1. CTEV : PaThoanaTomy and managEmEnT
dR. SUShIL PaUdEL
dR. PRaTyUSh
dR. Shah aLam Khan

2. Definition
Developmental deformation
of foot
 Rotational subluxation of
talocalcaneonavicular joint
complex with talus in plantar
flexion & subtalar complex in
medial rotation & inversion
Clinically characterized by
 Equinus & varus of heel
 Forefoot adduction
 Midfoot supination

3. Classification (Attenborough 1966)
Type Type
I(Extrinsic) II(Intrinsic)
Non Rigid Rigid
Foot size Normal Smaller
Heel Normal size Small, elevated
Can be brought Cannot be brought
down with ease down with ease
Minimal varus Marked varus
Creases More or less normal Deep medial,
posterior and lateral
creases
Reduced creases
laterally

4. Definitions in clubfoot
Rigid or resistant atypical clubfoot : Stiff, short,chubby
with a deep crease in sole of foot and behind ankle,
shortening of the first metatarsal with hyperextension of
the metatarsal phalangeal joint; occurs in otherwise
normal infant
Syndromic clubfoot: The clubfoot part of a syndrome
Teratologic clubfoot – such as congenital tarsal
synchondrosis
Neurogenic clubfoot – associated with a neurological
disorder such as meningomyelocele

5. Epidemiology
Commonest congenital orthopaedic abnormality
1.3:1000 live births
Males>Females – 2:1
30-50% bilateral
Much more common in Polynesian & Maori & lower in
Asians

6. Pathogenesis
 Unknown at this stage
 Gray et al (1981) : increase in % of type I fibres in soleus muscle;
suggested defective neural influence
 Recent study*: no evidence of type I fiber grouping
 Hypoplasia or absence of the anterior tibial artery in majority of CTEV
patients**
 Absence of the dorsalis pedis pulse in the parents of children with
clubfoot#
 Primary germ plasm defect in the talus: continued plantar flexion and
inversion of this bone, with subsequent soft-tissue changes in the
joints and musculotendinous complexes
*Sodre H et al. J Pediatr Orthop. 1990;10:101-4.
**Muir L et al. J Bone Joint Surg Br. 1995;77:114-6
# Milan B MD et al. Journal of Pediatric Orthopedics. 26(1):91-93, 2006 .

7.  Wynne-Davies : polygenic inheritance
 Multifactorial inheritance established by genetic epidemiologic
research by Idelberger
 32.5% concordance rate among monozygotic twins as compared to
2.9% among dizygotic twins
 Major gene effect (inherited in recessive manner) with additional
polygenes and environmental factors
 Tachdjian
 Patient with CTEV that has one child affected then 25% chance of
another affected
 If both parents are normal & have affected child then chance of
another is 5%
Idelberger K. et al 1939; 33:272–276

8. Intrauterine factors
Pressure theories:
 Oligohydramnios
 Abnormal fetal positioning
Placental insufficiency
Constriction bands
Toxins ( Maternal alcoholism, smoking)
Maternal illness ( anemia, thyroid disorders )
Infective pathogens (enteroviruses)
Drugs (abortifacients, salicylates, barbiturates)
Electromagnetic radiation

9. Bony abnormalities
 Talus:
 Head & neck deviated medially
& plantarward
 Body rotated externally in the
ankle mortise
 Body extruded anteriorly
 Smaller than normal

10. Navicular:
 Medially displaced
 Close to medial malleolus
 Articulates with medial
surface of head of talus
Calcaneus
 Anterior portion lies beneath
the head of talus causin
gvarus and equinus of heel
 In equinus
 Rotated medially

11. Cuboid
 Displaced medially on
the dysmorphic distal
end of the calcaneus
Talonavicular joint
 In inversion

12. Tibio-talar plantar flexion
Medially displaced navicular
Adducted and inverted
calcaneus
Medially displaced
cuboid

13. Soft tissue changes
 Posterior structures :
 Tendo achilles
 Post. capsule of ankle
joint & subtalar joint
 Post. talo fibular
 Calcaneo-fibular ligaments

14.  Medial :
 Tibialis posterior
 FHL,FDL, Master Knot of
Henry
 Talonavicular ligament
 Calcaneo-navicular ligament
 Deltoid ligament
 Interossseus talo calcaneal
ligaments
 Capsules of naviculo
cuneiform & cuneiform first
metatarsal

15. Plantar wards :
 Plantar fascia
 Plantar ligaments
 Flexor digitorum
brevis & abductor
hallucis
Laterally
 Calcaneofibular
ligament
 Bifurcated ligament
 Calcaneocuboid joint
capsule

16. Clinical features
 1. Deformity
 Heel equinus
 Heel varus
 Midfoot supination
 Forefoot adduction
 Maybe cavus

17.  2. Features 3. General
 Curved lateral border of foot  Calf atrophy
 Devil’s thumbprint over the  Calf shortening
lateral malleolus  Restricted ankle motion
 Medial & Lateral skin creases
 Navicular fixed to medial  Other Conditions should be
malleolus excluded
 Os calcis fixed to the lateral  Spinal Dysraphism
malleolus  Arthrogryposis
 Heel small & high  Neuromuscular Disorders

18. Radiology
Plain radiograph: Can be assessed prior to treatment
with A-P & Lateral of foot
Foot held in position of best correction, with weight-
bearing, or simulated weight-bearing
 AP view: Taken with foot in 30° of plantar flexion and
tube at 30° from vertical
Lat. View: Transmalleolar with the fibula overlapping the
posterior half of the tibia; foot in 30° of plantar flexion

19. Anteroposterior view
Talocalcaneal angle
Calcaneal-second
metatarsal angle
Talus –first metatarsal
angle

20. AP radiograph: Talo-Calcaneal angle
 Lines drawn through
center of the long axis of
talus (parallel to medial
border) and through the
long axis of calcaneum
(parallel to lateral border),
and they usually subtend
an angle of 25-40°.
 Any angle less than 20°
considered abnormal

21. Lateral view
 Talocalcaneal view
 Calcaneal-first metatarsal
view
 Tibiocalcaneal
 Tibiotalar angle
 Talus-first metatarsal angle
 Talocalcaneal index (Kite's
angles from AP and Lateral
views added)

22. Pirani’s severity scoring
Six parameters : 3 of midfoot and 3 of hindfoot
Each parameter is given a value as follows:
 0: normal
 0.5: moderately abnormal
 1: severely abnormal
Pirani s et al. A method of evaluating virgin clubfoot with substantial interobserver reliability. Annual
meeting of Pediatric orthopaedic society of North America 1995

23. Mid foot score
Curved lateral border
[A]
Medial crease [B]
Talar head coverage [C]

24. Hind foot score
Posterior crease [D]
Rigid equinus [E]
Empty heel [F]

25. Uses of Pirani’s score
Assessment of progress by serial plotting of the score
Predicting need for tenotomy (hs>1& ms<1)
Estimation of probable no. of casts reqd*
Very good interobserver reliability and reproducibility**
* J. Dyer et al Journal of Bone and Joint Surgery - British Volume, Vol 88-B, Issue 8, 1082-
1084P.
** Flynn JM, Donohoe M, Mackenzie WG. J Pediatr Orthop 1999;18:323-7

26. International Clubfoot Study Group Score
Introduced by Henri Bensahel et al in 2003
Found to have good interobserver reliability and
reproducibility**
Morhological (12 pts), functional (24 pts) &
radiological (12 pts) parameters
Maximum of 60 for most deformed and 0 for normal
feet
**Celebi L et al J Pediatr Orthop B. 2006;15:34-36.

27. Morphological parameters

28. Functional parameters

29. Radiological parameters

30. Classification of clubfoot severity by Diméglio A.Equinus
deviation B. Varus deviation C. Derotation D. Adduction.

31. Reducibility( deg Score Additional Score
rees) parameters
90-45 4 Marked posterior 1
crease
45-20 3 Marked 1
mediotarsal crease
20-0 2 Cavus 1
0 t0 -20 1 Poor muscle 1
condition

32. Grade Type Score Reducibility
i Benign 1-4 >90%
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

33. Aims of treatment
After sucessful treatment foot should
 Look good
 Feel good
 Move good
 Measure good

34. Ponseti cast correction

35. Outline of Ponseti regimen
Serial casting of lower
limb using a strictly
defined technique and
weekly change of casts
Percutaneous tenotomy of
tendo achilles for “hind
foot stall”
Once foot corrected, an
abduction foot orthosis
worn full time for 12
weeks, and then at nights
and naps, up to age of four

36. Manipulation and cast application
1.Manipulation
Manipulation: start as
soon after birth as possible
Setup for casting includes
calming the child with a
bottle or breast feeding
 Assistant holds the foot
while the manipulator
performs the correction

37. Tarsal joints functionally
interdependent
Movement of each tarsal
bone involves
simultaneous shifts in the
adjacent bones
Necessiates
SIMULTANEOUS
correction of adduction,
varus and inversion.

38. 2. Correction of cavus
 Cavus results from pronation of
the forefoot in relation to
hindfoot “ THE PRONATION
TWIST “
 Attempting to correct the
supination of hindfoot before
correction of varus results in an
iatrogenic increase in cavus
 Corrected by supinating the
forefoot to place it in proper
alignment with the hindfoot.

39. Cast application
Manipulation Padding

40. Plaster at toes Below knee pop

41. Molding Extension upto the thigh

42. Plantar support to toes Final appearance

43. Casts and foot Adequate abduction
Best sign of sufficient
abduction: ability to
palpate the anterior
process of the calcaneus as
it abducts out from
beneath talus
Abduction of approx.70
degrees in relationship to
the frontal plane of the
tibia possible

44. Complications of casting
Tight cast
Rocker bottom deformity
Crowded toes
Flat heel pad
Superficial sores
Deep sores
Pressure sores
Injury to distal tibial physis

45. Common errors(Kite errors)
No manipulation
Pronation/eversion of 1st
metatarsal
Premature dorsiflexion
of heel
Counterpressure at
calcaneocuboid joint
External rotation
Below knee casts
Short splints

46. Rocker bottom deformity
Dorsiflexion via midfoot
before correction of
hindfoot varus
Dorsal dislocation of
navicular on talus
Fixed equinus of
calcaneus

47. Correction of equinus and tenotomy
 No direct attempt at equinus correction is made
until heel varus is corrected
 Equinus deformity gradually improves with
correction of adductus and varus- calcaneus
dorsiflexes as it abducts under talus
 Residual equinus- manipulation and casting +/-
percutaneous tenotomy
Tenotomy : Indicated to correct equinus when cavus,
adductus, and varus fully corrected but ankle
dorsiflexion remains less than 10 degrees above
neutral

48. Percutaneous tenotomy under LA
 Foot held in max dorsiflexion by an assistant
 Tenotomy done 1.5 cm above calcaneal insertion
 Additional 25-30 deg dorsiflexion obtained
 Cast with the foot abducted 60 to 70 degrees with respect to the frontal plane of
the ankle, and 15 degrees dorsiflexion for 3 weeks

49. Foot Abduction braces
Shoes mounted to bar in
position of 70° of ER and 15°
of dorsiflexion in B/L cases
and incase of U/L cases 30 to
40° of ER in normal side,
distance between shoes set
at about 1˝ wider than width
of shoulders
 Knees left free, so the child
can kick them “straight” to
stretch gastrosoleus tendon

50. Bracing protocol
Worn 24 hours each day for first 3 months
For 12 hours at night and 2 to 4 hours in middle of day for
a total of 14 to 16 hours during each 24-hour period
Continued until the child is 3 to 4 years of age
Haft et al: noncompliance with bracing protocol – the
most common cause of recurrence in children on Ponseti
regimen
Haft, Geoffrey F. MD; Walker, Cameron G. PhD; Crawford,Haemish A. FRACS.J Bone Joint Surg Am, Volume 89-
A(3).March 1, 2007.487–493

51. Mitchell brace Dobbs dynamic brace

52. Dennis brown Romanus

53. CTEV Splint
 Straight inner border to prevent
forefoot adduction
 Outer shoe raise to prevent
fooot inversion
 No heel to prevent equinus
 Slight(1/8”) lateral sole raise
 Inner iron bar
 Outer t trap
 Walking age to 5 yrs of age

54. Results of Ponseti method
Cooper and Dietz in 1995:
 Reviewed a group of 45 adults, with 71 clubfeet, who had
been managed with the Ponseti method, 30 years after
treatment
Results compared with NORMAL CONTROLS.
Based on structured examination, radiographs,
electrogoniometry and measurements using a
pedobarography.
Using the Laaveg and Ponseti score, the results in the
normal controls and in those with treated clubfeet same
 Radiographs showed :feet not completely corrected, but
functioned well despite this
Cooper DM, Dietz FR. J Bone Joint Surg [Am] 1995;77-A:1477-89.

55. Results of Ponseti’s method..
Study from Iowa (2004) : short-term results of a more
recent series of 256 feet
Correction obtained in 98% with one to seven casts
 2.5% required extensive corrective surgery.
Percutaneous tenotomy in 86%.
 Mean angle of dorsiflexion : 20° (0° to 35°)
 Minor cast complications in 8%
Rate of relapse: 10%.
Morcuende JA, Dolan LA, Dietz FR, Ponseti IV. Radical reduction in the rate of extensive
correctivesurgery for clubfoot using the Ponseti method. Pediatrics 2004;113:376-80.

56. Khan et al
 Evaluated results of Ponseti's method in 21 children (25 feet) with neglected
club feet
 Underwent percutaneous tenotomy of Achilles tendon
 Mean age at the time of treatment 8.9 years
 Mean follow-up period 4.7 years
 Average Dimeglio score at start of treatment 14.2 compared with an average
score of 0.95 at the end of treatment at 1-year follow-up
 18 feet (85.7%) full correction, recurrence in 6 feet (24%)
 At 4-year follow-up, average Dimeglio score for 19 feet 0.18.
 Recommend Ponseti's method as initial treatment modality for neglected
clubfeet
J Pediatr Orthop B.2010 Sep;19(5):385-9.
Ponseti's manipulation in neglected clubfoot in children more than 7 years of age: a prospective evaluation of 25 feet with
long-term follow-up. Khan SA, Kumar A

57. Modifications of Ponseti’s method
 Accelerated Ponseti
 Morcuende et al , (2005) 7 day Vs 5 day interval
 Average time to tenotomy: 16 days in 5 day group and 24
days in 7 day group
Morcuende JA, Abbasi D, Dolan LA, Ponseti IV. Results of an accelerated Ponseti protocol for
clubfoot. J Pediatr Orthop 2005;25:623-6

58. Kite method
Believed heel varus would correct simply by everting
calcaneus
Did not realize calcaneus can evert only when it is
abducted (i.e., laterally rotated) under the talus
Each component corrected separately ( adduction, heel
varus and equinus)
Forefoot overcorrected into mild flatfoot
Calcaneus rolled out of inversion by placing plantar
surface of a slipper cast on glass plate to flatten the sole
Dorsiflexion of foot with wedging casts

59. The French method
Bensahel/Dimeglio regime
Daily manipulations by a skilled physiotherapist and
temporary immobilisation with elastic and non-elastic
adhesive taping
Mobilisation during the hours of sleep with CPM machine
Successful in 51% of cases ( of which 9% req TA tenotomy)
; 49% Reqd extensive soft tissue release -29% post release
and 20% comprehensive posteromedial release**.
** Richards BS, Johnston CE, Wilson H. Nonoperative clubfoot treatment using the French physical
therapy method. J Pediatr Orthop 2005;25:98-102.

60. Atypical clubfoot
2-3% Feet highly resistant
to correction
Severe plantarflexion of all
metatarsals, a deep crease
just above heel and across
the sole of the midfoot ,
short hyperextended big
toe, fibrotic muscles
Treatment by
manipulation and Ponseti
method

61.  When manipulating,index finger
should rest over posterior aspect of
lateral malleolus while thumb of
same hand applies counter pressure
over the lateral aspect of the talar
head
 Do not abduct more than 30
degrees
 After 30 degrees abduction is
achieved, change emphasis to
correction of the cavus and equinus.
 All metatarsals are extended
simultaneously with both thumbs
 Above-knee cast in 110 degrees
flexion

62. Follow up protocol
2 weeks: to troubleshoot compliance issues
3 months: to graduate to the nights and naps protocol
Every 4 months: until age 3 years to monitor compliance
and check for relapses
Every 6 months: until age 4 years.
Every 1 to 2 years: until skeletal maturity

63. Surgery in clubfoot
Resistant clubfoot( non-responsive to serial casting and
manipulation)
Persistently deformed clubfoot(non-operative correction
inadequately done with/without compliant bracing)
Relapsed clubfoot( initially satisfactorily corrected that
recurs in part or whole)
Neglected clubfoot( no treatment given till age of 2 yrs)

64. General Principles
Goal: address all pathoantomic structures
Decision regarding timing, extent
Index surgery, the most important
“A la carte" approach [Bensahel]
Turco’s ‘one size fits all’ approach
Posteromedial-plantar-lateral release: all deformities
present
Posterior release: straight lateral border, flexible forefoot
and hindfoot, and palpable gap between medial malleolus
and navicular tuberosity

65. Approaches
Turco Cincinnati

66. Caroll’s two incision technique
Medial incision - straight oblique incision
Straight lateral incision along the lateral
from first metatarsal, across tmedial
subtalar joint antr to distal fibula
malleolus to Achilles tendon

67. Extensile posteromedial and posterolateral release
Modified McKay
procedure
Cincinnati incision
Posterolateral release
 Z lengthening of the TA
 Posterior capsulotomy of
Ankle joint &Subtalar joint

68.  Incise superior peroneal
retinaculum
 Cut off calcaneofibular and
talofibular ligament
 Incise talocalcaneal ligament
and lateral capsule of
talocalcaneal joint
 EDB, inferior extensor
retinaculum and dorsal
calcaneocuboid ligamner cut
incase of severe clubfoot

69. Medial release
 Dissect and protect N-V
bundle
 Master knot of Henry
 Z-lengthening of the
Tibialis Posterior & release
of sheath
 Follow to navicular
insertion
 Capsule of T-N joint
released

70. Medial tibial navicular
ligament, dorsal
talonavicular ligamnet,
and plantar
calcaneonavicular
ligament cut
Capsule of T-N cut all the
way around

71.  Bifurcated ligament cut
 Complete release of
talocalcaneal joint ligaments
except interosseous
ligaments
 Detach origin of quadratus
plantae muscle from
calcaneus
 Roll talus back into ankle
koint, if not incise post.
talofibular ligament, post.
Portion of deep deltoid
ligament

72. Line up medial side of
head and neck of talus
with medial side of
cuneiforms, medially push
calcaneus post. to ankle
joint
K wire through
talonavicular
,talocalcaneal joints

73. Check for proper position
of foot
Longitudinal plane of foot
85-90° to bimalleolar ankle
plane, heel under tibia in
slight valgus
Suture all tendons with
foot in 20° dorsiflexion
Wound closure

74. Follow up :
 Wound inspection done under sedation at 1 week
 Foot held in neutral, plantigrade position and cast
applied – above knee
 Cast kept for 4 – 6 weeks
 Cast removed along with any K wires, if applied during
surgery for stabilisation
 AFO given for 6 months

75. Residual deformities
Residual hindfoot equinus : Achilles tendon
lengthening and posterior capsulotomy of ankle and
subtalar joints
Dynamic metatarsus adductus : Transfer of anterior
tibial tendon, either as split transfer or entire tendon

76. Resistant clubfoot
 Metatarsus adductus : >5 yrs metatarsal osteototomy
 Hindfoor varus : <2-3 yrs modified Mckay procedure
3- 10 yrs
Dwyer osteotomy ( isolated heel varus)
Dilwyn Evans procedure (short medial column)
Lichtblau procedure( long lateral column)
10-12 yrs triple arthrodesis
 Equinus : Achilles tendon lengthening and posterior
capsulotomy of subtalar joint, ankle joint / Lambrinudi procedure
 All three deformities >10 yrs triple arthrodesis

77. Neglected clubfoot
No / incomplete initial treatment till the age of 2 years
Moderately flexible, moderately stiff, and rigid
Modified Ponseti*: manipulation for 5-10 mins, two weekly
cast change, correction of foot to 30-40° abduction, and
AFO for 1 year
Extensive soft tissue release upto 4 yrs
Dilwyn-Evans, Lichtblau procedure
Triple arthrodesis
Ilizarov/ JESS
 Lourenco et al . Correction of neglected club foot by ponseti method. JBJS Br. 2007

78. Bony procedures
Dwyer osteotomy
Osteotomy of calcaneus
Opening wedge medial
osteotomy to increase the
length and height of
calcaneus
For isolated heel varus
Modified method uses
lateral incisions

79. Litchblau procedure
Medial soft tissue
release
Lateral closing wedge
osteotomy of calcaneus
Prevents long term
stiffness of hindfoot
Shortens the lateral
column

80. Dilwyn Evans Osteotomy
Posteromedial release
Calcaneocuboid wedge
resection and
arthrodesis of the joint
Shortens lateral column
Stiffness at subtalar and
midfoot joints
Preferred in older
children (4-8 yrs)

81. Salvage procedures
Triple arthrodesis
Salvage procedure for pain after previous surgical
correction.
Correction of large degrees of deformity in neglected
clubfeet.
Not performed before advanced skeletal maturity, at
age 10 to 12
Lateral closing wedge osteotomy through subtalar
and midtarsal joints

83. Triple arthrodesis
Dunn arthrodesis Hoke and kite

84. Talectomy
Severe, untreated clubfoot
Previously treated clubfoot
that is uncorrectable by
any other surgical
procedures
Resistant neuromuscular
or syndromic clubfoot

85. Ilizarov
 Correction slow enough
to protect soft tissue
 Correction at the focus
of deformity
 Simultaneous three-
dimensional, multilevel
correction
 Deformity correction
without shortening the
foot

86. Results with Ilizarov
Good to excellent results reported by various
surgeons( Grill et al, Huerta et al, Bradish et al,
Heymann et al, Hosny et al) over the last 15 years
Recent long term follow-up study** by Hari et al
(2007):74% good/excellent result
**Prem: J. pediatr. orthop., Volume 27(2).March 2007.220-224

87. JOSHI EXTERNAL STABILISATION SYSTEM
DR.B.B. JOSHI, MUMBAI
2 to 4 transfixing wires in
prox tibia
Metatarsal
Transfixing wire through
I &V MT; Medial half pin
through I, II, III MT; Lat
half pin thro’ IV, V MT
2 transfixing and 1 axial
wire through calcaneum

88. JESS
Fractional, differential distraction used to Sequentially
correct deformities (Medial- 0.25 mm every 6 hours
,Lateral- 0.25 mm every 12 hours)
Distraction continued until approximately 20 degrees of
dorsiflexion and overcorrection of the forefoot deformities
was achieved
Maintained in this overcorrected position for twice as long
as the distraction phase by casts/braces

90. Results with JESS
Good or excellent results reported by Joshi in 84% of
his patients
Recommended in all who have not responded to
serial plaster casting methods.
Similar good results have been reported by other
authors**
**Suresh et al,2003. Journal of Orthopaedic Surgery 2003: 11(2): 194–201

91. Complications of surgery
 Neurovascular injury
 Loss of foot (10% have atrophic dorsalis pedis artery bundle)
 Skin dehiscence
 Wound infection
 AVN talus
 Dislocation of the navicular
 Flattening and breaking of the talar head
 Undercorrection/ Overcorrection (esp with Cincinatti)
 Forefoot adductus
 Hindfoot varus
 Severe scarring
 Stiff joints
 Weakness of the plantar flexors of the ankle

92. Conclusion
Proper understanding of the patho-anatomy a must
Ponseti method is now the standard treatment
method
Indications of surgery limited but well defined
Turco’s posteromedial soft tissue release remains the
treatment of choice in most cases amenable to
surgical treatment

93. THANK YOU