Developmental deformation of the foot characterized by
rotational subluxation of the talocalcaneonavicular joint
complex with Talus in plantar flexion and Subtalar complex
in medial rotation and inversion
Established by genetic epidemiologic research by Idelberger
32.5% concordance rate among monozygotic twins as
compared to 2.9% among dizygotic twins
genetic heritability of 80% .
Idelberger K. et al 1939; 33:272–276.
A major gene effect (inherited in recessive manner) with
additional polygenes and environmental factors
complex segregation analyses of idiopathic clubfoot
populations. (de Andrade M ,1998)
deletion on Chromosome 2 (2q31-33) related to the
Heck AL et al. J Pediatr Orthop 2005;25:598-602
Conclusively disproved by Wynne-Davies
concordance between dizygotic twins was identical to the
non-twin sibling rate
Dizygotic twins “crowded” into a single uterus did not
demonstrate a higher concordance with respect to non-twin
Infective pathogens (enteroviruses)
Seasonal variation with significant increase in CTEV
incidence was seen in the winter (December–March ) in
Infective pathogens exhibiting seasonal activity
postulated as potential causes
Conflicting evidence –Carney et al (2005)**
* Barker SL. J Pediatr Orthop B 2002; 11:129–133.
** Carney BT. J Pediatr Orthop 2005;25:351-2.
Toxins and electromagnetic
(Halmesmaki et al. 1985)
(Alderman et al.)
(HONEIN M ,2000)
The results are
preliminary, and further
work is required
Irgens LM, et al.Teratology 1998;
Salicylate use in first
Prenatal exposure to
Chung C et al. Hum Hered. 1969;19:321-42
Byron-Scott R, et al. Paediatr Perinat Epidemiol
Gray et al (1981) : increase in % of type I fibres in the soleus
muscle; suggested defective neural influence.
Recent study**: no evidence of type I fiber grouping
** Milan B MD et al. Journal of Pediatric Orthopedics. 26(1):91-93, January/February
hypoplasia or absence of the anterior tibial
artery in majority of CTEV patients*
absence of the dorsalis pedis pulse in the
parents of children with clubfoot**
*Sodre H et al. J Pediatr Orthop. 1990;10:101-4.
**Muir L et al. J Bone Joint Surg Br. 1995;77:114-6.
Generalized disorder of development of
Lower limb in unilateral CTEV
- Redn in calf and thigh girth
- Significant shortening, most prominent
at ankle and least at femur
Shimode K, Myagi N, Majima T, Yasuda K, Minami A. J Pediatr Orthop [B] 2005;14:280-4.
Pathoanatomy of soft tissues
1. The plantar calcaneonavicular
2. The tibionavicular ligament
3. The superior, medial and plantar
parts of the talonavicular capsule
4. The posterior tibial tendon
5. The master knot of Henry
6. The calcaneofibular ligament
7. The superior
8. The posterior talocalcanel ligament
9. The posterior capsule of the
10. The tendo Achillis
11. The interosseous ligament
12. The long toe flexors
increase of collagen fibers and
cells in the ligaments.
The bundles of collagen fibers
display a wavy appearance
known as crimp.
crimp allows the ligaments to be
The crimp reappears a few days
later, allowing for further
TA : non-stretchable, thick,
tight collagen bundles with few
The tarsal bones, which are mostly
made of cartilage, are in the most
extreme positions of flexion,
adduction, and inversion at birth
The talus: severe plantar flexion, neck
medially and plantarly deflected, and
head wedge shaped.
Navicular: severely medially displaced,
close to the medial malleolus, and
articulates with the medial surface of the
head of the talus.
The Calcaneus adducted and inverted.
anterior portion of the Calcaneus lies
beneath the head of theTalus.
Tarsal joints are functionally interdependent. The
movement of each tarsal bone involves simultaneous shifts in
the adjacent bones.
No single axis of rotation
Necessiates SIMULTANEOUS correction of adduction,
varus and inversion.
A standardized examination initially and after each interval of
reference posn, usually the knee in 90° of flexion, chosen.
All deformities assessed in relation to the next most proximal
Exmn of the entire child to look for associated anomalies, esp the
Foot shorter and wider than
Transverse plantar creases or
clefts at the midfoot and
posterior part of the ankle.
Atrophy of the calf
Assessment of equinus
posterior aspect of the calcaneus
must be palpated carefully when the
equinus is measured
Equinus assessed with the knee
both in extension and in flexion.
equinus with knee extended
-The true contractureof the
gastro-soleus muscle complex.
The difference between the
equinus in knee flex and extn
indicates the amount of stiffness
in the ankle joint.
heel is in varus but the forefoot is well
aligned with the heel.There is no
supination of the forefoot on the
The varus of the heel at rest
and in the position of best
Posn of forefoot in relation
Palpation of the lateral
column with the foot in
Congenital vs Acquired
HistoryHistory Since birthSince birth Appears laterAppears later
BilateralBilateral In >50%In >50% Usually unilateralUsually unilateral
Forefoot adductionForefoot adduction
Congenital grooveCongenital groove PresentPresent Not presentNot present
HeelHeel SmallerSmaller Usually maintainsUsually maintains
CalfCalf Cylindrical and toughCylindrical and tough NormalNormal
Non RigidNon Rigid
Foot sizeFoot size NormalNormal SmallerSmaller
HeelHeel Normal sizeNormal size
Can be broughtCan be brought
down with easedown with ease
Minimal varusMinimal varus
Small , elevatedSmall , elevated
Cannot be broughtCannot be brought
down with easedown with ease
Marked varusMarked varus
CreasesCreases More or less normalMore or less normal Deep medial,Deep medial,
posterior and lateralposterior and lateral
Reduced creasesReduced creases
TelescopingTelescoping NegativeNegative PositivePositive
Club foot like appearance in cong. absence or hypoplasia of
tibia and in cong. dislocation of ankle
Careful palpation of Anatomical relationship and Radiograph
will establish the diagnosis
1. Difficult to position the foot
2. The ossific nuclei do not represent the true shape
3. In the first year of life, only the talus, calcaneus, and
metatarsals may be ossified
4. Failure to hold the foot in the position of
best correction makes the foot look worse than it is
The foot should be held in the position of best correction,
with weight-bearing, or, if an infant is being examined, with
Focused on the hindfoot (about 30° from the vertical for AP
Lat. View: transmalleolar with the fibula overlapping the
posterior half of the tibia
AP TaloAP Talo
20 -50 deg20 -50 deg <20 deg<20 deg
Upto 30 degUpto 30 deg
cuboid os.cuboid os.
center w.r.tcenter w.r.t
calcaneal axiscalcaneal axis
AP radiograph: Talo-Calcaneal angle
Normal foot: 20`-50` CTEV:<20 deg
Ideally done at 20 to 24 weeks
Recent reports*: positive predictive value of 83% with a
false positive rate of 17%.
26% no Rx reqd; 61% reqd Sx
* Baron E, Mashiach R, Inbar O, et al. J Bone Joint Surg [Br] 2005;87-B:990-3.
1. Recent study: to describe the morphological changes in a
comparative study of treatment methods
2. Used for demonstrating complete healing of TA at 3 wks
foll. Percutaneous tenotomy
ROLE OF MRI
NOT used in routine clinical practice
Important tool in research studies
PIRANI’S MRI PROTOCOL
Sagittal images perpendicular to the bimalleolar axis
Oblique axial images perpendicular to the talonavicular joint
Oblique axial images perpendicular to the calcaneocuboid
Oblique coronal images perpendicular to the subtalar joint
Uses of Pirani’s score
Assessment of progress by serial plotting of the score
Predicting need for tenotomy (hs>1& ms<1)
Estimation of probable no. of casts reqd*
very good interobserver reliability and reproducibility**
* J. Dyer et al Journal of Bone and Joint Surgery - British Volume, Vol 88-B, Issue 8, 1082-1084P.
** Flynn JM, Donohoe M, Mackenzie WG. J Pediatr Orthop 1999;18:323-7
Study Group (ICFSG)
Introduced by Bensahel et al in 2003
Found to have good interobserver reliability and
Morhological (12 pts), functional (24 pts) & radiological
(12 pts) parameters
Maximum of 60 for most deformed and 0 for normal feet
**Celebi L et al J Pediatr Orthop B. 2006;15:34-36.
Aims of treatment
Strong, painless, plantigrade and supple foot by conservative
Plantigrade, painless foot that can wear shoes by surgical
means if conservative regimen fails
DR. IGNACIO PONSETI
Introduction of Ponseti’s
method and its wide spread
use over the last decade
following the publication of
long-term results has been
the most significant event in
the history of CTEV
Outline of Ponseti regimen
Serial casting of the lower limb using a strictly defined
technique and weekly change of casts
Percutaneous tenotomy of the tendo achilles for “hind
Once the foot is corrected, an abduction foot orthosis
worn full time for 12 weeks, and then at nights and naps,
up to the age of four.
Transfer of the tibialis anterior tendon for dynamic
Cavus results from pronation of the forefoot in relation
to the hindfoot –“ THE PRONATION TWIST “
Attempting to correct the supination of hindfoot before
correction of varus results in an iatrogenic increase in
cavus corrected first by supinating the forefoot to place
it in proper alignment with the hindfoot.
Varus, inversion, and adduction
varus, inversion, and adduction of the hindfoot are corrected
after correction of cavus
Correction of all three components done simultaneously
as the tarsal joints are in a strict mechanical interdependence
Correction of equinus
No direct attempt at equinus correction is made until the
heel varus is corrected
The equinus deformity gradually improves with correction of
adductus and varus- calcaneus dorsiflexes as it abducts under
Residual equinus- manipulation and casting +/-
Percutaneous TA tenotomy
Tenotomy of the tendo Achillis is an integral step in the Ponseti
Tenotomy is indicated when HS > 1, MS < 1(Pirani’s hindfoot
and midfoot scores resp.), and the head of the talus is covered
The best sign of sufficient abduction is the ability to palpate the
anterior process of the calcaneus as it abducts out from beneath
the talus .
Percutaneous tenotomy under LA
* Foot held in max dorsiflexion by an assistant
* Tenotomy done 1.5 cm above calcaneal insertion
* additional 25-30 deg dorsiflexion obtained
POST TENOTOMY CAST WITH FOOT IN 60-
70 DEG ABDN
Complications of tenotomy
Healing of ruptured tendon:
. Barker et al* used USG studies to demonstrate complete
healing of TA BY 3 weeks
Dobbs MB et al ** reported a 2% incidence of serious
bleeding following tenotomy
* Barker SL et al. J Bone Joint Surg [Br] 2006;88-B:377-9.
** Dobbs MB et al. J Pediatr Orthop 2004;24:353-7.
Applied immediately after the last cast is removed, 3 weeks
The brace consists of open toe high-top straight last shoes
attached to a bar
worn full time (day and night) for the first 3 months after the
last cast is removed.
After that, 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
continued until the child is 3 to 4 years of age.
Significance of bracing
Haft et al**: noncompliance with bracing protocol – the most
common cause of recurrence in children on Ponseti regimen
**Haft, Geoffrey F. MD; Walker, Cameron G. PhD;
Crawford,Haemish A. FRACS.J Bone Joint Surg Am, Volume 89-
A(3).March 1, 2007.487–493
2-3% Feet highly resistant to correction
Deep skin creases, rigid and severe deformities, fibrotic
60 deg supination in 1st
AK casts with knee in 120 deg flexn
Tenotomy after correction of hyperflexion of
Post tenotomy casts changed every5 days
Follow up protocol
2 weeks: to troubleshoot compliance
3 months: to graduate to the nights-and-
every 4 months: until age 3 years to monitor
compliance and check for relapses
every 6 months: until age 4 years.
every 1 to 2 years: until skeletal maturity
Examine the toddler walking
Look for supination
Look for heel varus
Treatment of relapse
Equinus relapse: corrective casting +/- percutaneous
tenotomy in child < 2 yrs;
TA lengthening in older children
Varus relapse: recasting and restitution of bracing
Dynamic supination deformity
persistent varus and supination during walking
thickening of lateral plantar skin.
Will require anterior tibialis tendon transfer
fixed deformity corrected by casts before
best performed when the child is between 3
and 5 years of age.
delayed till radiographs show ossification of
No bracing is necessary after the procedure.
Results of Ponseti’s method
The key paper by Cooper and Dietz in 1995.
reviewed a group of 45 adults, with 71 clubfeet, who had been managed with
the Ponseti method, 30 years after treatment.
The results were compared with NORMAL CONTROLS.
Based on structured examination, radiographs, electrogoniometry and
measurements using a pedobarography.
Using the Laaveg and Ponseti score, the results in the normal controls and in
those with treated clubfeet were the same.
Radiographs showed that the feet were not completely corrected, but
functioned well despite this.
Cooper DM, Dietz FR. J Bone Joint Surg [Am] 1995;77-A:1477-89.
Results of Ponseti’s method..
study from Iowa (2004) described the short-term results of a
more recent series of 256 feet.
Correction obtained in 98% with one to seven casts.
2.5% required extensive corrective surgery.
Percutaneous tenotomy in 86%.
The mean angle of dorsiflexion : 20° (0° to 35°).
Minor cast complications in 8%
Rate of relapse: 10%.
Morcuende JA, Dolan LA, Dietz FR, Ponseti IV. Radical reduction in the rate of extensive correctivesurgery
for clubfoot using the Ponseti method. Pediatrics 2004;113:376-80.
OUTCOME AFTER CORRECTIVE SURGERY –
A STARK CONTRAST
Laaveg and Ponseti scores: 0% excellent, 33% good, 20% fair and
47% poor results.
significantly reduced scores in physical functioning, role physical,
general health, vitality, social functioning and physical components
similar to those with pain in the cervical spine with
radiculopathy,Parkinson‘s,haemodialysis, CHF and those awaiting
Dobbs MB, Nunley R, Schoenecker PL. Long term follow up of patients with clubfeet treated with extensive soft-tissue release. J Bone
Joint Surg [Am] 2006;88-A:986- [on 73 feet in 45 patients after a minimum follow-up of 25 years ]
Ponseti regime Vs surgical correction
CT at skeletal maturity
manipulation and serial casting, followed by posteromedial release
for the resisting feet vs modified Ponseti regime [open z-
lengthening of TA]
Ponseti group: better correction of cavus, supination and
Ippolito et al. J Bone Joint Surg [Br] 2004;86-B:574-80
Ponseti Vs Kite technique
Mean followMean follow
Need forNeed for
Segev E, Keret D, Lokiec F, et al. Early experience with the Ponseti method for the treatment of congenital
idiopathic clubfoot. Isr Med Assoc J 2005;7:307-10.
Modifications of Ponseti’s method
ACCELERATED PONSETI PROTOCOL
Morcuende et al , (2005) 7 day Vs 5 day interval
Average time to tenotomy: 16 days in 5 day group and
24 days in 7 day group
Morcuende JA, Abbasi D, Dolan LA, Ponseti IV. Results of an accelerated Ponseti protocol for clubfoot. J
Pediatr Orthop 2005;25:623-6
Botulinum toxin injection into the
Alvarez et al (2005)*: alternative to Achilles tenotomy
producing satisfactory results with less skin scarring and deep
prospective RCT(Cummings et al,2005)**:NO significant
difference between injections of a placebo or Botulinum
* Alvarez CM, Tredwell SJ, Keenan SP, et al. J Pediatr Orthop 2005;25:229-35.
** Cummings RJ, Shanks DE. POSNA Annual Meeting,
Paramedical staff-delivered Ponseti
Good results can be achieved by trained physiotherapists and
orthopedic clinical officers
enables many families in rural and remote areas to receive
treatment which would otherwise have been inaccessible and
Shack N, Eastwood DM.. J Bone Joint Surg [Br] 2006;88-B:1085-9.
Tindall AJ et al.J Pediatr Orthop 2005;25:627
Application in neglected club foot
Lourenco et al,2007: retrospective study on 17 children (24
feet) presenting after walking age (mean age 3.9 years)
Correction in 66.67% with ponseti’s method alone.
A. F. Lourenço, MD et al. Journal of Bone and Joint Surgery - British Volume,2007. Vol 89-B, Issue 3, 378-
The French method
daily manipulations by a skilled physiotherapist and temporary
immobilisation with elastic and non-elastic adhesive taping
mobilisation during the hours of sleep with CPM machine
Successful in 51% of cases ( of which 9% req TA tenotomy) ; 49%
Reqd extensive soft tissue release -29% post release and 20%
comprehensive posteromedial release**.
** Richards BS, Johnston CE, Wilson H. Nonoperative clubfoot treatment using the French physical therapy
method. J Pediatr Orthop 2005;25:98-102.
Manipulation and appln of
adjustable hinged orthosis
Correction reported in
76% of cases with mild to
severe CTEV **
**Adnan A.Faraj et al.Foot and Ankle Surgery.Volume 10,Issue 2,
Dennis Browne splint
The child’s ‘physiological motions’
are used to correct the deformity
Application of corrective shoes
attached to a bar allowing
progressive external rotation of the
Constant kicking by the infant
stretches the contracted tissues
correcting the deformity
RELAPSE AND RESIDUAL DEFORMITY ESP. AFTER
NEGLECTED CLUB FOOT
RELAPSED VS NEGLECTED CTEV
Initial correction done and
susequent deformity less
Post surgical: extensive
scarring and stiff foot
Deformity severe and
worsens as child starts
Lateral skin callosities and
fissures- prone to infection
2-4 years :
Soft tissue release
4 – 11 years :
Soft tissue release with
Osteotomy performed according to the deformities
>11 years :Salvage procedures:
EXTENT OF RELEASE
"À LA CARTE" approach [Bensahel]
-Full posteromedial plantar lateral release only if All
components of deformity present
-postr release: persistent isolated equinus
Turco’s ‘one size fits all’ approach
TIMING OF SURGERY
3-6 months: high remodelling potential in 1st
yr of life
9-12 months: pathoanatomy clearer and surgery easier to
Simons: size of foot >8 cm.
hockey-stick posteromedial type of
Crosses the skin creases on the
medial side of the foot and ankle.
more difficult to reach the
posterolateral structures, origin of
problems with the skin
limited exposure of the
Caroll’s two incision technique
medial incision - straight
oblique incision from the
first metatarsal, across the
medial malleolus to the
A second short, straight
lateral incision made
along the lateral subtalar
joint antr to distal fibula
Medial Plantar Release
posterior and medial subtalar joint capsule (leaving the
interosseous ligaments intact),
talonavicular joint capsulotomy (including the spring
ligament and bifurcate Y ligament),
medial calcaneocuboid joint capsulotomy,
knot of Henry,
the abductor hallucis,
lengthening of posterior tibial tendon
The plantar fascia, if cavus is present
The dorsal structures-
tibialis anterior and
the deep deltoid ligament
release of the posterior capsule of the ankle and subtalar joint
open Achilles tendon lengthening.
The posterior talofibular ligament
Talonavicular joint fixn
The talonavicular joint,
often with the subtalar
joint, is routinely pinned
with a K-wire
Soft tissue release
Follow up :
Wound inspection done under sedation at 1 week
Foot held in neutral, plantigrade position and cast applied –
Cast kept for 4 – 6 weeks
Cast removed along with any K wires, if applied during surgery
AFO given for 6 months
Soft tissue release alone may not fully correct the deformity
because of secondary bony deformity.
The combination of this soft tissue release with midfoot
osteotomy is usually required in children between
approximately 4 and 12 years of age
Correction of Adductus
bony lateral column is longer than the medial column,
relative lengthening of the lateral portion of the anterior
process of the calcaneus
obliquity of the calcaneocuboid joint
Shortening through the distal calcaneus to make the
calcaneocuboid joint transverse.
excision of the anterior
process of calcaneus
Preferred in younger
Dilwyn Evans Osteotomy
calcaneocuboid wedge resection
Arthrodesis of the joint
Reduced risk of relapse
Stiffness at subtalar and midfoot joints
Preferred in older children
Köse et al., in 1999, described trans-midtarsal osteotomy
opening-wedge osteotomy of the medial cuneiform and
dorsal, truncated wedge osteotomies of the middle and
Better correction of rotational and cavus deformities
Correction of Equinus
adequacy of release of the lateral tether
lateral column shortening
excision of a portion of the head of the talus or
final resort is to consider adding a distal tibial dorsiflexion
Correction of Calcaneal Varus
Calcaneal varus corrects as
the foot abducts after medial
soft tissue release.
Persistent calcaneal varus: a
lateral slide osteotomy of the
calcaneus is performed
Alternative: Dwyer lateral
closing wedge osteotomy
Correction of CAVUS
Steindler’s release of plantar fascia
Japas ’V’ osteotomy
Patients >6 years
Allows midfoot correction without foot shortening
Akron midtarsal Osteotomy :
Correction at midfoot
A dome shaped osteotomy for dorsoplantar and varus / valgus control
Salvage procedure for pain after previous surgical correction.
Correction of large degrees of deformity in neglected
Not performed before advanced skeletal maturity, at age 10
Modification of the classic
lambrinudi triple arthrodeses
Resection through the talus should
be minimized because of its
tenuous blood supply and
Most of the correction made
through the calcaneus.
Recent study in Uganda: 92%
patients happy with the procedure
TWO STAGE :
release + triple arthrodesis
minimizes bone rescection
risk of AVN talus
less time consuming
reduced risk of AVN
Penny, John Norgrove 2005.Uganda
1) Correction slow enough to protect soft tissues;
2) correction at the focus of deformity,
3) simultaneous three-dimensional, multilevel correction;
4) deformity correction without shortening the foot;
Rings are fixed to the tibia connected to half rings for the
calcaneus and the forefoot.
Asymmetric distraction corrects the various deformities
bony deformity not severe,(<8 yr): unconstrained frame
Severe deformities,(>8 yrs): distraction osteogenesis
through osteotomies using constrained frame with hinges
Results with Ilizarov
good to excellent results reported by various surgeons( Grill et
al, Huerta et al, Bradish et al, Heymann et al, Hosny et al) over
the last 15 years
Recent long term follow-up study**
by Hari et al (2007):74% good/excellent result
**Prem: J. pediatr. orthop., Volume 27(2).March 2007.220-224
DR.B.B. JOSHI, MUMBAI.
JOSHI EXTERNAL STABILISATION
2 to 4 transfixing wires in
Transfixing wire thro’
I &V MT; Medial half pin
thro’I, II, III MT; Lat half pin
thro’ IV, V MT
2 transfixing and 1 axial wire
Fractional, differential distraction used to Sequentially
Distraction continued until approximately 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
Results with JESS
Good or excellent results reported by Joshi in 84% of his
Recommended in all who have not responded to serial
plaster casting methods.
Similar good results have been reported by other authors**
**Suresh et al,2003. Journal of Orthopaedic Surgery 2003: 11(2): 194–201
Advantages over Ilizarov
The wires are not tensioned
stability depends on the placement of the wires, the use of
half pins and pre-tensioning.
Hinges are not used in this method.Thus the corrective
forces are not directed along a single axis, instead, the soft
tissue envelope in conjunction with the shape of the
articulating surfaces guide the correction.
frame is less bulky, is less expensive, and more simple to
Complications of surgery
Dislocation of the navicular
Flattening and breaking of the talar head
AVN of the talus
Weakness of the plantar flexors of the ankle
Cincinnati incision, neglected clubfeet
left in partly corrected posn in post op cast & remanipulation
done at 1 to 2 weeks .
Local rotation flap from the dorsum of the foot (Mittal,1987)
Posterior V-Y advancement flap.
Flap taken superficial to
Large proximal base
ensures adequate blood
Proper understanding of the pathology and kinematics of
clubfoot, meticulous application of therapeutic methods,
laying stress on parental education to ensure compliance and
resorting to surgery only as the last resort, and is essential to
successful therapy of this complex condition