Congenital Talipes Equinovarus (CTEV)

Congenital Talipes Equinovarus (CTEV) is also called clubfoot which involves deformity in the ankle and foot with Cavus, Adduction, Varus, and Equinus deformity.

Also called clubfoot

Cavus	Excessive arch of the foot
Adduction	Forefoot
Varus	Hindfoot varus with heel facing medially
Equinus(Horse hoof shape of foot)	Forefoot plantarflexed ( at the ankle and midtarsal region)

Some Important terms

Neglected Clubfoot:

Patients do not receive treatment (conservative/ operative) by walking age (typically 9 months)

Recurrent Clubfoot:

When one / many or all deformities recur during the course of treatment typically during manipulative correction which was successfully corrected previously

Relapsed Clubfoot:

When one or many or all deformities recur after successfully achieving correction of all the deformities i.e. after the end of treatment

Resistant Clubfoot:

Persistent clubfoot when correction is not obtained in any or all the deformities by manipulation and surgical methods

Etiology

1-2/ 1000 live birth

Bilateral involvement in 40-60% of patients

• Genetics
• Intrauterine pressure therapy
• Myogenic causes
• Germ plasma defect therapy ( Germ plasma defect in talus)
• Cartilage defect theory (Cartilage anlage of talus in anterior portion)
• Neurological defect
• Others ( Radiation, toxins, seasonal, etc)

So, during the examination, they should examine

• Hip for DDH
• Cerebral Palsy
• AMC
• Polio, tight ITB
• Cleft lips, palate, exophthalmos, congenital hernia
• Sensation of foot
• Power of gluteal Maximus and quadriceps (weakness of above can lead to compensatory equinus)

GAIT: STUMBLING GAIT (UNSTEADY GAIT)

Features:

ADMiT IT IS CTEV

Equinus at ankle joint (EA)

Inversion at subtalar joint (IS)

Adduction at the metatarsal joint (ADMiT)

Internal Tibial torsion (ITT)

Cavus deformity

The Head of the talus is prominent over the dorsolateral aspect of the foot. Inflexible clubfoot, this head of the talus can be reduced back by direct gentle pressure; emptiness of that area [ Empty Head Sign]

Atypical Clubfoot / Complex clubfoot:

Result of faulty manipulation and casting

1. The foot shows swelling and puffiness over the dorsum of the foot
2. The great toe is shortened, stubby and hyperextended
3. The medial crease is usually prominent and runs through the whole length of the sole
4. Equinus is rigid and difficult to correct
5. Plantarflexion of all metatarsal with excessive abduction (Most characteristics)

X-Ray findings:

Normally: Talus-Navicular-Medial cuneiform-1st metatarsal lies in straight line

In clubfoot: Displacement is medial and inferior

Important angles in clubfoot

Talocalcaneal angle:

Normal :- 30-55 degress

DECREASE in clubfoot

Talus-1^st Metatarsal angle:

Normal:- 5-15 degrees

Value is negative in clubfoot

Tibiocalcaneus angle:

Measure of equinus

Normal:- 10-40 degrees

Negative in clubfoot

Classifications

5-S

Congenital	Acquired	Neurogenic	Syndromic
Small foot size	Foot size normal	Small foot size	Small foot size
Symmetrical deformity	Asymmetrical deformity	Asymmetrical deformity	Asymmetrical deformity
Severity: Varying	Severity: Moderate	Severity: Supple	Severity: Very rigid
Motor weakness (-)	Motor weakness (+), Sensory Normal	Motor weakness (+), Sensory deficit (-)	Motor weakness (-)
Other anomalies: Cleft lip, palate, CDH	No other anomalies	Other anomalies: Cleft lip, palate, CDHpeci	Specific anomaly pattern

Other classification

Severe/ Rigid Type	Mild/ Moderate Type
The foot can’t be corrected to the anatomically neutral position	The foot can be manipulated to a correct position
Atrophied calf muscle	Not atrophied calf muscle
Small heel size	Heel size normal
Foot: small in size, reniform Deep crease in the medial border, concave medial border, and convex lateral border	No deep crease. Both borders of the foot have slightly deviated
Distance between navicular to the tip of the medial malleolus is decreased	The appreciable gap between the navicular and medial border
Talus head is subluxated outside ankle	Talar’s head is not palpable
Callosity in the anterolateral part of the foot	Calosity rarely present

Modified Pirani Score of Clubfoot

To check for treatment outcome: Detail link

	Mild	Moderate	Severe
Midfoot
– Curved lateral border	0	0.5	1
– Medial foot crease	0	0.5	1
– Talar Head Coverage	0	0.5	1
Hindfoot
– Posterior crease	0	0.5	1
– Rigid equinus	0	0.5	1
– Empty Heel	0	0.5	1

Maximum Score: 6

Minimum Score : 0

The more the score more severe is the case.

Treatment of Clubfoot

Principle of treatment

• Almost all the motion of the foot occurs around the talus
  • Pronation/ Supination (Subtalar joint/talonavicular joint)
  • Dorsiflexion/Plantarflexion (Ankle joint)
• The Calcaneo-pedis block
  • With pronation/ supination, there is very little movement between the tarsal bones at the midfoot and the calcaneocuboid joint. They move as a unit/block called Calcaneopedis block. So, the rearfoot can be mobilized with the help of the forefoot
• All the correction occurs simultaneously by the abduction of the foot around the talus (except the cavus)

Supination	Pronation
Adduction	Abduction
Inversion	Eversion
Plantar flexion	Dorsiflexion
Heel- Varus	Heel- Valgus

• The foot is corrected by allowing normal tarsal bones to follow normal kinematics of subtalar and talonavicular joint
• Kinematics coupling
  • Inversion and eversion kinematically coupled to abduction

So, We do,

Relapse in conservatively treated clubfoot

Incidence of 5-9 %

Majority of recurrences (80%) in the first 2 years

2- types:

• Dynamic supination (Overactivity of tibialis anterior- respond well to tibialis anterior muscle transfer)
• Hindfoot varus

Surgical Options

To persistent resistant or relapsed cases of clubfoot following treatment

• Soft tissue procedure
• Bony Procedure (Only after 8-9 years)

Soft tissue release:

Posterior (2CT): Correct equinus deformity

• CAST: Capsule of the ankle joint and subtalar joint
• CF: Calcaneofibular ligaments
• TF: Talofibular ligaments
• TA: Tendoachillis release (Z-Plasty)

Medial: For equinus varus deformity

• 3 Tendons: Tibialis Posterior, FDL, FHL
• 3 Ligaments: Spring, Talonavicular, Deltiod
• 3 Other structures: Interosseous talocalcaneal ligament, Naviculocuniform capsule, Cuniform, and 1^st Metatarsal capsule release

Plantar:

• Plantar fascia
• FDB
• Abductor Halllucis

Splints:

• CTEV splint, shoes
• Denis Brown splint

Arthrodesis

• > 10 years: Triple arthrodesis
  • Calcaneocuboidal
  • Talonavicular
  • Subtalar

Tendon transfer

• For Evertor insufficiency/tricep insufficiency
• Tibialis anterior:- Eversion of foot
  • SPLATT (Split anterior tibialis tendon transfer)
  • TATT ( Tibialis anterior tendon transfer)

Tarsectomy: Wedge

Dwyer’s osteotomy

Dillwyn-Evans Procedure

Short median column

CC fusion + PMSTR

Surgical Incisions for Clubfoot

1. Turco’s posteromedial Hockey stick incision
2. Cincinnati circumferential incision
3. Caroll’s dual incision techniques
   • Posteromedial incision
   • Small lateral incision over subtalar joint

Combined Bony and Soft tissue procedure: Done after the age of 3 years; adaptive bone artitecture takes place

Complications of Operative treatments

• Neurovascular damage, bone damage, physis injury, wound dehiscence
• Undercorrection: most commonly due to inadequate post-operative maintenance
  • Equinus
  • Heel varus
  • Forefoot adduction
  • Cavus
• Overcorrection:
  • Valgus overcorrection
  • Forefoot abduction
  • Calcaneus deformity
  • pes planus
• Skew foot:
  • Forefoot adduction and hindfoot valgus
• AVN talus/ navicular
• Sinus tarsi syndrome
• Dorsal navicular syndrome
• Dorsal bunion