Idiopathic Congenital Talipes Equinovarus

David P. Roye, Jr, MD, and Benjamin D. Roye, MD, MPH

Abstract
The etiology of idiopathic congenital talipes equinovarus is unknown, and there
is no consensus as to the best treatment. Increasingly, ultrasound is being used
to diagnose the condition prenatally, but the diagnosis remains clinical postnatally. Radiographs can help confirm the diagnosis and ascertain the severity of
the condition. There are many classification schemes, but none offers adequate
prognostic value. The mainstay of treatment is manipulation and casting, usually followed by soft-tissue release. However, some patients have been successfully treated with intensive physiotherapy instead of surgery.
J Am Acad Orthop Surg 2002;10:239-248

Idiopathic congenital talipes equinovarus (CTEV), also known as

clubfoot, has been a recognized
deformity since the time of the
ancient Egyptians and was independently described by both Hippocrates and the Aztecs. Initial treatment options all were variations on
manipulation and splinting. Surgical intervention began in the late
1700s with Lorenzs Achilles tenotomy, but effective soft-tissue releases,
osteotomies, and tendon releases
were not developed until the late
1800s with the advent of anesthesia
and aseptic technique. In 1930, Kite
popularized gentle manipulation
and serial casting, which remains
the initial treatment of choice. 1
Although the basic surgical concepts
have not changed, techniques for the
treatment of resistant CTEV continue
to be developed.
The incidence of CTEV varies
widely with respect to race and
geography. In Japan, this condition
affects approximately 0.5 per 1,000
live births, and in natives of the
South Pacific, the incidence jumps to
nearly 7 per 1,000 live births. In all
Caucasians, the incidence is 1.2 per

Vol 10, No 4, July/August 2002

1,000 live births. All populations

show a consistent 2:1 male predominance, and bilateral disease occurs in
approximately 50% of cases.2
In developed countries, untreated CTEV beyond early childhood is
rarely seen. However, CTEV is not a
self-limited disease. The deformity
continues to develop beyond skeletal maturity. 3 The patient with
uncorrected CTEV walks on the
dorsolateral aspect of the affected
foot and develops a callus, hyperpigmentation, and a subcutaneous
bursa. Additionally, the subtalar
and midtarsal joints become stiff.
The rate of collagen synthesis increases postnatally, which may
account for the stiffening of affected
feet after birth.4 Treatment options
are complicated by the fact that
there is usually little pain in the
affected foot.3

Pathogenesis
The cause of CTEV remains unclear.
Before the 1980s, many physicians
believed Hippocrates hypothesis
that intrauterine compression creat-

ed the fixed equinovarus deformity.2

However, this argument has been
systematically countered and has
fallen from favor.5,6 Current theories encompass environmental and
genetic factors.
Data from several studies show
abnormal muscle development,
including type I fiber predominance
and grouping. Whether this is
because of genetic factors, neurotrophic factors, or denervation is
unclear. Histologic and ultrastructural examination of the soft tissues
of the CTEV foot by both Kojima et
al7 and Handelsman and Glasser8
revealed a predominance of type I
muscle fibers in the lower legs of
patients with CTEV feet, a fiber type
IIB deficiency, and abnormal fiber
grouping. Although there was no
direct evidence of abnormal innervation, Handelsman and Glasser8
asserted that fiber grouping is
known to be a consequence of denervation. The changes in the sarcoplasmic reticulum and mitochondria, as well as the loss of myofibrils,
were all compatible with a neuro-

Dr. D. P. Roye is Livingston Professor of

Orthopaedic Surgery, Childrens Hospital of
New York, New York, NY. Dr. B. D. Roye is
Resident, New York Orthopaedic Hospital,
New York.
Reprint requests: Dr. D. P. Roye, 8th Floor N,
3959 Broadway, New York, NY 10032-1537.
Copyright 2002 by the American Academy of
Orthopaedic Surgeons.

239

Idiopathic Congenital Talipes Equinovarus

genic etiology.7,8 Localized soft-tissue
contracture also may be involved.
In one study,9 100% of deltoid ligaments resected from virgin clubfeet
but only 8% of control specimens
stained positive for vimentin,10 a relatively nonspecific marker that may
be seen in fetal cells but also in myofibroblasts involved in wound and
scar contracture.
Most clinicians agree that a
genetic component to CTEV is likely,
largely because one of nearly every
four patients with CTEV has a positive family history.2,11 Recent evidence has associated CTEV with
early amniocentesis (11th to 12th
gestational weeks).12 Other possible
causes, for which evidence is limited,
include the presence of a talocalcaneal bar and chromosomal, viral,
and vascular etiologies.6 Constricting annular bands also have been
implicated as an etiologic factor in
CTEV. Although elusive, the etiology of CTEV seems to be most consistent with multifactorial inheritance.2,11
Secondary etiologies, mostly neuromuscular in origin, can lead to a
talipes equinovarus deformity. This
form of CTEV is more complex and
difficult to treat than its idiopathic
counterpart. Conditions associated
with neuromuscular CTEV include
arthrogryposis, spinal muscular
atrophy, spina bifida, sacral agenesis, and other paralytic states.6

Normal Anatomy and

Biomechanics
Understanding CTEV requires a
thorough knowledge of the anatomy and biomechanics of the normal
foot and ankle. The tibiotalar joint
is essentially a hinge on which the
dome of the talus rotates in the
sagittal plane within the confines of
the mortise defined by the medial
and lateral malleoli. The talus has
no muscular attachments, and all
movement is determined by liga-

240

mentous attachments to the calcaneus and navicular.

The complex relationship between the talus, calcaneus, and navicular bones has been called the
talocalcaneonavicular joint or complex.13 This joint involves four articular surfaces (Fig. 1) and resembles
a ball-and-socket joint. The ball is
the head of the talus, which resides
in a socket composed of the concave
surface of the navicular and the
anterior and middle facets of the
calcaneus. The rest of the socket is
composed of connective soft tissue,
including the talonavicular joint
capsule, the tibialis posterior tendon, and the deltoid, spring, Y or
bifurcated, and interosseous talocalcaneal ligaments.
Horizontal movement in the
transverse plane is transmitted
through the midfoot and hindfoot.
Most motion takes place through
the talocalcaneonavicular complex
as the navicular and anterior calcaneus rotate about the talar head.
Additionally, inversion and eversion require talonavicular movement. Vertical movement in the

Navicular

Navicular
articular facet
Talonavicular
joint capsule

sagittal plane occurs mostly through

the tibiotalar joint. Dorsiflexion is
associated with concurrent pronation as the posterior tuberosity of
the calcaneus is pushed down and
the navicular is forced laterally with
respect to the talar head. Similarly,
in plantarflexion, the posterior tuberosity of the calcaneus moves up
and the navicular moves medially
with respect to the talus.
Because of the integrated meshwork of ligaments, motion in the foot
and ankle joints occurs at all joints
simultaneously. Therefore, motion
at one joint requires motion at another and, similarly, blocking motion
at one joint limits movement at other
joints. Huson called this phenomenon the constraint mechanism.14

Morbid Anatomy
CTEV is a three-dimensional deformity that must be understood
before contemplating corrective
measures. The talus, calcaneus, and
navicular and their corresponding
articulations are the primary in-

Cuboid

Bifurcated
Y ligament

Anterior facet

Middle facet
Posterior facet
Interosseus
talocalcaneal
ligament

Calcaneus

Figure 1 Superior view of the normal relationship and ligamentous attachments between
the bones of the hindfoot and midfoot. (Adapted with permission from Turco VJ, Spinella
AJ: Current management of clubfoot. Instr Course Lect 1982;31:218-234.)

Journal of the American Academy of Orthopaedic Surgeons

David P. Roye, Jr, MD, and Benjamin D. Roye, MD, MPH

volved components. The foot of a

child with CTEV is positioned in
equinus and varus. The talocalcaneonavicular joint space is diminished when the ankle is in equinus
and varus. The soft tissues lose
their elasticity as the ankle is held in
this position, and the absence of
capsular laxity or redundancy inhibits movement.13 Most anatomic
studies concerning this process are
based on postmortem examinations;
however, a recent magnetic resonance imaging (MRI) study by
Downey et al15 has confirmed many
findings in vivo.
Most authors believe the origin of
this deformity is in the talar neck,
which is the only universal deformity in CTEV.13,15,16 The talar neck
is medially rotated, shortened, and
plantarflexed.15 Plantarflexion results in an uncovering of the distal
50% of the articular surface of the
talus that becomes fixed outside the
mortise. The hyaline cartilage surface develops abnormally because it
no longer articulates with the remainder of the joint. Growth of the
anterior talus is stunted, and medial
neck deviation is a progressive deformity. Because growth occurs
preferentially under normal articular surfaces, the talus continues to
grow medially where the medially
subluxated navicular resides.16 The
posterior talus appears as nearly
normal because it remains within
the mortise. Coronal MRI does not
demonstrate any abnormality in this
region of the talus.15
Structurally, the calcaneus is not
as deformed as the talus, displaying
only slight shortening and widening
with mild medial bowing.16 However, the calcaneus is integral to the
positional deformities of CTEV:
equinus, varus, and adduction. 13
The medial growth of the talar head
pulls the calcaneus into adduction
by causing rotation about the interosseous talocalcaneal ligament,
such that the anterior calcaneus is
displaced medially (adduction) and

Vol 10, No 4, July/August 2002

the posterior calcaneus moves

toward the lateral malleolus. This
advances the normal talocalcaneal
joint space medially relative to normal. This rotation creates a parallelism between the anteroposterior
(AP) axis of the talus and calcaneus
(the lateral talocalcaneal angle),
which drops from 28 to approximately 5 in the CTEV foot. 15 In
addition, although the cuboid is
morphologically normal, it is medially displaced and inverted on the
calcaneus17 (Fig. 2).
Fibrotic shortened spring ligaments, the deltoid ligament, and the
posterior tibialis tendon prevent
reduction of the calcaneus distally.
A shortened interosseous talocalcaneal ligament prevents reduction
of the varus and adduction, and the
posterior talocalcaneal joint capsule
and Achilles tendon keep the calcaneus in equinus.13
The navicular is often triangular
in shape and is diminished in size
in proportion to the smaller talar
head.16 It is often located on the
extreme medial border of the talar
head and may even be completely
dislocated from the talus. In severe
forms of CTEV, the navicular can
come into contact with the medial
malleolus. Reduction of the navicular is prevented by many structures, including the deltoid and
spring ligaments, the talonavicular
joint capsule, the posterior tibialis
tendon, and the master knot of
Henry13 (the confluence of the flexor
digitorum longus and flexor hallucis longus muscles).

Physical Examination
Diagnosis of CTEV usually has been
made based on clinical criteria
found at physical examination.
Even today, with adjunctive tools
such as ultrasound, computed tomography, and MRI, CTEV is still
primarily diagnosed in the office or
at cribside. However, in the past 15

Navicular
Talus
Calcaneus
A

Figure 2 A, Superior view of the normal

relationship of the navicular, talus, and
calcaneus. B, In the foot affected by idiopathic CTEV, the talus and calcaneus rotate
laterally and the navicular is subluxated
medially on the talar head. The dashed
line represents the axis of the talus.
(Adapted with permission from Carroll
NC, McMurtry R, Leete SF: The pathoanatomy of congenital clubfoot. Orthop
Clin North Am 1978;9:225-232.)

years, the use of routine prenatal

screening with ultrasound has led to
the antenatal diagnosis of CTEV,
and accuracy is improving as experience is gained. When the diagnosis
is made, amniocentesis is recommended for genetic testing, given
the high incidence (14.2%) of genetic
anomalies associated with CTEV,
including trisomy 18, Larsens syndrome, neural tube defects, and congenital heart defects.18
Although the diagnosis is evident on physical examination in
nearly every case of CTEV, based on
the equinus and varus posture of
the foot (Fig. 3), a complete physical
examination must be done because
of the high incidence of associated
disorders. The examination includes
a detailed neurologic evaluation as
well as assessment of all joints and
the spine.19 When examining the
lower extremities, it is important to
document leg length, thigh and calf
circumference, and skin creases.
Patients with CTEV have a smaller
calf on the affected side compared
with the normal side. The depth of
skin creases on the medial side of

241

Idiopathic Congenital Talipes Equinovarus

Figure 3 Dorsal (A) and plantar (B) views of the foot of a child with idiopathic CTEV.
Note the medial skin creases.

the foot indicates the severity of the

deformity (Fig. 3, B). Documenting
the rigidity of all aspects of the deformity is important because this
may have prognostic implications.
It is also important to differentiate
between CTEV and metatarsus adductus, which lacks any component
of equinus deformity.19

Radiographic Evaluation
Radiographs can be used to confirm
the clinical diagnosis and help rule
out associated abnormalities. However, radiographs are of limited use,
given the eccentrically located ossification centers in the mostly cartilaginous tarsal bones. Additional
studies, including ultrasound, gait
analysis, pedobarographic analysis,
and electrogoniometric analysis,
may be obtained; however, the benefit of routine use of these modalities has not been established.
All radiographs of the foot should
simulate weight bearing (Fig. 4).
The two most commonly used measurements are the lateral and AP
views of the talocalcaneal angle
(Fig. 5). As mentioned, the talocalcaneal angle demonstrates a greater
parallelism in the CTEV foot in both
the lateral and AP views than is
observed in the normal foot. Other
measurements include the tibiotalar
angle, calcaneometatarsal V angle,

242

talometatarsal angle, angle of calcaneal dorsiflexion, and talocalcaneal index, which is a summation
of the AP and lateral talocalcaneal
angles.20
Few data support the value of
preoperative radiographs as a prognostic indicator because there is
wide variability in reported norms.
Postoperative measurements of
radiologic indices have an inconsistent relationship to functional outcome, 21 and several studies have
questioned the association between
radiographic and functional outcomes. 20,22 The use of computed
tomography or MRI in CTEV, other
than in an investigative setting, has
yet to be determined.

Classification
Although several classification systems of CTEV exist,23-26 no single
system is universally accepted. As
with other diagnoses, a satisfactory
classification system for CTEV
should identify patients likely to
improve from nonsurgical, limited
surgical, or extensive surgical intervention. This will help avoid patients undergoing unnecessary and
possibly harmful interventions.24
The Harrold and Walker scheme25
was based on the reducibility of the
equinovarus deformity by manipulation. Patients with a foot that was

manipulable to or beyond neutral

were described as grade I (mild).
Those with a varus and/or equinus
deformity manipulable to within 20
of neutral were described as grade II
(moderate). Patients whose deformity (either varus or equinus) could
not be manipulated to within 20 of
neutral were described as grade III
(severe). The authors found that
patients with mild CTEV had an
89% success rate with serial casting
versus 46% and 10%, respectively,
for those with moderate and severe
disease. Additionally, there was increased postoperative recurrence in
the higher-grade deformities.25
Catterall24 made several important general observations in describing his standardized assessment of
CTEV. He stated that when differentiating the CTEV foot from the
normal foot, the essential differences are the fixed deformities and
loss of movement present. The fixed
deformities are the result of tight
structures (ligaments and tendons),
whichmay be thought of as tethers. Based on these observations,
Catterall created an assessment form
that appraised creases, range of
motion, cavus, and the lateral border
of the foot, among other variables.24
The results were used to define four
patterns of soft-tissue contracture:
resolving, tendon, joint, and false
correction.
Flynn et al23 compared the systems of Dimeglio et al27 and Pirani
et al28 for reproducibility and found
that, after an initial learning curve,
both classification schemes showed
very good interobserver reliability.
Both systems graded clubfeet by
assigning numeric value to the
rigidity of the various aspects of the
deformity, the shape of the foot, and
the palpable bony abnormalities.
Flynn et al23 found that examiners
scores were within 10% of each
other approximately 90% of the
time in both schemes, and correlation coefficients approached 0.90 for
both schemes.

Journal of the American Academy of Orthopaedic Surgeons

David P. Roye, Jr, MD, and Benjamin D. Roye, MD, MPH

Figure 4 A, Anteroposterior radiograph of an infant with idiopathic CTEV of the right foot. Note the parallelism between the talus and
calcaneus. The normal left foot is shown for comparison. B, Lateral radiograph of the right clubfoot with simulated weight-bearing. The
long axes of the talus and calcaneus are nearly parallel. C, Lateral radiograph of the normal left foot.

It is not clear how age, growth

and development, and manipulative
treatment affect these classification
schemes. That is, the classification
may change depending on the age at
which the child is examined or after
a trial of manipulation. Currently,
the most widely used severity reporting systems are variations on
the Harrold and Walker system.25

Nonsurgical Management
Nearly all authors agree that initial
CTEV treatment should be nonsurgical, regardless of the severity of the
deformity.1,25 Historically, treatment
consisted of forcible serial manipulation under anesthesia, followed by
casting.1 Some authors, including
Kite1 and McKay,29 have championed the use of serial casting with
minimal force (not requiring anesthesia) and have stressed the importance and potential for success of this
treatment. Kite1 claimed to have successfully treated more than a thousand patients with CTEV with serial
casting over a span of 45 years and
asserted that medial releases and
tenotomies are for those who lack
patience or who have not acquired
the art of applying well fitting casts.
Casting remains the standard initial
care for all patients born with CTEV,
regardless of the severity.

Vol 10, No 4, July/August 2002

Kite 1 and Grant and Atar 6 emphasized that deformities must be

corrected in the following order:
adduction, varus, equinus. In other
words, the correction must begin
distally and work proximally. The
calcaneus cannot be dorsiflexed
until it is rotated from under the
talus (ie, correction of adduction),
and attempts to do so will bring
only the forefoot out of equinus and
result in the so-called rocker-bottom
foot.6 A short leg plaster cast with
minimal padding is most commonly
used. This cast should be changed
every week for the first 6 weeks,
then every 2 weeks until the age of 4
to 6 months.25 If this is successful,
many authors recommend following the casting regimen with use of
a splint or brace that may be prescribed for a lengthy period.
Despite Kites reported success
with his casting method, most authors describe a success rate of <50%,
usually closer to 15%, depending on
the severity of the deformity.30 This
should not, however, belittle the importance of casting because casting
provides at least a partial correction
of the deformity that will facilitate
any future surgery.
Laaveg and Ponseti31 modified
the Kite casting technique and reported success rates approaching
90% without the use of a traditional
open release. The casting technique

involved reducing the talonavicular

joint by externally rotating the forefoot around the talus, a maneuver
that also corrects adduction. After
the talonavicular joint is reduced,
which may take several casts, the
foot is dorsiflexed to neutral. In 70%
of cases, this requires an Achilles

Cu

Ca

Cu

Ca
T

Cu

Cu

Ca
T
B

Ca

Figure 5 A and B, Normal foot. C and D,

Clubfoot. The talocalcaneal angle is determined by the intersection of lines drawn
through the long axes of the talus (T) and
calcaneus (Ca) in the lateral and anteroposterior projections. Note the increased parallelism in the clubfoot compared with the
normal foot. Cu = cuboid.

243

Idiopathic Congenital Talipes Equinovarus

tenotomy, which can be done in the
office.31 The protocol of Laaveg and
Ponseti calls for splinting in a Denis
Browne bar full time until the child
is pulling to stand, then at night
only. The splinting may be continued until the child is of school age
(average, 49 months). Nearly 50%
of patients require anterior tibial
tendon transfers to maintain the
reduction.31 Although there is anecdotal evidence that the rates of tenotomies and tendon transfers have
dropped, no reports in the literature
support this claim.
Advocates assert that nearly
every case of idiopathic CTEV can
be successfully treated with this
essentially nonsurgical technique.
Ankle motion, radiographs, and
function are at least as good as those
in patients treated surgically. Critics, however, note that this is not a
nonsurgical technique because most
children require an Achilles tendon
lengthening and many require a
tendon transfer. In addition, many
of the failures are attributed to
patient/parent noncompliance with
bracing. This is important because
cooperation with nightly bracing for
5 years or longer is difficult in many
populations.
Splinting is another nonsurgical
treatment; most surgeons use some
modification of the Denis Browne
splint. The results of splinting are
similar to those of serial casting,
with success rates of 20% to 40%,
although some have reported success rates of 55% to 65%.25,32
Whereas casting and splinting
are the mainstays of nonsurgical
intervention for CTEV in North
America, many Europeans use physiotherapy and continuous passive
motion without immobilization.26,33
Although long-term results are not
yet available, early reports are
encouraging.33 This aggressive approach, consisting of daily manipulative therapy with splinting, is also
being evaluated at centers in the
United States.

244

Surgical Management
Surgery is the only recourse if nonsurgical measures fail to correct the
CTEV deformity. However, failure
of nonsurgical intervention is not
described by consistent criteria.
Most authors cite failure when the
affected foot fails to attain an anatomic or neutral position after 3 to 6
months of treatment, or earlier if the
rate of improvement from the treatment plateaus.26,29,34
Timing of surgery is critical
when it has been determined that
nonsurgical treatment has failed.
Although no ideal window for
surgery has been identified, there
are general guidelines. Attempts at
surgical treatment within the neonatal period have not proved to be
successful. 35 Green and LloydRoberts reported that surgery done
before 6 months of age leads to
increased scar formation.36 In infants less than 3 to 6 months of age,
foot size makes the surgery more
technically demanding and may
detrimentally affect outcomes.
Some surgeons prefer to wait until
the child is 9 months old.1 Simons37
advocates waiting for the foot
length to reach a minimum length
of 8 cm. Another consideration is
the safety of anesthesia in larger
compared with smaller infants. 34
However, opinion is universal that
the primary surgery should be
done in the first year of life if possible (ie, 6 to 12 months of age) because much of the potential for
growth and remodeling is diminished after this period.34
The goal of surgery is to restore,
or create, as normal a foot as possible. This involves reestablishing the
anatomic relationships between the
bones of the foot and ankle, particularly the talus, calcaneus, navicular,
and cuboid. Additionally, the surgeon must be careful to balance the
surrounding soft tissues to help
maintain the correction achieved at
surgery.34

Soft-Tissue Release
When considering surgery for
CTEV, one must first determine
what should be released.34 Although
some think that any surgery requires
a comprehensive release of all soft
tissues, Carroll,34 Bensahel et al,26
and Grant and Atar,6 among others,
plan for and approach each case
individually. In his classification
scheme, Catterall24 suggested what
Grant and Atar stated: The surgeon
should identify what failed in the
conservative treatment because
these are the structures that need release.6
Four regions may require release.
(1) Release of the plantar fascia
allows correction of forefoot equinus (cavus) and realignment of the
first ray with the talus. (2) A calcaneocuboid release laterally realigns
the cuboid with the long axis of the
calcaneus and straightens the lateral
border of the foot. (3) A medial
release realigns the navicular on the
talus, moves it away from the medial
malleolus, and adds midfoot mobility. This portion of the release includes a number of structures, with
the extent and completeness depending on the individual surgeon.34 The abductor hallucis muscle must be taken down to gain
access to the medial structures, and
the posterior tibial tendon is usually
lengthened. A talonavicular capsulotomy is always included, but the
extent of release varies widely.
Additionally, the subtalar and calcaneocuboid capsules are usually
incised, although Bensahel et al26
feel the subtalar joint does not need
to be violated. The superficial deltoid and spring ligaments also are
commonly incised, as is the knot of
Henry. (4) A posterior release corrects the equinus deformity and is
the only universally required release. 34 This release always involves the Achilles tendon and posterior tibiotalar joint capsule. The
posterior subtalar joint is usually
included, as are the posterior talo-

Journal of the American Academy of Orthopaedic Surgeons

David P. Roye, Jr, MD, and Benjamin D. Roye, MD, MPH

fibular, posterior deltoid, and tibiofibular ligaments.34 Bensahel et al26

stressed the importance of placing
the Achilles and posterior tibial tendons under some tension when they
are repaired because the strength of
their muscles is vital for a normally
functioning foot.

Surgical Technique
The surgical procedures used for
CTEV over the past three decades
have evolved from minimal surgery
to extensive release, then a return to
a more limited release based on
individual patient findings.34 The
initial reports of surgery were of
posterior releases.38 Limited success
with this technique led to the development of the one-stage posteromedial release.39 The posterior release
addressed only the equinus deformity and, as mentioned, the talus
may block attempts to bring the calcaneus out of equinus if the adduction and varus components of the
deformity are not addressed first.
In 1971, Turco 39 published the
early results of his posteromedial
release, a technique that quickly
gained widespread acceptance. This
approach utilized a single, straight
medial incision extending from the
base of the first metatarsal, under
the medial malleolus, to the Achilles
tendon. The extensive releases included nearly all of the medial and
posterior structures already mentioned. Turco was the first to promote the use of internal fixation to
maintain reduction of the talonavicular joint. In his 15-year follow-up
study,40 he reported 84% excellent
or good results, with only 7% of
feet demonstrating recurrent disease. Notably, 70% of feet in the
fair category (11% of all feet) were
overcorrected with this aggressive
release.40
Carroll et al41 in 1978 reported a
comprehensive release technique
using a chevron-shaped medial incision and a straight posterior incision
to allow better visualization of the

Vol 10, No 4, July/August 2002

Achilles tendon. Differences from

the Turco procedure included leaving the interosseous talocalcaneal
ligament intact and more complete
releases of the talonavicular, subtalar, and calcaneocuboid capsules.
The long-term results of the Carroll
procedure were compared with
those of more limited posterior
releases from the same institution.
Functional scores were not significantly different between the two
groups; however, patients undergoing the Carroll procedure had significantly fewer surgeries (P = 0.04)
and less stiffness (P = 0.01).42
In the 1980s, McKay 29 and
Simons37 both reported success with
aggressive, wide subtalar release.
McKays procedure was done
through the Cincinnati incision,
which extends from the navicular
on the medial foot posteriorly,
around the medial malleolus and
across the Achilles tendon, ending
by the lateral malleolus. This incision has been used for several foot
and ankle procedures and provides
excellent exposure with a minimum
of scarring29,43 (Fig. 6). However,
this exposure theoretically places
the heel flap at risk of ischemia in
addition to providing less than optimal exposure for release of the plantar fascia and Achilles tendon.34
More recent studies have indicated a return to a more limited release
for CTEV. Yngve et al44 reported
82% excellent or good results for
their limited CTEV surgery without
wide subtalar release. Although a
greater proportion of their patients
required revision surgery than did
patients in other studies (21% versus 5% to 9%), they also had a lower
incidence of overcorrection (4% versus 8% to 20%), which the authors
stated is a more difficult problem to
treat.29,39,44 However, as McKay29
pointed out, revision CTEV surgery is
very difficult and should be avoided.

Postoperative Care
There are as many postoperative

regimens as there are surgical interventions for CTEV. Although all

surgeons recommend cast immobilization, whether to put the plaster
on in the operating room29,37,39 or 1
week postoperatively is still debated.26,34 Additionally, there is no
agreement as to the type or duration
of immobilization. Options range
from a short leg cast34 to a long leg
cast 26,37,39 to a cast hinged at the
ankle.29 The length of immobilization ranges from 4 weeks 26 to 4
months.39 Also, many authors utilize
some sort of postimmobilization
splinting, which ranges from shortterm use of orthotics34 to a Denis
Browne splint39 or night brace37 for
up to 2 years.

Complications of
Nonsurgical Management
Crawford and Gupta 30 recently
published a detailed explanation of
complications related to nonsurgical
and surgical management of CTEV.
Although generally considered safer
than surgery, manipulation and serial casting are not without complications. Additionally, nonsurgical
treatment is successful only in about
15% to 50% of cases. 30 Pressure
sores are common if too much pressure and not enough padding are

Figure 6 Medial (left) and posterior (right)

views of the Cincinnati incision (dashed
line). (Adapted with permission from
Crawford AH, Marxen JL, Osterfeld DL:
The Cincinnati incision: A comprehensive
approach for surgical procedures of the
foot and ankle in childhood. J Bone Joint
Surg Am 1982;64:1355-1358.)

245

Idiopathic Congenital Talipes Equinovarus

used during cast application. Although avoidable and less common,
fractures can occur when excessive
force is used. Other complications
related to excessive force include
the flattop talus, which occurs when
the talus is crushed between the
tibia and calcaneus during forced
foot dorsiflexion.30
A rocker-bottom deformity results from attempting to force correction of the equinus deformity
before correcting the adduction and
varus components of the deformity.
In this situation, the forefoot becomes dorsiflexed without correction of the calcaneal plantarflexion
that is blocked by the talus, as described. Similarly, the bean-shaped
foot deformity occurs when correction of adduction is attempted before the varus deformity is reduced
because the abductive forces are
transmitted to the hindfoot.30

Complications of Surgical
Management
Several iatrogenic injuries can occur
during surgery for CTEV. After
repair, the posterior tibial artery is
placed on stretch when the equinus
deformity is corrected, which can
lead to vascular compromise. This
vessel takes on increased importance
in CTEV because an absent dorsalis
pedis artery has often been described
in this population.30,45 Releasing the
plantar fascia and casting in equinus
are two ways to avoid this complication.30,45 Transection of the artery is
unusual but is more common during
revision cases in which scarring has
obliterated normal planes. Unless
the posterior tibial artery is the sole
vascular supply to the foot, repair is
not usually needed.
As is evident on radiographs, an
infants tarsal bones are mostly cartilaginous and therefore soft and
susceptible to injury from surgical
instruments. Transection of the
head of the talus and sustentaculum

246

tali can occur during attempted capsulotomies. Careful dissection on

larger feet (infants older than 9
months or whose feet are longer
than 8 cm)1,30,37 and confirming the
location of joint spaces by aspirating
joint fluid can help avoid this complication. Should transection occur,
the anatomic reduction and pinning
of the fragment usually prevents
sequelae. 45 Another injury more
common in smaller feet is damage
to the posterior tibial physis, distal
fibular physis, or first metatarsal
physis. Early physeal closure leads
to deforming forces on the foot and
usually requires treatment consisting of bar excision of the physis
with fat interposition.30,45
Aside from direct bone injury, the
talus and navicular are susceptible
to osteonecrosis. Talar osteonecrosis, a result of extensive dissection, is
relatively common, occurring in
0.5%45 to 14%30 of cases. Treatment
is initially symptomatic, but arthrodesis may be necessary in some
cases.30,45 Osteonecrosis of the navicular may result in the classic wedgeshaped deformity. As with the
talus, treatment is symptomatic with
arch supports, and the navicular
usually reossifies without sequelae.
Wound-healing problems can
result from stretching the contracted
medial skin, especially in patients
with severe CTEV and in older children. Some authors recommend
allowing the incision to heal with
the foot remaining in slight equinus
and casting into the corrected position
after 1 to 2 weeks.43 Additionally,
the incision can be left open and
allowed to granulate if the closure is
thought to be too tight.30 Preoperative stretching of the medial skin,
maintenance of hemostasis during
surgery, two-layer closures, and use
of a drain will help reduce postoperative wound problems.30
Undercorrection can be prevented
with adequate soft-tissue releases
during surgery, with adequate internal and external fixation postop-

eratively. Simons37 and Tarraf and

Carroll46 recommend routine use of
intraoperative radiographs to confirm adequate correction. Persistent
equinus occurs after inadequate
release of posterior structures, and
treatment consists of splinting followed by revision release.30 Persistent heel varus results from inadequate subtalar release and failure to
correct calcaneal horizontal rotation.
Revision consisting of either softtissue release or osteotomy is required
to correct the problem.30 Persistent
forefoot adduction results from inadequate release of the navicular
cuneiform first metatarsal capsules,
the calcaneocuboid joint, and the
abductor hallucis muscle, and becomes more evident with growth.
Adduction is a very common component of residual deformity, occurring in 50% to 95% of cases. 30
Splinting may correct mild deformity, but moderate and severe
deformities require revision surgery
for soft-tissue release, metatarsal
osteotomy,30 and/or lateral border
shortening and medial border
lengthening. Tarraf and Carroll46
evaluated intraoperative radiographs and found that >50% of revisions performed for adduction had
evidence of incomplete correction of
this deformity at the time of surgery.
Depending on technique and disease severity, from 7%40 to 47%31 of
clubfeet have one or more revision
procedures. Failure should not occur in the acute setting because sufficient soft-tissue release should be
obtained intraoperatively, and
Kirschner wires should be used to
hold fixation until the tarsal bones
begin to remodel.30 When surgery
becomes necessary to correct recurrent deformity, some surgeons turn
to the Ilizarov multiplanar external
fixator to correct the deformity
gradually. Although the Ilizarov
technique is a powerful tool, it is
technically demanding and may be
complicated by pin-tract infections
and even osteomyelitis.47 If recur-

Journal of the American Academy of Orthopaedic Surgeons

David P. Roye, Jr, MD, and Benjamin D. Roye, MD, MPH

rence occurs despite an initial good

correction, spinal cord MRI should
be considered to rule out a spinal
lesion that may be contributing to
the deformity.
Overcorrection, which can be
more difficult to treat than undercorrection,29,39,44 may require surgical treatment. Overcorrection can
occur in any direction, including a
valgus hindfoot, forefoot abduction,
calcaneus deformity (excessive dorsiflexion), and pes planus. Hindfoot
valgus is often a result of transection of the deep deltoid ligament,
which should be preserved. 30,45
Forefoot abduction can occur after
transfer of the tibialis anterior
tendon into the base of the fifth
metatarsal, calcaneocuboid fusion
(Dillwyn-Evans procedure), metatarsal osteotomy, and tarsometatarsal
capsulotomy.30,45 Overlengthening
of the Achilles tendon, which can
lead to the calcaneus deformity that
causes heel walking, can be avoided
by tensioning the Achilles tendon
repair sutures with the ankle in 5 of
plantarflexion. Surgical correction
usually consists of a release of dorsal soft tissues, but results are seldom fully satisfactory.30 Pes planus
can occur after complete release of
the talocalcaneal ligament, release of
the tibialis posterior tendon, and
release of the spring ligament. This
can be prevented with a Z-plasty of
the tibialis posterior tendon and a
limited release of the plantar fascia,
especially in patients with a rockerbottom deformity. Treatment begins
with an arch support, but a lateral

calcaneal lengthening or triple

arthrodesis may become necessary
in rigid, painful feet.30

dardized method of evaluating

CTEV interventions. This method
of evaluation is gaining acceptance
as an integral component of outcomes reporting.

Evaluating Outcomes
Historically, outcomes evaluations
of CTEV treatment have used socalled intermediate end points,
such as radiographic angles and
physician-based assessments. The
utility of such measures, especially
radiographic data, has been questioned for more than three decades. 22,48 A recent study by
Herbsthofer et al 20 found a high
standard deviation in measurements of standard angles in both
normal and CTEV feet. These
results also confirmed the findings
of McKay21 demonstrating a lack of
correlation between these angles
and function. Because of this,
Herbsthofer et al concluded that
diagnosis of CTEV should be
undertaken mainly on the basis of
clinical examination, and that outcome scores relying on [radiographic angles] as a basis of evaluation mustbe viewed critically.20
Laaveg and Ponseti31 devised a
functional rating system that has
been widely adopted and incorporates such domains as patient satisfaction and pain, together with
more traditional end points, such as
gait, heel position, and range of
motion. Roye et al22 developed and
validated a CTEV-specific outcomes
assessment that used qualitative
research techniques to create a stan-

Summary
The etiology of CTEV remains
unknown, and the full extent of the
morbid anatomy is just beginning to
be understood with the aid of modern imaging techniques. Evaluation
continues to rely primarily on physical examination and radiographs,
although there is evidence that ultrasound and MRI may play a larger
role. There is no widely accepted
method of classification or posttreatment outcomes assessment.
The numerous management strategies include continuous dynamic
treatment with physical therapy
and continuous passive motion,
early percutaneous Achilles tendon
lengthening with casting, casting
and manipulation, and surgery.
The orthopaedic surgeon must use
evidence and experience to guide
treatment, which should begin
with careful assessment of the
entire child and gentle manipulation therapy with splinting and/or
casting, followed by measured and
thoughtful application of surgery
to the residual deformity. Progress
in the treatment of CTEV will be
based on further understanding the
anatomic changes and their etiology, as well as improving therapeutic methods.

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Journal of the American Academy of Orthopaedic Surgeons