This document discusses congenital talipes equino varus (clubfoot). It covers the etiology, pathoanatomy, clinical presentation, investigations, classifications, and treatment options. The Ponseti method of serial casting with Achilles tenotomies is the gold standard non-surgical treatment. Surgical options include soft tissue releases like the Turco or McKay procedures for resistant cases or residual deformities after casting fails. The goal of treatment is to achieve a functional, plantigrade foot without need for bracing or surgery.

1. CONGENITAL TALIPES EQUINO VARUS
DR RITESH JAISWAL
M.B.B.S D.Ortho DNB (Ortho) M.N.A.M.S M.Ch (Ortho)
Fellowship in Joint Replacement ( Mumbai )
Fellow AO Trauma ( Switzerland )

2. • INTRODUCTION
• ETIOLOGY
• PATHOANATOMY
• CLINICAL PRESENTATION
• INVESTIGATIONS
• CLASSIFICATIONS
• TREATMENT

3. INTRODUCTION
Deformity in which foot is turned inwards to varying degrees with
- Equinus at ankle
- Varus and Internal Rotation of heel
- Forefoot adduction with supination
- Cavus of midfoot
Secondary deformities
- Internal torsion of tibia
- Atrophy of calf
- Smaller foot

5. INCIDENCE OF IDIOPATHIC CLUB FOOT
- 1 - 2 / 1000 live births
- Highest prevalence in Hawaiians and Maoris
population
- Boys are affected more than girls ( 4:1 )
- U/L Right foot common than left ( R > L )
- B/L in approximately 50% of cases
- Increased incidence with positive family history
for clubfoot.

6. Associated anomalies and syndromes
Arthrogryposis
Hand anomalies (Streeter dysplasia)
Diastrophic dysplasia
Amniotic band syndrome
Pierre Robin syndrome
Larsen syndrome
Prune-belly syndrome
Absent anterior tibial artery
Freeman-Sheldon syndrome
Down syndrome
Tibia Hemimelia

7. ETIOLOGY
Clubfoot is usually an isolated finding which is IDIOPATHIC in
nature.
Multiple theories have been proposed to explain its etiology.
The “arrest of development” theory by Ignacio V. Ponseti
Multifactorial system of inheritance by Palmer
Polygenic theory supported by Wynne Davis and showed a rapid
decrease in incidence of clubfoot from first to second to third
degree relatives.

8. Deficiency of a part of the long arm of chromosome 18 - Insley
Primary defect in germ plasma - Sherman and Irani
( constant abnormalities were found in the anterior part of the talus)
Environmental factors
- External pressure in utero ( Hydroamnios or oligoamnios)
- Infectious disease during pregnancy
- Maternal nutrition defects
- Vitamin deficiency
- Toxic agents like azaserine, d-tubocurarine, aminopterin
- Maternal metabolic disorders

9. PATHOANATOMY

11. ANKLE – MEDIAL VIEW

12. ANKLE – LATERAL VIEW

18. BONES

19. . METATARSALS
Medial migration & Inversion of all 5 MT.
Cause forefoot adduction & contributes convexity of lateral border of foot

20. MUSCLES & TENDONS

23. 2 COMPONENTS OF PATHOLOGY
1) INTEROSSEOUS
- Foot Plantar flexion at Ankle & Subtalar joint
- Hindfoot inverted
- Forefoot, Midfoot are adducted, inverted & in Equinus
- Calcaneus & Navicular are Displaced medially and
plantarward over talus and Cuboid medially over calcaneus.
- Soft tissue contractures Maintain deformity

24. 2) INTRAOSSEOUS
Talus –
- Medial plantar deviation of anterior end – reduced angle of
declination to 115 degree & increased obliquity of neck
- Short neck misshapen ant talar facet
- Wider ant part may not enter ankle mortise
Calcaneus –
- inverted under talus – secondarily distal facet ant, medial &
plantar
so cuboid is medial
Articular Malalignment
- Tibio talar – equinus of talus exposes 1/3 rd of articular
surface
- Talonavicular – navicular is medial and plantar to head of
talus which is uncovered
- Subtalar – spin- calcaneus is rotated medially & in equinus
& inverted ( moving 3 axes )
This is important to understand because total posterolateral
release is needed to derotate the calcaneus

26. CLINICAL PRESENTATION
HISTORY
- Detail enquiry to rule out any congenital defect
- Family history
( helpful to prognosticate about incidence in future
offsprings 1 in 35 for second child )

27. EXAMINATION
- Fully undressed the child
- Examine supine , then prone
- Check for anomalies in Head, Neck, Chest ,
trunk & Spine
- Mobility of trunk & extremities should be
evaluated

28. MEASUREMENTS
- Measure limb length
- Circumference of thigh & calf
- Skin creases of thigh, ankle & foot
- Degree of equinus of heel and forefoot
adduction
ROM
- Hip & Knee
DO NOT FORGET NEUROLOGICAL EXAMINATION….

29. LOOK
- Morphological features
- Spine – dysraphism
- Neck- Torticollis
- Other limbs
FEEL
- Skin mobility
- Creases
- Hip for click
MOVE
- Pirani Scoring
- Telescopy
- Neck Movements
- Active toe movements – neuro examination
- Spasticity

31. CLINICAL TESTS :
DORSIFLEXION TEST – Screening test
SCRATCH TEST –
- Detect muscle imbalance in an infant who cannot follow commands
- In normal child when medial sole scratched foot everts – test peroneals
- If scratched on lateral sole foot inverts – test invertors
PLUMBLINE TEST –
To detect tibial torsion

32. CLASSIFICATION

33. ATTENBOROUGH ( 1966 )

34. CUMMIN CLASSIFICATION
SUPPLE – Foot can brought back to normal position and all joints are mobile
NEGLECTED – Never receive treatment (Conservative/operative) till walking age 1 year
RELAPSED – one or many or all deformities recur after successfully achieving correction of
all deformities
RECURRENT – one or many or all deformities recur during the course of treatment which
was successfully corrected previously
RESISTANT – correction is not obtained in any or all deformities by manipulation / surgical
methods ( commonly due to inappropriate technique )
RIGID – After conservative treatment forefoot deformity corrected hindfoot remains
uncorrected

35. The most commonly used classifications are
those described by
- Pirani
- Diméglio
Both classifications assign points based on
- the severity of the clinical findings
- the correctability of the deformity.

36. PIRANI SCORING

38. DIMEGLIO SCORING
Based on :
-Equinus
deviation
-Varus
deviation
-Derotation
-Adduction

40. RADIOGRAPHS
AT 3 months :
- Ossific centres of calcaneus, cuboid, talus, MT are
seen
- AP view with tube placed 30 deg cranial
- Lateral in max. dorsiflexion, foot to be parallel to
cassette
- Radiographs are not mandatory to diagnose or
treat clubfoot.
- Useful in complex clubfoot or to monitor
correction

41. TALOCALCANEAL ANGLE
- AP view for HEEL VARUS ( Kite’s Angle ): 30-55 degree
( Reduced in CTEV )
- Dorsi flexion Lateral view : 25 – 50 degree
TIBIOCALCANEAL ANGLE ( for Equinus )
- Stress lateral view : 10-40 degree
TALUS 1st METATARSAL ANGLE
( for Forefoot Adduction )

46. TREATMENT
- Every clubfoot has its own nature and
personality and need to be treated as
individual
-We can discuss only the guidelines

47. GOAL
To achieve functional, painfree, normal looking,
Plantigrade foot, with good mobility , without
calluses, and requiring no modified shoes
A I M S
To achieve concentric reduction of talocalcaneonavicular
joint , tarsus & ankle joint and to maintain it to establish a
balanced & mobile foot for cosmesis & function

48. OPTIONS
- SERIAL MANIPULATION & CAST APPLICATION
- SOFT TISSUE RELEASE
- BONY PROCEDURE
- EXTERNAL FIXATOR ( Instrumental Distraction )

49. Kite’s Technique
- Manipulation as soon as after birth
- 3 point pressure concept
- Fulcrum – Calcaneocuboid joint
- Forefoot grasped & distracted while other hand holds heel
- Applying counterpressure over calcaneocuboid joint the navicular is
pushed laterally
- Heel is everted as the foot is abducted
- Followed by cast application extended below knee with foot
everted with gentle external rotation
- Afterwards foot is pushed into DF to correct equinus once adductus
& Varus are corrected
LOTS OF COMPLICATIONS………

50. French Technique
- Daily manipulation for 2 mths by physiotherapist
- Peroneal ms stimulation
- Taping with Adhesive tape
- Paediatric CPM
- Thrice weekly session – 6 mths
- BRACING- 3 years
- Posterior release needed in 30 %

51. PONSETI METHOD
- Treatment starts soon after birth but may be
delayed for a few weeks in a premature baby.
- The sequence of deformity correction is cavus,
abduction, varus and finally equinus (CAVE)
- The forefoot is held supinated and not pronated.
- Lateral pressure with the thumb is over the neck of
the talus and not the calcaneocuboid joint.
- Long leg POP (plaster-of-Paris) casts are applied with
the knee in flexion. (This prevents the cast falling off
and controls tibial rotation.)
- Casts are changed on a weekly basis, although this
may be done at 5-day intervals.

52. - Equinus should be corrected without causing a
midfoot break and correction should start after
achieving forefoot abduction of about 60° with
the heel moved into the valgus position.
- Residual equinus is corrected by a percutaneous
Achilles tenotomy using a single incision
(Required in up to 90% of feet) this is followed by
a last cast for 2–3 weeks.

54. - After removing the last cast, a foot abduction orthosis
(Denis Browne boots and bar) is applied and worn
23 hours a day, initially for 3 months then only at
night-time for 2–4 years. This is required to facilitate
remodelling of the foot and prevent relapse of the
deformity.
- The most common cause of relapse of the deformity is
poor compliance with the Denis– Browne boot and bar.
- Relapse is treated by further serial casting with or
without an Achilles tenotomy.

60. COMPLICATIONS - of non operative treatment
- Rocker bottom foot
- Bean shaped foot
- Pressure sores
- Failure of correction
- Recurrence or Relapse
- Flat top talus

62. Indications for surgery in club foot
1) Failure of nonoperative treatment in an infant
2) Syndromic clubfoot
3) Residual deformity correction
4) Neglected clubfoot

63. SOFT TISSUE RELEASE - 6 mnths – 4 years
SOFT TISSUE RELEASE + LAT. COLUMN
SHORTENING – 4 – 8 years
BONY PROCEDURES ARE MUST - > 9 years

64. SOFT TISSUE RELEASE –
- To reduce TC-N & CC joints
- Turco’s ( 1971 ) – Most common
– Single stage PMSTR
- Mckay’s ( 1977 ) – Complete subtalar release
– Based on concept of calcaneal
rotation
– Need posterolateral release to
derotate calcaneum
– 2 incisions –
1) Cinncinnati
2) Posterolateral & Medial plantar

66. Posteromedial release. (A) Skin incision on medial aspect of foot. (B) Neurovascular bundle (black arrow), tibialis posterior
tendon (red arrow), flexor digitorum longus tendon (green arrow), and flexor hallucis longus tendon (pink arrow). (C)
Z-plasty of Achilles tendon. (D) Z-plasty of posterior tibial tendon. (E) Release of subtalar joint from medial aspect (black
arrow) (F) Reduction of talonavicular joint (black arrow).

67. MCKAY’s
Cinncinnati incision

68. Release of lateral structure of foot in complete subtalar release. (A) Peroneus longus and peroneus brevis.
(B) and (C) Calcaneocuboid joint from lateral side (black arrow). (D) Circumferential release of subtalar joint
(black arrow). (E) Reduction of talonavicular joint. (F) Release of plantar fascia.

70. SUMMARY SOFT TISSUE RELEASE
RULE OF 3 STRUCTURES ON MEDIAL SIDE
- 3 muscles – AHL, FHL,TP
- 3 Ligaments – Deltoid, Spring, Plantar
- 3 capsules – Subtalar, Tarsal, Tarsometatarsal
RULE OF 2 STRUCTURES ON POSTERIOR SIDE
- 2 muscles – Tendoachilles, TP
- 2 Ligaments – Talofibular, Calcanofibular
- 2 Capsules – Ankle jt, Subtalar jt
RULE OF 1 STRUCTURES ON ANTERIOR SIDE
- 1 muscle – TA if inserted abnormally
- 1 Ligament – Sup. Peroneal lig
- 1 Capsule – calcaneocuboid joint

83. THANKS
FOR YOUR
ATTENTION