2. Definition
Twisting of the scaphoid, os calcis and
cuboid around the astragalus
Congenital Talipes Equino Varus or club foot
has 4 basic deformation:
1. fore foot : adduction
2. hind foot : inversion or varus
3. hind foot : equinus
4. mid foot : cavus
3. Incidence : - (1-2) per 1000 births
- male : female = 7:5
- 50% bilateral
Incidence : of CTEV in various races
Race Cases per
thousand birth
Chinese 0.39
Japanese 0.53
Malay 0.68
Filipino 0.76
Caucasian 1.12
Puerto Rican 1.36
Indian 1.51
South African black 3.50
Polynesian 6.81
Tachjian, The child foot
7. ETIOLOGY
Otogenic theory (arrest theory)
arrest of development
related to a change in genetic factor known as “cronon”
Cronon : guide the precise time of the progressive
modification every structure during development
10. Schematic illustration of the critical periods in human development. During the first two weeks development, of the embryo is
usually not susceptible to teratogens. During these pre-embryonic stages, a teratogen either damages all or most of the cells,
resulting in its death, or damages only a few cells, allowing the conceptus to recover and the embryo to develop without birth
defects. Red denotes highly sensitive periods when major defects may be produced (e.g. amelia, absence of limbs). Yellow
indicates stages that are less sensitive to teratogens when minor defects may be induced (e.g. hypoplastic thumbs)
11. Etiology
- chromosomal theory
polygenic (multi factorial)
- defect in unfertilized
germ cell :
- in family
- race (palynesia-Maori)
Week
TERM3012850
- Embryonic theory
(0-12) weeks
defect occurs during
fertilized germ cell
Otogenic theory -- arrest theory
- Cronon : genetic factor which
determine the precise time for
progression modification during
development
- Cronon may be changed by certain
element (teratogen) abnormal
development of the limb
- growth arrest : permanent, temporair,
slowed growth permanent deformity
temporary CTEV, slow – steroid
- occur during (7-8) week marked CTEV
- occur during (9-12) week moderate
to mild CTEV
Specification defect (Hoofnick)
limb specification at 5 month (teratogen)
- neuromuscular
- vascular
- bone
CTEV : post
specification defect
primary muscle
abnormality?
Intra uterine pressure
(packing syndrome)
20
Ponseti : genetic, embryonic malformation, collagen
over production in ligament, collagen
fibres wavy arranged, dense, many cells
12. PATHOANATOMY
Major deformity
• Inward rotation of the whole foot on the talus
Rotation primarily takes place in :
• talocalcaneal joint
• talonavicular joint
• calcaneocuboid joint
17. Pathomechanics of talipes
equinovarus
A. Posterolateral view of the
calcaneus and talus of normal foot. B.
Lateral rotation of the talus, C. The
anterior part of the calcaneus is
pressed by the head of the talus and
forced into plantar
flexion, rotation, and varus position.
(From Carroll, N., Murphy, R, and
Leete, S.F. : The pathoanatomy of
congenital clubfoot, Orthop.Clin.N.
Amer., 9 : 227, 1978)
22. PATHOANATOMY
Calcaneo-cuboid joint:
Cuboid displaced medially on calcaneus and under navicular &
cuneiform
All ligaments : contracted
Forefoot : supination and adduction
Calcaneo-cuboid joint corrected nicely if other 2 subtalar
complex are corrected except in resistant CTEV
23. PATHOANATOMY
Muscles
Imbalance between agonist and antagonist
Muscles tonus determined by the amount of muscle
fibres type I & II
All muscle below knee in CTEV fibre Type I > II [similar
with L.M.N lesion : AMC, sacral agenesis, Charcot-
Marie, post poliomyelitis]
Some CTEV tendency to be recurrent
24. PATHOANATOMY
Vascular
By Doppler Technique :
In normal population : a.dorsalis pedis 2.2.% absent
In mild & moderate CTEV : a.dorsalis pedis = normal
In severe CTEV : a.dorsalis pedis = 6.7% absent
25. MECHANISM of the CTEV
Fetal posture abnormality :
foot in equinovarus
Muscle imbalance : tib.
post. contracted
Factors determine the
severity of the CTEV
Intrauterine position. The hips are always
flexed and externally rotated, while the knees
are usually flexed and the feet turned inward
33. Radiology : age more than (4-5) months
N : AP : talo-calcaneal angle :
(200-400), CTEV < 200
Lat : talo-calcaneal angle :
(350-500), CTEV<350
34. DIAGNOSIS
1. Non rigid type (packing syndrome)
2. Rigid type :
• Moderate
• Severe
3. Resistance rigid type :
• AMC
• Myelomeningocele
• Constriction band
42. TREATMENT
The goal of treatment :
• Realign the os calcis, scaphoid and cuboid
around the astragalus by correcting the varus,
adduction, varus and equinus
• Maintain the correction until stable
normal function, no pain, plantigrade, good
mobility, no callus formation, wearing normal
shoe
43. HISTORY
Egyptian : tomb painting
India (1.000 BC) : Tx
Hippocrates (400 BC) : manipulative Tx,
early Tx
Indian (Aztecs) Pre Columbian American
Tx : splint with cactus leaves
44. HISTORY : 20th century
Hugh Owen Thomas (1834 -1891)
Wrench
48. Conservative treatment
Golden period:
• 1st week
• laxity :estrogen
1. Serial plastering
2. Stretching Dennis Brown splint
3. Adhesive strapping
4. Physiotherapy
49. HIRAM KITE :
Brought Hippocrates’ view info focus :
Stressing slow, gentle, manipulative correction of
the adduction, varus and equinus with minimal
surgery
Three magic words for the successful and
enthusiasm carrying out his
treatment : knowledge,patience andenthusiasm
52. Ponseti
Based on kinematic of the subtalar joint.
1st concept : the whole foot moves under the talus “calcaneo-
pedis block”
2nd concept : fore foot and hind foot are corrected
simultaneously by abduction
Equinus correction :
• mostly close tenotomy
• tendo achilles non stretchable collagen, thick and
stiff
53. COMPARISON KITE and PONSETI treatment
Clubfoot
1. Adduction
2. Varus
3. Equinus
KITE
Fulcrum : calcaneo cuboid
Correction by serial plastering :
PONSETI
1. Adduction Abduction
2. Varus valgus
4 Cavus and pronation
Rigid 3 Equinus
tenotomy
Fulcrum : head talus
Correction by serial plastering :
Surgery no yes
plastering
(10-11) months Shoe
Denis-Brown
splint
(3-4) years Evaluation
3 Equinus Rigid
close tenotomy 90%
12 weeks
no =5% yes=95% Surgery
plastering
Shoe
splint
(3-4) years Evaluation
4. Cavus and pronation (realign cavus by supination)
to “unlock” subtalar movement
1. Adduction Abduction 600-750
2. Varus : will be corrected by 4 & 1
6 weeks
54. Abduction of fore foot in pronation the cavus becomes more severe, calcaneus
locked (jammed) under the head of talus; mid foot and forefoot are twisted eversion
Kite
Clubfoot correction
56. Calcaneo-cuboid is used as fulcrum which is pressed medial ward while fore foot
is moved lateral ward (abduction); calcaneus will not move lateral ward (no
abduction) that is why the varus will not be corrected; only naviculare and fore foot
will move lateral ward. To press the posterior part of calcaneus to correct varus is
a big mistake
Kite
57. Clubfoot correction
a. realign cavus : forefoot supinated (3,4)
b. fulcrum : caput tali – stabilisator (5)
c. forefoot in supination – abduction (6)
d. maximal abduction of forefoot (7)
e. dorso flexion of the ankle (+TAL)
Process of a,b,c,d (5-6) x each (5-7) days.
Plaster cast above knee (groin), knee
flexion 900
Ponseti
60. TAL
After 6x plastering
TAL (close), local anaesthesia
Plaster 3 weeks
bracing for 3 months (24hours)
(2-4) hours day time, 12 hours at
nigh
(3-4) years night splint
Ponseti success = 90%
69. Common errors
1. Forefoot still in pronation
during correction of
adduction to abduction
2. Not using head of talus
as fulcrum
3. Calcaneus is pressed
lateral ward to correct
varus
4. Equinus is corrected
before adduction and
varus are corrected
Rocker bottom foot
5. Plaster immobilisation
below knee
89. Surgical complication
1. Infection
2. Bad scar
3. Stiff joint
4. Over/under correction
5. Navicular dislocation
6. Flattening or beaking talar head
7. Talar necrosis
8. Weakening of the muscles
9. Skew foot (severe valgus of the heel and adduction
of the fore foot)
10. Main artery injury foot necrosis
