Clubfoot, also known as congenital talipes equinovarus, is a birth defect where the foot is twisted inward and downward. It is caused by abnormal muscle and tendon development in the leg. Treatment involves serial casting and manipulation during infancy to gradually correct the deformity. Surgery may be needed for resistant cases or residual deformities, and involves soft tissue releases and osteotomies. The goal of treatment is to achieve a plantigrade foot that is functional and pain-free.

2. CLUBFOOT
 VAGUETERM USEDTO DESCRIBE A
NUMBER OF DIFFERENTABNORMALITIES
INTHE SHAPE OFTHE FOOT
 NOW IT HAS COMETO BE SYNONYMOUS
WITH THE COMMONEST CONGENITAL
FOOTABNORMALITY i.e., CTEV

3. ANATOMY

5. ANATOMY-JOINTS
 ANKLE JOINT :TIBIA ANDTALUS
 SUBTALAR JOINT :TALUS AND CALCANEUM
 TALONAVICULAR JOINT
 CALCANEO- CUBOID JOINTS

6. ANATOMY
 TENDONS
 TIBIALIS POST
 FLEXOR DIG. LONGUS
 FLEXOR HALLUSIS LONGUS

7. ANATOMY
 LIGAMENTS
 DELTOID L. : MEDIAL COLLATERAL LIG. OF ANKLE
 SPRING L. : CALCANIUM – NAVICULAR
 CAPSULAR L. :T – N , N – C , C – M
 PLANTAR L. :LONGITUDINAL ARCH OF FOOT

8. NOMENCLATURE
Planus: flatfoot
Cavus: highly arched foot
Varus: heal going towards
the midline
Valgus: heel going away
from the midline
Adduction: forefoot going
towards the midline
Abduction: forefoot going away
From the midline

9. CLUB FOOT

10. CLUB FOOT
Definitions
Talipes: Talus = ankle
Pes = foot
Equinus: (Latin = horse)
Foot that is in a position of
planter flexion at the ankle,
looks like that of the horse.
Calcaneus: Full dorsiflexion at the ankle

11. CLUB FOOT
Types
 Idiopathic (Unknown Etiology) :
 CongenitalTalipes Equino-Varus CTEV
 Acquired, Secondary to :
 CNS Disease : Spina bifida, Poliomyelitis
 Arthrogryposis Multiplex Congenita
 Absent Bone : fibula / tibia

12. CTEV
 MOST COMMON CONGENITAL FOOT DISORDER
 MALES
 1/1000 LIVES BIRTHS

13. TYPES
 OSSEOUS : absent tibia / fibula
 MUSCULAR : AMC
 NEUROPATHIC : spina bifida
 IDIOPATHIC
 CLASSIFICATION : Ponsetti
 Supple
 Rigid
 Teratologic

14. CLASSIFICATION
 EXTRINSIC
 FLEXIBLEWITH ABNORMAL BONE RELATION
 WITHOUT MARKED FIBROSIS
 CONSERVATIVETREATMENT
 INTRINSIC
 RIGIDWITH ABNORMAL BONE RELATION
 MARKED FIBROSIS
 OPERATIVETREATMENT

15. THEORIES OF CTEV
 TURCO’S : medial displacement of navicular and
calcaneous around talus
 BROCKMAN’S : congenital atresia of theT – N joint
 Mc- KAY’s :3-D bony deformity of the subtalar complex
 INTRAUTERINE:compression by malpositon of fetus in utero
 Germ plasm theory
 Soft tissue theory
 Prenatal muscle imbalance theory

16. PATHO-ANATOMY
 BONES AND JOINTS
 CALCANEUS : INVARUS POSITION
 TALUS : DISPLACED MEDIAL AND PLANTARWARDS
 NAVICULAR : MEDIALLY DISPLACED AND ROTATED
 CUBOID : DISPLACED MEDIALLY AND ARTICULATES
WITHTHE NON-ARTICULAR SURFACE
OF CALCANEUM ( CUBOID SIGN /
LOCKED CUBOID )
 METATARSALS : DEVIATES MEDIALLY ATT-M JOINTS
 DISLOCATION OFTALOCALCANEAL ARTICULATION
 TIBIA – MEDIALTORSION

17. PATHO-ANATOMY
 BONESAND JOINTS
 EQUINUS - ANKLE JOINT
 INVERSION - SUBTALAR JOINT
 FOREFOOT ADDUCTION - MIDTARSAL JOINTS
 FOREFOOT CAVUS – EXCESSIVE ARCHING
AT MIDTARSAL JNTS

18. PATHO-ANATOMY
 MUSCLES CAPSULESAND LIGAMENTS
STRCTURES CONTRACTED ONTHE MEDIAL SIDE
3 MUSCLES
• AHL
• TP
• FHL
3 LIGAMENTS
• DELTOID
• SPRING
• PLANTAR
3 CAPSULES OF
• SUBTALAR
• TARSAL
• TARSOMETATARSAL

19. 2 MUSCLES
• TIBIALIS POST.
• TENDO-ACHILLES
2 LIGAMENTS
• TALOFIBULAR
• CALCANEOFIBULAR
2 CAPSULES OF
• ANKLE JNT
• SUBTALAR JNT
PATHO-ANATOMY
 MUSCLES CAPSULESAND LIGAMENTS
STRCTURES CONTRACTED ONTHE POSTERIOR SIDE

20. 1 MUSCLE
• TIBIALIS ANT.
1 LIGAMENT
• SUPERIOR
PARONEAL
RETINACULA
1 CAPSULES
• CALCANEO-
CUBOID JNT
PATHO-ANATOMY
 MUSCLES CAPSULESAND LIGAMENTS
STRCTURES CONTRACTED ONTHE ANTERIOR SIDE

21. PATHO-ANATOMY
 SKIN
 Adapts shortening on the medial side
 Deep creases on the medial side
 Dimples on the lateral aspect
 SECONDARY CHANGES
 Occurs when the child starts walking-exaggerates the
deformity
 Callosities and bursae

22. CLINICAL FEATURES
 COMMON PRESENTATIONS
 Detected at birth
 Infancy and early child hood
 Late childhood

23. CLINICAL FEATURES
 Short Achilles tendon
 High and small heel
 No creases behind Heel
 Abnormal crease in middle of the foot
 Foot is smaller in unilateral affection
 Callosities at abnormal pressure areas
 Internal torsion of the leg
 Calf muscles wasting
 Deformities don’t prevent walking

24. CLINICAL FEATURES
 Seek a detailed family history of clubfoot or
neuromuscular disorders, and perform a general
examination to identify any other abnormalities.
 Similar deformities are seen with myelomeningocele
and arthrogryposis.Therefore, always examine for
these associated conditions.

25. CLINICAL FEATURES
 DORSIFLEXION TEST :
 PLUMBLINETEST : tibial torsion
 child is made to sit on a table with both LL hanging from the
edge.
 Line drawn from the centre of the patella to the tibial tubercle
when extended down should cut the foot at 1st or 2nd
intermetatarsal space normally.- PLUMBLINE
 In CTEV , with medial rotation of tibia it cuts through 4th or 5th
space
 SCRATCHTEST – INFANTS
 MEDIAL SCRACTHTEST : FOOT EVERTS - PERONEALS
 LATERAL SCRACTHTEST: FOOT INVERTS - INVERTORS

26. INVESTIGATIONS
 RADIOGRAPHY
 APVIEW :angle formed b/w
 talus and calcaneum ( NORMAL 30-35) REDUCED
 Talus and metatarsals ( NORMAL 5 -15 )  -VE
Helps to asses angle of varus and forefoot adduction

27. RADIOGRAPHY
 LATERALVIEW - ANGLE FORMED B/W
 TIBIA AND CALCANEUM ( NORMAL 5- 15 )  -VE
 TALUS AND CALCANEUM ( NORMAL 20- 50) 
TO KNOWTHE EXTENTOF EQINUSANDVARUS DEFORMITY
 CT , MRI , ARTHROGRAPHY

28. MANAGEMENT
The goal of treatment for clubfoot is to obtain a plantigrade foot
that is functional, painless, and stable
A cosmetically pleasing appearance is also an important goal
 CONSERVATIVE
 SURGICAL
 EXTERNAL FIXATORS

29. CONSERVATIVE
 INFANTS (< 6 MONTHS)
 1ST 6WEEKS : SERIAL MANIPULATION AND CASTING
 Corrective casting
 First correction of adductus of midfoot
 Folowed by correction of inversion
 Finally correction of the equinus

30. Conservative management
Weekly serial manipulation and casting
Every weekly for 1st 6 week
Fortnightly till 6 months
Correction acheived Correction not achieved
Splint
day time
Phelp’s Brace
night time
Dennis Brown Splint
For 6 – 18 mothhs
CTEV shoes
( upto 4 years )
SURGERY EXT. FIXATOR
<4YRS STR
>4YRS STR+BONY
PROCEDURE

31. SURGICAL TRATMENT
Indications
 Late presentation, after 6 months of age
 Complementary to conservative treatment
 Failure of conservative treatment
 Residual deformities after conservative treatment
 Recurrence after conservative treatment

32. SURGICAL TREATMENT
 Soft tissue operations
 Release of contractures
 Tendon elongation
 Tendon transfer
 Restoration of normal bony relationship
 Bony operations
Usually accompanied with soft tissue operation
Types:
 - Osteotomy, to correct foot deformity or int. tibial torsion
 - Wedge excision
 - Arthrodesis (usually after bone maturity)
 one or several joints
 - Salvage operation to restore shape

33. P M S R
POSTERO MEDIAL SOFTTISSUE RELEASE ( 6-12 months )
 TURCO’S PROCEDURE
 On the posterior Side
 Z- plasty of tendo – Achilles
 Posterior capsulotomy of ankle and subtalar jnt
 Release of posterior talo-fibular and calcaneo-fibular lig
 On the medial side
 Lenghtening ofTP , FHL, FDL
 Release of talonavicular lig., spring lig., superficial part of
deltoid lig.
 Release of interossious talocalcaneal lig, capsules of naviculo-
cuniform and 1st metatarsao-cuniform jnts

34. P M S R
 On the plantar side
 Plantar fascia release
 Release of AH , FDB
 Post – op regimen
 Change cast at 2 weeks
 Remove K wire at 6 weeks
 Long leg cast for 3 months
 Ankle foot orthoses for 6- 9 months

35. LIMITED SOFT TISSUE RELEASE
 When only one component present
 Equinus – posterior release
 Adduction – medial release
 Cavus – plantar release

36. CIRCUMFERENTIAL RELEASE
 McKAY’s
 All structures on PMSR + lateral structures
 Superior peroneal retinaculam
 Inferior extensor retinaculam
 Dorsal calcaneo-cuboid lig.
 12 – 36 months
 Passively correctable deformity resulting from muscle
imbalance

37. RESISTANT CLUBFOOT
• >5YR. METATARSAL OSTEOTOMY
METATARSUS
ADDUCTUS
• <2- 3YR .modified McKey”s procedure
• 3- 10 yr
• Dwyer osteotomy
• Dilwyn –Evans operation
• 10-12 yr tripple arthrodesis
HIND FOOT
VARUS
• TendoAchillus lengthening + posterior capsulotomy sub
talar and ankle joint
• Lambrunidis triple arthrodesis
EQINUS

38. OPERATIONS
 TRIPPLE ARTHRODESIS(>10YRS)
 Lateral closed wedge osteotomy through subtalar and
midtarsal joints is done to fuse
 SUBTALAR
 TALONAVICULAR
 CALCANEOCUBOID
 TALECTOMY
 Severe uncorrected club-foot
 SURGERY FOR CORRECTION OFTIBIALTORSION
 >15deg should be corrected by derotation osteotomy

39. DILWYN-EVANS OPERATION
 Soft tissue release and calcaneocuboid fusion
 1st three stages : extensive soft tissue release
 Finally calcaneaocuboid wedge is excised
 Neglected or recurred foot in children of 4-8 yrs

40. EXTERNAL FIXATORS
 ILIZAROV’S EXTERNAL FIXATOR FRAME
 JOSHI’S EXTERNAL FIXATOR FRAME
 Allows gradual distraction
 Transfixing wires through
 Tibia, calcaneum ad metatarsals
 Distractors positioned
 Posteriorly, medially and laterally
 Frame completed by
interconnecting the components

41. TREATMENT IN ADULT PATIENT
 CUNIFORMTARSECTOMY
 Vertical wedge of bone , with its base laterally is
removed from
 Calcaneus – behind the metatarsal joints
 Cuboid – infront of the joint
 Curved wedge , with its base upwards and laterally
 from head and neck of talus

42. RETENSION OF CTEV CORRECTION
 DENIS BROWN SPLINT
 PHELP’S BRACE
 BELOW KNEEWALKING CALIPERS
 CTEV SHOES