CONGENITAL TALIPES

EQUINO VARUS
Children with physical
disabilities are often
socially and
economically
disadvantaged

Importance of
Clubfoot easily
diagnosed
-easily treated
CTEV congenital
talipes equino-varus
Talipes - The term
talipes is derived from
a contraction of the
Latin words for ankle,
talus, and foot, pes.
The term refers to the
gait of severely
affected patients, who
walked on their
ankles

Definition
Club foot is a
congenital deformity
of the foot and ankle
characterized by
equinus deformity at
the ankle, inversion at
the subtalar
,adduction at the
midtarsal joint,cavus
and internal tibial
torsion


INCIDENCE
About 1 in 1000 live
births
Most cases sporadic
Sometimes
Autosomal dominant
trait with incomplete
penetrance
More common in boys than girls
50 % cases are bilateral
In unilateral cases right side is more often
involved
Types According To Cause
1) Idiopathic
2) Secondary
3) Postural / Positional
Idiopathic
Diagnosed when child has normal upper
and lower extremities spine and
neurological status apart from club foot
Can be detected by USG by 16 wks
gestation
Combination of genetic and environmental
factors are involved
Theories regarding cause
Primary germ plasm
defect of talus
Contractile
myofibroblastic tissue
in the
musculotendinous
units
Secondary Clubfoot
Diagnosed when deformity forms part of
another health condition
a) Neuropathic deformity in
association with neurological abnormalities
or spina bifida
b) Syndromic clubfoot in association
with other syndromes
Congenital Talipes Equino-Varus
CTEV


Spina Bifida = Paralytic TEV
Syndromes Producing CTEV

Streeters dysplasia
Arthrogryposis
Edwards syndrome trisomy 18
Postural
Due to abnormal intrauterine position
Easily corrected by massage by mother or
by 1 or 2 casts
Types of Clubfoot According to
Treatment Stage
Untreated
Treated
Resistant
Recurrent
Neglected
Complex
Untreated affected child is under 2 yrs of
age and had no or very little treatment

Treated affected childs feet have
corrected with ponseti mehod and they
have completed the casting phase
Resistant child has previously untreated
clubfoot and that does not correct with
Ponseti method. This is usually syndromic
and surgery may be necessary
Recurrent clubfoot children who show
signs of deformity in previously treated
clubfoot
supination of foot tib ant
hindfoot equinus tendoachilles
usually due to failure to wear FAO
treated by casting or surgery
Neglected clubfoot child older than two
years who had little or no treatment
usually severe soft tissue contractures
and bony deformities
Ponseti treatment has some success
but many require surgery
Complex clubfoot clubfoot treated by any
method other than ponseti technique
- complicated by additional pathology or
scarring
Pathological Changes
Four basic
components are

midfoot Cavus (tight
intrinsics, FHL, FDL)
forefoot Adductus
(tight tibialis posterior)

hindfoot Varus (tight
tendoachilles, tibialis
posterior)


hindfoot Equinus
(tight tendoachilles )

The ankle, subtalar and midtarsal joints
are involved
The severity of deformity varies and is
graded by the pirani score


McKays Description of
Pathological Anatomy
calcaneus rotates horizontally and the
tuberosity moves towards the lat malleolus
The taolonavicular joint is in extreme
inversion
Cuboid is displaced medially on the
calcaneus
Congenital Talipes Equino-Varus
CTEV
Associated findings- hypotrophic anterior
tibial artery
-atrophy of muscles
around the calf
-abnormal foot is
smaller

Soft Tissue Abnormalities
Talocalcaneal (subtalar) joint realignment
is opposed by-
- calcaneo fibular ligament
- peroneal tendon sheath
- posterior talo calcaneal ligament
Talo navicular joint realignment is opposed
by- posterior tibial tendon
- deltoid ligament
- spring ligament
- joint capsule
- dorsal talonavicular ligament
- bifurcated Y ligamant
Calcaneo cuboid joint realignment is
opposed by-bifurcated Y ligament
- long plantar ligament
- plantar calcaneo cuboid
ligament

If the deformity is left untreated late
adaptive changes occur in the bones.
These depend on the severity of soft
tissue contracture and effect of walking
Radiological Evaluation
Talocalcaneal angle -
Anteroposterior view:
30-55 degrees






Talocalcaneal angle -
Dorsiflexion lateral
view: 25-50 degrees
Tibiocalcaneal
angle Stress lateral
view: 60-90 degrees


Talusfirst metatarsal
angle Anteroposterior
view: 5-15 degrees


Treatment
Non operative Ponseti technique
Kite technique
French technique
SurgicalPosteromedial soft tissue release
Osteotomies
Triple arthrodesis
Achilles tendon lengthening
Ilizarov / JESS
Ponseti technique
Weekly Serial manipulation and
casting (long leg cast)
goal is to rotate foot lateraly around a fixed
talus
order of correction (cave)
midfoot cavus
forefoot adductus
hindfoot varus
hindfoot equinus (TAL)
After the last cast TA
lengthening
FAB for 23 hrs a day
for 3 months and
night splint till 2-3 yrs
of age
Chance of recurrence
up to 4 or 5 yrs of age
Kites technique
Foot manipulated with calcaneo cuboid
joint as fulcrum
Casting done after manipulation
After correction Denis Browne splint
applied
French Technique
Daily manipulation by physical therapist for
30 mts
Electrical stimulation of peroneal muscles
done
Reduction maintained by adhesive taping

PMR
Done at age 1 yr
Tight structures in
posterior and medial
aspect of the foot is
released or
lengthened
Osteotomies for
residual hind foot
varus
Triple arthrodesis in
children more than 12
yrs old
TA lengthening for
residual equinus
Ilizarov and JESS are
for older children with
recurrence or residual
deformity


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