CO CTEV NGENITAL

TALIPES

Anuj Shrestha
PG2, Orthopaedic Resident
NMCTH
OBJECTIVES:
INTRODUCTION

PATHOANATOMY

CLASSIFICATION

CLINICAL FEATURES

RADIOGRAPHIC EVALUATION

TREATMENT OPTIONS

SUMMARY
 INTRODUCTION:
• CTEV- Congenital Talipes EquinoVarus
• A/K/A Congenital Clubfoot.
 Talipes : Talus- Latin = Ankle & Pes = Foot Equinovarus : Equino -
like a horse & Varus - turned inward.
• M/C congenital orthopedic foot deformity.
• Characterized by four components of foot deformities:
 Hindfoot equinus, Hindfoot varus, Midfoot cavus, and Forefoot
adduction.
 Deformity components : CAVE
 C- Cavus - Exaggerated medial longitudinal arch at midfoot

 A- Adduction -Forefoot in adduction at tarsometatarsal

Junction

 V- Varus- Hindfoot rotated inward at talonavicular joint

 E- Equinus- Foot fixed in plantar flexion at ankle joint

 EPIDEMIOLOGY:
• Incidence- 1 per 1000 Live birth
• First born male baby
• Male:Female- 2.5 :1
• 50% = Bilateral
• If unilateral : Right > Left

sources: https://pubmed.ncbi.nlm.nih.gov/28632733/
 ETIOLOGY:

• Primary – Idiopathic(M/C).

• Secondary CTEV: Associted with

underlying cause.
IDIOPATHIC CTEV: Theories:

a) Primary germ plasma defect: Waisbrod suggested defect in

primary germ plasma of talus

b) Primary soft tissue changes : Ippolito and ponseti found increase

in collegen fibres and fibroblastic cells in ligaments and tendons of
clubfoot

c) Vascular hypothesis: Keith suggested hypertrophic ant.tibial artery

 Arrested fetal development: Bohm proposed arrest of fetal
development of the lower limb in 6-8 weeks

 Mechanical factor in utero: Hippocrates suggested foot was held

in equino varus by external uterine compression

 Hereditary: Wynne- davies suggested club foot are part of

numerous syndromes following Mandelian pattern of either AD
or AR inheritance.
SECONDARY CTEV:
• Associated with neuromuscular or syndromic etiologies-
• Arthrogryposis Multiplex Congenita
• Diastrophic Dysplasia
• Streeter syndrome (constriction band syndrome)
• Freeman Sheldon Syndrome
• Mobius syndrome
• Nail patella syndrome
• Associated with paralytic disorder-
• Poliomyelitis
• Spina bifida
• Myelodysplesia
• Freidrich’s ataxia
ANATOMY OF FOOT:
PATHOANATOMY :
2) MUSCLES AND TENDONS-
• Atrophy of peroneal group of muscles
• Contracture of tibialis posterior, FDL and FHL.
• Number of fibres in muscle is normal but are smaller in size.
• Thickening and contracture of tendon sheaths of tibialis posterior and
peroneal.
3) Ligaments- Thickening and contractures
4) Joints capsule and fascia- Contractures are seen in Posterior ankle
capsule,Subtalar capsule, Plantar fascia contracture (cavus deformity)
 5)Skin changes-
• Deep crease on medial side
• Shortening on medial side of sole
• Callosities on lateral side of foot

6) Vascular changes-
• Hypoplasia or absence of dorsalis paedis and
hypertrophic anterior tibial artery
 CLINICAL FEATURES:
• Heel - Small & Equinus
• Foot- Inverted
• Deep creases -medial and posterior aspect
• Abnormal thin calf
• Varying degree of resistance/ fixed
deformity when try to dorsiflex and evert
the foot(dorsiflexion test :+ve)
• Associated anomalies condition &
Neuromuscular disorders
 CLASSIFICATION SYSTEM:
1. IDIOPATHIC AND SECONDARY(ACC. TO CAUSE)

2. CUMMIN CLASSIFICATION

3 DIMEGLIO ET. AL. SCORING SYSTEM BASED ON

SEVERITY OF THE DEFORMITY

4. PIRANI SCORING SYSTEM

 CUMMIN CLASSIFICATION:
• Supple: Foot can be brought to normal position and all joints are
mobile
• Neglected: No treatment for 1 year.
• Relapsed: Corrected deformities appears again.
• Reccurent: type of relapse due to muscle imbalance
• Resistant: no correction after conservative management.
• Rigid : After conservative treatment forefoot deformity
Corrected and hindfoot deformity remain uncorrected.
DIMEGLIO SCORING SYSTEM: based on physical
examination:reducibility with gentle manipulation measured by goniometer
PARAMETERS 1. EQUINUS 2. VARUS 3.SUPINATION 4.
ADDUCTION
PIRANI SCORING SYSTEM:
• Simple and reliable system to determine severity and monitor
prognosis in the assessment

• 3 signs in mid foot

• 3 signs in hind foot

• Severely abnormal = score 1
• Partially abnormal = score 0.5
• Normal = score 1

• Total score varies from 0 to 6 and is the sum of midfoot and hindfoot
contracture scores
PIRANI SCORE:
 Mid foot parameter:
Medial crease(MC)
Curved Lateral border(CLB)
Lateral head of talus(LHT)

 Hind foot parameter:

Posterior Crease(PC)
Empty Heel(EH)
Rigid Equinus(RE)
RADIOGRAPHIC EVALUATION:
 For non ambulatory child-
⮚AP view of foot
⮚Stress dorsiflexion lateral view
 For older child-
⮚Standing AP view
⮚Standing lateral view
Talocalcaneal angle in AP
View(Kite’s angle)-
 1st line through the centre of long axis of
talus (parallel to medial border)
 2nd line along long axis of calcaneum (parallel
to lateral border)
 Normal = 30 - 55
 In CTEV ,Talocalcaneal angle/kite’s angle = <
30
Talocalcaneal angle in
Lateral view-Turco’s angle:
❖1st line midpoint of head and
body of talus
❖2nd line along bottom of
calcaneum
❖Normal = 25-50
❖In CTEV,angle progressively
decreases and make 0  or
parallesim C-CLUB FOOT
D- NORMAL FOOT
OTHER RADIOLOGICAL FINDING :
 On anteroposterior view-
⮚Talus first metatarsal angle( Mery’s angle, Normal 5-15): In
CTEV usually negative indicates Adduction of forefoot

 On stress lateral view-

⮚Tibiocalcaneal angle normal (10-40) ; negative indicating equinus of
calcaneus in relation to tibia.
 TREATMENT:
• Goal: To achieve
⮚Plantigrade foot
⮚ Flexibilty
⮚Cosmetically acceptable functional and pain free foot in shortest time
Principles:
⮚ Soft tissue contracture release or stretching to restore normal tarsal
relationship.
⮚ Once normal tarsal relationship attained, correction should be maintained
till tarsal bones remoulds stable articular surface.
 NONOPERATIVE TREATMENT
95% - Non-operative treatment
1. Ponseti technique:
⮚2 phases – a) Treatment and b) Maintenance phase
⮚Treatment phase-
❑Begins as early as possible.
❑Order of correction-

CAVUS ADDUCTION WITH EQUINUS

 Talus head is used as fulcrum. VARUS

❑ 6 serial weekly casting with manipulation is generally enough to correct the

deformity.
Correction of cavus deformity:

 By elevating first ray of forefoot in

relation to hindfoot(in supination)

 Tend to exaggerate foot

Inversion.

E. RIGHT MANEUVER TO CORRECT CAVUS

DEFORMITY
F. WRONG MANEUVER TO CORRECT CAVUS
DEFORMITY
 Correction of adduction & varus :

A: thumb is positioned over lateral aspect of head of talus and finger correct the forefoot.
B: cavus and adduction are corrected by slight supination of forefoot in relation to hindfoot.
Pressure exerted on metatarsal and counter pressure on lateral aspect of
head of talus. Further abduction of foot held in flexion and supination.
Foot is further
abducted and
supination
decreased but
without
pronating the
foot
Characteristics of adequate abduction:
 Confirm foot sufficiently abducted to safely bring the foot into
0-5 degree of dorsiflexion before tenotomy

 Best sign -ability to palpate anterior process of calcaneous

 Abduction of approx. 60 degree in relation to frontal plane of tibia

 Neutral or slight valgus to os calcis

Correction of equinus:
 Attempted when hindfoot is in neutral position to slight valgus and
foot is abducted 70 relative to leg

 Equinus is coorected by progressive dorsiflexing the foot

 To facilitate rapid correction S/C tenotomy is done

 Care should be taken while dorsiflexing foot by applying
pressure under entire sole and not under metatarsal heads.
Foot is further abducted upto 70  to
Stretch to stretch medial tarsal
ligament.

Note: heel is not grasped by hand

thus allowing calcaneus to abduct
with foot and heel varus to correct
Equinus corrected by subcutaneous
section of tendo achilles
PERCUTANEOUS TENOTOMY
Foot held in dorsiflexion and tendon is felt

Blade of 11 size enters parallel to medial border of tendoachilles 1cm above insertion at calcaneum.

Blade is pushed medial to tendon and rotated 90 underneath it. Tendon is cut from medial to
lateral direction.

"Pop" is felt and cast is applied in maximal

dorsiflexion 15 and 70 abduction for 3 weeks.
PERCUTANEOUS ACHILLES
TENOTOMY FROM MEDIAL TO
LATERAL
Maintenance phase:
 After final cast is removed

 Placed in foot abduction orthosis in corrected position

(abducted & dorsiflexed)


 Brace is worn 23 hrs per day for first 3 months

.
 After 3 months while sleeping for 3 years

 Frequent F/U during bracing is needed to encourage

continued compliance & to detect early recurrence
FOOT ABDUCTION ORTHOSIS:
• A/K/A denis brown splint.

• Consist of shoes mounted to

crossbar in position of 70 ER and 15
dorsiflexion.

• Distance between shoes is set at about 1inch

wider than the width of infant’s shoulder.

• In unilateral cases normal foot should in

40 ER
 CTEV SHOES:
• Modified shoes for child who start
walking.

• These shoes are use

until 5 years of age.

• Special features:
⮚Straight inner border
⮚Outer shoe rise
⮚No heel
 2.Kite’s method of manipulation:
⮚Correction of each component separately
⮚Correction was done in following order

FOREFOOT HEEL VARUS EQUINUS

ADDUCTION

⮚ Kite’s errors:
❑Pronation/ eversion of 1st metatarsal.
❑Premature dorsiflexion of heel.
❑Used calcaneocuboid joint as fulcrum that blocks abduction of calcaneus , therby prevents
eversion of calcaneus.
3. Stretching and adhesive strapping (Robert jones):
⮚Principle- apply eversion correction force on foot with help of
adhesive strapping.

4. French technique:
⮚Goal is to reduce talonavicular joint, stretch out medial tissues and
then sequentially correct forefoot adduction, hindfoot varus and
equinus of calcaneum.
COMPLICATIONS OF CASTING:
• Rocker Bottom foot: (due to dorsiflexing foot to early against tight AT)
• Crowded toes ( due to tight casting over toes)
• Flat heel pad( when pressure applied to heel)
• Pressure sores( common sites: head of talus,heel,under 1 st MT head,popliteal
&groin)
• Failure of correction
 SURGICAL TREATMENT:
• Indication:

⮚Neglected CTEV
⮚Relapsed CTEV
⮚ Reccurent CTEV
⮚Resistant CTEV
⮚ Rigid CTEV
Choice of surgery:
❖1-4 years:
⮚Soft tissue release
❖4-11 years:
⮚Soft tissue release with
⮚Osteotomy performed according to the deformities
❖>11yrs- salvage procedures:
⮚Triple arthrodesis
⮚Talectomy
 SOFT TISSUE RELEASE OPERATION:
⮚ Turco ’s operation: 1 stage posteromedial release(PMSTR). Subtalar
release along with calcaneofibular ligament.

⮚ Caroll’s incision: Plantar fascia release and capsulotomy of

calcaneocuboid joint. Include 2 incisions; medial and postero-lateral
incision.
⮚ Cincinnati incision: Done for posteromedial and posterolateral
soft tissue release. Prefered technique for initial surgical management of
club foot.
⮚ Tendoachilles tendon release with posterior capsulotomy- to
correct residual hind foot equinus
 TURCO’S OPERATION:
• Medial incision given

• Expose tibialis posterior, FDL,FHL, AT and posterior neurovascular

bundle

• Divide master knot of henry

• Divide calcaneonavicular ligament and abductor hallucis from tibialis

posterior tendon,navicular tuberosity and 1st metatarsal.

• Posterior release , Medial plantar & Sutalar release

• After reducing navicular bone transfix talonavicular joint by k-wire and
nd
CINCINNATI INCISION:
• Transverse circumferential incision
ACHILLES TENDON LENTHENING AND
POSTERIOR CAPSULOTOMY
 To correct residual hindfoot
equinus z-plasty is done to
lengthen AT

 Release medial half distally &

lateral half proximally

 . Posterior capsulotomy of ankle and

subtalar joint to release capsule
contracture.
 TENDON TRANSFER:
Indication-
 Passively correctable deformity resulting
from muscle imbalance.
 Anterior tibial tendon transfer: Tendon is
transferred either to middle cunieform or
to base of 5th metatarsal.
 Split anterior tibialis tendon transfer- lateral
part of tendon is split and inserted to
cuboid.
DWYER OSTEOTOMY

Indication :Persistent varus deformity of

heel when soft tissue surgeries are
contraindicated.

• Age: 3-4yrs

• Done by medial open wedge osteotomy

or by lateral closed wedge osteotomy
 LATERAL COLUMN SHORTENING
PROCEDURE:
• Indication- Recurrence of clubfoot deformity after surgical
release (due to disparity between medial and lateral
border of foot)

 Dillwynn evans procedure

⮚Lichtblau procedure

⮚Fowler procedure
 LATERAL COLUMN SHORTENING PROCEDURE
DILLWYN EVANS PROCEDURE LICHTBLAU PROCEDURE

Age: 4-8 yrs Age-: 3-4 yrs

Indication- midfoot in varus due to Indication- heel varus & residual internal
talonavicular and calcaneocuboid subluxation deformity of calcaneus with long lateral
column
FOWLER PROCEDURE:
• Indication- sufficient scarring that
medial soft tissue and subtalar
release would be in effective.

• Age- 6-8 years

Procedure- Lateral column
shortening combining with medial
column lengthing by removing
wedgefrom cuboid and transfering it
to an opening wedge
 SALVAGE PROCEDURE:
• Indication-
⮚Uncorrected clubfoot or with residual deformity after the age of 10 yrs.
⮚Painful stiff foot with poor function
⮚Difficult to accommodate to foot wear
Goal-
⮚Correct residual deformity which is resistant to soft tissue release.
⮚To attain functionally and cosmetically acceptable foot.
Procedure-
⮚Triple arthrodesis
⮚Talectomy
TRIPLE ARTHRODESIS:
• Indication-
⮚Painful stiff foot with poor function

⮚Difficult to accommodate to foot wear

⮚All other correction failed

• Age – 10 – 12 years

• Procedure-

⮚ Osteotomy followed by fusion of talonavicular,

talocalcaneum and calcaneocuboid joint.
TALECTOMY
• Indication:
• RESERVED FOR SEVERE UNTREATED cases; age - <6 years

• Procedure-
⮚ Complete excision of talus

⮚ Derotate the foot and displace the calcaneus

posteriorly into ankle mortise until navicular abuts
the anterior edge of tibial plafond.

• Complication-
⮚ Loss of limb length
⮚ Limitation of ankle movement
 EXTERNAL FIXATOR:
• Indication-
⮚ In case of neglected and reccurent deformity with severe scarring
• Modalities-
⮚Illizarov’s external fixator
⮚JESS (Joshi External Stabilizing System)
• Advantage-
⮚Prevent crushing of the tissues on convex side
⮚ Lenghtens the limb
⮚Effectively correct the deformity at same time
A. FRESH CASE OF CTEV AT BIRTH TREAT AS B
PONSETI
METHOD

TREATMENT SUCCESSFUL FOLLOW TILL 10-

12 YEARS OF AGE
TENOTOMY

ALL DEFORMITIES LEFT: PMSTR

ONLY EQUINUS: POSTERIOR RELEASE
ONLY HEEL VARUS: DWYER’S OSTEOTOMY
B. OLD AND NEGLECTED CASES
< 3 YEARS OLD 4-8 YEARS OLD 10-12 YEARS OLD

SOFT TISSUE SOFT TISSUE

RELEASE RELEASE
+ OSTEOTOMY

ALREADY OPERATED
Studied from Hong Kong in 2017
Conclusion: This study reviewed all aspects of Ponseti techniques, comparison of the Ponseti method with the
Kite method, and the outcome of the results, number of casts used in clubfoot intervention, number of patients
underwent for surgical procedures, and the relapses pattern of clubfoot followed by correction of clubfoot.
Overall, this review found that the Ponseti method required fewer casts, shorter duration to achieve the
correction, less relapses rate than other methods.
Studied from Malaysia in 2016
Results: Mean age at presentation was 4.9 months. The mean number of casting was 6 and mean duration of
casting was 2.7 months. The initial success rate of 91.1%, with four feet (8.8%) diagnosed as resistant clubfoot
and eventually required soft tissue surgery. With mean follow up of 14.1 months, four other feet (8.8%)
developed relapse but were treated with repeat Ponseti method.
Conclusion: Many CTEV patients present late for treatment. However, the Ponseti method remained effective
with high initial success rate of 91.1%. Relapsed CTEV can still be treated successfully with repeat casting using
SUMMARY:
 Deformities in Club foot are Cavus, Adduction, Varus & Equinus
 Clubfoot deformity occurs mostly in Tarsus
 Severity and prognosis of treatment is assessed by PIRANI score
 Poneseti method of management is most effective & least expensive
treatment of clubfoot
 Ponseti technique corrects deformity by gradual rotating the foot
around head of talus
 Rocker Bottom deformityis M/C complication of poor technique of
casting
THANK YOU