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

 Streetersdysplasia
 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
 Fourbasic
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
 McKay’s 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
 Talonavicular joint realignment is
opposed by- posterior tibial tendon
- deltoid ligament
- spring ligament
- joint capsule
- dorsal talonavicular ligament
- bifurcated Y ligamant
 Calcaneocuboid 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
 Talus–firstmetatarsal
angle Anteroposterior
view: 5-15 degrees
 Treatment
 Non operative – Ponseti technique
Kite technique
French technique
 Surgical–Posteromedial 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
 Kite’s 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
 Ilizarovand JESS are
for older children with
recurrence or residual
deformity
THANK YOU