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 ed the fixed equinovarus deformity.2
is no consensus as to the best treatment. Increasingly, ultrasound is being used However, this argument has been
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to diagnose the condition prenatally, but the diagnosis remains clinical postna- systematically countered and has
tally. Radiographs can help confirm the diagnosis and ascertain the severity of fallen from favor.5,6 Current theo-
the condition. There are many classification schemes, but none offers adequate ries encompass environmental and
prognostic value. The mainstay of treatment is manipulation and casting, usu- genetic factors.
ally followed by soft-tissue release. However, some patients have been success- Data from several studies show
fully treated with intensive physiotherapy instead of surgery. abnormal muscle development,
J Am Acad Orthop Surg 2002;10:239-248 including type I fiber predominance
and grouping. Whether this is
because of genetic factors, neuro-
trophic factors, or denervation is
Idiopathic congenital talipes equi- 1,000 live births. All populations unclear. Histologic and ultrastruc-
novarus (CTEV), also known as show a consistent 2:1 male predomi- tural examination of the soft tissues
clubfoot, has been a recognized nance, and bilateral disease occurs in of the CTEV foot by both Kojima et
deformity since the time of the approximately 50% of cases.2 al7 and Handelsman and Glasser8
ancient Egyptians and was indepen- In developed countries, untreat- revealed a predominance of type I
dently described by both Hippoc- ed CTEV beyond early childhood is muscle fibers in the lower legs of
rates and the Aztecs. Initial treat- rarely seen. However, CTEV is not a patients with CTEV feet, a fiber type
ment options all were variations on self-limited disease. The deformity IIB deficiency, and abnormal fiber
manipulation and splinting. Surgi- continues to develop beyond skele- grouping. Although there was no
cal intervention began in the late tal maturity. 3 The patient with direct evidence of abnormal inner-
1700s with Lorenz’s Achilles tenoto- uncorrected CTEV walks on the vation, Handelsman and Glasser8
my, but effective soft-tissue releases, dorsolateral aspect of the affected asserted that fiber grouping is
osteotomies, and tendon releases foot and develops a callus, hyper- known to be a consequence of de-
were not developed until the late pigmentation, and a subcutaneous nervation. The changes in the sar-
1800s with the advent of anesthesia bursa. Additionally, the subtalar coplasmic reticulum and mitochon-
and aseptic technique. In 1930, Kite and midtarsal joints become stiff. dria, as well as the loss of myofibrils,
popularized gentle manipulation The rate of collagen synthesis in- were all compatible with a neuro-
and serial casting, which remains creases postnatally, which may
the initial treatment of choice. 1 account for the stiffening of affected
Although the basic surgical concepts feet after birth.4 Treatment options
have not changed, techniques for the are complicated by the fact that Dr. D. P. Roye is Livingston Professor of
treatment of resistant CTEV continue there is usually little pain in the Orthopaedic Surgery, Children’s Hospital of
to be developed. affected foot.3 New York, New York, NY. Dr. B. D. Roye is
The incidence of CTEV varies Resident, New York Orthopaedic Hospital,
New York.
widely with respect to race and
geography. In Japan, this condition Pathogenesis Reprint requests: Dr. D. P. Roye, 8th Floor N,
affects approximately 0.5 per 1,000 3959 Broadway, New York, NY 10032-1537.
live births, and in natives of the The cause of CTEV remains unclear.
South Pacific, the incidence jumps to Before the 1980s, many physicians Copyright 2002 by the American Academy of
nearly 7 per 1,000 live births. In all believed Hippocrates’ hypothesis Orthopaedic Surgeons.
Caucasians, the incidence is 1.2 per that intrauterine compression creat-

Vol 10, No 4, July/August 2002 239

Idiopathic Congenital Talipes Equinovarus
genic etiology.7,8 Localized soft-tissue
contracture also may be involved.
In one study,9 100% of deltoid liga-
ments resected from virgin clubfeet
but only 8% of control specimens
stained positive for vimentin,10 a rel-
atively nonspecific marker that may
be seen in fetal cells but also in myo-
fibroblasts 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 posi-
tive family history.2,11 Recent evi-
dence 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 talocal-
caneal bar and chromosomal, viral,
and vascular etiologies.6 Constrict-
ing annular bands also have been
implicated as an etiologic factor in
CTEV. Although elusive, the etiolo-
gy of CTEV seems to be most con-
sistent with multifactorial inheri-
tance.2,11
Secondary etiologies, mostly neu-
romuscular 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 agene-
sis, and other paralytic states.6
Normal Anatomy and
Biomechanics
Understanding CTEV requires a
thorough knowledge of the anato-
my 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 calca-
neus and navicular.
The complex relationship be-
tween the talus, calcaneus, and na-
vicular bones has been called the
talocalcaneonavicular joint or com-
plex.13 This joint involves four artic-
ular 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 ten-
don, and the deltoid, spring, “Y” or
bifurcated, and interosseous talocal-
caneal 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 calca-
neus rotate about the talar head.
Additionally, inversion and ever-
sion require talonavicular move-
ment. Vertical movement in the
Navicular
Navicular
articular facet
Talonavicular
joint capsule
Middle 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
sagittal plane occurs mostly through
the tibiotalar joint. Dorsiflexion is
associated with concurrent prona-
tion 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 tu-
berosity of the calcaneus moves up
and the navicular moves medially
with respect to the talus.
Because of the integrated mesh-
work of ligaments, motion in the foot
and ankle joints occurs at all joints
simultaneously. Therefore, motion
at one joint requires motion at an-
other and, similarly, blocking motion
at one joint limits movement at other
joints. Huson called this phenome-
non the constraint mechanism.14
Morbid Anatomy
CTEV is a three-dimensional defor-
mity 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
Posterior facet

volved components. The foot of a
child with CTEV is positioned in
equinus and varus. The talocalca-
neonavicular joint space is dimin-
ished 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 in-
hibits movement.13 Most anatomic
studies concerning this process are
based on postmortem examinations;
however, a recent magnetic reso-
nance 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 defor-
mity in CTEV.13,15,16 The talar neck
is medially rotated, shortened, and
plantarflexed.15 Plantarflexion re-
sults in an “uncovering” of the distal
50% of the articular surface of the
talus that becomes fixed outside the
mortise. The hyaline cartilage sur-
face develops abnormally because it
no longer articulates with the re-
mainder of the joint. Growth of the
anterior talus is stunted, and medial
neck deviation is a progressive de-
formity. Because growth occurs
preferentially under normal articu-
lar 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 How-
ever, 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 in-
terosseous talocalcaneal ligament,
such that the anterior calcaneus is
displaced medially (adduction) and
Vol 10, No 4, July/August 2002
David P. Roye, Jr, MD, and Benjamin D. Roye, MD, MPH
the posterior calcaneus moves
toward the lateral malleolus. This
advances the normal talocalcaneal
joint space medially relative to nor-
mal. This rotation creates a paral-
lelism between the anteroposterior
(AP) axis of the talus and calcaneus
(the lateral talocalcaneal angle),
which drops from 28° to approxi-
mately 5° in the CTEV foot. 15 In
addition, although the cuboid is
morphologically normal, it is medi-
ally displaced and inverted on the
calcaneus17 (Fig. 2).
Fibrotic shortened spring liga-
ments, the deltoid ligament, and the
posterior tibialis tendon prevent
reduction of the calcaneus distally.
A shortened interosseous talocal-
caneal ligament prevents reduction
of the varus and adduction, and the
posterior talocalcaneal joint capsule
and Achilles tendon keep the calca-
neus 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 navic-
ular is prevented by many struc-
tures, 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 hallu-
cis 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 to-
mography, and MRI, CTEV is still
primarily diagnosed in the office or
at cribside. However, in the past 15
Navicular
Talus
Calcaneus
A B
Figure 2 A, Superior view of the normal
relationship of the navicular, talus, and
calcaneus. B, In the foot affected by idio-
pathic 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 patho-
anatomy 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 experi-
ence is gained. When the diagnosis
is made, amniocentesis is recom-
mended for genetic testing, given
the high incidence (14.2%) of genetic
anomalies associated with CTEV,
including trisomy 18, Larsen’s syn-
drome, neural tube defects, and con-
genital heart defects.18
Although the diagnosis is evi-
dent 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
A B
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 de-
formity is important because this
may have prognostic implications.
It is also important to differentiate
between CTEV and metatarsus ad-
ductus, 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. How-
ever, radiographs are of limited use,
given the eccentrically located ossi-
fication centers in the mostly carti-
laginous tarsal bones. Additional
studies, including ultrasound, gait
analysis, pedobarographic analysis,
and electrogoniometric analysis,
may be obtained; however, the ben-
efit of routine use of these modali-
ties has not been established.
All radiographs of the foot should
simulate weight bearing (Fig. 4).
The two most commonly used mea-
surements are the lateral and AP
views of the talocalcaneal angle
(Fig. 5). As mentioned, the talocal-
caneal 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 cal-
caneal dorsiflexion, and talocal-
caneal index, which is a summation
of the AP and lateral talocalcaneal
angles.20
Few data support the value of
preoperative radiographs as a prog-
nostic indicator because there is
wide variability in reported norms.
Postoperative measurements of
radiologic indices have an inconsis-
tent relationship to functional out-
come, 21 and several studies have
questioned the association between
radiographic and functional out-
comes. 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 sys-
tems 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 inter-
vention. This will help avoid pa-
tients’ undergoing unnecessary and
possibly harmful interventions.24
The Harrold and Walker scheme25
was based on the reducibility of the
equinovarus deformity by manipu-
lation. Patients with a foot that was
Journal of the American Academy of Orthopaedic Surgeons
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 defor-
mity (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 in-
creased postoperative recurrence in
the higher-grade deformities.25
Catterall24 made several impor-
tant general observations in describ-
ing his standardized assessment of
CTEV. He stated that when differ-
entiating the CTEV foot from the
normal foot, “the essential differ-
ences are the fixed deformities and
loss of movement present. The fixed
deformities are the result of tight
structures (ligaments and tendons),
which…may be thought of as teth-
ers.” 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 sys-
tems 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 correla-
tion coefficients approached 0.90 for
both schemes.

A B
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 re-
porting systems are variations on
the Harrold and Walker system.25
Nonsurgical Management
Nearly all authors agree that initial
CTEV treatment should be nonsurgi-
cal, regardless of the severity of the
deformity.1,25 Historically, treatment
consisted of forcible serial manipula-
tion under anesthesia, followed by
casting.1 Some authors, including
Kite1 and McKay,29 have champi-
oned the use of serial casting with
minimal force (not requiring anes-
thesia) and have stressed the impor-
tance and potential for success of this
treatment. Kite1 claimed to have suc-
cessfully treated more than a thou-
sand 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
David P. Roye, Jr, MD, and Benjamin D. Roye, MD, MPH
C
Kite 1 and Grant and Atar 6 em-
phasized 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 follow-
ing the casting regimen with use of
a splint or brace that may be pre-
scribed for a lengthy period.
Despite Kite’s reported success
with his casting method, most au-
thors describe a success rate of <50%,
usually closer to 15%, depending on
the severity of the deformity.30 This
should not, however, belittle the im-
portance 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 re-
ported success rates approaching
90% without the use of a traditional
open release. The casting technique
involved reducing the talonavicular
joint by externally rotating the fore-
foot 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
Ca T Cu
Cu
Ca
T
A C
Cu
Cu
Ca
T T Ca
B D
Figure 5 A and B, Normal foot. C and D,
Clubfoot. The talocalcaneal angle is deter-
mined by the intersection of lines drawn
through the long axes of the talus (T) and
calcaneus (Ca) in the lateral and anteropos-
terior projections. Note the increased par-
allelism 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 contin-
ued 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 anec-
dotal evidence that the rates of tenot-
omies 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. Crit-
ics, 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 suc-
cess 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 phys-
iotherapy and continuous passive
motion without immobilization.26,33
Although long-term results are not
yet available, early reports are
encouraging.33 This aggressive ap-
proach, consisting of daily manipu-
lative therapy with splinting, is also
being evaluated at centers in the
United States.
244
Surgical Management
Surgery is the only recourse if non-
surgical 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 ana-
tomic or neutral position after 3 to 6
months of treatment, or earlier if the
rate of improvement from the treat-
ment 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 neona-
tal period have not proved to be
successful. 35 Green and Lloyd-
Roberts reported that surgery done
before 6 months of age leads to
increased scar formation.36 In in-
fants 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 possi-
ble (ie, 6 to 12 months of age) be-
cause much of the potential for
growth and remodeling is dimin-
ished after this period.34
The goal of surgery is to restore,
or create, as normal a foot as possi-
ble. This involves reestablishing the
anatomic relationships between the
bones of the foot and ankle, particu-
larly the talus, calcaneus, navicular,
and cuboid. Additionally, the sur-
geon must be careful to balance the
surrounding soft tissues to help
maintain the correction achieved at
surgery.34
Journal of the American Academy of Orthopaedic Surgeons
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 re-
lease.6
Four regions may require release.
(1) Release of the plantar fascia
allows correction of forefoot equi-
nus (cavus) and realignment of the
first ray with the talus. (2) A calca-
neocuboid 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 mobil-
ity. This portion of the release in-
cludes a number of structures, with
the extent and completeness de-
pending on the individual sur-
geon.34 The abductor hallucis mus-
cle must be taken down to gain
access to the medial structures, and
the posterior tibial tendon is usually
lengthened. A talonavicular capsu-
lotomy is always included, but the
extent of release varies widely.
Additionally, the subtalar and calca-
neocuboid capsules are usually
incised, although Bensahel et al26
feel the subtalar joint does not need
to be violated. The superficial del-
toid and spring ligaments also are
commonly incised, as is the knot of
Henry. (4) A posterior release cor-
rects the equinus deformity and is
the only universally required re-
lease. 34 This release always in-
volves the Achilles tendon and pos-
terior tibiotalar joint capsule. The
posterior subtalar joint is usually
included, as are the posterior talo-

fibular, posterior deltoid, and tibio-
fibular ligaments.34 Bensahel et al26
stressed the importance of placing
the Achilles and posterior tibial ten-
dons 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 devel-
opment of the one-stage posterome-
dial release.39 The posterior release
addressed only the equinus defor-
mity and, as mentioned, the talus
may block attempts to bring the cal-
caneus out of equinus if the adduc-
tion 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 in-
cluded nearly all of the medial and
posterior structures already men-
tioned. Turco was the first to pro-
mote the use of internal fixation to
maintain reduction of the talonavic-
ular joint. In his 15-year follow-up
study,40 he reported 84% “excellent
or good” results, with only 7% of
feet demonstrating recurrent dis-
ease. 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 inci-
sion and a straight posterior incision
to allow better visualization of the
Vol 10, No 4, July/August 2002
David P. Roye, Jr, MD, and Benjamin D. Roye, MD, MPH
Achilles tendon. Differences from
the Turco procedure included leav-
ing the interosseous talocalcaneal
ligament intact and more complete
releases of the talonavicular, subta-
lar, 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 signifi-
cantly different between the two
groups; however, patients undergo-
ing the Carroll procedure had sig-
nificantly 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.
McKay’s 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 inci-
sion 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 opti-
mal exposure for release of the plan-
tar fascia and Achilles tendon.34
More recent studies have indicat-
ed 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% ver-
sus 5% to 9%), they also had a lower
incidence of overcorrection (4% ver-
sus 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 inter-
ventions for CTEV. Although all
surgeons recommend cast immobi-
lization, whether to put the plaster
on in the operating room29,37,39 or 1
week postoperatively is still de-
bated.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 immobiliza-
tion ranges from 4 weeks 26 to 4
months.39 Also, many authors utilize
some sort of postimmobilization
splinting, which ranges from short-
term 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 se-
rial casting are not without compli-
cations. Additionally, nonsurgical
treatment is successful only in about
15% to 50% of cases. 30 Pressure
sores are common if too much pres-
sure 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. Al-
though 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 re-
sults from attempting to force cor-
rection of the equinus deformity
before correcting the adduction and
varus components of the deformity.
In this situation, the forefoot be-
comes dorsiflexed without correc-
tion of the calcaneal plantarflexion
that is blocked by the talus, as de-
scribed. Similarly, the bean-shaped
foot deformity occurs when correc-
tion of adduction is attempted be-
fore 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 complica-
tion.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
infant’s tarsal bones are mostly car-
tilaginous 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 cap-
sulotomies. 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 com-
plication. 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 consist-
ing 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 osteonecro-
sis, a result of extensive dissection, is
relatively common, occurring in
0.5%45 to 14%30 of cases. Treatment
is initially symptomatic, but arthro-
desis may be necessary in some
cases.30,45 Osteonecrosis of the navic-
ular may result in the classic wedge-
shaped 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 chil-
dren. 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 Preopera-
tive stretching of the medial skin,
maintenance of hemostasis during
surgery, two-layer closures, and use
of a drain will help reduce postop-
erative wound problems.30
Undercorrection can be prevented
with adequate soft-tissue releases
during surgery, with adequate in-
ternal and external fixation postop-
Journal of the American Academy of Orthopaedic Surgeons
eratively. Simons37 and Tarraf and
Carroll46 recommend routine use of
intraoperative radiographs to con-
firm adequate correction. Persistent
equinus occurs after inadequate
release of posterior structures, and
treatment consists of splinting fol-
lowed by revision release.30 Persis-
tent heel varus results from inade-
quate subtalar release and failure to
correct calcaneal horizontal rotation.
Revision consisting of either soft-
tissue release or osteotomy is required
to correct the problem.30 Persistent
forefoot adduction results from in-
adequate release of the navicular
cuneiform first metatarsal capsules,
the calcaneocuboid joint, and the
abductor hallucis muscle, and be-
comes more evident with growth.
Adduction is a very common com-
ponent of residual deformity, occur-
ring in 50% to 95% of cases. 30
Splinting may correct mild defor-
mity, 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 radio-
graphs and found that >50% of revi-
sions performed for adduction had
evidence of incomplete correction of
this deformity at the time of surgery.
Depending on technique and dis-
ease severity, from 7%40 to 47%31 of
clubfeet have one or more revision
procedures. Failure should not oc-
cur in the acute setting because suf-
ficient 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 recur-
rent 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-

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 under-
correction,29,39,44 may require surgi-
cal treatment. Overcorrection can
occur in any direction, including a
valgus hindfoot, forefoot abduction,
calcaneus deformity (excessive dor-
siflexion), and pes planus. Hindfoot
valgus is often a result of transec-
tion 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), metatar-
sal 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 dor-
sal soft tissues, but results are sel-
dom 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 rocker-
bottom deformity. Treatment begins
with an arch support, but a lateral
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