This document summarizes information about clubfoot (congenital talipes equinovarus), including: 1. There are different types of clubfoot including idiopathic, postural, neurogenic, and syndromic. The Ponseti method is the gold standard non-operative treatment using serial casting and percutaneous Achilles tenotomy. 2. Surgical management is indicated if non-operative treatment fails or for neglected cases. Common procedures include soft tissue releases and osteotomies. Complications can include wound healing issues, neurovascular injury, and residual deformity. 3. Evaluation of clubfoot correction includes assessing for 15-20 degrees of dorsiflexion and 70-75

1. Clubfoot
(Congenital Talipes Equinovarus)
Stase Pediatri November 2020
Pembimbing :
- Prof. DR. dr. Respati S. Dradjat, Sp.OT(K)
- Dr. dr. Panji Sananta, M.Ked, Sp.OT(K)

2. DEFINITION
 Congenital deformity of the foot and
ankle characterized by equinus deformity
at the ankle, inversion at the subtalar,
adduction ad the midtarsal joint, cavus
and internal tibial torsion
 Complex, congenital, contractural
malalignment of the bones and joints of
the foot and ankle

3. Type of Clubfoot
 Idiopathic variety (most common type)
 Found in otherwise normal children
 Does not resolve without intensive
treatment
 Postural variety
 Resolves completely without
intervention, or with manipulation alone,
or with one or two casts
 Neurogenic clubfoot
 Myelomeningocele
 Syndromic clubfoot
 Children with other anomalieS

4. Clinical features
C A V E (Typical)
 Cavus (plantar flexion of the forefoot on
the hindfoot)
 Adductus of the forefoot on the
midfoot
 Varus (or inversion) of the subtalar joint
complex
 Equinus of the hindfoot

5. PATHOLOGICAL ANATOMY:
1. BONES
• TALUS
Head and neck deviated medially and downward.
Medial And Plantar Deviation Of Navicular Articulation.
Body Rotated Externally And Is In Equinus Of Neck In Ankle
Mortise.
Body Extruded Anteriorly
Smaller Than Normal
Neck- Body Angle Is 90-110* (Normal- 150*)
Dislocation Of Head Of Talus Out Of Its Socket.

6. • NAVICULAR
Medially and plantar
displacement
Close to medial malleolus
Articulates with medial surfacfe
Of dysmorphic talus
Talonavicular joint subluxation

7. • CALCANEUS
Often small in size
Medially rotated
Anterior portion lies beneath the head of talus
causing varus and equinus of heel.
Sustentaculum tali is underdeveloped.
• CUBOID
Medially
head
Subluxated Over CALCANEUS

8. 2. MUSCLES AND TENDONS
Atrophy Of Peroneal Group Of Muscles
Contracture Of Tricep Surae,tibialis
Posterior,flexor Digitorum Longus And Flexor
Hallucis Lungus.
Number Of Fibres In Muscle Is Normal But
Are Smaller In Size.
Thickening And Contracture Of Tendon
Sheaths Especially Of Tibialis Posterior And
Peroneal.

9. 3. LIGAMENTS
THICKENING AND CONTRACTURES ARESEEN
IN :
 Calcaneofibular ligament
 Talofibular ligament
 Deltoid ligament
 Long and short plantar ligament
 Spring ligament
 Bifurcate ligament
 Interosseous talo calcaneum ligament
 Master knot of henry

10. 4. JOINTS CAPSULE AND FASCIA
• CONTRACTURES ARE SEEN IN
Posterior ankle capsule
Subtalar capsule
Talonavicular joint capsule
Calcaneocuboid joint capsule
Plantar fascia contracture are seen which is responsible cavus deformity

11. Clinical features
Others finding clubfoot; atypical
 Posterior ankle skin crease; single
 Empty Heelpad sign
 Tibial torsion
 Deep transverse skin crease crosses the midfoot and
extends under the longitudinal arch
 Hyperextended great toe; appear short
 The calf smaller than contralateral side
 Increased internal hip rotation
 Looked and palpated of head talus on the
dorsolateral aspect of the midfoot/hindfoot just
anterior to the ankle joint  solid fulcrum
 In idiopathic clubfoot; The navicular will not fully
align with the head of the talus and displace the
examiner’s thumb

12. Contributing soft tissue

13. Pirani scoring system
 Simple & Reliable to determine severity
 Monitor progress of treatment
 6 Signs are assesed :
 3 signs in midfoot (MFS)
 Assesses severity of supination, adductus, and cavus
 0 (normal) to 3 (severe)
 3 signs in hindfoot (HFS)
 Assesses severity of equinus
 0 (normal) to 3 (severe)
 Total Score (TS) is the sum of HFS and MFS
 It assesses severity of the clubfoot as a whole with a score range from 0
(normal) to 6 (severe)

14. Pirani scoring system
 HFS sign ; asses equinus

15. Pirani scoring system
• MFS signs ; assess subtalar supination, midfoot adduction, and
cavus

16. Radiographic Features
 No consensus on the role of radiographs in the diagnosis and
management
 To demonstrate the relationships between bones
 To confirm correction or to identify the sites of residual deformity
has been undergoing serial manipulation and casting
 Surgical planning

17. Plain x-ray
Talo-calcaneal angle (Kite’s
Angle)
• AP View
• Mid-talar line (through to
medial base 1st metatarsal) &
Mid-calcaneal line (through to
base 4th metatarsal)
• 20 - 40° (Normal)
• <20° (CTEV)
• Lateral
• 35 - 50° (Normal)
• <35° (CTEV)

18. Other Imaging Studies
 Arthrography, CT, MRI
 May have a role in research or in
the evaluation of postsurgical
deformities
 Do not have a role in the routine
assessment of the idiopathic
clubfoot
 USG
 Intrauterine diagnosis
 Accuracy is 12 weeks of
gestational age

19. Natural history
 The untreated clubfoot persists as a rigid
 Develops of Callused bursa over the
dorsolateral aspect
 In the most extreme cases, the toes point
backward
 City-dwelling adolescents and adults
with untreated clubfoot experience pain
& disability

20. NON OPERATIVE
Treatment of Clubfoot
Goal :
 Achieve a plantigrade, supple, painless foot that looks normal,
although it is not technically normal, and provides good function
 Achieve good pressure distribution on the skin and no need for special
or modified shoes wear
Kite (1939)
 Presented cast correction but required a lengthy period of immobilization,
often >1.5 to 2 years
Ponseti and Smoley (1940)
 Developed a casting method for clubfoot that differed significantly from
Kite’s

21. PONSETI TREATMENT
 Gold standard treatment
 Based on pathoanatomy of deformity
 The efficacy due to :
 Viscoelasticity
 Rate-dependent
 Behavior of the collagen in the
ligaments & tendons

22. Ponseti method
 Old standard : POP
 Semirigid fiberglass more superior in
 Durability
 Convenience
 Performance
 Ease of removal
 But more challenging in molding
 Remove cast before return to clinic
 Maintenance the cast until 5 -7 days
 If not achieve good correction in 3
months : Operative
 Full correction Cavus, adductus & varus
deformity : 90%
 Equinus deformity achieved by 10° of
ankle dorsiflexion
 If not achieved : Percutaneous complete
transection of the Achilles tendon

23. PONSETI CAST
CORRECTION :
CAVUS
 Forefoot supination relative to the hindfoot
 Pronation of the first metatarsal at the first session
the forefoot is simultaneously supinated and
abducted
 The cavus is almost always corrected with the first
cast
VARUS, ADDUCTION, INVERSION
 Correct simultaneously
 Abduction foot in supination
EQUINUS
 The last correction
 Residual equinus need Tenotomy

24. Ponseti cast

25. Ponseti cast

26. Continues passive movement
 Developed by Masse & Bensahel et al. In
1970 (France)
 Dynamic method of management
 Utilizing physiotherapist-implemented
exercises by Adhesive Taping
 Begun immediately after birth
 Stretch the tight plantar-medial structures
(posterior tibial tendon and plantar soft
tissues
 Strengthen the peroneal muscles
 Allows some functional motion that is not
permitted in rigid casts
 0-2 months (daily treatment)
 2-6 months (3x / weeks)
 Continued : Physical therapy & night
splinting (for 2 to 3 years)

27. Percutaneus tenotomy
 Integral step in Ponseti technique
 HS > 1, MS < 1, Head talus is covered
PROCEDURE :
 Incision 1 cm above insertion of achilles on the calcaneus
 Used a small blade, small cataract knife, Needle
 Insert the blade from medial side of the heel
perpendicular to the medial border of the foot
 The blade parallel and directed to the Achilles tendon
 Slowly moved the blade anteriorly until it slips past the
anterior border of the tendon
 This technique will help ensure that the blade does
not pass near the posterior tibial neurovascular
bundle
 Turned the blade to a 90° posteriorly  Section the
tendon
 The foot : 20° of dorsiflexion & 70° of abduction
 Cast for 3 weeks

28. BOTULINUM TOXIN
INJECTION
 By Alvarex et.al (2005)
 Injected into triceps surae muscle complex to weaken its
function
 Minimal scar & deep tissue fibrosis
 Need more experiment

29. AFTER CORRECTION
EVALUATE :
 In the final cast :
 15 - 20° of dorsiflexion
 70 - 75° of external rotation of the foot relative to the thigh
MANAGEMENT AFTER CORRECTION :
 Semirigid shoes connected together by bar
 (Foot Abduction Orthosis / Denis Browne bar & shoes)
 70° of external foot rotation (45° for a contralateral normal foot)
 5-10° of dorsoflexion
 For 3 – 4 months, 23 hours per day  worn at nap and nighttime
for 2 to 4 years
 But, challenging to maintain nightime in 4 years children
 Ankle dorsiflexion stretching exercises for at least 1 minute at
least 3x/day

32. Surgical management
INDICATION :
 Failed with non-operative
 Resistant, persistant, relapsed
 Neglected case
 Others secondary deformity
Early surgery not recommended ; 
stimulated Myofibroblast  poor
outcome
Avoid multiple operation
COMPLICATION :
 Wound-healing problems
 Neurovascular injury
 bone/cartilage damage
 avascular necrosis of the talus and
navicular
 Pain
 Stiffness
 Weakness
 residual deformity
 recurrent deformity
 dorsal bunion
 overcorrection at the talonavicular,
talocalcaneal, and
talocalcaneonavicular joints

33. Percutaneous lengthening of
the Achilles tendon

34. Timing of surgical procedure
 After failed nonoperative management
 12 months
 Structure were larger
 Anatomy clearly
 Tendon lengthening repair more
secure
 Only little advantage surgery < 12
monts
 Because weight bearing &
standing position will be delayed
by the postoperative
immobilization
 Soft tissue release : 1 – 4 years old
 Soft tissue release + Osteotomy :
4 – 11 years old
 Salvage procedure (Triple
arthrodesis,
Talectomy/astragalectomy) : > 11
years old

35. THANK YOU

36. Procedure PMR

37. Turco approach
 Popular in 1970s
 Hockey-stick posteromedial
incison
 Straight from base 1st
metatarsal under medial
malleolus until reached
Achilles
 Crosses the skin creases on
the medial side
 Identified all medial
neurovascular structures and
tendons

38. cincinnati approach
 Circumferential incision
 Problems with skin edges
 Limited exposure of achilles
 Extensile
 Cosmetic
 Safe (as long as, placed at least 1
cm at proximal ankle crease)
 Lower placement high risk slough
of the heel pad

39. Carrol’s approach
 Double incision technique (posterior &
medial)
 Base of triangle :
 Center of calcaneus
 Front of medial malleolus
 Base of 1st metatarsal
 Center incision paralel of the base
triangle
 Proximal part toward the center of the
heel
 Distal part crosses over the dorsum of
the foot
 Safe
 Extensile
 Less cosmetic

40. Suggested technique
 Prone position
 Cincinnati incision
 Successful comprehensive release : involving multiple anatomic
steps, exposure
 Better place : posterolateral corner of the ankle
 After identified & protected the sural nerve & lesser saphenous
vein  opened the peroneal sheath to allow full anterior
retraction of the two tendons
POSTERIOR RELEASE :
 The calcaneofibular and lateral subtalar ligaments, avoiding
blind peroneal tendon injury
 Longitudinal exposure of the Achilles tendon permits a long Z-
lengthening
 The posterior talofibular ligament
MEDIAL PLANTAR RELEASE :
 The posterior & medial subtalar joint capsule (leaving the
interosseus ligament intact
 Talonavicular joint capsulotomy (including spring ligament &
bifurcatio Y ligament)
 Medial calcaneocuboid joint capsulotomy

41. Suggested technique
STRUCTURE PRESERVED :
 The dorsal structure tibialis anterior
and extensor tendon
 Neurovascular bundle
 The deep deltoid ligament

42. Soft tissue surgery;
Anterior Tibial Tendon
Transfer
 4cm incision over of tibialis anterior  extend from its
insertion to proximally
 Sharply incision of tibialis anterior tendon sheath
 Dissected the insertion as far distally
 Avoid injury to the 1st metatarsal growth plate
 Avoid bow stringing tendon
 Used absorsable suture (vicryl 0)  (Bunel type fashion)
 4cm incision over 3rd cuneiform (proximal from 3rd
metatarsal; between EDL & peroneus tertius)
 Insert small gauge (confirm with minifluoroscopy)
 Make a drill hole on the 3rd cuneiform  tract to tibialis
anterior tendon meet to ankle retinaculum
 The foot position : maximal dorsoflexion & evertion
 Suture periosteum of 3rd cuneiform with two interrupted
absorsable suture

43. Soft tissue surgery;
Transfer for Insufficient Triceps Surae
(Calcaneus Gait)
 Overlengthening of the Achilles tendon or triceps insufficiency
secondary to inadequate excursion from scarring is notoriously
difficult to reconstruct and is best prevented rather than
reconstructed
 The surgeon must diagnose plantar flexion weakness as early as
possible if muscle transfer is to have any chance of being effective
 Muscles for transfer to reconstruct :
 Peroneals
 Tibialis posterior
 Long toe flexors

44. Soft tissue surgery;
Transfer for Insufficient Triceps Surae (Calcaneus
Gait)
LATERALLY
 The peroneus brevis can be divided distal to the fibula
and the proximal end rerouted to the calcaneus
tuberosity (Tendon-to-Bone transfer)
 Drill hole on the calcaneal tuberosity – to – button on
plantar heel
 The distal stump of the brevis  tenodesed side to side
to the longus to maintain eversion power
MEDIALLY
 The tibialis posterior or flexor hallucis longus 
rerouted in a similar fashion & interwoven with the
residual Achilles tendon, if present, or anchored to
bone
 Immobilized with NWB 6-8 weeks

45. Bony surgery;
Lateral Column Shortening
EVANS PROCEDURE
 Standard technique for recurrent clubfoot
deformity
 Calcaneocuboid fusion
 4 - 8 years old (<4 ; large amount of cartilage 
difficult to fusion)
 Recurrent deformity : medial contracture &
excessive length of lateral collumn
 Combines posteromedial release & lateral column
shortening in one stage
 Concepts of midfoot (talonavicular and
calcaneocuboid) dislocation  by allowing
reduction of the navicular on the talar head by
lateral column shortening  avoid
recurrence/relapsed

46. Bony surgery;
Lateral Column Shortening
LICHTBLAU PROCEDURE
 Concept : overgrowth lateral part of
calcaneus
 Recommended for >6 years old
 Calcaneocuboid arthroplasty
 Resection of the anterior end of the
calcaneus
 Shortening of the calcaneal neck proximal
to the calcaneocuboid joint

47. Bony surgery;
Lateral Column Shortening
GOLDNER PROCEDURE
 Less commonly used
 Ideal age range is unknown
 Close wedge osteotomy of the
anterior calcaneus
 Preserve cuboid
Goldner

48. Bony surgery;
Lateral Column Shortening
CUBOID DECANCELLATION PROCEDURE
 Can be used at any age
 Wedge resection
 Preserve articular surface

49. Bony surgery;
Lateral Column Shortening
 Fixation with small staples or a
Kirschner wire
 NWB short leg cast
 Cast and pin are removed after 6
weeks

50. Bony surgery;
calcaneal osteotomy
 Advantage : Preserve subtalar motion (Dwyer)
 Can be combined with other procedure; Triple
arthrodesis
 Open or closed wedge osteotomy
 Better perform at 10 years old
Open wedge;
 Medial approach ; wound closure can be
compromised
 Stabilized with bone graft (tricortical iliac crest
graft)  increase height of heel  required
more achilles
 Delayed weight bearing
Closed wedge;
 Less wound healing morbidity
 Decreased height of heel  impingement

51. Bony surgery;
Supramalleolar Osteotomy
 Persistent in toeing gait
 Cause by Muscle imbalance (abnormal
histopatology peroneal muslce)
 Failed with 2 years observe 
Supramalleolar external rotation
osteotomy
 Effective
 Not contribute to stiffness
 Goldner;
 up to 35° of external rotation
 Correction at level proximal and
distal tibial physis
 Using 2 pin between level of
osteotomy

52. Bony surgery;
Supramalleolar Osteotomy
 For severe valgus deformity of ankle
Wiltse’s technique
 Anterior approach to the distal tibial
metaphysis at the level of the metadiaphyseal
junction
 A triangular piece of bone is removed from the
region of the distal tibial metadiaphyseal
junction
 The apex of the cut is centered on the
longitudinal axis of the tibia
 The magnitude of the angle of the lateral
portion of the triangle should be equal in size
to the magnitude of the deformity to be
corrected
 Stabilized by a plate and screws or Kirschner
wires
 A cast is placed as below

53. Triple arthrodesis (Astragalectomy)
 Fusion : talocalcaneal, calcaneocuboid &
talonavicular joints
 Indicated for salvage procedure or 'last resort’ in
severe, rigid deformities of the hindfoot that are
unresponsive / resistant to less invasive methods of
treatment
 Considered : >10 years of age
 Used for varus or overcorrected valgus feet
 The goal of surgery
 To achieve a plantigrade foot by restoring the
anatomic relationships between the affected
bones or regions of the foot
 Relieve pain
• Positioning : Supine
• Approach
• Single lateral
• Ollier
• Most common
• Anterolateral
• Medial
• Useful for calcaneuovalgus foot
• Lambrinudi procedure, for severe
equinus deformity
• Combined medial & lateral

54. Lambrinudi
triple arthrodesis
 Incision begin 1 cm distal to tip fibula
 It curves dorsolaterally and extends to the lateral border of the
talonavicular joint
 Retract Extensor tendons to medially
 Mobilized and protected of peroneal tendons
 Retract Extensor digitorum brevis to distally
 Exposing sinus tarsi, calcaneocuboid joint & lateral aspect of
talonavicular joint
 The sinus tarsi is cleared of soft tissue to expose the anterior,
middle & posterior facets of the subtalar joints

55. Lambrinudi
triple arthrodesis
 Make a sequential osteotomies
1st osteotomy :
at the inferior part of the talus perpendicular to the
long axis of the tibia in both planes
2nd osteotomy :
at the superior part of the calcaneus parallel to the
sole of the foot in both the longitudinal and
transverse planes
3rd osteotomy :
at the distal end of the calcaneus at a right angle to
the long axis of the calcaneus
 The final cut is made along the proximal end of the
cuboid at a right angle to the longitudinal axis of the

56. PENNY'S MODIFIED LAMBRINUDI
TRIPLE ARTHODESIS
Special attention triple arthrodesis in Neglected clubfoot in adolescent
 Lengthening achilles is required in first step
 The main components :
hindfoot equinus and varus, midfoot cavus, and forefoot adduction
 Significant obliquity of the calcaneocuboid joint  requires a specially oriented
lateral wedge excision of the calcaneocuboid joint
 Typically severely plantarflexed
 Need aggressive resection of the talar head to correct the midfoot cavus &
plantigrade position

57. PENNY'S MODIFIED LAMBRINUDI
TRIPLE ARTHODESIS
INCISION & DISSECTION :
 1 cm distal tip of fibula
 Curve dorsolaterally & extend to lateral border of talonavicular joint
 Medially retracted of extensor tendon
 Mobilized & protected peroneal tendon
 Identified & protected sural nerve
 Elevated off extensor digitorum brevis from the origin & reflected distally
 Exposed the sinus tarsi, calcaneocuboid joint, & lateral aspect of talonavicular
joint
 Cleared soft tissue from sinus tarsi
 Identified facet of subtalar joint

58. PENNY'S MODIFIED LAMBRINUDI
TRIPLE ARTHODESIS
 Removing a lateral wedge (calcaneocuboid resection)
 Transverse cut perpendicular to the long axis of the lower leg
 Removes the joint surface of the cuboid and should be
conservative (several millimeters)
 Removing an anteriorly based wedge from the anterior process of the
calcaneus to correct equinus
 Resecting a portion of the head & neck talus
 The cut begins at the dorsal articular margin of the talus and
extends in a proximal and plantar direction through the posterior
subtalar joint
 This cut is oriented perpendicular to the long axis of the tibia
 Conservative resection of the articular surface of navicular, as well as
removal of the tuberosity of the navicular
 A notch is made in the inferior articular surface of the navicular to
accept the anterior portion of the talus
 With the surfaces of the talus and calcaneus apposed, the anterior end
of the talus is pushed into the notch under the navicular while
abducting the forefoot

59. TRIPLE ARTHRODESIS USING
A SINGLE MEDIAL INCISION
 A 2-cm longitudinal incision is made over the peroneal
tendons 10 em above the level of the ankle joint, and
both tendons are delivered using a mosquito clamp
and divided sharply
 An 8-cm medial longitudinal incision extends from the
undersurface of the posterior medial malleolus across
the talonavicular joint
 The talonavicular joint is exposed, and the tibialis
posterior tendon is released from its insertion. The
talonavicular capsule is released. Flexor digitorum
longus tendon, flexor hallucis tendon, and
neurovascular bundle are protected by a retractor
 The talocalcaneal interosseous ligament is divided, and
the anterior, middle, and posterior facets of the
subtalar joint are visualized
 The subtalar and talonavicular joint surfaces are
denuded and prepared
 The calcaneocuboid joint capsule and bifurcate
ligaments are released sharply, and a lamina spreader
is inserted to facilitate removal of the joint surfaces

60. BEAK TRIPLE ARTHRODESIS
FOR SEVERE CAWS
DEFORMITY
 A lateral approach is employed, as outlined above
Wedges to be removed
 The articular cartilage of the subtalar and
calcaneocuboid joints is denuded
 The talar neck is osteotomized from inferior to
superior, forming a beak superiorly
 The soft tissue structures on the superior aspect of the
talus anterior to the ankle are left undisturbed
 The dorsal cortex of the navicular is excised
 The forefoot is displaced plantarward and the
navicular is locked beneath the remaining part of the
talar head and neck
 Stability can be maintained while plaster is applied by
slight upward pressure under the forefoot. a staple
may be used for fixation

61. the Ilizarov in ctev
 Neglected or recurrent deformity
 Combining multiple-plane corrections through the use of
hinged distraction between a tibial & foot frame
 Corection slow enough to correction soft tissue
 Correction of the focus of deformity
 Simultaneus three-dimensional, multilevel correction
 Deformity correction without shortening the foot
 Ring are fixed to the tibia connected to half ring for the
calcaneus and the forefoot
 Asymetric distraction corrects the various deformity
 Bony deformity not severe (<8 years); unconstrained
frame
 Severe deformities (>8 years); distraction osteogenesis
through osteotomies using constrained frame with hinges
Adductus & Equinus Correction

62. Outline treatment of
equinus deformity

63. Outline treatment of
equinovarus deformity; infant & young child

64. Outline treatment of
equinovarus deformity; children 4 – 7 years old

65. Outline treatment of
equinovarus deformity; adolescent