2. Most common congenital orthopaedic condition
requiring intensive treatment.
Most likely it represents the congenital dysplasia of
all musculoskeletal tissues distal to the knee`
3. Derived from Latin
CTEV stands for
Congenital- present since birth
Talipes- combination of words-
Talus- ankle & pes- foot
Equinus- horse like where the foot is in plantar flexion
Varus- foot is inverted and adducted
4. CTEV also known as CLUBFOOT
Resemblance with the club of Golf
5. Common congenital deformity occuring in
1-2 per 1000 live births.
Male to Female ratio is 2:1.
Bilateral in 50% cases.
6. Multifactorial etiology
Probably represents an endpoint of many disease
processes
Etiological factors
Intrinsic (genetic) factors
Extrinsic (intrauterine) factors
7. A major gene effect (inherited in recessive manner)
with additional polygenes and environmental
factors
complex segregation analyses of idiopathic clubfoot
populations.
deletion on Chromosome 2 (2q31-33) related to the
CASP10 gene.
9. Incidence in the general population is 1 per 1000
live births.
Incidence in first-degree relations is
approximately 2%.
Incidence in second-degree relations is
approximately 0.6%.
10. In monozygotic twins, the second twin has a 32%
chance of having CTEV.
When one parent is affected with clubfoot, 3% to 4%
chance that the offspring will also be affected.
If both parents are affected, the offspring have a 30%
chance of developing clubfoot.
11. Arrest in embryonic development in fibular stage.
Innate stiffness of clubfeet due to myofibroblastic
retractile tissue in the medial ligaments
retractive fibrotic response is due to
abnormal ligamentous and fascial restraints in the
soft tissues that inherently resists correction of
deformity
12. Neuromyogenic imbalance-Congenital fiber-type
disproportion
Primary germ plasm defect in the cartilaginous talar
anlage- dysmorphic talar neck and navicular
subluxation.
Vascular insufficiency
15. Scarpa(1803)-medial and plantar displacement of
the navicular, cuboid and calcaneus around the
talus- inverted and varus hindfoot and the entire
complex rests in equinus.
Contracture of soft tissues-Equinovarus
16. Scarpa, Adams an Elmslie in 1920 emphasise the
midtarsal subluxation – navicular and cuboid
displace medially with plantar and medial rotation
of the calcaneus.
Talonavicular subluxation and dislocation of head
of talus out of its socket.
17. Head - medially deviated ; talonavicular
articulation in a more sagittal plane than normal
coronal plane
Neck - short ; decreased neck-body axis from
normal 150–160 deg to 90-115deg
- internally rotated relative to ankle mortise
Body - Externally rotated
- broader anterior portion of trochlea
18. involved in all the 3 components of deformity-equinus,
varus, adduction
The contour generally normal
although the calcaneus is small with altered orientation of
articular surface
The sustentaculum tali is usually underdeveloped, consistent
with dysplasia of the talar facets above.
The anterior articular surface is deviated
downwards,medially and inverted.
19. More normal shape and are misshapen by their
articulations with the talus and calcaneus
hypertrophy of medial tuberosity due to thick
ligamentous structures tethering navicular to
medial malleolus and calcaneus
false articulation with medial malleolus in severe
defomity
20. The cuboid is medially subluxated over the
calcaneal head.
Controversy exists concerning the presence or
absence of excessive medial or internal tibial torsion
22. Atrophy of the leg muscles, especially in the
peroneal group.
The number of fibers in the muscles is normal,
but the fibers are smaller in size.
The triceps surae, tibialis posterior, flexor
digitorum longus (FDL), and flexor hallucis longus
(FHL) are contracted.
The calf is of a smaller size and remains so
throughout life, even following successful long-
lasting correction of the feet.
23. Tendon sheaths: Thickening of the tibialis posterior and peroneal
sheaths.
Joint capsules: Contractures of the posterior ankle capsule,
subtalar capsule, and talonavicular and calcaneocuboid joint capsules
Ligaments: Contractures are seen in the calcaneofibular, talofibular,
(ankle) deltoid, long and short plantar, spring, and bifurcate
ligaments.
Fascia: The plantar fascial contracture contributes to the cavus, as
does contracture of fascial planes in the foot.
25. Supple: foot can be brought to normal position ,
all joints are mobile
Relapsed: deformities are corrected initially but
appears again in later years partially or totally
Recurrent: type of relapse , the cause being muscle
imbalance which was overlooked initially
26. Rigid : it’s a type in which forefoot deformity is corrected
but the hindfoot deformities remain uncorrected after
conservative treatment
Neglected : patient has not received any treatment for one
year(or started walking unaided)
Resistant: it’s a type of clubfoot where there is no
correction after conservative treatment
Atypical clubfoot: short, chubby, stiff feet with a deep
crease in the sole of the foot and behind the ankle, and
shortening first metatarsal with hyperextension of the MTP
joint.
27. Classic appearance of the heel in marked equinus.
Foot inverted on the end of tibia
Upside down appearance in more severe cases
28. PIRANI’S SEVERITY SCORE
Six parameters : 3 of midfoot and 3 of hindfoot
Each parameter is given a value as follows:
0: normal
0.5: moderately abnormal
1: severely abnormal
30. ‘LOOK’
Lateral border of foot
0 No deviation from straight line
0.5 Medial deviation distally
1 Severity deviation proximally
‘FEEL’
Talar head
0 Reduced talo navicular jt.
0.5 Subluxated but reducible talo-
navicular joint
1 Irreducible talo-navicular joint
‘MOVE’
Medial crease ( at
maximum correction)
0 No medial crease
0.5 Mild medial crease
1 Deep crease altering contour of foot
32. ‘LOOK’
Posterior crease
0 No heel crease
0.5 Mild heel crease
1 Deep heel crease
‘FEEL’
Empty heel sign
0 Hard heel
0.5 Mild softness
1 Very soft heel
‘MOVE’
Rigidity of equines
0 Normal dorsiflexion
0.5 Foot reaches plantigrade
with knee extended.
1 Fixed equinus
33. Assessment of progress by serial plotting of the
score
Predicting need for tenotomy
Estimation of probable no. of casts required
Very good interobserver reliability and
reproducibility
34. Based on Classification of clubfoot severity by-
A. Equinus deviation
B. Varus deviation
C. Derotation
D. Adduction.
35.
36. Imaging studies generally are not required to
understand the nature or the severity of the deformity.
Radiographs, are a useful baseline prior to and
following surgical correction of the feet, closed Achilles
tenotomy, or a limited posterior release.
Radiographs show the true gain in foot (ankle)
dorsiflexion and confirm the appearance of an
iatrogenic rockerbottom foot.
37. 2 views are usually taken-
a)Kites view: AP Radiographs are taken with foot in
300 planter flexion and the x-ray tube angled at 300
anteriorly in saggital plane.
b)Stress lateral view: lateral view taken at the limit
of dorsiflexion.
38. 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
39. Talocalcaneal parallelism is the radiographic feature
AP and Lateral Talocalcaneal angle is reduced ( < 20
degrees ). In lateral view it almost approaches to
become horizontal.
Talar-first metatarsal angle is mild to severe varus
(negative) in clubfoot.
Tibiocalcaneal angle in clubfoot is generally
negative, indicating equinus of the calcaneus in
relation to the tibia.
40. CONSERVATIVE METHODS-
Kite’s technique: In his 1964 monograph The Clubfoot
Kite corrected each component of the clubfoot deformity
separately and in order
41. starts with reduction of the Talonavicular
joint. Thumb is placed laterally in the
over the calcaneo cuboid joint and the
navicular is gently pushed onto the head
of talus with the index finger of the same
hand.
He was adamant that one could not
proceed to correct the next deformity
until the previous one had been
corrected.
42. kite’s method blocks calcaneal abduction
and interferes with correction of heel varus.
Kite did not realize that the calcaneus
everts only when abducted
KITE’S ERROR
43. Early 1970s by Masse and by Bensahel and
colleagues.
Daily manipulations
Stimulation of the muscles
Temporary immobilization of the foot with
nonelastic adhesive strapping.
The daily treatments were continued for
approximately 2 months
progressively reduced to 3sessions/wk * 6 months.
Then taping was continued until the child became
ambulatory, and then nighttime splinting was used
for 2 to 3 years.
44. His method of weekly manipulation and cast
application to hold correction allows
relaxation of the collagen and atraumatic
remodeling of joint surfaces without the
fibrosis and scarring associated with surgical
release.
45. Increase of collagen fibers and cells in ligaments
of neonates
Bundles of collagen fibers display a wavy form
known as “ Crimp” – which allows stretching.
Crimp reappears a few days later, allowing for
further stretching. So gentle manual correction
is feasible.
Clubfoot deformity is mainly in tarsal bones.
Tarsal bones are mostly cartilage and they
remodel due to ligaments stretching.
46. Abnormal tarsal relationship maintained by
pathological soft tissues contractures.
Soft tissues contractures must be stretched
to restore normal tarsal relationships
After normal tarsal relationships, correction
must be maintained until tarsal bones remold
stable articular surfaces
Recurrent deformity results from failure to
either attain a complete correction or maintain
the correction
48. ankle is stabilized by applying pressure over head of the
talus
Adduction and inversion is corrected simultaneously by
pulling the forefoot and the navicular along with it ,
laterally onto the head of the talus.
The forefoot should be kept supinated
49. To stretch the ligaments and
gradually correct the deformity, the
foot is manipulated for 1 to 3
minutes.
The correction is maintained for 5-7
days with a plaster cast extending
from the toes to the upper third of
the thigh and the knee at 90 degrees
of flexion.
50. 5-6 cast are sufficient in most cases
clubfeet.
Casting is usually timed to coincide
with routine feedings; after
manipulation, the infant is fed a
bottle, which tends to relax the infant
and allow easier cast application
51. Elevation of the first metatarsal
as a first step, even if it means
seemingly exacerbating the
deformity
At successive manipulation and
casting sessions, metatarsus
adductus and hindfoot varus are
simultaneously corrected by
abducting the foot while
counterpressure is applied
laterally over the talar head.
52. With this technique, the calcaneus, navicular, and
cuboid are gradually displaced laterally
Remember 3 points:
First, forefoot abduction should be performed with
the foot in slight supination
Second, the heel should not be constrained by
premature dorsiflexion. It is important that
abduction be accomplished with the foot in equinus
to allow the calcaneus to abduct freely under the
talus and evert to a neutral position without
touching the heel
Third, care is taken to locate the fulcrum for
counterpressure on the lateral head of the talus
53. palpate the malleoli with the thumb and index
finger of one hand while the toes and
metatarsals are held with other hand.
Next, slide your thumb and index finger of
hand forward to palpate the head of the talus
in front of the ankle mortis.
Because the navicular is medially displaced
and its tuberosity is almost in contact with the
medial malleolus, the prominent lateral part
of the talar head barely covered by the skin
can be felt in front of the lateral malleolus
56. After each cast, foot supination is
gradually decreased to correct the
inversion of the tarsal bones while the
foot is further abducted under the talus.
Equinus is the last deformity that is
corrected, and correction should be
attempted when the hindfoot is in
neutral to slight valgus and the foot is
abducted 70 degrees relative to the leg.
57. Equinus may be completely
corrected through further
progressive stretching and casting.
However, to facilitate more rapid
correction, subcutaneous heel cord
tenotomy is performed in the vast
majority (at least 85%) of patients
59. The Ponseti technique
corrects the deformity
by gradually rotating
the foot around the
head of the talus over a
period of weeks during
cast correction.
60. When possible, start soon after birth (7 to 10
days). When started before 9 months of age,
most clubfoot deformities can be corrected by
using this management.
Most clubfoot deformities can be corrected in
approximately 6 weeks by weekly manipulations
followed by plaster cast applications.
If the deformity is not corrected after six or
seven plaster cast changes, the treatment is
most likely faulty.
61. when the anterior calcaneus can be
abducted from underneath the talus. This
abduction allows the foot to be safely
dorsiflexed without crushing the talus
between the calcaneus and tibia .
If the adequacy of abduction is uncertain,
apply another cast or two to be certain
62. The best sign is the ability to palpate
the anterior process of the calcaneus as
it abducts out from beneath the talus.
Abduction of approximately 60 degree
in relationship to the frontal plane of
the tibia is possible.
63. Equipment- Select a tenotomy blade such as a #11 or #15 or
any other small blade such as an ophthalmic knife.
Skin preparation -Prepare the foot thoroughly from
midcalf to midfoot with an antiseptic while the assistant
holds the foot from the toes with the fingers of one hand
and the thigh with the other
Heel cord tenotomy -Perform the tenotomy
approximately 1.5 cm above the calcaneus with the foot
held in maximal dorsiflexion by the assistant. Avoid
cutting into the cartilage of the calcaneus. A “pop” is felt as
the tendon is released. An additional 20 to 25 degrees of
dorsiflexion is typically gained after the tenotomy.
64. foot abducted 60 to 70 degrees with
respect to the frontal plane of the
ankle..
Dorsiflexion maintained at 20
degrees.
Cast removal- After 3 weeks, the cast
is removed
65. The brace is applied immediately after the last cast is
removed, 3 weeks after tenotomy.
The brace consists of open toe high-top straight last
shoes attached to a bar .
For unilateral cases, the brace is set at 60 to 70
degrees of external rotation on the clubfoot side and
30 to 40 degrees of external rotation on the normal
side .
In bilateral cases, it is set at 70 degrees of external
rotation on each side.
66. The bar should be of sufficient length so that the heels
of the shoes are at shoulder width. The bar should be
bent 5 to 10 degrees with the convexity away from the
child, to hold the feet in dorsiflexion .
The brace should be worn full time (day and night) for
the first 3 months after the last cast is removed. After
that, the child should wear the brace for 12 hours at
night and 2 to 4 hours in the middle of the day for a
total of 14 to16 hours during each 24-hour period. This
protocol continues until the child is 3 to 4 years of age.
67. Maintains correction
3 months full time
2-4 yr. night time
Bar as wide as shoulders
Externally rotate 70 degrees
Dorsiflex 10-15 degrees
Heelcup
68. Early Recurrence (< 2y)
◦ 2 or 3 Ponseti casts
◦ If dorsiflexion limited - redo TA tenotomy (<2y)/ Open
TAL (>2y)
◦ Re brace
Late Recurrence (> 2y)
◦ 2-3 Ponseti casts to get heel in valgus & foot plantigrade
◦ Tibialis Anterior transfer (TAT) to 3rd cuneiform for 2nd
recurrence if age >2.5y (add open TAL if < 10 degrees
dorsiflexion)
69. Thumb on Calcaneo-cuboid joint
Pronation or Eversion of the foot
Attempts to correct the equinus before the heel
varus and foot supination are corrected will
result in a rocker bottom deformity
70. Failure to use a foot abduction brace for three
months full-time and at night for two to four years.
Attempts to obtain a perfect xrays. Long term follow
up xrays are abnormal. No correlation between the
radiographic appearance of the foot and long-term
function.
Failure to treat recurrence at earliest presentation
72. Surgical correction is the last resort.
Multiple operations are to be avoided because
increasing stiffness, deepening of scars, and
hardening of tissue , as well as atrophy
introduced by immobilization
The most frequent cause of repeat surgery for a
severe clubfoot is incomplete or inadequate
correction
Considerations: age of the child and the
deformity to be corrected
74. Turco recommended surgery at the age of 1
year or older, (usually 1-2 yrs) primarily
because of the advantages that the structures
were larger, the anatomy more easily evaluated
and corrected, and the tendon lengthening
repairs more secure.
Simons (1993) suggested that size and not age
should be the limiting factor - the foot should
be at least 8 cm long
75. Treatment by age :
• Less than 5 years : soft tissue procedures
eg. ( PMSTR)
• More than 5 years : Requires bony
reshaping, eg. Evans procedure, Dwyer
procedure .
• More than 10 years : Lateral wedge
tarsectomy or Triple arthrodesis if the foot
is mature ( salvage procedures ).
76. SOFT TISSUE RELEASES:
Rationale
Realignment of the talus, calcaneum
and navicular allows remodeling of
their articular surfaces.
The earlier is the intervention greater is
the chance of remodeling.
77. Posterior Release
If the forefoot adduction and heel varus are virtually
corrected after conservative treatment, a posterior release
can be performed.
Attenborough (1972) did TA lengthening and
posterior capsulotomy of the tibiotalar and subtalar
joints.
Fuller (1984) added release of' the posterior talofibular
and calcaneofibular ligament to this procedure
79. Postero-Medial Soft Tissue Release
(TURCO)
Treatment of choice for mild deformities
with no severe internal rotational
deformity of the calcaneus.
80. Incision - J-shaped or hockey stick
incision.
A medial incision 8-9 cm long is made
extending several inches above the medial
malleolus along the inner side of the
Achilles tendon, curving below the medial
malleolus to the first metatarsal base.
81. Plantar: Plantar fascia, abductor hallucis, flexor
digitorum brevis, long and short plantar ligaments
Medial: Medial structures, tendon sheaths, talonavicular
and subtalar release, tibialis posterior, FHL, and FDL
lengthening
Posterior: TA, Ankle and subtalar capsulotomy,
especially releasing post talofibular and tibiofibular
ligaments and the calcaneofibular ligaments
Structures released
83. COMPLICATION
This incision can lead to wound
breakdowns, especially at the corner of the
vertical and medial limbs.
To avoid this, some surgeons prefer the two
separate incisions - A posterior vertical, and
a medial.
84. Stiendler's Release
If there remained only cavus
deformity after conservative
treatment
percutaneous release of the plantar
fascia is done.
abductor hallucis, intrinsic toe flexors
and abductor digiti quinti stripped
subperiosteally from calcaneus
3 – 5 yrs. Old
85. INDICATIONS :
Obvious clubfoot deformity with RIGID foot
Walking on lateral border of foot with heel varus
Parallelism of talocalcaneal angle
86. INCISIONS: Two types of incisions
can be used:
1) Circumferrential Cincinnati incision
( McKay)
2) Carroll’s two separate incision- a
curvilinear medial incision and a
posterolateral incision to allow
adequate exposure for plantar, lateral,
medial, and posterior releases.
89. LATERAL RELEASE:
-Superior peroneal retinaculum.
-Calcaneofibular ligament
-Lateral capsule of subtalar joint
In resistant cases- origin of Extensor digitorum
brevis, Inferior extensor retinacula, dorsal
calcaneocuboid ligament, cubonavicular oblique
ligament have to be dissected off the calcaneus
90. MEDIAL RELEASE:
-Lengthening of tibialis posterior but its never
released.
-FHL & FDL should be released or lengthened.
-Plantar fascia.
-Superficial part of deltoid ligament
-Dorsal talonavicular ligament
-Calcaneonavicular (spring) ligament
-Bifurcated Y ligament
-Subtalar & talonavicular capsule
-Origin of qudratus plantae muscle
91. The most important structures preventing
correction of CTEV deformity by maintaining
malrotation of calcaneus are-
1. Calcaneo-fibular ligament
2. Talo-calcaneal interosseus ligament
93. Complications of soft tissue release :
1. Infection.
2. Wound breakdown.
3. Stiffness / restricted ROM
4. AVN of Talus : Combined simultaneous
medial and lateral release -40% incidence of
AVN of talus.
5. Persistent in toeing
6. Overcorrection.
94. OSTEOTOMIES :
These procedures are carried out on residual
deformities in older children. They should be
reserved for children over 5 years old.
Types-
Dwyer 0steotomy :.
Dillwyn-Evans Procedure
Wedge Tarsectomy
Lichtblau Procedure
95. Dwyer (1963) described an opening wedge
osteotomy on the medial aspect to increase the
height and length of the calcaneus.
The osteotomy was held open by a wedge
taken from the tibia.
There is a chance of sloughing of the medial
skin because; of stretching.
96. Osteotomy of calcaneus
a lateral closing wedge osteotomy is
preferred, though there may be some loss of
height of calcaneum.
Calcaneus is exposed from the lateral aspect
and a horizontal wedge is removed, the heel
varus is then corrected by closing the
osteotomy.
Care should be taken not to injure the
peroneal tendons.
If necessary the osteotomy is fixed by a K
wire.
Age: ideal age is 3 to 4 years, but there is
really no upper age limit
97. This consists of a closing wedge resection
of the calcaneocuboid joint after release of
the talonavicular capsule, division of the
tibialis posterior and release of the plantar
fascia.
The shortening of -the lateral side of the
foot thus achieved, is usually held by a
staple.
This is done for recurrent or neglected
CTEV between 4- 8 years.
98. Indication :heel varus and residual internal rotation of
the calcaneus with a long lateral column of the foot
This procedure corrects the long lateral column of the
foot by a closing wedge osteotomy of the lateral aspect
of the calcaneus or by cuboid enucleation.
The best results with this procedure are obtained in
children 3 years of age or older.
This may prevent the long term stiffness of the hindfoot
seen with Dillwyn-Evans procedure
Potential complications -‘ Z ’-foot, or ‘skew’-foot,
deformity.
99. This is a closing wedge
osteotomy through the
midtarsal joint having base
dorsally and laterally.
This corrects the adduction
and cavus deformity
simultaneously.
This operation is usually
performed for neglected
CTEV between the age of
8 - 11years.
100. TRIPLE ARTHRODESIS
salvage procedure, skeletal age is at least 12 years.
Following joints are arthodosed; talonavicular, the
calcaneocuboid and the subtalar joints
101. At the completion of the operation the foot must be
plantigrade .
Likewise there must be close apposition of the
excised joint surfaces in all the three joints;
otherwise, nonunion of one may occur and cause
pain.
102. Lambrinudi Arthrodesis :
This is a salvage procedure which
is done in isolated fixed equinus
deformity in an older child.
104. No / incomplete initial treatment till the age of
1 years
Moderately flexible, moderately stiff, and rigid
Modified Ponseti: manipulation for 5-10 mins,
two weekly cast change, correction of foot to
30-40° abduction,
Extensive soft tissue release upto 4 yrs
Dilwyn-Evans, Lichtblau procedure
Triple arthrodesis
Ilizarov/ JESS
105. EXTERNAL FIXATORS
INDICATIONS :
1. > 3 years, adolescents adults
2. relapsed, resistant or neglected clubfeet
3. arthrogryphotic foot
4. children treated with extensive open surgery
5. scarred or infected skin from previous surgery
106. ADVANTAGES :
• can be done when conventional surgery is
contraindicated :
• inadequate, scarred skin
• infected foot
• very short foot
• anesthetic clubfoot d/t myelomeningocele
• foot due to polio/ cerebral palsy
• simultaneous correction of other deformities
• softens the contractures
• less stiffness
107. PRINCIPLES :
1. DISTRACTION HISTOGENESIS - below 8
years
2. WOLFF’S LAW
3. DIFFERENTIAL DISTRACTION on both sides to
prevent articular damage on convex side
(Convex side distraction is half the rate of concave side)
108. Correction slow enough to protect
soft tissue
Correction at the focus of
deformity
Simultaneous three-dimensional,
multilevel correction
Deformity correction without
shortening the foot
109. Fractional, differential distraction used to
Sequentially correct deformities (Medial- 0.25
mm every 6 hours ,Lateral- 0.25 mm every 12
hours)
Distraction continued until approx. 20 degrees of
dorsiflexion and overcorrection of the forefoot
deformities was achieved
Maintained in this overcorrected position for
twice as long as the distraction phase by
casts/braces
110. CONTROLLED DIFFERENTIAL
FRACTIONAL DISTRACTION USING
JESS
2 to 4 transfixing wires in prox tibia
Metatarsal Transfixing wire through MTs
2 transfixing and 1 axial wire through calcaneum
111. Good or excellent results reported
by Joshi in 84% of his patients
Recommended in all who have not
responded to serial plaster casting
methods.
