1. Congenital Clubfoot (Congenital Talipes Equino-Varus)
dr n. med. Dariusz Mątewski

2. THE NORMAL FOOT Complex organ that is required to be
Stable: for supporting the body weight during standing
Resilient: for walking and running
Mobile:  to accommodate variations of surface
Cosmetic

3. FOOT ABNORMALITIES Definitions Talipes: Talus = ankle Pes = foot
Equinus: (Latin = horse)
Foot that is in a position of
plantar flexion at the ankle,
Calcaneus: Full dorsiflexion at the ankle

4. FOOT ABNORMALITIES Planus: flatfoot Cavus: highly arched foot
Varus: heel going towards
the midline
Valgus: heel going away
from the midline
Adduction: forefoot going
towards the midline
Abduction: forefoot going away
From the midline
Forefoot
Hind foot

5. CONGENITAL CLUBFOOT
Substantial deformity of the foot, which gives its stunted lumpy appearance
In the full-blown equinovarus deformity the heel is in equinus, the entire hindfoot in varus and the mid and forefoot adducted and supinated.
In the full-blown equinovarus deformity the heel is in equinus, the entire hindfoot in varus and the mid and forefoot adducted and supinated.

6. CONGENITAL TALIPES Types Postural : Equino-Varus Calcaneo-Valgus
Minor and correctable Look for DDH

7. CONGENITAL CLUBFOOT Types Idiopathic: Teratologic:
Acquired, Secondary to :
CNS Disease : Spina bifida, Poliomyelitis
Arthrogryposis
Bone Defect : fibula / tibia

8. CONGENITAL CLUBFOOT Congenital clubfoot (CTEV) occurs
typically in an otherwise normal child.

9. CONGENITAL CLUBFOOT Etiology Multifactorial Polygenic
although many of these factors are speculative

10. CONGENITAL CLUBFOOT Etiology Some of these factors are :
Histologic anomalies in connective tissue
Abnormal muscle and tendon insertions
Vascular anomalies
Abnormal intrauterine forces
Germ defects
Arrested fetal development

11. CONGENITAL CLUBFOOT Incidence
Occurs approximately in 1-2 of every 1000 live birth
In affected families, clubfeet are about 30 times more frequent in offspring
Male are affected in about 65% of cases
Bilateral cases are as high as 30 – 40 %

12. Geographic Distribution
CONGENITAL CLUBFOOT
Geographic Distribution
White race (caucasian)
Mediterranean Coast & North Africa

13. CONGENITAL CLUBFOOT Basic Pathology EGG & CHICKEN
Abnormal Tarsal Relation
Congenital Dislocation / Subluxation
Talo Calcaneo Navicular Joint
Soft Tissue Contracture
Congenital Atresia
EGG & CHICKEN

14. CONGENITAL CLUBFOOT
The neck of the talus points downwards and deviates medially, whereas the body is rotated slightly outwards in relation to both the calcaneum and the ankle mortise (Herzenberg et al., 1988). The posterior part of the calcaneum is held close to the fibula by a tight calcaneo-fibular ligament, and is tilted into equinus and varus; it is also rotated medially beneath the ankle. The navicular and entire forefoot are shifted medially and rotated into supination (the composite varus deformity).
The neck of the talus points downwards and deviates medially.
The posterior part of the calcaneum is held close to the fibula by a tight calcaneo-fibular ligament, and is tilted into equinus and varus;
The navicular and entire forefoot are shifted medially and rotated into supination (the composite varus deformity).

15. CONGENITAL CLUBFOOT Adaptive Changes Wolff’s Law Davis Law
“ Every change in the use of static function of bone caused a change in the internal form or architecture as well as alteration in its external formation and function according to mechanical law ”
Davis Law
“ When ligaments and soft tissue are in loose or lax state; they gradually shorten ”

16. CONGENITAL CLUBFOOT Adaptive Changes Soft Tissue : Bony :
Change in the shape of tarsal and metatarsal
bones especially after walking
Soft Tissue :
Shortening ? Contracture in the Concave Side
1- Muscles Tendons
3- Ligaments Joints Capsule
5- Skin Nerves & Vessels

17. CONGENITAL CLUBFOOT Diagnosis General Examination :
Exclude
Neurological lesion that can cause the deformity “Spina Bifida”
Other abnormalities that can explain the deformity “Arthrogryposis, Myelodysplasia”
Presence of concomitant congenital anomalies
“Proximal femoral focal deficiency”
Syndromatic clubfoot
“Larsen’s syndrome, Amniotic band Syndrome”

18. CONGENITAL CLUBFOOT
Diagnosis
Spina Bifida = Paralytic TEV

19. CONGENITAL CLUBFOOT Diagnosis Characteristic Deformity : Hindfoot
Equinus (Ankle joint)
Varus (Subtalar joint)
Forefoot
Supination (Forefoot)
Adduction (Lisfranc joint)
Cavus
The neck of the talus points downwards and deviates medially, whereas the body is rotated slightly outwards in relation to both the calcaneum and the ankle mortise (Herzenberg et al., 1988). The posterior part of the calcaneum is held close to the fibula by a tight calcaneo-fibular ligament, and is tilted into equinus and varus; it is also rotated medially beneath the ankle. The navicular and entire forefoot are shifted medially and rotated into supination (the composite varus deformity).

20. CONGENITAL CLUBFOOT Diagnosis
The deformity is usually obvious at birth; the foot is both turned and twisted inwards so that the sole faces posteromedially. More precisely, the ankle is in equinus, the heel is inverted and the forefoot is adducted and supinated; sometimes the foot also has a high medial arch (cavus), and the talus may protrude on
the dorsolateral surface of the foot. The heel is usually small and high, and deep creases appear posteriorly and medially; some of these creases are ncomplete
constriction bands. In some cases the calf is abnormally thin.
the foot is both turned and twisted inwards so that the sole faces posteromedially.

21. CONGENITAL CLUBFOOT Diagnosis
More precisely, the ankle is in equinus, the heel is inverted and the forefoot is adducted and supinated; sometimes the foot also has a high medial arch (cavus), and the talus may protrude on the dorsolateral surface of the foot. The heel is usually small and high, and deep creases appear posteriorly and medially; some of these creases are ncomplete constriction bands. In some cases the calf is abnormally thin.
Hindfoot Forefoot
Equinus, Varus Adduction, Supination, Cavus
the ankle is in equinus, the heel is inverted and the forefoot is adducted and supinated

22. CONGENITAL CLUBFOOT
Diagnosis

23. CONGENITAL CLUBFOOT Diagnosis Short Achilles tendon
High and small heel
No creases behind heel
Abnormal crease in middle of the foot
Foot is smaller in unilateral affection
Callosities at abnormal pressure areas
Internal torsion of the leg
Calf muscles wasting
Deformities don’t prevent walking

24. CONGENITAL CLUBFOOT
Diagnosis

25. CONGENITAL CLUBFOOT Diagnosis
X-Ray needed to assess progress of treatment

26. CONGENITAL CLUBFOOT Treatment
The goal of treatment of clubfoot is to obtain a plantigrade foot that is functional, painless, and stable over time
A cosmetically pleasing appearance
is also an important goal sought by
the surgeon and the family

27. CONGENITAL CLUBFOOT Treatment
Non surgical treatment should begin shortly after birth
Gentle manipulation
Immobilization
- Strapping ????
- POP or synthetic cast

28. CONGENITAL CLUBFOOT Treatment
Non surgical treatment should begin shortly after birth
Gentle manipulation
Immobilization
- Strapping ????
- POP or synthetic cast

29. CONGENITAL CLUBFOOT Treatment
Non surgical treatment should begin shortly after birth
Splints to maintain correction
- Dennis Brown splint
- Ankle-foot orthosis ????

30. Manipulation and serial casts
CONGENITAL CLUBFOOT
Treatment
Manipulation and serial casts
Validity, up to 6 months !
Technique “Ponseti”
Avoid false correction
When to stop ?
Maintaining the correction
Follow up to watch and avoid recurrence

31. CONGENITAL CLUBFOOT Treatment Ponseti technique
Always use long leg casts, change weekly.
First manipulation raises the 1st metatarsal to decrease the cavus
All subsequent manipulations include pure abduction of forefoot with counter-pressure on neck of talus.
Never pronate !
Never put counter pressure on calcaneus or cuboid.

32. Ponseti technique (cont.)
CONGENITAL CLUBFOOT
Treatment
Ponseti technique (cont.)
Cast until there is about 60 degrees of external rotation (about 4-6 casts)
Percutaneous tendo Achilles tenotomy in cast room under local anesthesia, followed by final cast (3 weeks)
After final cast removal, apply Normal last shoes with Denis Browne bar set at 70 degrees external rotation (40 degrees on normal side)
Denis Browne splint full time for two months, then night time only for two-four years.
35% need Anterior Tibialis tendon transfer at age 2-3

33. Ponseti technique

34. CONGENITAL CLUBFOOT Surgical Treatment Indications
Late presentation, after 6 months of age !
Complementary to conservative treatment
Failure of conservative treatment
Residual deformities after conservative treatment
Recurrence after conservative treatment

35. CONGENITAL CLUBFOOT Surgical Treatment
Types (soft tissue and bony operations)
Time of surgery
Selection of the procedure and the incision
Post operative care
Follow up
Complications

36. CONGENITAL CLUBFOOT Surgical Treatment Soft tissue operations
Release of contractures
Tenotomy
Tendon elongation
Tendon transfer
Restoration of normal bony relationship

37. CONGENITAL CLUBFOOT
Surgical Treatment

38. CONGENITAL CLUBFOOT
Surgical Treatment

39. CONGENITAL CLUBFOOT Surgical Treatment Bony operations Indications
Usually accompanied with soft tissue operation
Types:
- Osteotomy, to correct foot deformity or int. tibial torsion
- Wedge excision
- Arthrodesis (usually after bone maturity)
one or several joints
- Salvage operation to restore shape

40. CONGENITAL CLUBFOOT
Surgical Treatment

41. CONGENITAL CLUBFOOT
Surgical Treatment

42. Late complication