This document provides information about congenital talipes equinovarus, or clubfoot. It defines clubfoot and describes the four main deformities as cavus, adduction, varus, and equinus. It discusses the causes and classifications of clubfoot, as well as the bony and soft tissue changes associated with the condition. The Ponseti method is described as the standard non-operative treatment, involving serial casting and bracing. Surgical options are outlined for resistant cases.

1. CONGENITAL TALIPES EQUINUS
VARUS
(CLUBFOOT)
BY: DR BIPUL BORTHAKUR
PROFESSOR
DEPT OF ORTHOPAEDICS, SMCH

2. Congenital Talipes Equino Varus
 It is derived from the Latin Term
 Talipes- talus ( Ankle) and pes (Foot)
 Equines -horse like
 Varus -inverted and adducted.
 It is also known as clubfoot because of its resemblance with
the club of golf

3. Deformities
• Cavus
• Adduction
• Varus
• Equinus
The four
basic
components
of clubfoot
are

5. • Internal rotation of tibia
• Medial subluxation of
the navicuiar on the
head of the talus
Other
Deformities
Include

6.  The incidence is approximately one in every 1000 live births.
 Bilateral deformities occur in 50% of patients.
 Most cases are sporadic.
 Families have been reported with clubfoot as an autosomal
dominant trait with incomplete penetrance.

7. Pathogenesis
Primary germ plasm defect in Talus
Continued plantar flexion and inversion
of Talus
Subsequent soft tissue changes in the
joints and musculotendinous complexes

8. Primary soft tissue abnormalities
within the neuromuscular units
Secondary Bony Changes

9. Types of Clubfoot
• Secondary Clubfoot
• Postural Clubfoot
• Metatarsus Adductus
• Idiopathic Clubfoot
According
to
Etiology

10. Secondary Clubfoot
• Neurogenic Clubfoot –
Associated with neurological
disorders such as Spina bifida,
Cerebral Palsy
• Syndromic Clubfoot – forms part
of a wider musculoskeletal
syndrome, such as arthrogryposis,
amniotic band syndrome
It is diagnosed
when clubfoot
forms part of
another health
condition

11. Postural Clubfoot
Very flexible clubfoot deformity
Can be reduced almost completely on passive
stretching
It is thought to result purely from posture in the womb
late in pregnancy

12. Metatarsus Adductus
It is not a true clubfoot
Diagnosed when child has forefoot adduction but
normal range of motion at ankle
In Pirani’s Scoring HFCS is zero and MFCS is higher
than zero

13. Types of Clubfoot
• Untreated Clubfoot
• Treated Clubfoot
• Resistant Clubfoot
• Recurrent Clubfoot
• Neglected Clubfoot
• Complex Clubfoot
According
to
Treatment
Stage

14. • When the affected child is under two
years of age and has had no treatment to
date
Untreated
Clubfoot
• When a child’s feet have corrected with
the Ponseti method and they have
completed the casting phase of treatment
Treated
Clubfoot

15. • When the child has previously
untreated clubfoot that doesnot
correct with Ponseti method
Resistant
Clubfoot
• When the child show signs of
recurrence in previously treated
clubfoot
Recurrent
Clubfoot

16. • Is a clubfoot in a child older than
two years who has little or no
treatment
Neglected
Clubfoot
• Is classified for any clubfoot that
has received any type of treatment
other than Ponseti method
Complex
Clubfoot

17. Pathoanatomy – Bony Changes
Talus-
• talar neck has been shown to be internally rotated relative
to the ankle mortise
• the talar body is externally rotated in the mortise
Navicular-
• navicular moves medially around the head of the talus
• The talonavicular joint is in an extreme position of inversion

18. Calcaneus
• The calcaneus rotates horizontally while pivoting on the
interosseous ligament, it slips beneath the head and neck
of the talus anterior to the ankle joint, and the calcaneal
tuberosity moves toward the fibular malleolus posteriorly
• The heel appears to be in varus because the calcaneus
rotates through the talocalcaneal joint in a coronal plane
and horizontally

19. Cuboid
• medially subluxated over calcaneal head
Forefoot
• The forefoot is adducted and supinated; severe
cases also have cavus

20. Tibia
• Smaller in size
• Internally rotated
Fibula
• Smaller in size

21. Soft Tissue Changes
 Muscle fibres are smaller in size
 Tibialis posterior, flexor digitorum longus (FDL), and flexor
hallucis longus (FHL) are contracted
 The calf is of a smaller size
 Atrophy of the leg muscles, especially the peroneal group

22.  Tendon sheaths: Thickening, especially of the tibialis
posterior and peroneal sheaths.
 Joint capsules: Contractures of posterior ankle, subtalar, and
talonavicular and calcaneocuboid capsules
 Ligaments: Contraction of calcaneofibular, talofibular, deltoid,
long and short plantar, spring, and bifurcate ligaments
 Fascia: The plantar fascial contracture contributes to the
cavus

24. Grading Of Clubfoot
 Pirani’s Score
 Midfoot Contracture Score
0 0.5 1
Curved Lateral
Border
Straight and without
deviation
Deviates at the level
of metatarsals
Deviates at
calcaneo-cuboid
joint
Medial Crease Several fine crease One or two deep
creases
Single Deep crease
Lateral Head Of
Talus
Head sinks
Completely
Head sinks partially Head remains fixed

26.  Hindfoot Contracture Score
0 0.5 1
Posterior Crease Several fine
Crease
Two or three
moderate crease
Single deep
crease
Rigidity Of
Equinus
<90 degrees =90 degrees >90 degrees
Empty Heel Calnaneus easy to
palpate
Palpated through
a layer of flesh
Very difficult to
palpate

28. GRADE TYPE SCORE REDUCIBILITY
I Benign 1-4 >90% soft-soft, resolving
II Moderate 5-9 >50% soft-stiff, reducible, partially resistant
III Severe 10-14 >50% stiff-soft, resistant, partially reducible
IV Very severe 15-20 <10% stiff-stiff, resistant

29. Treatment
 The aim of treatment is a normal, painfree and functional foot
 The initial treatment of clubfoot is non-operative
 The most widely accepted technique is that described by
Ignacio Ponseti.

30. Ponseti Method
 Consists of weekly serial manipulation and casting during the
first weeks of life
 It relies on the visco-elastic nature of the connective tissue to
produce plastic deformation through a process known as
stress relaxation.
 after about 1 minute of manipulation, toe-to-groin cast is
applied

31.  The casts should be applied in two stages:
 First, a short-leg cast to just below the knee
 Followed by extension above the knee when the plaster sets
 One week after application, the cast is removed and a new
cast is applied

32.  Cavus is corrected by supinating forefoot in proper alignment
with the hindfoot.
 Adduction corrected by abducting the entire foot under the
talus with the foot in slight supination
 Heel varus will be corrected when the entire foot is fully
abducted
 Equinus is corrected by dorsiflexing the foot (facilitated by
percutaneous tenotomy of Tendo-achillis)

33. Cavus Correction
 Correct method- Supination of forefoot
 Common Error : Pronation increases the cavus

34. Varus and Adduction Correction
 Correct- Abduct foot in supination while applying counter pressure against
the head of the talus
 Common Error: “Kite’s Error”- Abducting the forefoot while applying
counter-pressure at calcaneo-cuboid joint

35. Kite’s Error

36. Equinus Correction
 Dorsiflexion should be done in a fully abducted foot
 It is usually facilitated by percutaneous tenotomy
 The final cast is applied with the foot in the same maximally
abducted position and dorsiflexed 15 degrees

37.  Complete section of the tendon heals in three weeks

40. Maintenance Phase
 Steenbeek Foot Abduction Brace
 Maintains correction
 3 months 23 Hours a day
 2-3 yr. night time and nap time
 1 inch wider than the width of the infant’s shoulder
 Externally rotated 70 degrees
 Dorsiflexion of 10 to15 degrees
 Heelcup
 Failure to wear is the most common cause of recurrence

43. MANAGEMENT OF RECURRENCE
 Recurrence of the deformity is infrequent if the bracing
protocol is followed closely
 Early recurrences are best treated with repeat manipulation
and casting
 Achilles tendon lengthening may be necessary if dorsiflexion
is insufficient
 For dynamic metatarsal adduction transfer of the anterior
tibial tendon may be needed.

44. Surgical Management
 Surgery in clubfoot is indicated for deformities that do not
respond to conservative treatment by serial manipulation and
casting
 Must be tailored to the age of the child and to the deformity to
be corrected.

45. Timing Of Surgery
 When a plateau phase has been reached in non-operative
treatment.
 Turco (1971) recognized the best time period for surgical correction
to be one to two years of life
 Simons (1993) suggested that size and not age should be the
limiting factor - the foot should be at least 8 cm long.

46. Treatment By Age
 Less than 5 years : Correction can be obtained by soft tissue
procedures
 More than 5 years : Requires bony reshaping procedures
 More than 10 years : Triple arthrodesis if the foot is mature (
salvage procedures ).

47. Deformity Treatment
Metatarsus adductus >5 yrs: metatarsal osteotomy
Hind foot varus <2-3 yrs: modified McKay procedure
3-10 yrs: Dwyer osteotomy (isolated heel varus)
Dillwyn-Evans procedure (short medial column)
Lichtblau procedure (long lateral column)
10-12 yrs: triple arthrodesis
Equinus Achilles tendon lengthening plus posterior capsulotomy of
subtalar joint, ankle joint (mild-to-moderate deformity)
Lambrinudi procedure (severe deformity, skeletal immaturity)
All three
deformities
>10 yrs: triple arthrodesis

48. Gradual Distraction Procedures:
 Ilizarov Procedure: This is mostly reserved for recurrent and
resistant CTEVs. This is based on the principle that
continuous distraction of tissues resulted in neohistogenesis.
 JESS (Joshi's External Stabilising System) is a
modification of the llizarov procedure. It is based on the
principle of differential distraction of the soft tissues

49. Thank You