April 11, 2024

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

CavusExcessive arch of the foot
AdductionForefoot
VarusHindfoot 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-1st 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

CongenitalAcquiredNeurogenicSyndromic
Small foot sizeFoot size normalSmall foot sizeSmall foot size
Symmetrical deformityAsymmetrical deformityAsymmetrical deformityAsymmetrical deformity
Severity: VaryingSeverity: ModerateSeverity: SuppleSeverity: Very rigid
Motor weakness (-)Motor weakness (+), Sensory NormalMotor weakness (+), Sensory deficit (-)Motor weakness (-)
Other anomalies:
Cleft lip, palate, CDH
No other anomaliesOther anomalies:
Cleft lip, palate, CDHpeci
Specific anomaly pattern

Other classification

Severe/ Rigid TypeMild/ Moderate Type
The foot can’t be corrected to the anatomically neutral positionThe foot can be manipulated to a correct position
Atrophied calf muscleNot atrophied calf muscle
Small heel sizeHeel 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 decreasedThe appreciable gap between the navicular and medial border
Talus head is subluxated outside ankleTalar’s head is not palpable
Callosity in the anterolateral part of the footCalosity rarely present

Modified Pirani Score of Clubfoot

To check for treatment outcome: Detail link

MildModerateSevere
Midfoot
– Curved lateral border00.51
– Medial foot crease00.51
– Talar Head Coverage00.51
Hindfoot
– Posterior crease00.51
– Rigid equinus00.51
– Empty Heel00.51
Modified Pirani score

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)
SupinationPronation
AdductionAbduction
InversionEversion
Plantar flexionDorsiflexion
Heel- VarusHeel- Valgus
Sub-talar motion
  • 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,

Ponseti Technique

Elevation of First Ray (Correction of First Ray)-Correction of pronation twist

Supination of the foot seems to be exaggerated but brings forefoot in the line of hindfoot before other correction

( During manipulation: 1. Thumb on talar head,-One hand 2. Supinate the forefoot (long finger), 3. Abduct the supinate foot (Index finger)- Another hand=> Fibrosis in medial aspects stretch)

Then subsequently casts are applied.

The foot is never pronated, pronation only increases cavus deformity.

Then – correction of varus, inversion and adduction done

Head of talus (as fulcrum)

In KITES:-Calcaneocuboidal joint is used as the center of rotation

As the foot abducts- inversion automatically everts and the foot becomes plantigrade

As the foot is abducted:- eversion spontaneously occurs and the heel moves from varus to valgus

Then tenotomy is done:

Palpate tendon and locate tenotomy site 1.5 cm above the insertion. Infiltrate Local anesthesia just anteromedial to the tendon at the tenotomy site

Insert blade anterior and parallel to the tendon to avoid neurovascular bundle and calcaneal apophysis

Heel Varus is corrected with/ without touching calcaneum

Final cast before tenotomy:- 50 degrees of abduction

Cast after tenotomy (Last cast):

  • 70 degrees of abduction
  • 10-15 degrees in dorsiflexion

Heals in 3 weeks

Tenoachillis tenotomy

  • Pirani’s midfoot contracture <1
  • The lateral head of talus=0
  • Hindfoot contracture score <1

Complete percutaneous tenotomy is done 1 cm above the insertion of Tendoachillis

Kite’s Method

A-I-V-E

Corrected one deformity after another in set of other

  • Forefoot adduction ( So, that it points outwards 20 degrees)
  • Heel Varus (Inversion at a sub-talar joint)
  • Ankle equinus

These occur simultaneously in Ponseti techniques

Dorsiflexion to correct equinus before correcting inversion locks the subtalar joint decreasing the chance of further correction and foot may break in the midfoot region = rocker-bottom foot

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 1st 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

Summary of surgical treatments:

6-12 months:

Turco’s posteromedial soft tissue release

Posterior + Medial + Subtalar ligaments ( Talocalcaneum, Interosseous, bifurcated Y ligaments)

12-36 months:

Mckay’s procedure: Turcos + Lateral structure released

Lateral structures:

  • Superior peroneal retinaculum
  • Inferior externsor retinaculum
  • Dorsal calcaneo-cuboid retinaculum
  • Origin of ext digitorum brevis

The lateral subtalar joint capsule

Calcaneo-fibular ligaments

For Older Children:

Metatarsal adductus> 5 yearsMetatarsal osteotomy
Hindfoot varus< 2-3 yearsModified Mckay’s procedure
3-10 yearsDwyer’s osteotomy (Isolated heel varus)
Dillwyn Evan”s procedure ( Short medial column)
Lichtblau procedure ( Long lateral column)
Davis procedure ( Wedge resection from the mid-tarsal area)
10 years aboveTriple arthrodesis
Equinusmild to moderateTendoachillis lengthening + posterior capsulotomy of ankle/ subtalar joint
SevereLambrunidi’s triple arthrodesis
All 3 deformity> 10 yearsTriple arthrodesis

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