Congenital Talipes Equinovarus

(Clubfoot)
Anatomy/Terminology

•3 main sections
1.Hindfoot – talus,
calcaneus
2.Midfoot – navicular,
cuboid, cuneiforms
3.Forefoot –

metatarsals and
phalanges
Anatomy/Terminology

• Important joints
1. tibiotalar (ankle) – plantar/dorsiflexion
2. talocalcaneal (subtalar) – inversion/eversion

• Important tendons
1. achilles (post calcaneus) – plantar flexion
2. post fibular (navicular/cuneiform) – inversion
3. ant fibular (med cuneiform/1st met) – dorsiflexion
4. peroneus brevis (5th met) - eversion
Anatomy/Terminology

• Varus/Valgus
 Talipes Equinovarus (congenitalclubfoot)

- ‘talipes’ : Talus (bone), Pes (foot)

- The heel : inverted
- The forefoot & midfoot : inverted & adducted
(varus)
- The ankle : equinus
→ in utero displacement & mal alignment of the
talocalcanealnavicular & calcaneocuboid joint
Talipes Equinovarus (congenital clubfoot)
Incidency

-Varies with race & sex

-Caucasians : 1,2/1000 , ♂ : ♀ = 2 : 1
-Hawaiians : 4,9/1000
-Maori : 6,5-7,0/1000
-Bilateral : 50%, 1/3 of cases
-Unilateral : right > left
Heredity

-Genetic factors : 10%, others → sporadis

-Environmental factors :
Idelberger :
Identical (Monozygotic) twins → 32,5%
Fraternal (Dizygotic) twins → 2,9%

Etiology

- The exact cause : unknown

1. Intrauterine Mechanical Factors

- The oldest, Hipocrates

- External mechanical forces → equinovarus

posture → the ligaments, muscles, bones

changes → articular mal alignment
- Twining, high birth weight, primiparous
uterus, hidramnios
2. Neuromuscular Defect

- White, 1929 : A peroneal N. lesion caused by

pressure at the intrauterine stage
- Middleton, 1934 : Mal development of the
striated muscle
- Flinchum, 1953 : Muscle imbalance due to
dysplasia of the peroneals
- Ritsila : Concluded that primary soft tissue
changes
→ provoking skeletal deformities
3. Arrest of Fetal Development
- Huter : Result of an arrest of development of
the foot in one of the physiologic phases of its
embryonic life
4. Primary Germ Plasm Defect
- Irani & Sherman : CTEV is the result of
a
defective cartilagineous anlage
produced by a
primary germ plasm defect, developing
in the
first trimester
Pathology

- The foot is plantar flexed at the ankle & subtalar

joints, the hindfoot is inverted & the mid and
forefoot are adducted, inverted & equinus
- Fixed contractures of the related soft tissue (the
ligaments, capsules, muscles, tendons)
maintained articular mal alignment
A. Bony Deformities

1. The Talus
- Medial & plantar deviation of the anterior end of
the talus
- “declination angle” : by the long axis of the head
& neck of the talus with the long axis of its body
- Obliquity the neck of talus : medial tilting of the
anterior part of the talus (adult : 12-32 degrees,
fetus : 35-75 degrees, CTEV : 50-65 degrees)
2. The Calcaneus
- Much less deformed than the talus
- Rotated on its long axis inward & downward
beneath the talus
- The sustentaculum tali usually
underdeveloped
& in close proximity to the medial maleolus

3. The Forefoot & Tibia

- Smaller than normal
B. Articular Malalignments

1. Relationship of talus to distal tibia & fibula

- The talus has no muscle attachments, it
is stabilized by the ankle mortis
2. Relationship of navicular to talus
3. Relationship of talus to calcaneus
4. Relationship of
Calcaneus to Cuboid
bone
- The cuboid is
displace medially in
relation to the
anterior end of the
calcaneus
C. Soft-Tissue Changes

- The soft tissues on the medial & posterior aspect

of the foot & ankle are shorten (ligaments,
capsules, muscles, tendons, vessels, nerves,
skin)
- In eversion, the navicular & anterior end of the
os calcis move laterally, in inversion they move
medially
Diagnosis

Clinical picture :
- Clublike appearance
- Deep creases at the posterior aspect of the
ankle joint
- Mid & forefoot are adducted, inverted & equinus
- The navicular bone abuts the anterior & medial
margin of the medial maleolus, on palpation
can’t insert a finger between the two bones
Radiographic Assessment
-The purpose is to define precisely the anatomic
relationship of talocalcaneonavicular, tibiotalar,
midtarsal & tarso-metatarso joint
-To assess the degree of subluxation of the
talocalcaneonavicular joint & the severity of the
deformity before treatment
- To provide an accurate guide to progress during the
course of closed non operative treatment
- To assess wether reduction of the talocalcaneonavicular
dislocation & normal articular alignment have been
achieved
Normal range of roentgenographic
angles
• Talocalcaneal angle
– Anteroposterior view: 30 to 55 degrees
– Dorsiflexion lateral view : 25 to 50 degrees
• Tibiocalcaneal angle
– Stress lateral view : 10 to 40 degrees
• Talo-first metatarsal angle
– Anteroposterior view : 5 to 15 degrees
 Treatment
The objective :
1. To achieve reduction of the dislocation or
subluxation of the talocalcaneonavicular joint
2. To maintain the reduction
3. To restore normal articular alignment of the
tarsus & the ankle
4. To establish muscle balance between the evertors
& invertors, and the dorsiflexors & plantarflexors
5. To provide a mobile foot with normal function &
weight bearing
- Treatment should be started as soon as
possible, immediately following birth
- The first three weeks of life are the golden
period, because the ligamentous tissues
are still lacks under the influences of
maternal sex hormones
- Managements extends until adolescent
Closed Non-Operative Method

- Elongation of the contracted soft tissues by

passive manipulation → gentle with a non
irritative adhesive liquid, use gloves
- Shouldn’t stretch the midfoot by forced
dorsiflexion of the forefoot → rocker bottom
deformity of the foot → transversed breech
- The stretched position is maintain to the count
of ten, repeated 20-30 times each session
Advantage :

- A dynamic corrective
force is transmitted to the
foot
- In expensive, applied
easily, reapplied at
frequent intervals
- Relatively safe
- Being least likely to cause
pressure sores
Closed reduction of the medial & plantar
dislocation of talocalcaneonavicular joint

- The success of reduction confirm by AP & Lat X-

ray
- AP : The talocalcaneal angle should be >20º,
the talo-first metatarsal angle <15º
- Lat : The talocalcaneal angle should be 30-45º
Retention of reduction

- Above knee cast to maintain the reduction

- Three persons
- The cast should extend from the toes to the
groin with the knee flexed at 60-80º to control
the heel & prevent the cast from slipping
- Proper & carefull molding of the cast :
calcaneocuboid area, back of the heel, the
midtarsal joint area to prevent a rocker bottom
deformity
- The cast is change at 2-3 weeks
- intervals → 3 months →
polypropylene above knee splint (hold
the hindfoot in 15-20º of eversion, the
midfoot & forefoot in 20º of
abduction, the ankle at 0-5º of
dorsiflexion, the knee flexed 60º) the
splint is worn only at night & at nap
times
- A pre walker clubfoot shoes is worn during
the day
- When the child begins to walk → wear
outflare (tarsal pronator ) shoes, with
outer lateral side heel & sole wedges to
encourage walking in eversion &
abduction
- X-ray periodically, if there is no reccurents
of deformity after 2 years → normal shoes
Treatment of resistant clubfoot
• Metatarsus adductus
– >5yr : metatarsal osteotomy
• Hindfoot varus
– <2-3yr : modified McKay procedure
– 3-10yr :
• Dwyer osteotomy (isolated heel varus)
• Dillwyn-Evans proc (short medial column)
• Lichtblau proc (long lateral column)

– 10-12yr : triple arthrodesis

• Equinus
– Tendo calcaneus lengthening plus posterior
capsulotomy of subtalar joint, ankle joint (mild
to moderate deformity)
– Lambrinudi procedure (severe deformity,
skeletal immaturity)
• All three deformities :
– >10yr : triple arthrodesis
Talipes Equinovarus (congenital
clubfoot)