Congenital Talipes Equinovarus

(Clubfoot)

Taufan Herwindo Dewangga

Anatomy/Terminology
3 main sections
1.Hindfoot talus,
calcaneus
2.Midfoot navicular,
cuboid, cuneiforms
3.Forefoot

metatarsals and
phalanges
Anatomy/Terminology

Important joints
1. tibiotalar (ankle) plantar/dorsiflexion
2. talocalcaneal (subtalar) inversion/eversion

Important tendons
1. achilles (post calcaneus) plantar flexion
2. post tibial (navicular/cuneiform) inversion
3. ant tibial (med cuneiform/1st met) dorsiflexion
4. peroneus brevis (5th met) - eversion
 Talipes Equinovarus (congenitalclubfoot)

- talipes : Talus (bone), Pes (foot)

- The heel : inverted
- The forefoot & midfoot : inverted & adducted
(varus)
- The ankle : equinus
in utero displacement & mal alignment of the
talocalcanealnavicular & calcaneocuboid joint
Talipes Equinovarus (congenital clubfoot)
Incidency

-Varies with race & sex

-Caucasians : 1,2/1000 , : = 2 : 1
-Hawaiians : 4,9/1000
-Maori : 6,5-7,0/1000
-Bilateral : 50%, 1/3 of cases
-Unilateral : right > left
Heredity

-Genetic factors : 10%, others sporadis

-Environmental factors :
Idelberger :
Identical (Monozygotic) twins 32,5%
Fraternal (Dizygotic) twins 2,9%

Etiology

- The exact cause : unknown

1. Intrauterine Mechanical Factors

- The oldest, Hipocrates

- External mechanical forces
equinovarus
posture the ligaments, muscles,
bones
changes articular mal alignment
- Twining, high birth weight,
primiparous uterus, hidramnios
2. Neuromuscular Defect

- White, 1929 : A peroneal N. lesion

caused by
pressure at the intrauterine stage
- Middleton, 1934 : Mal development of
the
striated muscle
- Flinchum, 1953 : Muscle imbalance due
to
dysplasia of the peroneals
- Ritsila : Concluded that primary soft
tissue changes
provoking skeletal deformities
3. Arrest of Fetal Development
- Huter : Result of an arrest of development of the foot
in one of the physiologic phases of its embryonic life
Pathology

- The foot is plantar flexed at the ankle & subtalar joints,

the hindfoot is inverted & the mid and forefoot are
adducted, inverted & equinus
- Fixed contractures of the related soft tissue (the
ligaments, capsules, muscles, tendons) maintained
articular mal alignment
A. Bony Deformities

1. The Talus
- Medial & plantar deviation of the
anterior end of the talus
- declination angle : by the long axis of
the head & neck of the talus with the
long axis of its body
- Obliquity the neck of talus : medial
tilting of the anterior part of the talus
(adult : 12-32 degrees, fetus : 35-75
degrees, CTEV : 50-65 degrees)
2. The Calcaneus
- Much less deformed than the talus
- Rotated on its long axis inward &
downward
beneath the talus
- The sustentaculum tali usually
underdeveloped
& in close proximity to the medial
maleolus
3. The Forefoot & Tibia
- Smaller than normal
B. Articular Malalignments

1. Relationship of talus to distal tibia &

fibula
- The talus has no muscle attachments,
it
is stabilized by the ankle mortis
2. Relationship of navicular to talus
3. Relationship of talus to calcaneus
4. Relationship of
Calcaneus to
Cuboid bone
- The cuboid is
displace
medially in
relation to the

anterior end of
the
calcaneus
C. Soft-Tissue Changes

- The soft tissues on the medial & posterior aspect of the

foot & ankle are shorten (ligaments, capsules, muscles,
tendons, vessels, nerves, skin)
- In eversion, the navicular & anterior end of the os calcis
move laterally, in inversion they move medially
Diagnosis

Clinical picture :
- Clublike appearance
- Deep creases at the posterior aspect of the ankle joint
- Mid & forefoot are adducted, inverted & equinus
- The navicular bone abuts the anterior & medial margin
of the medial maleolus, on palpation cant insert a
finger between the two bones
Radiographic Examination
The images are hard to reproduce,
evaluate, and measure
There are several reasons for this:
(1) it is difficult to position the foot
(2) the ossific nuclei do not represent the
true shape of the mostly cartilaginous tarsal
bones
(3) in the first year of life, only the talus,
calcaneus, and metatarsals maybe ossified
(the cuboid is ossified at six months; the
cuneiforms, after one year; and the
navicular, after three years and even later)
(4) rotation distorts the measured angles
and makes the talar dome appear flattened
(Fig. 3)
(5) failure to hold the foot in the position of
best correction makes the foot look worse
than it is on the radiograph
Radiographic Examination
To optimize the radiographic
studies:
the foot should be held in the
position of best correction, with
weight-bearing
or with simulated weight-bearing
The clubfoot is bean-shaped,
and placement of the
radiographic plate medially
forces the foot to be rotated
laterally in the x-ray beam (Figs.
4-A and 4-B)
Radiographic Examination
Three measurements should be
made on the AP radiograph:
(1) the anteroposterior
talocalcaneal angle (usually <20
deg in a clubfoot)
(2) the talar-first metatarsal angle
(up to about 30 deg of valgus in a
normal foot and mild-to-severe
varus in a clubfoot)
(3) medial displacement of the
cuboid ossification center on the
axis of the calcaneus
Radiographic Assessment
-The purpose is to define precisely the anatomic
relationship of talocalcaneonavicular, tibiotalar,
midtarsal & tarso-metatarso joint
-To assess the degree of subluxation of the
talocalcaneonavicular joint & the severity of the
deformity before treatment
- To provide an accurate guide to progress during the
course of closed non operative treatment
- To assess wether reduction of the talocalcaneonavicular
dislocation & normal articular alignment have been
achieved
 Normal range of roentgenographic
angles
Talocalcaneal angle
Anteroposterior view: 30 to 55 degrees
Dorsiflexion lateral view : 25 to 50 degrees
Tibiocalcaneal angle
Stress lateral view : 10 to 40 degrees
Talo-first metatarsal angle
Anteroposterior view : 5 to 15 degrees
 Treatment
The objective :
1. To achieve reduction of the dislocation or
subluxation of the talocalcaneonavicular joint
2. To maintain the reduction
3. To restore normal articular alignment of the
tarsus & the ankle
4. To establish muscle balance between the evertors
& invertors, and the dorsiflexors & plantarflexors
5. To provide a mobile foot with normal function &
weight bearing
- Treatment should be started as soon as possible,
immediately following birth
- The first three weeks of life are the golden period,
because the ligamentous tissues are still lacks under
the influences of maternal sex hormones
- Managements extends until adolescent
Nonoperative Treatment
Hippocrates (400 BC): gentle manipulation splinting
1836, Guerin introduced the PoP cast
Thomas wrench: forceful manipulation
In 1932, Dr. Hiram Kite:
forceful manipulation & extensive surgical releases were harmful
return to gentle manipulation & cast immobilization
Nonoperative Treatment
Stretching & Manipulation
The basis: the correction of deformity through the production of
plastic (permanent) deformation (lengthening) of the
shortened ligaments & tendons
Serial manipulation & cast immobilization relies on the
viscoelastic nature of connective tissue to produce plastic
deformation through a process known as stress relaxation
Gentle stretching, which places the shortened tissues under
tension
As the foot is held in the maximally corrected position by the
cast, the tension in the shortened tissues decreases over time
Nonoperative Treatment
When the tension decreases sufficiently, more correction can be
obtained by repeating the process
The duration for which the foot needs to be stretched, the
amount of force that needs to be applied, and whether the
force should be applied continuously or intermittently are
unknown
Consequently, there is controversy regarding how much
preliminary stretching of the foot should occur before
manipulative correction of the deformity is attempted
However, all authors seem to agree that treatment should be
started as early as possible
Nonoperative Treatment
Many techniques for manipulative treatment
Success rates of <50%
2 methods (most widely performed & highest success rates): the
Kite & Lovell technique and the Ponseti technique
K&L: starts with stretching of the foot through longitudinal
traction applied to the foot
P: did not describe the use of preliminary stretching
Both: the manipulation starts with reduction of the talonavicular
joint
Newer Methods
of Nonoperative Treatment
For some time, there has been an interest in nonoperative methods that
emphasize motion and minimize immobilization
In 1937, Denis Browne introduced a technique, which was modified in 1942
by Thomson, in which the child's own "physiologic motions" were used to
correct the foot through a dynamic mechanism
The technique consisted of the application of corrective shoes that were then
attached to a bar
The attachment of the shoes to the bar allowed progressive external
rotation of the feet
While the feet were in this apparatus, the constant kicking by the infant
stretched the contracted tissues, thereby correcting the deformity
Recently, Yamamoto and Furuya reported on a series of 91 clubfeet treated
with a modified Denis Browne splint
60 feet were corrected without surgery, and good or excellent correction was
maintained at an average of six years and three months after treatment
Newer Methods
of Nonoperative Treatment
Bensahel et al. developed a non-- operative technique involving manipulation of the foot by a physical
therapist
Each manipulative session lasts thirty minutes and is followed by taping of the foot to a wooden
splint
This treatment is performed daily for up to eight months
48% of their patients had a good result

Dimeglio et al. described what would seem to be the ultimate stretching treatment for congenital
clubfoot-i.e., continuous passive motion
As with the Bensahel method, the foot is manipulated by a physical therapist for thirty minutes
After the manipulation, the foot is placed in a machine that performs stretching (continuous passive
motion)
Treatment is usually started at about two weeks of age
The machine is adjusted each day on the basis of an examination of the foot
The foot is maintained in the machine for up to eight hours each day
After each session, a splint is applied to hold the foot in the maximally corrected position until the next
day
Newer Methods
of Nonoperative Treatment
Johnston and Richards recently reported their results with what they termed the
French method.
Richards et al. found the French technique to be more effective than traditional
manipulation and immobilization in a short-leg cast

An interesting adjunct to the French technique as described by Johnston and Richards

has recently been reported. Delgado et al.
Injected Botox (botulinum toxin type A) into the gastrocnemius-soleus and
posterior tibial muscles of three infants with congenital clubfoot that had been
incompletely corrected by the French method
After the injections, additional correction was obtained with continued nonoperative
treatment
The rationale for the use of Botox appears to be that a reduction of tone in the most
contracted muscles might facilitate their lengthening by manipulative stretching
Determining whether such pharmacologic intervention is useful will require additional
study
Newer Methods
of Nonoperative Treatment
Another process that can be used to produce plastic deformation
of soft tissues is known as creep
Creep occurs when tendons and ligaments elongate as a result
of a continuous stretching
Creep can be produced by dynamic splinting, which has been
found to be helpful when used in conjunction with serial
manipulation and cast treatment
We have been unable to find reports on the use of dynamic
splinting as a primary nonoperative treatment modality
Skin irritation and, on occasion, skin breakdown may limit the
usefulness of this technique
Closed Non-Operative Method

- Elongation of the contracted soft tissues by passive

manipulation gentle with a non irritative adhesive
liquid, use gloves
- Shouldnt stretch the midfoot by forced dorsiflexion of
the forefoot rocker bottom deformity of the foot
transversed breech
- The stretched position is maintain to the count of ten,
repeated 20-30 times each session
Advantage :

- A dynamic corrective force is transmitted to the foot

- In expensive, applied easily, reapplied at frequent
intervals
- Relatively safe
- Being least likely to cause pressure sores
Closed reduction of the medial & plantar
dislocation of talocalcaneonavicular joint
- The success of reduction confirm by AP & Lat X-ray
- AP : The talocalcaneal angle should be >20, the talo-
first metatarsal angle <15
- Lat : The talocalcaneal angle should be 30-45
Retention of reduction

- Above knee cast to maintain the reduction

- Three persons
- The cast should extend from the toes to the groin with
the knee flexed at 60-80 to control the heel & prevent
the cast from slipping
- Proper & carefull molding of the cast : calcaneocuboid
area, back of the heel, the midtarsal joint area to
prevent a rocker bottom deformity
- The cast is change at 2-3
weeks
- intervals 3 months
polypropylene above knee
splint (hold the hindfoot in 15-
20 of eversion, the midfoot &
forefoot in 20 of abduction, the
ankle at 0-5 of dorsiflexion,
the knee flexed 60) the splint
is worn only at night & at nap
times
- A pre walker clubfoot shoes is worn during
the day
- When the child begins to walk wear
outflare (tarsal pronator ) shoes, with outer
lateral side heel & sole wedges to
encourage walking in eversion & abduction
- X-ray periodically, if there is no reccurents
of deformity after 2 years normal shoes
Operative Treatment
Despite our best efforts, some clubfeet cannot be completely corrected with nonoperative
treatment
In such feet, soft-tissue release is clearly indicated

Preoperative Assessment
All clubfeet are not the same
Therefore, it is important to assess the foot carefully to determine the components of the
deformity that remain
Once that has been done, the surgeon must think about what anatomical structures
contribute to each component of the deformity
Obviously, those are the structures that need to be addressed at the time of surgery
A foot in which all components of the deformity are still present likely requires a full
posteromedial plantar lateral release
If the clinical examination indicates a flexible forefoot and midfoot with a straight lateral border
and a palpable interval between the tuberosity of the navicular and the medial malleolus but a
persistent equinus, then a posterior release may be all that is needed
Operative Treatment
Age
Most surgeons have one of two opinions concerning the optimum age at which
surgery should be performed
Advocates of "early" treatment perform the surgery when the patient is between 3 and
6 months of age
They argue that there is a great deal of growth in the foot, and therefore a lot of
remodeling potential, during the first year of life
In contrast, advocates of "late" treatment prefer to wait until the child is 9 to 12
months of age
They believe that, because the components of the foot are larger, the pathoanatomy is
more obvious and the surgery is easier to perform
Also, because the child is old enough to walk, early weight-bearing may help to prevent
recurrence of deformity
Simons recommended that the size of the foot, rather than the age of the patient, be
used to determine the optimum time to perform the surgery
He stated that the foot should be >=8 cm long at the time of surgery
Operative Treatment
Incisions
Incisions fall into 1 of 3 categories:
the Turco oblique or hockey-stick posteromedial type of incision
the circumferential incision, more commonly referred to as the Cincinnati incision
the two-incision or Carroll approach
Each has its own limitations

The Turco incision crosses the skin creases on the medial side of the foot and ankle
It is certainly more difficult to reach the posterolateral structures, such as the talofibular
and calcaneofibular ligaments, through this incision
The origin of the plantar fascia may also be a challenge to expose and release

The Cincinnati incision has the potential for creating problems with the skin edges
It has also been criticized for limited exposure of the Achilles tendon

The criticism of the Carroll approach is that it can limit the correction of the equinus and/or
varus deformity because of the posteromedial skin tether
Operative Treatment
Operative Treatment
Identify and preserve the neurovascular bundle and the sural
nerve. Take care to preserve the medial calcaneal branch of
the post tibial nerve
Care must be taken handling the posterior tibial vessel as the
dorsalis pedis artery is often attenuated or absent
"Z"-lengthen tendo achilles
divide and lengthen Tibialis Posterior, FHL and FDL
Capsulotomies
ankle posteriorly
subtalar joint
calcaneocuboid joint
release plantar ligament
Operative Treatment
release abductor hallucis
release FDB
peroneal tendon sheath may need release (can release
everything except deep deltoid ligament)
repair tendons
K-wires may be passed into talus and calcaneus to hold reduction
Close skin, but release tourniquet before final skin closure
Above knee POP cast in comfortable position for skin closure
Change cast at 2-3wks for neutral postition
Retain cast for 12 weeks total
Treatment of resistant
clubfoot
Metatarsus adductus
>5yr : metatarsal osteotomy
Hindfoot varus
<2-3yr : modified McKay procedure
3-10yr :
Dwyer osteotomy (isolated heel varus)
Dillwyn-Evans proc (short medial column)
Lichtblau proc (long lateral column)

10-12yr : triple arthrodesis

 Equinus
Tendo calcaneus lengthening plus posterior
capsulotomy of subtalar joint, ankle joint (mild
to moderate deformity)
Lambrinudi procedure (severe deformity,
skeletal immaturity)
All three deformities :
>10yr : triple arthrodesis