully corrected or even overcorrected
 Fixed
[Link] – correctable with non-operative
treatment
[Link] - surgery
 Epidemiology
 incidence of CTEV varies widely with race and
geography.
 In Japan, the disease affects approximately 0.5:1,000
live births;
 in Caucasians, the incidence is 1.2:1,000 live births;
 in natives of the South Pacific, the incidence is nearly
7:1,000 live births.
 All populations show a consistent 2:1 male
predominance, with bilateral disease affecting
approximately 50%.
 Aetiology

 The true aetiology of congenital club foot

is unknown.
 Most infants who have clubfoot have no
identifiable genetic/syndromal/ extrinsic
cause
 Associations:
 Extrinsic causes:
 Teratogenic agents eg sodium aminopterin
 Oligohydramnios
 Congenital constriction bands/rings
 Genetic causes:
 Mendelian inheritance: eg Diastrophic dwarfism-
 Cytogenetic abnormalities- CTEV can be seen in
syndromes involving chromosomal deletion.
 Multifactorial inheritance
 Pathogenesis

 its cause remains unclear, and

innumerable theories have attempted to
explain its origins.
 Theories of pathogenesis
 Arrest of foetal development in the fibular stage
( Bohm JBJS 11: 229, 1929)
 Defective cartilaginous anlage of the talus ( Irani
and Sherman JBJS 45A: 45, 1963)
 Neurogenic factor- histochemical abnormalities
have been found in posteromedial and peroneal
muscle groups of
 CTEV thought due to innervation changes in
intrauterine life ( Isaacs etal JBJS 59B:
465,1977)
 Theories of pathogenesis
Cont.
 Neurological imbalance deformity - The
incidence of varus and equino-varus
deformity in spina bifida is about 35%
 Retracting fibrosis- increased fibrous tissue
in muscles and ligaments
 Myoblasts in medial fascia- found on EM
studies-postulated to cause medial
contracture
 Signs
 affected foot is in equinus and varus.
 There is a crease of varying depth over the
medial midfoot wherein the foot appears to be
folded on itself
 there is some degree of rigidity that may be
severe.
 The calf on the affected side is smaller than that
on the normal side, a difference that persists
even after correction of the deformity.
 Pathology
 Bone
 Femur, tibia and fibula
 the entire lower limb can be shorter
 fibular shortening most common

 Talus : all relationships of the talus are

abnormal- including:
 anterior extrusion of the body of the talus
 medial and plantar deviation of the neck of the
talus
 Pathology, cont
 Os calcis
 medial rotation, equinus

 Navicular
 medial subluxation

 Cuboid
 medial subluxation

 Forefoot
 adducted and supinated, severe cases have
cavus also
 Muscle
 Atrophy of the leg especially in peroneal
group - number of fibres is normal , fibres are
smaller in size
 Triceps surae, Tib post, FDL,FHL are
contracted
Other soft tissues

 Tendon sheaths
 frequently thickened, esp. about Tib post and perinea

 Joint capsules
 resistant CTEV - contractures of ankle, subtalar, talonavicular,
calcaneocuboid jts

 Ligaments
 Resistant CTEV - contractures of calcaneofibular + talofibular
ligs, deltoid lig, long and short plantar ligs, spring lig, long
plantar lig. (bifurcate lig )

 Fascia
 Contracture of fascial planes and of plantar fascia
 No specific contraindications to surgery
exist, although the child's size dictates
that surgery is best performed at
approximately age 6 months.
 With greater acceptance of the Ponseti
conservative technique, surgery is seen to
be a contentious issue.
Two categories identified
1. Easy: Corrects with splintage alone
2. Resistant:
 Respond poorly to splintage
 relapse quickly and need early
operative correction
 Associated with thin calf and small high
heel
 Imaging Studies:
 Imaging studies generally are not required
to understand the nature or the severity of
the deformity.
 Radiographs, however, are a useful
baseline prior to and following surgical
correction of the feet, closed Achilles
tenotomy, or a limited posterior release.
 Radiographs show the true gain in foot
(ankle) dorsiflexion and confirm the
appearance of an iatrogenic rockerbottom
foot should one result.
 Occasionally, radiographs are necessary to
diagnose clubfeet associated with tibial
hemimelias.
 Radiographs
 Simulated weight bearing AP
 Measure the talocalcaneal angle in the AP and
lateral films.
 AP lines are drawn through the center of the
long axis of the talus (parallel to the medial
border) and through the long axis of the
calcaneum (parallel to the lateral border), and
they usually subtend an angle of 25-40°.
 Talocalcaneal angle (A) - normal range 20-40º
abnormal if <20º
 Lateral lines are dawn through the
midpoint of the head and body of the
talus and along the bottom of the
calcaneum, usually 35-50°.
 Clubfoot ranges between 35° and
negative 10°.
 Treatment

 Aims
 Correct deformity early
 Correct deformity fully
 Hold the correction until growth stops
 Non operative treatment
Serial casting
 2 weekly changes for 3 months
 40-60% will be corrected
 Splintage
 Either with single boot or Denis Brown splints (for bilateral
cases)
 Splintage begins at 2 - 3 days post birth
 Order of correction
 Forefoot adduction
 Forefoot supination
 Equinus
 NB. Attempts to correct equinus first may break the foot
producing a rocker bottom foot Force must never be used
 Ponseti method

 This method was developed by Ignacio

Ponseti, MD, of the University of Iowa.
The premise of the method is based on
the cadaveric and clinical observations of
Dr. Ponseti.
 Steps are as follows:
1. The calcaneal internal rotation
(adduction) and plantar flexion is the
key deformity.
 The foot is adducted and planter-flexed at
the subtalar joint, and the goal is to abduct
the foot and dorsiflex it.
 the calcaneum should be allowed to rotate
freely under the talus, which also is free to
rotate in the ankle mortise.
 Thecorrection takes place through the
normal arc of the subtalar joint.
 Thisis achieved by placing the index
finger of the operator on the medial
malleolus to stabilize the leg and
levering on the thumb placed on the
lateral aspect head of the talus while
abducting the forefoot in supination.
2. Foot cavus increases when the forefoot
is pronated.
• If cavus is present, the first step in the
manipulation process is to supinate the
forefoot by gently lifting the dropped first
metatarsal to correct the cavus.
3. The manipulation is carried out in the cast
room, with the baby having been fed just prior
to the treatment or even during the treatment.
• After the foot is manipulated, a long leg cast is
applied to hold the correction.
• Initially, the short leg component is applied.
• The cast should be snug with minimal but adequate
padding
• Apply additional padding strips along the medial and
lateral borders to facilitate safe removal of the cast
with a cast saw.
• The cast must incorporate the toes right
up to the tips but not squeeze the toes
or obliterate the transverse arch.

• The cast is molded to contour around

the heel while abducting the forefoot
against counter pressure on the lateral
aspect of the head of the talus.
• The knee is flexed to 90° for the long
leg component of the cast.

• This allows for monitoring of the

progress of the forefoot abduction, and
in the later stages, the amount of
dorsiflexion or equinus correction
4. Forcible correction of the equinus (and
cavus) by dorsiflexion against a tight
Achilles tendon results in a spurious
correction through a break in the
midfoot, resulting in a rockerbottom foot.
5. Following the manipulation and casting phase,
the feet are fitted with open-toed straight-laced
shoes attached to a Dennis Brown bar.
 The affected foot is abducted (externally rotated) to
70° with the unaffected foot set at 45° of abduction.
 The shoes also have a heel counter bumper to
prevent the heel from slipping out of the shoe.
 The shoes are worn for 23 hours a day for 3 months
and are worn at night and during naps for up to 3
years.
 Operative treatment
 Indication
 when a plateau has been reached in non-operative treatment
 persisting deformity
 rockerbottom deformity
 rapid relapse after correction has stopped
 when the child is of sufficient size to enable anatomy to be
recognised

 Treatment by age
 Less than 5 years correction can be achieved by soft tissue
procedures (Postero-medial release)
 More than 5 years requires bony reshaping, eg dorso-lateral
wedge excision of the calcaneo cuboid joint (Evans procedure)
or osteotomy of the calcaneum to correct varus
 More than 10 years lateral wedge tarsectomy or triple if the
foot is mature (salvage procedures)
Postero-Medial Release Technique

 Incision
 Cincinnati - Transverse incision around
hind foot which gives excellent exposure
 J-shaped or hockey stick incision
 Procedure

 Identify and preserve the neurovascular bundle

and the sural nerve. Take care to preserve the
medial calcaneal branch of the post tibial nerve
 Care must be taken handling the posterior tibial
vessel as the dorsalis pedis artery is often
attenuated or absent
 "Z"-lengthen tendo achilles
 divide and lengthen Tibialis Posterior, FHL and
FDL
 Capsulotomies
 ankle posteriorly
 subtalar joint
 calcaneocuboid joint
 release plantar ligament
 release abductor hallucis
 release FDB
 peroneal tendon sheath may need release (can
release everything except deep deltoid
ligament)
 repair tendons
 K-wires may be passed into talus and calcaneus to hold
reduction
 Close skin, but release tourniquet before final skin
closure
 Above knee cast in comfortable position for skin closure
 Change cast at 2-3wks for neutral position
 Retain cast for 12 weeks total.
 The transfixion pins usually are removed in 3-6 weeks.
 Complications
 Infection (rare)
 Wound breakdown
 Stiffness / restricted ROM (early stiffness
correlates with a poor result)
 AVN of the talus: Combined simultaneous medial
and lateral release 40% incidence of AVN of the
talus
 Persistent intoeing is quite common which is not
due to tibial intorsion but rather insufficient
external rotation correction of the subtalar joint
 Overcorrection associated with
 release of interosseous ligaments in the subtalar joint
 excess lat displacement of navicular on talus
 overlengthening of tendon units

 Residual deformity
 Must ensure there is not a neurological cause for recurrence eg
tethered cord
 Residual deformity may be
 Dynamic - if unable to actively evert foot, treat with SPLATT (split
ant. tibialis transfer)
 Fixed if not too much scarring and less than 5 y - repeat release
if more than 5y will need bony procedure to straighten the lat
border of the foot