C. T. E.V.

CONGENITAL
TALIPES
EQUINO VARUS
[CLUB FOOT]
 DEFINITION
Congenital dysplasia of musculoskeletal structures
distal to knee leading to :
-Forefoot and midfoot-inversion & adduction (varus)
-Heel inversion
-Ankle equinus
 CONGENITAL CLUBFOOT
 Idiopathic  Non- Idiopathic
1. Muscle imbalance
2. Fibrosis of soft parts
3. Bone and joint anomalies
 ETIOLOGY

Theories :
 Mechanical factor in utero
 Neuromuscular defect
 Primary Germ Plasma defect
 Arrest of fetal development
 Heredity
 Heredity & environment
 Retractile fibrosis
 MECHANICAL FACTOR IN
UTERO

 Oldest theory
 Proposed by Hippocratus
 Believed that foot was held in
equinovarus by external pressure
 Neuromuscular imbalance
theory

 Dominant neurogenic factor.

 Muscle imbalance may produce the deformity.
 Congenital fiber imbalance between type 1 &
2 muscle fibers and atrophy of type 1 fiber
found in peroneal and triceps surae muscle in
histopathological specimen.
 E.g.Cerebral palsy, spina bifida,poliomyelitis
 PRIMARY GERM PLASM
DEFECT
 Irani
 Primary Germ Plasm defect
affecting the head and neck of
talus.
 Defect in cartilaginous talar
analge producing dysmorphic
neck and navicular
subluxation.
 ARREST OF FETAL
DEVELOPMENT
 Intrauterine mechanical factors:
 Normally the foot in 6 to 8 wk old
fetus has characteristics of Club
foot and becomes normal at 12 to
14 wks
 Arrest in physiological
developmental phase results into
equinovarus deformity.
 GENETIC THEORY

 In otherwise normal infants is the result of a

multifactorial system of inheritance.
 RETRACTILE FIBROSIS

 Increased fibrous tissue in muscles and

ligaments leads to contracture of soft
tissues and hence development of
deformity.
 e.g.A.M.C.
 Evidence :
1. In general population – 1/1000 live births
2. 1st degree relative - Risk 2%.
3. One parent affected - Risk 3-4%.
4. Both parents affected - Risk 15%
 COMPONENTS OF THE
DEFORMITY
Equinus
1. Ankle joint equinus
2. Inversion of talocalcaneonavicular complex
3. Plantar flexion of foot
 Components of deformity
 Varus
– Hindfoot is rotated inwards ,
– occur primarily at Talocalcaneonavicular
joint
 Adduction
– foot is deviated medially
– Occurs at talonavicular and calcaneo-cuboid
joint subtalar joint
 Cavus
– Forefoot plantar flexion in relationship to hind
foot causes cavus deformity
– Occurs at midtarsal joint.
 Osseous deformities
TALUS
 Body :
– anterior part of talus fail to develop its normal
contour.

 Head & Neck :

– Broad and flattened.
– Head and neck shifted medially.
– Angle formed by head & neck.
– Normal 150-160 degree
– In ctev reduced to 115-135 degree.
 CALCANEUM
 It is abnormal position of calcaneus & not
abnormal shape.
– posterior tuberosity displaced upwards & laterally.
– anterior end displaced downwards & medially.
– Sustantaculum tali displaced medially to under talar
head, may be underdeveloped.
 Navicle :
– Navicular articular surface faces laterally to
articulate with the medially deviated head and
neck of talus.
 Cuboid :
– Moves medially with anterior end of
calcaneus.
 Cuneiform and metatarsal :
– Minimal displacements
 SOFT TISSUE
CONTRACTURES
 Posterior
1. Tendo Achillis
2. Tibio-talar capsule
3. Talo-calcaneal capsule
4. Posterior talo-fibular ligament
5. Calcaneo-fibular ligament
 MEDIAL PLANTAR
CONTRACTURES
1. Tibialis posterior tendon
2. Deltiod ligament
3. Talo-navicular capsule
4. Spring ligament
5. Henrys knot
6. FHL/ FDL
SUBTALAR CONTRACTURES

 Talocalcaneal interosseous ligament

 Bifurcated Y ligament
 PLANTAR CONTRACTURES
 Abductor hallucis
 Intrinsic toe flexors
 Quadratus plantae
 Plantar aponeurosis
 CLINICAL FEATURES
 Club like appearance
 Foot points plantar wards with heel drawn up
and inverted
 Feet are usually smaller
 shortened 1st metatarsal ray
 Mid, forefoot adducted, inverted & have equinus
 Anterior end of talus is the most prominent
subcutaneous bone
 Deep creases on posteror aspect of ankle joint.
 CLINICAL FEATURES

 Skin on lateral side is thinned and

stretched & atrophied
 Deep cleft on the medial planter surface
 Lateral malleolus is posterior to and more
prominent than the medial malleolus
 CLINICAL FEATURES

 Forefoot is in equinus
 On passive dorsiflexion and eversion, taut
TA and post. Tibial tendon can be
palpated
 Atrophy of calf muscles
 Painful callosities and bursa on lateral
aspect
 PATHOGNOMONIC SIGN
 In normal newborn,on
passive dorsiflexion, the
dorsum of the foot will
usually touch or closely
approximate the anterior
end of the lower tibia
 In clubfoot , dorsiflexion
is impossible even when
strong pressure is
applied
 ASSOCIATED CONDITIONS
 Paralytic clubfoot
1. Myelomeningocoele
2. Intraspinal tumors
3. Diastematomyelia
4. Poliomyelitis
5. CP
6. GB syndrome
 ASSOCIATED CONDITIONS
 Arthrogryposis multiplex congenita
 Congenital Hip/ Knee/ Elbow/ Shoulder
dislocation or subluxation
 Congenital annular constriction band
syndrome
 Classifications
 Dimeglio
 Pirani
 Functional
 Goldner
 Carrols
 caterall
 Dimeglio’s classification
1.The equinus deviation in the sagital plane (0-4
points).
2.Varus deviation in the frontal plane (0-4
points).
3.Derotation of the calcaneo-forefront block (0-4
points).
4.Forefoot adduction in the horizontal plane (0-4
points).
 Further elements

Posterior crease 1
Medial crease 1
cavus 1
Poor muscle condition 1
Total from elements- 0-4

Total points- 0 -20

 GRADES
GRADE
POINTS

I Benign 0-5

II Moderate 5-10

III Severe 10-15

IV Very severe 15-20

 PIRANI’S CLASSIFICATION
 Medial component :
-medial crease
-palpation of talar head
-deviation of forefoot from
midline
 Post component :
-post crease
-empty heel sign
-equinus
 Curvature of lateral border of foot
– Straight -0
– Mild distal curve-0.5
– Curve at calcaneocuboid joint-1
 medial crease
– Multiple fine creases -0
– One or two deep creases -0.5
– Single Deep crease-1
 Palpation of lateral part of head of talus
– lateral talar head cannot be felt-0
– lateral head less palpable-0.5
– lateral talar head easily felt-1
 posterior crease
– Multiple fine creases-0
– One or two deep creases-0.5
– Sigle Deep crease-1
 Emptiness of heel
-Tuberosity of calcaneus easily palpable-0
-Tuberosity of calcaneus more difficult to
palpate-0.5
– Tuberosity of calcaneus not palpable-1
 Rigidity of equinus
– Normal ankle dorsiflexion>90-0
– Ankle dorsiflexes 90 -0.5
– Cannot dorsiflex ankle <90-1
 Total score-0 to 6
 0 score –no deformity
 6 score-severe deformity
 CARROLL’S 10 POINT SCORING
SYSTEM
1. Calf atrophy
2. Position of fibula
3. Creases
4. Curved lateral border
5. Cavus
 CARROLL’S 10 POINT SCORING
SYSTEM
6. Navicular fixed with medial malleolus
7. Calcaneum fixed with fibula
8. Fixed equinus
9. Fixed adductus
10.Fixed forefoot supination
 RADIOLOGY
 USES-
1. Assessment of severity of deformity
2. Accurate diagnosis to progress of deformity
3. Analyze composite deformities pre- operatively
4. To assess reduction of talocalcaneal jt after
manipulation
5. To plan operative line of management.
6. Post op. confirmation and monitoring of alignment
normal articular surface.
C
AP VIEW

AP VIEW
A – AP Talocalcaneal angle(20-
B
50)
B
C – 2nd Metatarso calcaneal
– 1st metatarso talar angle(5-15

A
 LATERAL VIEW

E
D
F

D – Talo calcaneal angle(20-50)

E – 1st metatarso calcaneal angle
F – Tibio calcaneal angle(10-40)
G –Tibio talar angle(70-100)
 Talocalcaneal index
– Sum of T-C angles in A-P and Lateral
projections .
– Normal - >40°.
>40
 C-t scan
 To study bony anatomic status of foot in
ctev in children of >2 yrs old.
 Arthrography

 To study shape and size of talus with

respect to its length and medial declination
of talonavicular joint.
 Foot prints
 Serial weight bearing foot prints can serve
an important documentation of deformity
and also help in confirming improvement
after correction
 MANAGEMENT
 Non-operative
1.Manipulation & casting
2.Manipulation & strapping
3.Dennis brown splint
 Operative
1.Soft tissue release
2.Bony procedures
3.Differential distraction
 IMMOBILIZATION IN CAST

 Ponseti method
 Turco’s method – Simultaneous correction
 Kites method
 PONSETI METHOD
 Steps:
Cavus is corrected by
supinating the
forefoot and
dorsiflexing the 1st
metatarsal
 PONSETI METHOD

To correct the varus and

adduction, the foot in
supination is abducted while
counter pressure is applied
over head of talus.
The calcaneus abducts by
rotating and sliding under
the talus and as the
calcaneus is abducted it
simultaneously extends
and everts and heel varus
is corrected.
5 –6 serial casts may be
required.
 IMMOBILIZATION IN CAST
 As early as 1 week
 Above knee casts are given
 Plaster cast changed every week
 At the end of 3 months, assess the foot that is going to
corrected by conservative management
 TURCO’S METHOD
 Goal : to relocate the navicular in front of
the talus & evert, dorsiflex the calcaneus.
 Correct all deformities simultaneously.
 Damage during manipulation occurs from
excess dorsiflexion force.
 KITE’S METHOD
 Correction in a sequential order
first – foot adduction
then – heel varus
Finally- equinus
 Adviced change of cast every 3 weeks till
correction is achieved.
 ROBERT JONES ADHESIVE
STRAPPING
 Proposed by Robert jones
 Principle depends on the
child’s knee motion to
apply an active eversion
force
 Inexpensive
 Easy to use
 Dynamic corrective force
 DENIS BROWN BAR
 The aim is to maintain the correction that is
achieved by serial casting and reduce the
incidence of recurrence
 Consist of 2 foot pieces connected by a bar
 20° midfoot and forefoot abd
 0-5° dorsiflexion
 70° ext rotation
 D-B is worn 24 hrs a day & removed for
exercise and passive stretching or when the
child is bathed&fed
 used as a night splint when child starts
walking
 OPERATIONS
 1. Soft tissue release

2. Bony procedures

3. Differential distraction
 Soft tissue release

– One stage PMR with internal fixation( Turco )

– posterolateral ligament complex release most
often is required for severe posterolateral
deformity.
– PM & PL release
 McKay procedure
 Carroll method
 Manzone method
 TREATMENT OF RESISTANT CLUB
FOOT
 Basic surgical correction of resistant clubfoot includes
both soft tissue release & bony osteotomies
 Appropriate procedures & combinations depend on
the age of the child, severity of deformity & pathology
involved
NO DEFORMITY TREATMENT
1 Metatarsus >5yrs metatarsal osteotomy
adductus
2 Hindfoot <2-3 yrs - Modified Mckay procedure
varus 3-10 yrs -
Dwyer osteotomy
Dillwyn evans procedure
Lichtblau procedure
10-12 yrs - Triple arthrodesis

3 Eqinus >10 yrs – Triple arthodesis

4 All 3 Tendocalcaneus lengthening and posterior
deformities capsulotomy of subtalar, ankle joint (mild,
moderate)
Lambrudoni procedure (severe)
 SHORTENING OF THE LATERAL
COLUMN

 Ogston:
– Enucleation of the cuboid bone,
– ant part of calcaneum,
– head of talus.
– Results were disappointing.
 EVANS

 Evans: medial and

posterior release
followed by wedge
resection of
calcaneocuboid joint
 Age : 4-8 yrs
 LICHTBLAU

Combined medial release

with resection of anterior
end of calcaneum of 1 cm
CUBOID DECANCELLATION
 DWYER’S OSTEOTOMY

 Lateral closed wedge osteotomy or medial

open wedge osteotomy of calcaneum with
bone grafting
 Z lengthening of TA
 Medial plantar fasciotomy
 Dependent on the flexibility of subtalar &
midtalar joint
 Pre requisite – sufficient ossification of
calcaneum for bone grafting
 TRIPLE ARTHRODESIS

 Salvage procedure
 Tarsal reconstruction by wedge resection
and fusion of the subtalar and midtarsal
joints
 Results are not good functionally &
cosmetically
 TALECTOMY

 Age< 4 years
 Rigid paralytic deformities of the foot
 Principle is that by excision, sufficient
laxity of soft tissues is provided to correct
equinus and varus deformities without soft
tissue tension
JOSHI’S EXTERNAL FIXATOR
Indications :
1. Neglected cases
2. Relapsed cases
3. Known resistant cases eg Arthrogryposis
4. Late presentation
ILIZAROV