CTEV

(Congenital talipes equinovarus)

Presenter: Nurul Saadah binti Joraimi

Matric number : MBBS 0917210
Date: 10th September 2021
 INTRODUCTION

• Is a deformity characterized by complex, malalignment of

the foot involving soft & bony structures in the hindfoot,
midfoot & forefoot.
• Also known as clubfoot.
• Common in infants & children.
• Postural problems when one or sometimes both of feet tend
to move inward & upward, esp. in non-weight bearing
position.
• 1/1000 delivery; male: female ratio approximately 2:1
• 50% of cases are bilateral, 80% clubfoot as an isolated
deformity
 TYPES OF CTEV

1. Postural
• d/t muscle tightness (without the
involvement of the surrounding
bone and joint)
2. Structural
• d/t bones and joints caused by
delayed development.
• Foot’s range can’t be fully achieved
passively.
• Unknown cause., might be due to
genetic influences.
 ETIOLOGY

1. Pathophysiology
2. Genetics
3. Associated condition
 1. Pathophysiology
a) Muscle contractures contribute to the characteristic deformity that includes CAVE :

Cavus (increase in Equinus of ankle joint

Adduction of forefoot Varus of hindfoot
medial arch)
 (a)

Cavus Tight intrinsics, FHL, FDL

Adduction Tight tibialis posterior

(b) (c)

Varus Tight tendoachilles, tibialis posterior,

tibialis anterior

Equinus Tight tendoachilles

b) Bony deformity consists of medial spin of the midfoot and forefoot relative to the hindfoot:
• Talar neck: medially &plantarly deviated
• Calcaneus is in varus & rotated medially around talus
• Navicular & cuboid: displaced medially
2. Genetics
• Unaffected parents with affected child have 2.5% - 6.5% chance of having another
child with a clubfoot
• Familial occurrence in 25%
• Recent link to PITX1
• Common genetic pathway may exist with congenital vertical talus
3. Associated condition

i. Arthrogryposis 
ii. Diastrophic dysplasia 
iii. Myelodysplasia 
iv. Tibial hemimelia 
v. Amniotic band syndrome (Streeter dysplasia)
vi. Prune-belly syndrome
 PRESENTATION

• Physical exam – Inspection:

a) Small foot and calf d) Foot deformities

b) Shortened tibia • Hindfoot in equinus and
varus
c) Medial and posterior foot skin
creases • Midfoot in cavus
• Forefoot in adduction
a) b)
 IMAGING

a) Radiograph
b) U/S (prenatal)
 a) Radiograph
X-ray view Description Example

Turco view i. Hindfoot parallelism

(dorsiflexion between the talus &
lateral) calcaneus (less
convergent than in a
typical foot)  

ii. Talocalcaneal angle <

25°

iii. Flat talar head in older

children (not in infants)
 X-ray view Description Example

AP i. Talocalcaneal (Kite) angle

is < 20° (normal: 20-
40°)  

ii. Talus-first metatarsal

angle is negative (normal
is 0-20°) -- talus points
lateral to first metatarsal

iii. Also shows hindfoot

parallelism
b) US
i. 1st trimester
 Associated anomalies, including non-
musculoskeletal ones, are very
common in children diagnosed with
clubfoot in the first trimester

ii. 2nd trimester

 Typically true clubfeet, but associated
anomalies are less common

iii. 3rd trimester

 False positive rate is higher due to
higher probability of intrauterine
crowding
 TREATMENT

a) Non-operative
b) Operative
a) Non-operative:
• Ponseti method of serial
manipulation and casting:
 Gold standard
 Standard of care for untreated
clubfeet
 > 90% success rate in avoiding
comprehensive surgical release
 Children can be expected to walk,
run and be fully active in the
absence of other comorbidities
 Involve corrective phase &
maintenance phase
b) Operative:

i. Posteromedial soft tissue release and

tendon lengthening
ii. Medial column lengthening or lateral
column-shortening osteotomy, or
cuboid decancellation
iii. Talectomy
iv. Multiplanar supramalleolar
osteotomy
v. Ring fixator (Taylor Spatial Frame)
application and gradual correction
vi. Triple arthrodesis