Clubfoot, or congenital talipes equino varus (CTEV), is a birth defect where the foot is twisted inward and downward. It has 4 main deformities - adduction of the forefoot, inversion/varus of the hindfoot, equinus of the hindfoot, and cavus of the midfoot. Incidence is 1-2 per 1000 births and is more common in males. Etiology may include chromosomal, embryonic, neurological, and fetal theories. Pathoanatomy involves twisting of the talus, calcaneus, and other bones. Treatment goals are to realign the bones through serial casting or surgery. The Ponseti method uses serial plaster casts and foot manipulation to gradually

1. Clubfoot
Congenital Talipes Equino Varus
(CTEV)

2. Definition
Twisting of the scaphoid, os calcis and
cuboid around the astragalus
Congenital Talipes Equino Varus or club foot
has 4 basic deformation:
1. fore foot : adduction
2. hind foot : inversion or varus
3. hind foot : equinus
4. mid foot : cavus

3. Incidence : - (1-2) per 1000 births
- male : female = 7:5
- 50% bilateral
Incidence : of CTEV in various races
Race Cases per
thousand birth
Chinese 0.39
Japanese 0.53
Malay 0.68
Filipino 0.76
Caucasian 1.12
Puerto Rican 1.36
Indian 1.51
South African black 3.50
Polynesian 6.81
Tachjian, The child foot

4. ETIOLOGY
 Chromosomal theory
 Embryonic theory
 Otogenic theory
 Fetal theory
 Neurological theory
 Muscular theory

5. ETIOLOGY
Chromosomal theory
defect : in unfertilized germ cell (defect exists
before fertilization)

6. ETIOLOGY
Embryonic theory
defect : within fertilized germ cell
Occurs : between conception-12 weeks (Irani,
Sherman and Settle)

7. ETIOLOGY
Otogenic theory (arrest theory)
arrest of development
related to a change in genetic factor known as “cronon”
Cronon : guide the precise time of the progressive
modification every structure during development

8. ETIOLOGY
Neurologic theory
Muscular theory

9. ETIOLOGY
Fetal theory (packing syndrome)
Intrauterine packing (mechanical factors)

10. Schematic illustration of the critical periods in human development. During the first two weeks development, of the embryo is
usually not susceptible to teratogens. During these pre-embryonic stages, a teratogen either damages all or most of the cells,
resulting in its death, or damages only a few cells, allowing the conceptus to recover and the embryo to develop without birth
defects. Red denotes highly sensitive periods when major defects may be produced (e.g. amelia, absence of limbs). Yellow
indicates stages that are less sensitive to teratogens when minor defects may be induced (e.g. hypoplastic thumbs)

11. Etiology
- chromosomal theory
polygenic (multi factorial)
- defect in unfertilized
germ cell :
- in family
- race (palynesia-Maori)
Week
TERM3012850
- Embryonic theory
(0-12) weeks
defect occurs during
fertilized germ cell
Otogenic theory -- arrest theory
- Cronon : genetic factor which
determine the precise time for
progression modification during
development
- Cronon may be changed by certain
element (teratogen)  abnormal
development of the limb
- growth arrest : permanent, temporair,
slowed growth permanent deformity
temporary CTEV, slow – steroid
- occur during (7-8) week  marked CTEV
- occur during (9-12) week  moderate
to mild CTEV
Specification defect (Hoofnick)
limb specification at 5 month (teratogen)
- neuromuscular
- vascular
- bone
CTEV : post
specification defect
primary muscle
abnormality?
Intra uterine pressure
(packing syndrome)
20
Ponseti : genetic, embryonic malformation, collagen
over production in ligament, collagen
fibres wavy arranged, dense, many cells

12. PATHOANATOMY
 Major deformity
• Inward rotation of the whole foot on the talus
 Rotation primarily takes place in :
• talocalcaneal joint
• talonavicular joint
• calcaneocuboid joint

13. PATHOANATOMY
Talocrural (ankle ) joint :
• Talus in equinus
• Talus in mortise = external rotation (horizontal breach)
• Posterior = capsule & ligament contracted

14. “Horizontal breach” according to the concept of Swann,
Lloyd-Roberts, and Catterall

15. PATHOANATOMY
TALUS
 Constriction encasement
 Head & neck : medial & plantar deviation

16. PATHOANATOMY
TALOCALCANEAL JOINT:
Calcaneus :
rotation in 3 dimensions :
• Sagittal
• Coronal
• Horizontal

17. Pathomechanics of talipes
equinovarus
A. Posterolateral view of the
calcaneus and talus of normal foot. B.
Lateral rotation of the talus, C. The
anterior part of the calcaneus is
pressed by the head of the talus and
forced into plantar
flexion, rotation, and varus position.
(From Carroll, N., Murphy, R, and
Leete, S.F. : The pathoanatomy of
congenital clubfoot, Orthop.Clin.N.
Amer., 9 : 227, 1978)

18. The articular relationship of the calcaneus to the talus as seen from the front in the left foot.

19. Pathoanatomy
Talonavicular joint :
 Navicular : displaced medial & plantarward
 Tib.posterior tendon
 Tibio-navic. Ligament (deltoid lig.)
 Calcaneo-navic.lig. (spring lig.)
 Talo-navic. Ligament
 Bifurcate ligament
 Cubonavic. Oblique ligament
 All navicular ligament
contracted

22. PATHOANATOMY
Calcaneo-cuboid joint:
 Cuboid displaced medially on calcaneus and under navicular &
cuneiform
 All ligaments : contracted
 Forefoot : supination and adduction
 Calcaneo-cuboid joint corrected nicely if other 2 subtalar
complex are corrected except in resistant CTEV

23. PATHOANATOMY
Muscles
 Imbalance between agonist and antagonist
 Muscles tonus determined by the amount of muscle
fibres type I & II
 All muscle below knee in CTEV fibre Type I > II [similar
with L.M.N lesion : AMC, sacral agenesis, Charcot-
Marie, post poliomyelitis]
 Some CTEV tendency to be recurrent

24. PATHOANATOMY
Vascular
By Doppler Technique :
 In normal population : a.dorsalis pedis 2.2.% absent
 In mild & moderate CTEV : a.dorsalis pedis = normal
 In severe CTEV : a.dorsalis pedis = 6.7% absent

25. MECHANISM of the CTEV
 Fetal posture abnormality :
foot in equinovarus
 Muscle imbalance : tib.
post. contracted
 Factors determine the
severity of the CTEV
Intrauterine position. The hips are always
flexed and externally rotated, while the knees
are usually flexed and the feet turned inward

26. EXAMINATION
 History
 Physical examination
 Radiologic examination

33. Radiology : age more than (4-5) months
N : AP : talo-calcaneal angle :
(200-400), CTEV < 200
Lat : talo-calcaneal angle :
(350-500), CTEV<350

34. DIAGNOSIS
1. Non rigid type (packing syndrome)
2. Rigid type :
• Moderate
• Severe
3. Resistance rigid type :
• AMC
• Myelomeningocele
• Constriction band

35. DIFFERENTIAL DIAGNOSIS
1. Constriction bands (Streeter disease)
2. A.M.C
3. Myelomeningocel
4. Sacral agenesis
5. Tibial agenesis
6. Charcot-Marie disease

36. Constriction bands

37. Arthrogryposis Multiplex Congenita

38. Spina bifida

39. Sacral agenesis

40. Tibial agenesis

41. Charcot-Mary disease

42. TREATMENT
The goal of treatment :
• Realign the os calcis, scaphoid and cuboid
around the astragalus by correcting the varus,
adduction, varus and equinus
• Maintain the correction until stable
 normal function, no pain, plantigrade, good
mobility, no callus formation, wearing normal
shoe

43. HISTORY
 Egyptian : tomb painting
 India (1.000 BC) : Tx
 Hippocrates (400 BC) : manipulative Tx,
early Tx
 Indian (Aztecs) Pre Columbian American
Tx : splint with cactus leaves

44. HISTORY : 20th century
Hugh Owen Thomas (1834 -1891)
Wrench

46. W.H. Trethewan (1882-1934) :
Thomas Wrench is a barbarous weapon

47. TREATMENT
1. Conservative
2. Operative

48. Conservative treatment
Golden period:
• 1st week
• laxity :estrogen
1. Serial plastering
2. Stretching  Dennis Brown splint
3. Adhesive strapping
4. Physiotherapy

49. HIRAM KITE :
Brought Hippocrates’ view info focus :
Stressing slow, gentle, manipulative correction of
the adduction, varus and equinus with minimal
surgery
Three magic words for the successful and
enthusiasm carrying out his
treatment : knowledge,patience andenthusiasm

51. Ponseti :
Concept biomechanical
understanding
SURGERY is the wrong approach for the treatment of the clubfoot.
Ponseti

52. Ponseti
Based on kinematic of the subtalar joint.
1st concept : the whole foot moves under the talus “calcaneo-
pedis block”
2nd concept : fore foot and hind foot are corrected
simultaneously by abduction
Equinus correction :
• mostly close tenotomy
• tendo achilles non stretchable collagen, thick and
stiff

53. COMPARISON KITE and PONSETI treatment
Clubfoot
1. Adduction
2. Varus
3. Equinus
KITE
Fulcrum : calcaneo cuboid
Correction by serial plastering :
PONSETI
1. Adduction  Abduction
2. Varus  valgus
4 Cavus and pronation
Rigid 3 Equinus
tenotomy
Fulcrum : head talus
Correction by serial plastering :
Surgery no yes
plastering
(10-11) months Shoe
Denis-Brown
splint
(3-4) years Evaluation
3 Equinus Rigid
close tenotomy 90%
12 weeks
no =5% yes=95% Surgery
plastering
Shoe
splint
(3-4) years Evaluation
4. Cavus and pronation (realign cavus by supination)
to “unlock” subtalar movement
1. Adduction  Abduction 600-750
2. Varus : will be corrected by 4 & 1
6 weeks

54. Abduction of fore foot in pronation the cavus becomes more severe, calcaneus
locked (jammed) under the head of talus; mid foot and forefoot are twisted  eversion
Kite
Clubfoot correction

55. Kite

56. Calcaneo-cuboid is used as fulcrum which is pressed medial ward while fore foot
is moved lateral ward (abduction); calcaneus will not move lateral ward (no
abduction) that is why the varus will not be corrected; only naviculare and fore foot
will move lateral ward. To press the posterior part of calcaneus to correct varus is
a big mistake
Kite

57. Clubfoot correction
a. realign cavus : forefoot supinated (3,4)
b. fulcrum : caput tali – stabilisator (5)
c. forefoot in supination – abduction (6)
d. maximal abduction of forefoot (7)
e. dorso flexion of the ankle (+TAL)
Process of a,b,c,d (5-6) x each (5-7) days.
Plaster cast above knee (groin), knee
flexion 900
Ponseti

58. Ponseti (Clubfoot correction)

59. Ponseti

60. TAL
 After 6x plastering
 TAL (close), local anaesthesia
 Plaster 3 weeks
 bracing for 3 months (24hours)
 (2-4) hours day time, 12 hours at
nigh
 (3-4) years night splint
 Ponseti success = 90%

62. Pre ATL

63. Pre ATL

64. Daffa pre ATL

66. Daffa Post ATL

67. Daffa

69. Common errors
1. Forefoot still in pronation
during correction of
adduction to abduction
2. Not using head of talus
as fulcrum
3. Calcaneus is pressed
lateral ward to correct
varus
4. Equinus is corrected
before adduction and
varus are corrected 
Rocker bottom foot
5. Plaster immobilisation
below knee

70. BK plastering High heel

71. Post posterior release ATL & capsulotomy

73. Plaster correction complication
1. Neuromuscular
2. Pressure necrosis

74. Plaster correction complication
3. Rocker bottom foot

75. Plaster correction complication
4. Flat top talus

76. Plaster correction complication
5. Increase cavus deformity
6. Longitudinal breach
7. Stiff joint

77. Operative treatment
Indication
1. Conservative Tx—fail Ponseti + 10%
2. Neglected

78. Postero medial release (Turco)

81. Cincinati

85. Ilizaroff

86. Tripple arthrodesis (adult)

89. Surgical complication
1. Infection
2. Bad scar
3. Stiff joint
4. Over/under correction
5. Navicular dislocation
6. Flattening or beaking talar head
7. Talar necrosis
8. Weakening of the muscles
9. Skew foot (severe valgus of the heel and adduction
of the fore foot)
10. Main artery injury  foot necrosis

91. Out patient clinic
RSUD.Dr.Soetomo