Congenital

Talipesequinovarus
HERNANDA HAUDZAN HAKIM
22010118220079
References
Ponseti IV, Smoley EN (1963) Congenital club foot: The results of treatment. J Bone Joint Surg.
Dimeglio A (1991) Classification of Congenital Talipes Equinovarus.
PJ Gibbons et al. (2013) Updates on clubfoot. J Paediatr Child Health.
Pirani, S. 1991. A Relible & Valid Method of Assesing the Amount of Deformity in the Congenital
Clubfoot Deformity.
Soule, R. E. 2008. Treatment of Congenital Talipes Equinovarus in Infancy and Early Chlidhood.
Rani, Manisha. 2017. Congenital Clubfoot: A Comprehensive Review. Juniper Publisher.
 Congenital Talipesequinovarus
• Clubfoot is also known as
CTEV which means
Congenital Talipes Equino
Varus.
• Congenital - Present at birth
• Talipes - Latin word for ankle
(talus) & foot (pes)
• Equino - Heel is elevated
• Varus - Foot is turned
inwards
Congenital Talipesequinovarus
• Incidence is about 1-2 in 1000 live births.
• It is developmental deformation.
• A normally developing foot turns into a
clubfoot during 2nd trimester of pregnancy.
• Rarely detected with USG before 16th week.
• When left untreated, children having clubfoot
walk on the sides and/or top of their feet,
which leads to callus formation, skin and bone
infections, substantial limitation in mobility,
reduced employment opportunities and
inability to wear standard shoes.
 ANATOMY of Pedis
The forefoot contains the five toes
(phalanges) and the five longer bones
(metatarsals).
The midfoot is a pyramid-like collection
of bones that form the arches of the
feet. These include the three cuneiform
bones, the cuboid bone, and the
navicular bone.
The hindfoot forms the heel and ankle.
The talus bone supports the leg bones
(tibia and fibula), forming the ankle. The
calcaneus (heel bone) is the largest bone
in the foot.
 Anatomy of Pedis
The muscles that control the movements of
the foot originate in the lower leg and are
attached the bones in the foot with tendons.
The main muscles that facilitate movement in
the foot are:

•Tibialis posterior (supports the foot's arch)

•Tibialis anterior (allows the foot to move
upward)
•Tibialis peroneal (controls movement on the
outside of the ankle)
•Extensors (raise the toes to make possible to
take a step)
•Flexors (stabilize the toes)
Etiology of CTEV
Mechanical Factors in Utero
According to theory of Hippocrates, due to the compression of uterus, foot got the position of
equinovarus. However, Parker and Browne believed that oligohydramnios restrict the movement
of fetus.
Neuromuscular Defect
Some investigators maintain the opinion that equinovarus foot is always the result of
neuromuscular defect. On contrary, some studies of histological finding shows no abnormalities
or no deformities.
Etiology of CTEV
Arrested Fetal Development
Intrauterine environment: In 1863, Heuter and Von Volkman proposed that the early in embryonic life
arrest of fetal development was a cause of congenital clubfoot.
Environmental influences: The harmful influence of teratogenic agents on fetal environment and
development are well illustrated by the effect of rubella and thalidomide. Many authors believe that club
foot and temporary growth arrest happens due to various environmental factors. Honein et al. reported
the exposure of cigarette smoke and family history is associated with the causative factors for the club
feet especially in Antenatal period.
Polygenic theory of Hereditary Pattern
Club foot tends to be familial in a significant number of cases. Wynne Davis supported the polygenic
theory and showed a rapid decrease in incidence of clubfoot from first to second to third degree relatives.
About 2.9% of siblings in the first degree relatives had this deformity as compared to 1-2 per thousand
masses and chances of getting affected in siblings are more than 25 times.
Classification of CTEV
Using Pirani Score
• A reliable method for assessing amount Parameters Normal
Midfoot
Moderate Severe

of deformity in clubfoot Curved lateral

border
0 0.5 1

• Formulated by Dr Shafique Pirani Medial crease 0 0.5 1

• A child's total score is between 0 & 6 Talar Head 0 0.5 1
coverage
• 6 signs are assessed & each is
Hind Foot
scored 0,0.5 & 1 depending on Posterior crease 0 0.5 1
severity.
Rigid equines 0 0.5 1
• Total score of 0 - no deformity
Empty heel 0 0.5 1
• Total score of 6 - severe deformity
PATHOLOGICAL ANATOMY:

• CTEV is a complex deformity with

four clinical components:

• 1.Hind foot equinus

• 2.Hind foot varus
• 3.Mid/forefoot adductus
• 4.Cavus
The deformity has the following
features:
Equinus:
• Severe tibio-talar &
talocalcaneal plantar flexion.
Adductus:
• Medial talar neck inclined
• Medial displacement of
navicular & cuboid
• Calcaneus rotated medially
beneath ankle
• Distal calcaneous
articulating surface
adducted
Varus:
• Adducted, plantar flexed & inverted calcaneus.
Cavus:
Plantar flexed 1st metatarsal.
Radilogical Finding of CTEV
Assessment requires weight bearing
DP and lateral radiographs. Where weight
bearing is not possible, it should be
simulated. Talipes equinovarus consists of
four elements:
1. Hindfoot equinus is plantar flexion of the
anterior calcaneus (similar to a horse's
hoof) such that the angle between the
long axis of the tibia and the long axis of
the calcaneus (tibiocalcaneal angle) is
greater than 90° (see the image).
Radilogical Finding of CTEV
2. In hindfoot varus, the talus is assumed to
be fixed relative to the tibia. The calcaneus is
considered to rotate around the talus into a
varus (toward midline) position. On the
lateral view, the angle between the long axis
of the talus and the long axis of the calcaneus
(talocalcaneal angle) is less than 25°, and the
2 bones are more nearly parallel than in the
normal condition (see the images).
Radilogical Finding of CTEV
3. In hindfoot varus, the talus is assumed to
be fixed relative to the tibia. The calcaneus is
considered to rotate around the talus into a
varus (toward midline) position. On the
lateral view, the angle between the long axis
of the talus and the long axis of the calcaneus
(talocalcaneal angle) is less than 25°, and the
2 bones are more nearly parallel than in the
normal condition (see the images).
Radilogical Finding of CTEV
4. Forefoot varus and supination increase the
convergence of the bases of the metatarsals
on the DP view, compared with the normal
slight convergence (see the image).
Therapy of CTEV
using Ponseti’s Method
The Ponseti method is a specific method of casting, serial manipulation and surgery
of cutting down the achillestendon i.e tenotomy. Treatment is provided instantly
after birth and leads to plaster casting and serial manipulation. The foot’s ligament
and tendon are starched and manipulated on the weekly basis followed by
implementing the cast of soft fiberglass that helps to bring the ligament in its
original position. The goal and result of the Ponseti treatment is to reduce if not
eliminate all elements of the Clubfoot deformity to obtain a functional, flexible,
pain free, strong, normal looking, plantigrade and normal shoeable foot. In general
the success rate (in babies without other health issues) can be expected to be 95+
%.
Ponseti’s Method
The treatment result depends on:
Severity of the Clubfoot.
Involvement of other health issues (e.g. neuromuscular disease, syndrome).
Age and physical development stage of the child at treatment start.
Experience of the doctor/health care worker.
Cooperation of the parents.
Brace compliance.
Ponseti’s Method
When to start the Ponseti treatment?
 Soon after birth (~7-10 days): The best
 Not yet walking child: Very effective
 Walking child up to several years of age: Effective in correcting all or much of the deformity.
Depending on severity and other associated health issues, older children may require additional
surgery.
Ponseti’s
Method
Surgical Treatment
If the manipulation or serial casting treatment fails, surgery is required. The
surgical correction is usually not done until the child is between six and nine
months of age. Surgical treatment is performed to correct clubfoot and align the
foot in original position. The surgical procedure usually consists of releasing and
lengthening the tight tendons and joint capsule of the foot. Surgery almost takes
2 to 3 hours including the stay of two days for observation in hospital. Surgery
required two incision and insertion of small pins to fix the correction of
deformity. Pins are disconnected from the operation foot after four to six week
of surgery and cast is placed for the time periods of eighty four days.
Classification of Surgical
Treatment
Soft tissue releases that release the tight tendons/ ligament around
the joints and result in lengthening of the tendons. This step is
needed in approximately 30-50% of all treated clubfoot patients.
Tendon transfers improve the tendons or ligaments in proper
position.
Osteotomies or arthrodeses are the procedure performed on bone.
This method makes bone and joint more stabilize, to facilitate the
bones to grow firmly.
Thankyou