CTEV(CONGENITAL
TALIPES
EQUINOVARAS)
INTRODUCTION
• 'Clubfoot' is a rather vague term which has been used to
describe a number of different abnormalities in the shape of
the foot, but over the years it has come to be synonymous
with the commonest congenital foot deformity i.e.,
Congenital Talipes Equino Varus (CTEV). It occurs once in
every 1000 live births.
RELEVANT ANATOMY
• The joints of the foot relevant to understanding of this
condition are:
• (i) the ankle joint between the tibia and the talus;
• (ii) the subtalar joint between the talus and the calcaneum;
• (iii) the talo-navicular joint; and
• (iv) the calcaneo-cuboid joint.
• For the purpose of description, the foot is often divided into
hindfoot, midfoot and forefoot.
• The hindfoot is the part comprising of talo-calcaneal
(subtalar) and calcaneo-cuboid joints.
• Midfoot comprises of talo-navicular and naviculo-cuneiform
joints.
• The forefoot is cuneiform-metatarsal and other joints beyond
it.
The ligaments related to the aetiology of clubfoot are as follow
• Deltoid ligament: This is the medial collateral ligament of
the ankle. It has a superficial and a deep component.
• Spring ligament: This is a ligament which joins the anterior
end of the calcaneum to the navicular.
• Interosseous ligament: This ligament is between the talus
and calcaneum, joining their apposing surfaces.
• Capsular ligaments: The thickened portions of the capsule
of the talo-navicular, naviculo- cuneiform, and cuneiform-
metatarsal joints, termed as the capsular ligaments, are
important structures in pathology of CTEV.
• Plantar ligaments: These are ligaments extending from the
plantar surface of the calcaneum to the foot, giving rise to the
longitudinal arch of the foot.
• Tendons related to the pathology of clubfoot are those on the
medial side of the foot.
• The tendon immediately behind the medial malleolus is that
of the tibialis posterior.
• More posteriorly are the flexor digitorum longus tendon,
posterior tibial artery and nerve, and flexor hallucis longus
tendon.
• The tibialis posterior tendon has its main insertion on the
navicular.
• This is the most important muscle related to pathology of
clubfoot.
NOMENCLATURE
• used to describe foot deformities. The Following are some
such terms:
• Equinus: (derived from 'equine' i.e., a horse who walks on
toes). This is a deformity where the foot is fixed in plantar-
flexion.
• Calcaneus (reverse of equinus): This is a deformity where
the foot is fixed in dorsiflexion.
• Varus: The foot is inverted and adducted at the mid-tarsal
joints so that the sole 'faces' inwards.
• Valgus: The foot is everted and abducted at the mid-tarsal
joints so that the sole 'faces' outwards.
• Cavus: The logitudinal arch of the foot is
exaggerated.Planus: The longitudinal arch is flattened.
• Splay: The transverse arch is flattened.Invariably, the foot
has a combination of above mentioned deformities; the
commonest being equino-varus. The next most common
congenital Foot deformity is calcaneo-valgus.
AETIOLOGY
• In the vast majority of cases, aetiology is not known, hence it
is termed idiopathic.
• In others, the so called secondary clubfoot, some underlying
cause such as arthrogryposis multiplex congenita (AMC) can
be found.
• Idiopathic clubfoot: Following are some of the theories
proposed for the aetiology of idiopathic clubfoot:
• a) Mechanical theory: The raised intrauterine pressure forces
the foot against the wall of the uterus in the position of the
deformity.
• b) Ischaemic theory: Ischaemia of the calf muscles during
intrauterine life, due to some unknown factor, results in
contractures, leading to foot deformities.
• c) Genetic theory: Some genetically related disturbances in
the development of the foot have been held responsible for
the deformity.
Secondary clubfoot:
• Following are some of the causes of secondary clubfoot:
• a) Paralytic disorders: In a case where there is a muscle
imbalance i.e., the invertors and plantar flexors are stronger
than the evertors and dorsiflexors, an equino-varus deformity
will develop. This occurs in paralytic disorders such as polio,
spina bifida, myelodysplasia and Freidreich's ataxia.
• b) Arthrogryposis multiplex congenita (AMC):This is a
disorder of defective development of the muscles. The
muscles are fibrotic and result in foot deformities, and
deformities at other joints.
CLINICAL FEATURES
Presenting complaints:
Though, the history dates back to birth, a child with CTEV
may present some time after birth, often as late as adulthood.
Following are some of the common presentations:
a) Detected at birth: At places where delivery is conducted by
trained medical personnel, CTEV is detected at the time of
routine screening of newborns for congenital mal-
formations. At times, the deformity is very mild, the so-
called postural equino-varus.
TREATMENT
Principles of treatment:
• In principle, treatment consists of correction of the deformity,
and its maintenance.
• Correction can be achieved by non- operative or operative
methods.
• Maintenance is continued until the foot (and its bones) grows
to a reasonable size, so that the deformity does not recur.
METHODS OF CORRECTION OF DEFORMITY
• A deformity can be corrected by non-operative or operative
methods.
Non-operative methods:
• Following are the non- operative methods of correcting
deformities:
a) Manipulation alone:
• In a newborn, the mother is taught to manipulate the foot
after every feed.
• The foot is dorsiflexed and everted. While manipulating,
sufficient pressure should be applied by the person so as to
blanch her own fingers.
• This pressure should be maintained for about 5 seconds, and
this is repeated several times, over a period of roughly 5
minutes.
• Minor deformities are usually corrected by this method alone.
• For major deformities, further treatment by corrective plaster
casts is required.
b) Manipulation and PoP:
• In this method, the surgeon manipulates the foot after
sedating the child.
• The foot is then held in the corrected position with plaster
casts.
• There are two philosophies of treatment of clubfoot: Kite's
and Ponsetti’s.
• Kite's philosophy: This has been a popular method for over
40 years. The foot is treated by manipulation and PoP,
beginning at the age of 1 month.
• The deformities are corrected sequentially.
• Adduction deformity is corrected first followed by inversion
deformity and then equinus deformity.
• A below-knee plaster cast is usually sufficient.
• The casts are changed every 2 weeks, and are continued until
it is possible to overcorrect' all the deformities.
• Once this happens, the foot is kept in a suitable maintenance
device.
• By this method, correction is achieved in 30% of cases, over
a period of 6-9 months. The rest need surgical correction.
• Ponsetti's philosophy: This philosophy is based on better
understanding of the pathoanatomy of the deformed foot.
• According to Ponsetti, the calcaneo-cuboid-navicular
complex is internally rotated (adducted) under the
plantarflexed talus, Hence, the deformity can be corrected by
bringing the complex back under the talus by gradually
stretching the tight structures.
• This is done by putting thumb pressure over the talus head
(and not over calcaneo-cuboid joint as in Kite's method).
• By doing this, the calcaneo- cuboid-navicular complex is
externally rotated under the talar head.
• Treatment is started within 1st week of life.
• The cavus aspect of the deformity is corrected first, followed
by the adduction, then varus and lastly equinus.
• After every manipulation, an above-knee PoP cast is applied,
which is changed every 5-7 days.
• It is usually possible to correct all components of the
deformity within 6 weeks.
• The equinus deformity often remains undercorrected, and can
be treated by percutaneous tenotomy of tendoachilles.
• The cut tendoachilles regenerates spontaneously.
Operative methods:
• In more severe deformities, which are not corrected by
conservative methods, or in those that recur, operative
treatment is required.
• Soft tissue release operations may be sufficient in younger
children (younger than 3 years), but bony operations are
required in older children.
The following operations are performed:
a) Postero-medial soft tissue release (PMSTR):
• This operation consists of releasing the tight soft tissue
structures (tendons, ligaments, capsule etc.) on the posterior
and medial side ofthe foot.
• This can be performed in younger children. In older children,
an additional bony procedure is required.
The following structures are generally released:
ON THE POSTERIOR SIDE:
• Lengthening of the tendoachilles by Z-plasty.
• Release of posterior capsules of the ankle and subtalar joints.
• Release of posterior talo-fibular and calcaneo- fibular
ligaments.
ON THE MEDIAL SIDE:
• Lengthening of 3 tendons" i.e., tibialis posterior, flexor
digitorum longus and flexor hallucis longus. In addition, their
contracted thickened sheaths are excised.
• Release of 3 ligaments i.e., talo-navicular ligament,
superficial part of the deltoid ligament and the spring
ligament.
• Release of 3 more structures is needed in severe cases. These
are the interosseous talo- calcaneal ligament, capsules of the
naviculo- cuneiform and cuneiform-first metatarsal joints.
ON THE PLANTAR SIDE:
• Plantar fascia release. Release of the short flexors of the toes
(flexor digitorum brevis) and abductor hallucis from their
origin on the calcaneum.
b) Limited soft tissue release:
• In some cases, the foot remains partially corrected after
conservative treatment, and only limited soft tissue release
may be sufficient as shown below:
• For equinus alone
• For adduction alone a posterior release a medial release
• For cavus alone a plantar release.
• c) Tendon transfers:
• In some cases, the tibialis anterior and tibialis posterior (both
invertors of the foot) may exert a deforming force against the
weak peronei (evertors).
• This muscle imbalance may be corrected by transfering the
tibialis anterior to the outer side of the foot, where it acts as
an everter.
• Minimum age for tendon transfers is 5 years.
• d) Dwyer's osteotomy: This is an open-wedge osteotomy of
the calcaneum, performed in order to correct varus of the
heel.
• Minimum age at which this operation can be performed is 3
years, as prior to this the calcaneum is mainly cartilaginous.
• Some prefer a closed-wedge osteotomy on the lateral side.
• e) Dilwyn Evan's procedure: This consists of a thorough
soft tissue release (PMSTR) with calcaneo-cuboid fusion.
• It is used for a neglected or recurred clubfoot in children
between 4-8 years.
• With fusion of the calcaneo- cuboid joint, the lateral side of
the foot does not grow as much as the medial side, thus
resulting in gradual correction of the deformity.
• f) Wedge tarsectomy: This consists of removing a wedge of
bones from the mid-tarsal area.
• The wedge is cut with its base on the dorso-lateral side.
• Once the wedge is removed the foot can be brought to normal
(plantigrade) position.
• This operation is performed for neglected clubfeet between
the age of 8-11 years.
• g) Triple arthrodesis: This consists of the fusion of three
joints of the foot (subtalar, calcaneo- cuboid and talo-
navicular), after taking suitable wedges to correct the
deformity.
• It is performed after the age of 12 years, because before this
the bones are cartilaginous and it is difficult to achieve
fusion.
• Of the three, talo- navicular joint fusion is most difficult to
achieve.
• h) Ilizarov's technique: Using the principles of Ilizarov's
technique, different components of the deformity are
corrected by gradual stretching, using an external fixator.
• Once correction is achieved, it is maintained by plaster casts.
Ilizarov's technique is indicated in neglected clubfeet
METHODS OF MAINTENANCE OF THE CORRECTION
• Correction once achieved, is maintained by the following
methods:
• a) CTEV splints: These are splints made of plastic, moulded
in such a way that when tied with straps, it keeps the foot in
corrected position.
• b) Denis-Brown splint (DB splint): This is a splint to hold the
foot in the corrected position.
• It is used throughout the day before the child starts walking.
• Once he starts walking, a DB splint is used at night and
CTEV shoes during the day.
• c) CTEV shoes: These are modified shoes, used once a child
starts walking.
The following modifications are made in the shoe:
• Straight inner border to prevent forefoot adduction.
• Outer shoe raise to prevent foot inversion.
• No heel to prevent equinus.
• These shoes are used until the child is 5 years old.
COMPLICATIONS
• Clubfoot typically doesn't cause any problems until a child
starts to stand and walk. If the clubfoot is treated, the child
will most likely walk fairly normally. He or she may have
some difficulty with:
• Mobility. The child's mobility may be slightly limited.
• Shoe size. The affected foot may be up to 1 1/2 shoe sizes
smaller than the unaffected foot.
Complication of manipulation
• Tear of contracted tissue
• Joint can be damaged - fractures
• Rocker bottom foot
• Bean shaped foot
Complication of cast :
• swelling, pressure sore
• Blister due to tight plaster
• irritabilitiy
Complications of surgery
• Neurovascular injury (10% have atrophic dorsalis pedis
artery bundle)
• Skin dehiscence
• Wound infection
• AVN talus
• Dislocation of the navicular
• Flattening and breaking of the talar head
• Sinus tarsi syndrome, Severe scarring
• Stiff joints
