 At the end of the Lecture, students should be

able to :
 Explain CTEV and its types
 Identify the possible causes of CTEV
 Discuss the biomechanical changes in CTEV
 Discuss about the surgical management
 Explain the conservative & P.T management
 Congenital Talipes Equinovarus (CTEV) also
known as ‘club-foot’, is the most common
congenital orthopedic anomaly seen in
children.
 CTEV affect the lower limb and can be
challenging to treat (Hippocrates-400 BC).
 CTEV is a malformation immediately
recognizable at birth.
 In CTEV
Ankle is in a plantar flexed position
Heel is inverted
The mid-foot and forefoot are inverted & adducted.
 There are two types of CTEV.
Postural
CTEV
 Postural CTEV involves Structural
Muscle imbalance and or tightness.
No bone or joint involvement.
 Structural CTEV involves the
Bone and joints of the foot
The child's foot cannot be passively put through a
full range of motion.
 Prevalence of CTEV 0.3 to 7 per 1000 live
births & it may be bilateral or unilateral.
 CTEV is twice as common in boys.
 CTEV has four components:
Equinus
Forefoot adductus
Hindfoot varus
Hindfoot cavus.
 These deformities cause shortening of
musculature, ligaments, and skin medially
and posteriorly.
 CTEV is termed ‘syndromic’ & idopathic.
Syndromic occurs in association with other
neurological and neuromuscular disorders
Spina bifida or spinal muscular atrophy
Idopathic occur in isolation and by far it is the
most common.
The upper limb is normal.
 Hippocrates advised treatment with
manipulation and bandages.
 Modern treatment still uses manipulation and
immobilization.
Serial manipulations
Immobilization with strapping or casts
 Ponseti method is the most effective of these
methods which can substantially reduce the
need for surgery.
 Nevertheless, many cases still require surgery
and disability often persists despite treatment
 1 in 1000 birth
 Male: Female ratio = 2.5:1
 50% of cases are bilateral involvement of
lower limbs
 20 -30 times common if one sibling is
affected
 1 - 4% if one parent affected
 15 - 20% if both parents affected
 32% in case of monozygotic twins
 3% in case of dizygotic twins.
 Clinical inspection of a newborn child with
CTEV reveals
Malposition of the tarsal bones
Atrophy of the calf muscle
Shortness of the foot
The hindfoot is in equinus position + tight heel
cord.
Retraction and atrophy of the gastrosoleus muscles
Calcaneus is inverted in varus position
Forefoot is held in adduction and supination
A cavus deformity with a medial and a posterior
skin crease (more pronounced in severe cases)
 On palpation, the change in kinematics is
apparent.
 Decreased subtalar motion severe
shortening of the medial and posterior tarsal
ligaments and the tightness of the tibialis
posterior and gastrosoleus muscles.
 The active and passive motion of the forefoot is
relatively preserved with only slight restriction.
 Investigations on muscle and ligament specimens
diverge.
 A change in composition of muscles samples,
with a type I fiber predominance in
Soleus
Tibialis posterior
Long toe flexors compared to the non-affected leg
Peroneal muscles
 Others report increased fibrosis in affected
muscles, indicating a neurogenic defect.
 The talus is deformed with medial angulation of
the neck and the head is dome-shaped.
 The calcaneus is medially rotated underneath the
talus and both the calcaneus and talus are in
plantar flexion.
 Producing varus deformity of the hindfoot.
 On X-ray, this de-rotation between talus and
calcaneus produces a / near 0o talo-calcaneal
angle on both AP & lateral view.
 In CTEV the position of the distal part of the
calcaneus beneath the head of the talus.

 It prevents the talus from pronation &

dorsiflexion.

 Thereby, calcaneus blocking the talus in an

equinus position.
Normal foot CTEV talus
 5° internal rotation of body  14° external rotation of body
 25° internal rotation of neck  45° internal rotation of the
neck
 Thick and tight tibio-navicular ligament,
calcaneo-navicular ligament, and tibialis
posterior tendon sheath found on medial and
plantar side of the foot.
 This “medial tie” is described as crucial for
the development of the mid-foot part of the
deformity.
 The fibulo-calcaneal ligament (Lat) is short
and thick, forming a fibrotic mass merged
with the peroneal tendon sheaths.
 Kamegaya et al. define the long axis of the body
of the talus as perpendicular to the
transmalleolar line.
 With a talar neck angle pointing more medially
in CTEV than in normal feet, the navicular is
positioned either medially or laterally in relation
to the talar head.
 The greater the severity, the greater was the
medial shift and the angulation of the neck of
the talus.
 Wedge-shaped distal calcaneus articular surface
contributing to increased forefoot adduction.
 Nutcracker effect produced when dorsal
flexion is tried before the calcaneus is rotated
out of supination and posterior elements are
still too tight to allow the talus to rotate.
 Talar flattening is common and more
pronounced due to improper positioning.
 Some findings reports that there is a mean
external torsion of the tibia of 18° (normal 40°)
in children with CTEV.
 However, other authors claim there is no tibial
torsion in patients with clubfeet.
 Race
 Gender (M:F = 2.5:1)
 Affected family members (24.4% family history,
32.5% monozygotic, 2.9% dizygotic)
 Associated disorders
◦ Developmental hip dysplasia, spina bifida,
arthrogryposis, chromosomal abnormalities, cerebral
palsy, neuromuscular diseases and myotonic dystrophy
 Intrauterine factors
◦ Intrauterine compression (large baby, abnormally shaped
or small uterus, folding the foot against the shin long
periods in the intrauterine life or abnormal intrauterine
fluid levels)
 Primary germ plasm defect
Indications (Ebnezar, 2007)
 No response to conservative treatment after 6
months
 Rigid club-foot (forefoot deformities are
corrected but hind-foot deformities remain
uncorrected after conservative treatment)
 Relapsed club-foot (initially corrected but relapse
back to deformity later)
 Recurrent club-foot (muscle imbalance was
overlooked)
 Resistant club-foot (cannot be corrected
conservatively)
The table below shows the possible surgeries done according to age
according to Ebnezar (2007)

Age of 6-12 12-36 Above 2 years old

child months months
Type of TURCO McKay’s - Metatarsal osteotomy
surgical (postero (Complete - Dwyer lateral closed wedge
treatment medial subtaloid osteotomy of calcaneus
release) release) - Dilwyn Evan’s procedure of
resection & arthrodesis of
calcenocuboid joint
- Davis procedure wedge
resection of mid tarsal
- Triple arthrodesis
- Tendo-Achilles lengthening
(treat equinus)
- Posterior capsulotomy
- Ilizarov external fixator
- Joshi’s external stabilisation
system (JESS)
 Soft
Bone Surgical
tissue
operation treatment operation
Soft Tissue Operation Bone Operation
- TURCO (Posteromedial Soft - Metatarsal osteotomy
Tissue Release) - Dwyer lateral closed wedge
- McKay’s (Complete Subtaloid osteotomy of calcaneus
Release) - Dilwyn Evan’s procedure of
resection & arthrodesis of
calcenocuboid joint
- Davis procedure wedge
resection of mid tarsal
- Triple arthrodesis
1) TURCO (posteromedial soft tissue release)
(Ebnezar,
Posterior2007)Z-plasty of tendo-Achilles to lengthen it
side Posterior capsulotomy of ankle & subtalar joints
Release of posterior talofibular & calcaneofibular
ligaments
Medial side Lengthening of tibialis posterior, flexor hallucis
longus & flexor digitorum longus muscle
Release of talonavicular ligament, spring ligament
& superficial part of deltoid ligament
Release of interosseous talocalcaneal ligament,
naviculocuneiform capsules & 1st metatarso-
cuneiform joints

Plantar side Plantar fascia

2) McKay’s (Complete sub-taloid release)
(Ebnezar, 2007)
 TURCO + Released lateral structures
 Lateral structures
◦ Superior peroneal retinaculum
◦ Inferior external retinaculum
◦ Dorsal calceneo-cuboid ligament
◦ Origin of extensor digitorum brevis muscle
Surgeries Treatment
Metatarsal osteotomy Treat metatarsal adduction

Dwyer lateral closed wedge Treat hind foot varus

osteotomy of calcaneus
Dilwyn Evan’s procedure of Treat hind foot varus
resection & arthrodesis of
calcenocuboid joint
Davis procedure wedge resection Treat hind foot varus
of mid tarsal
Triple arthrodesis - Lateral closed wedge
osteotomy through subtalar &
midtarsal joints to fuse the
subtalar, talonavicular &
calceneocuboid joints
- Treat metatarsal adduction,
hind foot varus & equinus
 Done if surgical intervention is risky or
difficult to perform
 Non-invasive techniques
 To correct all aspects of the deformity by
sequential stretching of soft tissues
 Eg. Ilizarov external fixation & Joshi
apparatus (JESS)
Diagram shows Ilizarov external fixator (left) and JESS (right)
Conservative treatment
 Non-operative treatment of CTEV commence manipulative
treatment with stretching of the foot.
 There is controversy regarding how much preliminary
stretching of the foot should occur before manipulative
correction.
 The controversy facts:-
 Duration for stretching
 The amount of force
 Continuous or intermittent
 However, all authors seem to agree that treatment should be
started as early as possible.
 The most common methods that most widely performed and
that have the highest reported long-term success rates are
 French methods
 Ponseti technique
 Kite's method
 Effective use of either of these techniques can alleviate the
need for extensive soft tissue release in most children, thus
avoiding the risk for potential over correction, stiffness, and
pain.
 Dr. Ponseti developed the method over 50
years ago at the University of Iowa.
 Starting at 1-2 weeks of age, the tendons and
ligaments in the foot are gently manipulated.
 This does not hurt the child.
 Correction start with cavus.
 The results of treatment are enhanced by
Starting within the first month of life
Understanding of the biomechanics of CTEV
 Manipulation lasts for 1–3 minutes and
includes stretching of tight ligaments.
 1st session :- Cavus is corrected by elevating
the first metatarsal & supinating the forefoot.
 At successive weekly intervals, the calcaneus,
navicular and cuboid are gradually displaced
laterally.
 There are three crucial points:
Forefoot abduction is performed with slight
supination.
Equinus is maintained as long as the heel is in varus
and allow the calcaneus to move freely under the
talus.
Counter pressure on the lateral head on the talus,
not on the lateral column (hinders the correction of
the heel varus)
 Equinus is the last to be corrected.
 Correction need to be done when the
hindfoot is in slight valgus and the forefoot
abducted 70° relative to the leg.
 This degree of hyper-abduction is considered
necessary to prevent recurrence of the
deformity.
 In 70–75% of patients, a percutaneous
Achilles tendon lengthening is performed.
 After each manipulation, a well-moulded toe-
to-groin cast maintains the foot in abduction
and enables moulding of the joints.
 To prevent recurrence a Foot Abduction
Orthosis (Denis Browne bar) applied for 3
months and during naps and overnight for 3–
4 years.
 89% of the feet had a good or excellent result
at the time of the thirty-year follow-up.
 However, Achilles tenotomies were required
in 70% of patients.
 In 1992, Ponseti reported a 50% rate of
recurrence requiring additional cast
treatment.
 Deformities that recurred frequently required
lengthening of the Achilles tendon and
transfer of the anterior tibial tendon to
maintain correction.
 Ponseti now reports that the recurrence rate
in his patients is far lower.
 The primary factors responsible for club-
foot are (Bensahel et al)
Retraction of tibialis posterior muscle
Weak peroneal muscles, together with
A fibrous zone in the medial part of the midfoot.
 This functional method consists of,
Daily manipulation Temporary
-skilled physiotherapist immobilization of foot
-non-elastic adhesive
3X/Week strapping.
6months 6 months
 Night time splinting is recommended for an
additional 2–3 years.
 The focus is to relax the stiff tissues by
progressive passive manipulation & active
muscle stimulation = 30 minutes per foot,
followed by taping and splinting.
 Manipulation done gently and smoothly to
avoid defense reactions with further
contractions occurring.
Progressive release of the
The medial tissues are
navicular from the medial
stretched
malleolus

Stretching the joints

Cutaneous reflexes are
along the medial ray of
stimulated
the foot.
(strengthen the pronation
(Reduce Forefoot
forces)
adduction)

Loosening posterior
structures
(corrects the equinus)
 Continuous passive motion (CPM) used in
clubfoot treatment in the early 1990s.
 Aim of CPM is to :-
Maintain the passive range of motion
Soften the tissues during sleep
 Dr Kite find a non-invasive treatment strategy
for clubfoot after he became dissatisfied with
the poor results of surgical treatment.
 Dr Kite published a series of manipulations
and castings followed by night splinting.
 Feet held in dorsiflexion and slight abduction
in night splint.
 He aimed at correcting each component of
CTEV separately, and not simultaneously by
using repeated manipulation and casting.
 Adduction correction.
Foot abduction with fulcrum in the midfoot and
support in the calcaneocuboid joint.
 Varus correction.

Hindfoot eversion (wedges or plaster cast)

 The manipulations successively forced abduction

and pronation of the forefoot.

 Adduction and inversion correction.

 The forefoot and hindfoot equinus deformities

were correction.
Progressive dorsiflexion.
 Manipulation was performed with pressure
applied over the calcaneocuboid joint (as a block
to the corrective force) and the foot was never
beyond neutral.
 The toe-to-groin cast was changed every 7 to 10
days until full correction.
 This was followed by full-time splinting in a
neutral position with a heel lock to avoid
recurrence of varus, and a straight medial bar to
avoid recurrence of adduction.
 Once the patient began walking, the splints
were used at night only.
 By day, shoes with following characteristic
were used until the age of 4 to 5 years.
Open toe box
Straight medial border
Lateral flaring of the sole
Reverse Thomas heels
 Kite reported good outcomes with non-
invasive treatment in 800 cases of CTEV.
 Orthosis are used to prevent a relapse of the
condition. Some are designed to allow active
movement while others are use completely
for immobilization (although complete
immobilization is usually avoided if possible
to prevent a stiff immobile foot)
 Denis Browne splint (used at night usually)
(The clubfoot Club, 2014)
◦ Shoes are attached to a bar
◦ Adjustable to accommodate to the progressing
change in the feet
◦ Used after serial casting to maintain correction
◦ Have many types (metal splints, bootee splints)
◦ Holds the legs in a dorsiflexed position with
evertion and external rotation
◦ In a unilateral case, both the affected foot and the
non-affected foot will be placed into the splint
Denis Browne
Splint

CTEV
Shoes
Ankle Foot
 Phelp’s brace (mostly in the daytime)
(Ebnezar, 2007)
 Below-knee walking calipers (Ebnezar, 2007)
 CTEV shoes (used for when child begins to
walk up to 5 years of age) (Ebnezar, 2007)
 The Ponseti Foot Aduction Brace (more
comfortable then Denis Browne Boots) (The
clubfoot Club, 2014)
 Ankle-foot orthoses (AFO’s) (The clubfoot
Club, 2014)
◦ Hard & rigid plastic splint
◦ Held on with velcro worn at the lower leg and foot
for ankle support & for correction of foot
◦ Used after surgeries
 The prognosis depends largely upon the age at
which primary treatment begun, and upon the
efficiency with which it is carried out.
 The longer the delay before treatment, the
smaller is the prospect of complete cure.
 Yet even with prompt treatment the outcome is
uncertain.
 In a proportion of cases, despite the greatest
care from the time of birth, there is a tendency to
relapse when treatment discontinued.
 These are the usually cases that show marked
hypoplasia of the muscles of lower limb,
especially peroneal group.
 Even in the most severe cases, however, it should
always be possible to ensure a plantigrade foot,
if not a normal foot, by operative means
 Congenital Talipes Equino Varus is a
developmental abnormality of the foot.
 Foot is positioned in hindfoot equinus and
varus, and forefoot adduct, supinate, and
cavus.
 There are interuterine causes as well as
extrauterine causes, both idiopathic and non-
idiopathic, genetic and environmental. Yet
these require further research to confirm
these findings.
 Biomechanical changes in CTEV involve the
ankle, subtalar and midtarsal joints and the
severity of deformity varies and is graded by
the pirani score.
Surgeries are of a last resort, only used when
conservative methods are unable to correct the
deformity. Surgeons may choose to do a soft tissue
operation, a bone operation, or both depending on
the severity of the deformity. All these operations
can be used together with orthosis.
Treatment over time has varied. Initially, it was
Kite's technique which gave excellent results.
However, since his results were not reproducible,
this was replaced by conservative treatment and/or
operative treatment.
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