This presentation discusses congenital talipes equinovarus (clubfoot) including its epidemiology, anatomy, classification, clinical features, and management. Clubfoot is a deformity of the foot and ankle characterized by equinus, inversion, adduction and internal tibial torsion. It occurs in approximately 1 in 1000 live births. Treatment involves serial casting or the Ponseti method for mild-moderate cases and soft tissue releases and osteotomies for severe cases. Long term follow up is important to prevent recurrence of the deformity.

1. RESIDENTS’ PRESENTATION
ORTHOPEDIC DEPARTMENT
FMC LOKOJA
TOPIC: PATHOLOGY AND MANAGEMENT
OF CONGENITAL TALIPES EQUINOVARUS
DEFORMITY
BY
DR ENEJO JOSEPH

2. OUTLINE
• INTRODUCTION
• EPIDEMIOLOGY
• ANATOMY
• ETIOLOGY
• CLASSIFICATION
• CLINICAL FEATURES
• MANAGEMENT
• COMPLICATIONS
• FOLLOW UP
• PROGNOSIS
• CONCLUSION

3. INTRODUCTION
• The term ‘talipes’ is derived from talus(
Latin=ankle) and pes(Latin=foot).
• Equino & varus (turned inward)
• Congenital talipes equino varus also known as
Club foot
• Diagnosis is clinical
• It is a congenital deformity of the foot and ankle
characterized by equinus deformity at the
ankle, inversion at the subtalar, adduction at
the midtarsal joint, cavus and internal tibial
torsion

4. INTRODUCTION
• Variants: talipes varus
(commonest), talipes
valgus, talipes equines
and talipes calcaneus

5. EPIDEMIOLOGY
• Most cases are sporadic
• Globally 100,000 – 200,000 cases are born each year
• 80% occur in low to middle income countries
• Data from Miracle feet: 9000 new cases per year in Nigeria.
• The global average incidence is 1:1000 live birth but may be as high as
6.8:1000 live birth in Polynesians
• Incidence in first degree relation- 2%
• Male > female: 2:1
• South-East Nigeria M:F = 56%:44%
• About 50% of cases are bilateral
• In unilateral case: right > left

6. PATHO- ANATOMY
2,3,1,0,4

7. PATHO- ANATOMY

8. PATHO- ANATOMY
Basic Pathology: Abnormal tarsal relationship + Pathological
contractures of the associated soft parts
• Talus: Body (Broadened + flattened), Head and Neck (Constricted
Medially deviated and plantar flexed)
• Navicular: Medial deviation
• Calcaneus : Anterior part (medial deviation), Posterior part
(tuberosity:Upwards + laterally)
• Cuboid: Medial deviation
• 1st Ray is depressed

9. PATHO- ANATOMY

10. PATHO- ANATOMY
Soft Tissue Contractures:-
• Posterior: Tendo Achilles, Talocalcaneal Capsule,Calcanoefibular lig,
Posterior talofibular lig., Posterior Capsule of the ankle joint)
• Medial –Plantar: (Tibialis posterior, Spring ligament, Talonavicular
capsule, Deltoid ligaments)
• Subtalar: (interosseous ligaments and Y-ligament)
• Plantar: Abductor halluces,Plantar aponeurosis,Quadratus plantae,
Masters knot of Henry)
• Lateral: Tendon sheeth of peroneus muscle, Posterior displacement of
distal fibula

11. AETIOPATHOGENESIS
The exact cause is unknown
• Various hypothesis has been postulated
• Primary germ cell defect of talus  Irani
• Abnormal mechanical intra-uterine forces  Hippocrates
• Early intra-uterine growth arrest of the foot  Bohm
• Hereditary  Wynne- Davies
• Contractile myofibroblastic tissue in the Musculotendinous units
Ippolito and Ponseti
• Vascular insufficiency  Keith
• Muscle imbalance from neurological deficit
• Genetic: PITX1, TBX5

12. AETIOPATHOGENESIS
PATHOLOGY
• Club foot
• Midfoot cavus (tight intrinsics, FHL, FDL)
• Forefoot adductus (tight tibialis posterior)
• Hindfoot varus (tight tendoachilles, tibialis posterior)
• Hindfoot equinus (tight tendoachilles )
• The ankle, subtalar and midtarsal joints are involved
• Abnormal gait
• Pain
• Callosities
• Osteoarthritis

13. AETIOPATHOGENESIS
Associated findings
• Absent or hypoplastic anterior tibial artery
• Atrophy of muscles around the calf
• Abnormal foot is smaller

14. CLASSIFICATION
According To Cause
• Idiopathic
• Secondary:
• Neurogenic
• syndromic (Streeters dysplasia, arthrogryposis, edwards syndrome)
• Postural / Positional

15. CLASSIFICATION
According to stage of treatment (CUMMIN)
• Delayed
• Untreated
• Treated
• Resistant
• Recurrent
• Neglected
• Complex
Harold and walker
Grade I = correctable beyond neutral
Grade II = correctable to neutral or < 20 degree heel varus
Grade III = fixed equinous or >20 degree heel varus

16. CLASSIFICATION
According to severity of deformity

17. CLASSIFICATION
• Others
• Browns classification
• Pirani classification

18. CLINICAL FEATURES

19. MANAGEMENT
HISTORY
• Biodata: Age, sex,
• Associated conditions
• Pregnancy, antenatal and delivery history
• Family history
• Previous treatment
• General examination: facie,
• MSS: Spine, muscle tone

20. INVESTIGATION
• Prenatal Ultrasound Scan

21. INVESTIGATION
Xrays
• Limited use
• AP film
• 30 degrees foot plantar
flexion and tube 30 degrees
perpendicular
• Talo-calcaneal angle 20-40
degrees (kite’s angle)
• Less or parallel in club foot
(hind foot parallelism)
• Talo-first metatarsal angle 0-20
degrees
• May be negative in club foot

22. INVESTIGATION
• Lateral film
• Dorsiflexion lateral (Turco view)
• Talo-calcaneal angle below
20 degrees (normal: 25-50
degrees)

23. INVESTIGATION
• CT- Scan :
• FBC
• Genotype
• Genetic studies
• E/U/CR
• GXM

24. TREATMENT
Treatment: Multidisciplinary
The role of parents/guardian
AIMS
• Plantigrade
• Pliable
• Pain-free
• Cosmetically acceptable
TREATMENT
• Non-operative
• Operative

25. TREATMENT
Non operative
• Ignacio Ponseti technique (1940s)
• Joseph Hiram Kite technique (1930s)
• Turco’s Method
• French technique
Surgical
• Soft Tissue Operations: ETA; PMR; TATT;
• Bony Operations: Calcaneo-cuboid; Osteotomy of Calcaneus; Talectomy;
Triple Arthrodesis
• Combined Bony & Soft Tissue Operation
• Ilizarov / Joshi’s External Stabilization System (JESS)

26. TREATMENT
Ponseti technique
• Goal is to rotate foot laterally around a fixed talus
Treatment phase
• Weekly Serial manipulation and casting (long leg cast)
Order of correction (cave)
• Midfoot cavus
• Forefoot adductus
• Hindfoot varus
• Hindfoot equinus (TAL)

27. TREATMENT

28. TREATMENT
• After the last cast Tendo-achelles lengthening
Maintenance phase
• FAB for 23 hrs a day for 3 months and night splint till 2-3 yrs of
age
• Chance of recurrence up to 4 or 5 yrs of age

29. TREATMENT
French technique
• Goal is to reduce talonavicular joint, stretch out medial tissues
• Sequentially correct forefoot adduction, hindfoot varus and
equinus of calcaneum.
• Electrical stimulation of peroneal muscles done
• Reduction maintained by adhesive taping

30. TREATMENT
Kite’s technique
• Foot manipulated with Calcaneo-cuboid joint as fulcrum
• Correction in a sequential order
• Foot adduction
• Heel varus
• Equinus
• Advised change of cast every 3 weeks till correction is achieved.
• After correction Denis Browne splint applied

31. TREATMENT
SURGICAL PROCEDURES
A SOFT TISSUE OPERATIONS: Posterior Release,
Posteromedial Release, Posterolateral Release, Circumferential
Release (Cincinati), Steindler Operation, Tendon transfer, Illizarov
technique
B BONY OPERATIONS: Calcaneo-cuboid orthrodesis, Osteotomy of
the calcaneus, Talectomy, Tripple Arthodesis,Tibial Osteotomy
C COMBINED SOFT TISSUES + BONY OPERATIONS
D OTHERS
- Transposed Skin Graft
- Fascio-Cutaneous Flap

32. TREATMENT
Soft tissue release
Posteromedial release (PMR)
• Done at age 1 yr
• Tight structures in posterior and medial aspect of the foot is released or
lengthened
Posterolateral ligament complex release (PLR)
• Most often is required for severe posterolateral deformity
PMR & PLR
• McKay procedure
• Carroll method
• Manzone method

33. TREATMENT
DEFORMITY TREATMENT
Metatarsus adductus >5yrs metatarsal osteotomy
Hindfoot
varus
<2-3 yrs - Modified Mckay procedure
3-10 yrs -
Dwyer osteotomy
Dillwyn evans procedure
Lichtblau procedure
10-12 yrs - Triple arthrodesis
Eqinus >10 yrs – Triple arthodesis
All 3
deformities
Tendocalcaneus lengthening and posterior
capsulotomy of subtalar, ankle joint (mild,
moderate)
Lambrudoni procedure (severe)

34. TREATMENT
TRIPLE ARTHRODESIS
• Salvage procedure
• Tarsal reconstruction by
wedge resection and fusion of
the subtalar and midtarsal
joints
• Results are not good
functionally and cosmetically

35. TREATMENT
Mordified DWYER’S OSTEOTOMY
• Lateral closed wedge osteotomy or
medial open wedge osteotomy of
calcaneum with bone grafting
• Z lengthening of Tendo-achilles
• Medial plantar fasciotomy
Dependent on the flexibility of
subtalar and midtalar joint

36. TREATMENT
Dillwyns and Evans procedure
• Indicated for a shortened medial column
• wedge resection of calcaneocuboid joint
with arthrodesis
• Age : 4-8 yrs

37. TREATMENT
LICHTBLAU
• Resection of anterior
end of calcaneum of
1 cm
• Indicated in a long
lateral column
• This can be
combined with
Medial release

38. TREATMENT
• CUBOID DECANCELLATION

39. TREATMENT
TALECTOMY
• Age< 4 years
• Rigid paralytic deformities of the foot
• Principle is that by excision, sufficient laxity of soft tissues is
provided to correct equinus and varus deformities without soft
tissue tension

40. TREATMENT
• Ilizarov and Joshi’s External Stabilization System (JESS) are for older
children with recurrence or residual deformity

41. COMPLICATIONS
NOM
• Pressure sores
• Compartment syndrome
• Fractures
• Limb loss
• Burns
• Foot anomaly: Rocker bottom foot, bean shaped foot, flat top talus
• Failure of correction
• Recurrence

42. COMPLICATIONS
Oprative care
• Infection
• Non-union
• Compartment syndrome
• Neurovascular injuries
• Recurrence

43. FOLLOW UP
Follow-up of patient is essential to:
• Monitor treatment
• Prevent recurrence

44. PROGNOSIS
• Prognosis is good
• It however depends on
• Age at presentation
• Severity of the disease
• Associated anomalies
• Availability of experience care giver

45. CONCLUSION
• Club foot deformity as been with mankind for ages
• The etiology is unknown
• Genetic and environmental factors
• Diagnosis is clinical
• Options of care depend on the age at presentation, severity of
deformity and pathology involved
• Surgical correction of resistant clubfoot includes both soft tissue
release & bony osteotomies
• Follow up is essential to prevent recurrence

46. THANK YOU

47. REFERENCES
• Tochukwu NU, Nwakamma JI, KachisichonTA, Faith WC. (2020).
Epidemiology and pattern of Clubfoot in Enugu, South-East, Nigeria.
Amr J BSRB, Vol. 11, Issue 2,
• MiracleFeet. Accessed @ https://www.miraclefeet.org>nigeria
• Tope Omogbolagun (2022). Punch News paper 10th June 2022.
• Manjappa CN.Joshi’s External Stabilization System(JESS) Application
for correction of Resistant Club-Foot. The Internet Journal of
Orthopedic Surgery. 2009, Vol. 18, Numb. 1
• ArchampongEQ, NaaederSB, UgwuB.(2015 ). Baja’s principles and
practice of surgery including pathologies in the tropics: Orthopedic
surgery. 5thEd. Vol2. Repro India Ltd. Chapt.54, page 1202-1207.
• Campbell’s operative orthopaedics, 13th Ed (2017),
• Apley’s system of orthopaedics and fractures, 9th Ed (2010),

48. REFERENCES
• Campbells operative orthopaedics volume 2; 12th edition
• Tachdijian’s pediatric orthopedics volume 2; 4th edition
• Al-falloujiM.A.R (1998). Postgraduate Surgery; The Candidate’s Guide:
Surgical Oncology. 2ndEd. The Bath Press Plc Britain. Pg. 208-236.