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CONGENITAL TALIPES EQUINUS VARUS


Abstract:
Talipes equinus varus or clubfoot is the most common congenital orthopaedic
anomaly seen in pediatric orthopaedic clinics. The etiology and pathological anatomy
are still controversial. Diagnosis can be easily made when the child presents to the
clinic. Initial treatment consists of non-operative intervention and surgical options are
reserved for those that failed conservative treatment.
Case Report:
A 9-month-old boy presented to our clinic with deformity in both his feet since birth.
Birth history was uneventful .He was born as a full term normal vaginal delivery. His
milestones were generally normal .His speech was normal. On examination, he was
adequately built for his age and height. There was no other congenital anomaly
detected .His spine was normal .The muscle tone of his upper and lower limb were
normal. Hip examination revealed no dislocation or subluxation. Examination of his
feet revealed a gross deformity .The right and left foot were in adduction, varus and
equinus position. There was a prominent medial transverse crease line on both foot
.On attempting to correct the deformity; it was noted to be rigidly fixed. Ankle
dorsiflexion was less than 10 degrees and both feet were in severe equinus.
Xray of both feet were taken in the anterior-posterior and lateral views. On anteriorposterior view, the talo-calcaneal angle of the left foot was 15degrees as compared to
17 degrees on the right, the talo-first metatarsal angle was minus 10 degrees on the
left and minus 8 degrees on the right and the vertical talo-first metatarsal angle on
lateral view was 140 degrees on the left and 135 degrees on the right.
A diagnosis of bilateral congenital talipes equinus varus (CTEV) and the patient was
planned for bilateral posterior medial and lateral release using the Turco method. In

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our patient conservative method like manual correction with application of serial
corrective cast or special foot wear was not tried because his deformity was rigidly
fixed. An attempt to correct the deformity manually was not successful.
Under general anaesthesia and tourniquet control, the child was placed in a prone
position. Both feet were operated on simultaneously by two teams. Using the posterior
lateral incision starting from the distal half of the calf the incision was extended to
below the lateral malleolus and then distally to the calcaneocuboid joint .The short
saphenous vein and sural nerve were preserved during the dissection and the tendon
sheath of the peronei was opened and retracted after incising the extensor
retinaculum. The posterior talofibular ligament and the calcaneofibular ligament were
then incised. The lateral part of the ankle and subtalar joint capsule were sectioned as
were the calcaneocuboid ligament and capsule. Next a posterior medial release was
done. A curvilinear incision was made extending from the base of the 1 st metatarsal to
the medial malleolus and then ascending proximally and posteriorly to the center of
the distal third of the calf.
The neurovascular bundle were preserved and the dissection was continued till the
flexor tendon were exposed .The tendocalcaneus sheath was opened and a Z plasty
was preformed The tendon sheath of the flexor hallucis longus (FHL) and flexor
digitorum longus (FDL) were opened and followed till the master knot of Henry. A Z
plasty of both the tendon and the tibialis posterior (TP) tendon was then preformed.
The posterior capsule of the ankle and subtalar joint were incised and the joints
exposed .The deltoid ligament was sectioned except the anterior and deep parts. The
interrossei ligament was also preserved .The spring ligament, plantar aponeurosis and
taolnavicular joint capsule were also released .The foot was then manipulated into a
reduced position and the Z plasty was completed. Hemostasis was secured and the
subdermal layer was closed with vicryl 3/0 and the skin with subcuticular sutures.
Both the feet were placed in a below knee cast and held in a reduced position with the
ankle joint in neutral position.

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The child was discharged on the second post-operative day and the cast was planned
for 6 weeks. When seen at 2 weeks postoperative, there was no loosening of the cast
or cast damage. The cast was removed and a new cast was applied for another 4
weeks. At 6 weeks, the cast was removed and the correction was maintained. He was
put on ankle- foot orthosis during nighttime and was made told to do so for about 1-2
years.
Discussion:
CTEV or clubfoot is not an uncommon condition. It was first mentioned in 400 BC by
Hippocrates. The incidence is about 1:1000 live births and is even higher in first
degree relatives being 2.4:1000 live births .It is seen more commonly in boys than
girls, the ratio being 2:1.It has been associated with autosomal dominant inheritance
pattern, autosomal recessive and X linked recessive inheritance pattern. The etiology
of clubfoot is unknown several theories have been postulated which include germplast
defect, developmental arrest theory and fetal theory. Handelsman and Badalamente
(cited in Cumming, 1988) in their study of muscle biopsy specimen taken from
clubfoot pateints found presence of ultrastructural abnormalities and concluded that
neurogenic disorder could be a pathogenesis in clubfoot. Myogenic theory postulates
that the primary defect is in the muscle, as evident by calf atrophy in all clubfoot
patients. Developmental arrest theory put forward by Bohm 4, suggest that arrest of
embryogenic development during the first few weeks of life could cause clubfoot.
This is due to the fact that the foot during this period is in the position of adduction.
Embryological review of anatomy of fetus with clubfoot by Waisbrod showed 2
striking features. The talus was found to be smaller, the body less developed with a
thinner and longer neck and pointed head. The declination angle i.e., head body angle
was less than normal in those with clubfoot as compared with normal foot which was
between 150 to 160 degrees.13
In CTEV, the forefoot is adducted and the hindfoot is in varus angulation .The entire
talus is in equinus. The navicular is displaced medially as is the cuboid .The os calcis

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is also in equinus .The cavus deformity of the foot is the result of contractures present
in the palmar aponeurosis, abductor hallucis and flexor digitorum brevis.

4,9

Mc Kay

in 1982 reported on the notion in clubfoot that the talocrural, talocalcaneal,


talonavicular and calcanealcuboid joints are subluxed or dislocated are not true, rather
they are fixed in extremes of equinus and inversion. He believed that major deformity
in clubfoot is the inward rotation of the whole foot on the talus involving mainly the
talocalcaneal, talonavicular and the calcanealcuboid joints .In the talocalcaneal joint,
there is not only horizontal rotation of the calcaneus around the interosseous ligament
but also rotation around the coronal plane. As a result not only the heel tips into varus
position, the calcaneal fibular, posterior talocalcaneal ligaments, superior peroneal
retinaculum and the peroneal tendon sheath become shortened and thickened. 10
In the talonavicular joint , the navicular has moved around the most medial and
plantar side of the talus head .As a result , the cartilage on the lateral aspect of the
talus head atrophies and results in growth of the talus in the medial and plantar
direction .Structures that resists realignment of the joint are posterior tibial tendon ,
deltoid ligament , spring ligament, entire talonavicular ligament ,bifurcate ligament ,
inferior extensor ligament and cubonavicular ligament.
In the calcanealcuboid joint, the cuboid is displaced medially on the calcaneus and
under the navicular and cuneiform bones .As internal rotation continues, the bifurcate
ligament, the long plantar ligament, plantar calcanealcuboid ligament, navicular
cuboid ligament, inferior extensor retinaculum, dorsal calcanealcuboid ligament all
get contracted causing supination in the midfoot and adduction of the forefoot.
Classification of clubfoot is related to its severity of involvement. In assessing the
interobserver reliability of clubfoot classification, Flynn et al concluded from their
study using the Pirani et al and Dimeglio et al classification, that both types of
classification had good interobserver reliability 6. However the most widely used
classification system is the Dimeglio system, which is graded as
1)

postural or mild clubfoot

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2)

moderate clubfoot

3)

severe clubfoot

4)

very severe or defiant clubfoot

In the postural type, which is uncommon, the foot can be corrected passively with
little difficulty .The moderate type, which is the largest is fairly supple, transverse
crease is absent and the heel is definable. The severe clubfoot is less common and
almost always requires surgery .The foot is short, exhibits a transverse crease and has
tight skin .The defiant foot is one which there is difficulty in palpating the calcaneus
Catterall on the other hand had also classified clinical types of CTEV. They are
divided into either
i)

postural resolving - where there is no fixed deformity

ii)

tendon contracture type - no fixed deformity in the midtarsus or forefoot


but tight structures are present posteriorly

iii)

joint contracture type - there is fixed deformity in both forefoot and


hindfoot

Diagnosis is one of clinical. Management includes investigation and treatment of the


deformity. Investigation includes x-ray of the foot in anterior posterior and lateral
view while standing and a lateral view in maximum dorsiflexion.

13

The anterior

posterior radiographs are taken with the beam at 30 degrees to the vertical. This view
allows for measurement of the talocalcaneal and talo-firstmetatarsal angles. The
talocalcaneal angle which is the angle between the long axis of the talus and calcaneal
is an index of varus deformity .The talo-first metatarsal angle which is the angle
between the long axis of the talus and the first metatarsal is an index of adduction
deformity.
On the lateral view in maximum dorsiflexion, the tibiocalcaneal angle measures the
index of equinus deformity and from lateral standing radiograph the vertical talo-first
metatarsal angle measures index of cavus deformity.

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The choice of treatment of clubfoot still remains controversial. All associated


disorders should be treated otherwise recurrence is common. Most surgeons agree that
initial treatment should be non-operative even with a severe deformed foot, which is
less likely to respond to non-operative treatment.
The more common non-operative method is by gentle manipulation or realignment of
the foot followed by application of a series of carefully molded corrective plaster
cast .30% to 50% of foot treated by this method eventually need surgical correction.

The plaster cast is used to maintain the position of correction but not to produce the
correction .The principle of correction is to correct the forefoot adduction and varus
then correction of hindfoot supination and lastly correction of equinus
Technique for correcting the deformity include applying force on the lateral side of
the talus head, then traction is applied to the 1st ray to stretch the tibialis posterior
tendon and correct the forefoot adduction and supination. Next the talonavicular joint
is reduced by observing the navicular drawing away from the medial malleolus. Once
this is done, the equinus can be corrected by pushing upon the front of the calcaneus
and pulling the calcaneus down and away from the fibula.

The plaster is then

applied to maintain the reduction .It is important to correct all elements of the
deformity because failure to correct any of it will require operative intervention. Once
cast is applied, it is repeated weekly till the deformity is corrected. Some surgeons
prefer to overcorrect the deformity slightly as they believe that the foot will usually
tend to revert slightly to its previous deformity .If good correction cannot be obtained
at the end of 3 months, it is unlikely that non-operative treatment will be successful
.On the other hand if correction is achieved, it is maintained by having the child to
wear on ankle foot orthosis (AFO) during his unattended hours at the same time
exercising the foot and ankle regularly to prevent stiffness and maintain ankle
motion .This is continued for many months to years .Other forms of non-operative
treatment include adhesive strapping , taping on a Denis Brown splint , orthosis and
special foot wear .Denis Brown splint has been used since 1931. Brown initially used
the splint to maintain either partial or total correction after manipulation to give the

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foot a normal range of movement and position of rest .But this resulted in difficulty to
hold the hindfoot and to correct the equinus deformity .Hence Thopmson modified
this and applying his principle that the deformity should be allowed to correct by the
infants own kicking and hence evolved the use of modified Denis Brown splints . It
works on the principle that when one leg extends , the other flexes in the splint and
the foot of the flexed side is forced into dorsiflexion , abduction and eversion (cited
in Yamamoto , 1990) . Further Yamamoto et al modified the Denis Brown splint
using Thompson principle and used it to treat 91 infants with clubfoot. 14
They replaced footplates or shoes by plastic shoes made from molding plastic sheets
over a corrected cast and held it to a cross bar at an angle of 25degree to 75 degrees
as apposed to the Denis Brown splints where the shoes are held at 70 degrees of
external rotation . They believe that as the angle increases, the calcaneum is abducted
and by fitting it to a corrected cast, the forefoot adduction and together with the
displaced navicular acts effectively when the child kicks.

In assessing clubfoot

correction, Laaveg et al found that the lateral talocalcaneal angle to be a more


accurate indicator 7.
The timing for operative surgery remains controversial. Most surgeons agree that it
should be done within the first year of life approximately 4 to 6 months of age. 4 The
reason being that there is a lot of growth in the foot during the first year of life and
hence if the bony architecture is properly aligned, there is great potential to remodel
and congruent development of the foot. Levin et al also reported better result in those
that were operated before one year of age.

Before 4 months it is not advisable to

operate because the foot during this period has abundant fatty tissue and the bones are
small and cartilaginous.
Surgical procedures currently used to treat clubfoot can be divided into 3 basic
groups 14;
i)

those that involve soft tissue

ii)

those that involve bone

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iii)

combined soft tissue and bony procedure

The principle of surgery is to correct the bony architecture of the foot and to balance
the muscle forces so that the correction obtained at surgery will be maintained as the
child grow. Soft tissue procedure consists of either release or lengthening of tight
deforming soft tissue structures like ligaments, joint capsules and tendon as well as
tendon transfer. Tendon transfer are only done after all fixed deformities are corrected.
Release procedures commonly done are the posterior release, posterolateral release ,
posteromedial release , combination of both or circumferential release.3,4,5,11
Posterior release must not be done until the adduction of the forefoot and varus
deformity of the heel has been completely corrected. Posterior release can be done by
using a posterior lateral incision which consists of an oblique incision running down
from the midline of distal calf posteriorly to a point midway between the
tendocalcaneus and lateral malleolus .A complete release consists of lengthening of
tendocalcaneus , posterior capsulotomy of the tibiotalar and subtalar joint , sectioning
the posterior talofibular ligament and the calcaneofibular ligament . These structures
must be released to permit normal excursion of the fibula and dorsiflexion of the
talus .
The posteromedial release or Turco procedure was introduced in 1978 by Turco and is
widely used nowadays.

3,4

The aim of this procedure is to excise or release all of the

pathologically contracted soft tissue that prevents the complete correction of the
deformity .It involves Z plasty of the tendocalcaneus, tenotomy of the tibialis
posterior tendon, Z plasty of the FHL and FDL tendons, plantar fascia release,
capsulotomy of talonavicular, subtalar and calcaneocuboid joints including the
naviculocuneiform and cuneiform metatarsal joints, sectioning the talocalcaneal
interroseous ligament, deltoid ligament, spring ligament and the naviculocuneiform
ligaments. Once corrected alignment is achieved, it can be maintained with 1 or 2 Kwires.

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Levin et al reported on the in their study on long-term follow up of patients who with
posteromedial release before one year of age, had better results than other method of
release and similarly less post operative stiffness . 9 Among the drawback are that the
incision crosses the medial skin crease , exposure of the plantar fascia is difficult and
difficult to see structures in the posterolateral aspect of the foot .
Another release which is gaining popularity is the circumferential one stage subtalar
release as described by Mc Kay. 4 Using a circumferential or Cincinnati incision, soft
tissue release of the posterior, medial, lateral and plantar aspect are done. It was
designed to correct the horizontal subtalar rotation of the calcaneum. Mc Kay also
showed that this procedure alone not only markedly improve ankle motion but further
improvement of ankle motion can be obtained when this procedure is combined with
sheath recession and hinge cast brace .11
In a study carried out by Flugstad and Staheli (cited in Cummings, 1988) comparing
Turco one stage posteromedial release and Mc Kay one stage circumferential release,
they concluded that Mc Kay s one stage procedure showed better outcome in terms
of correction of deformity, range of ankle motion and fewer complications.
Circumferential subtalar release described by Simon differ from that of Mc Kay in
that in the former, there is in addition the release of interroseous talocalcaneal
ligament as well as posterior talofibular ligament aiding in better correction of the
deformity.

3,4

Mc Kay did not advocate releasing the structures because he thought

that it lead to subtalar instability with a valgus heel resulting in poor ankle motion . 11
In cases of bilateral clubfoot , some surgeons prefer to do them at 3 weeks apart as it
will enable them to change the cast . However simultaneous procedure on both foot
has also been advocated by some with no significant difference in outcome. If
transfixation pins were used at the initial surgery, they were removed at 6 weeks postoperative .The use of Denis Brown splint during sleep after surgery is still a
controversy but it is usually the preference of the surgeon.

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Tendon transfer procedures are usually not indicated at the initial surgery. It may be
used if there is tendency for the forefoot to supinate during gait. Here either the lateral
half of the tibialis anterior can be transferred to the 2 nd or 3rd cuneiform or
transplantation of the tendon of tibialis posterior to the middle of the dorsum of the
foot may help in correcting the problem.
Release involving the forepart of the foot have also been described which includes
release of tarsometatarsal and intermetatarsal joint structures mainly to correct the
adduction of forefoot .However this procedure has questionable benefits because the
deformity tends to recur and residual pain and stiffness have been reported . Pain is
usually felt at the anterior aspect of the ankle , the heel and sinus tarsi . Post
operatively either a above or below knee cast is applied for 8 weeks changing at 4
weekly interval. On removal of cast, the child is put on an orthosis until he is walking
and there is clinical and radiological evidence of plantigrade foot.
Whichever type of release procedure that is selected, the ultimate goal is to have a
supple foot that is pleasing in appearance and can accept conventional shoe with no
pain or discomfort on weight bearing.
Procedures that involve bone are directed at correcting residual deformity in clubfoot
and are generally reserved for patients who are 4 to 6 years old. Among the residual
deformities , adductus and cavus are the most commonest .
The main cause of forefoot adduction is metatarsus varus, talonavicular subluxation
or a combination of both . Otremskiet al concluded from their study that recession of
the origin of abductor hallucis and release of the short plantar muscle and fascia
satisfactorily corrected 90% of forefoot adduction.

12

Another method to correct

residual forefoot adduction is osteostomy of the metatarsus at the bases.


To correct the varus deformity of the hindfoot, Dwyer devised open wedge
osteostomy of the calcaneus.

For older patients who have residual painful and stiff

foot, triple arthrodesis is regarded as a last resort salvage procedure. However it

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should be delayed till the patient 's skeletal age is about 12 years. This may help
reduce the rate of pseudoarthrosis and shortening of the foot.
At an average 20% of patients treated with surgery has poor results . Atar et al
reported a 25% poor result for operated clubfoot.2 Among the possible explanation
include presence of talocalcaneal bar, over correction of the deformity and scarring of
the tendons that were lengthened. One way to overcome the scarring of the tendon is
to perform fractional lengthening of the tendon. This is done by finding the
intramuscular portion of the tendon to be lengthened and to interrupt it at that point
leaving the muscle intact. As a result, the muscle is intact throughout their excursion. 1
Combined soft tissue and bone procedure has also been preformed to some success.
Among them were those that were described Lundberg (cited in Cummings, 1988)
where he combined posteromedial release with medial opening wedge osteotomy of
the calcaneus. Evans procedure is another example, which is mainly used to correct
residual adductus deformity. Here a closing wedge resection of the calcanoecuboid
joint is done to shorten the lateral column of the foot combined with a medial and
posterior release. Hoffmann et al (cited in Cummings, 1988) also described an
opening wedge osteotomy of the first cuneiform combined with a radical plantar
release to correct residual adductus deformity. He found good success rate using this
method. Other bony procedure include cuboid decancellation , talectomy and wedge
tarsectomy .
In correcting severe deformity, problem may arise with skin closure. This can be
avoided by one of these methods:
i)

primary closure in the

undercorrected position followed by weekly

manipulation till full correction is achieved


ii)

using lateral skin release and flap

iii)

using myocutaneous or fasciocutaneous flaps or

iv)

using tissue expanders pre-operatively2

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In conclusion, in all degree of clubfoot, initial treatment should always be gentle


corrective manipulation and serial casting. Surgery is indicated only if complete
correction cannot be obtained and maintained. Soft tissue release are favored over
bone procedure which should be regarded as salvage procedure and done only in older
children.
References:
1.

Atar D, Lehman W.B, Grant A.L and Strongwater A.M. Revision Surgery
in Clubfoot. Clin. Orthop. 1992 ; 283 : 223-229

2.

Atar D, Lehman W.B , Grant A.L and Strongwater A.M. Fractional


lengthening of the flexor tendon in clubfoot surgery . Clin. Orthop. 1991 ;
264 : 267-269

3.

Canale S.T. The Pediatric Foot . Campbell s Operative Orthopaedics 1998;


9th Ed : 937-951

4.

Cummings R.J. and Lovell W.W. Current Concepts Review . Operative


treatment of congenital Idiopathic Clubfoot . J Bone Joint Surgery 1988 ; 70-A
. No 7 : 1108-1112

5.

Dee .R . Principles of Orthopaedic Practice ; 2nd Ed 1997: 803-820

6.

Flynn J.M, Donohoe M, P.T. and Mackenzie W.G.

An

Independent

assessment of two Clubfoot Classification Systems . J. Pediatr. Orthop 1998;


Vol 18 No 3 : 323-327
7.

Laaveg S.J. and Ponseti I.V. Long term results of treatment of congenital
clubfoot . J Bone Joint Surgery 1980; 62-A : 23-30

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8.

Law J.H.K, Meyer L.C. and Law H.C. Results of surgical treatment of
talipes equinus varus congenita . Clin. Orthop 1989 ; 248 : 219-226

9.

Levin M.N , Kuo K.N , Harris G.F and Matesi D. V. Posterior medial
release for Idiopathic Talipes Equinusvarus . Clin. Orthop 1989 ; 242 : 265268

10.

Mc Kay D.W. New Concept of and approach to Clubfoot treatment : Section I


Principles and morbid Anatomy . J. Pediatr. Orthop 1982 ; Vol 2 No4 : 347356

11.

Mc Kay D.W. New Concept of and approach to the Clubfoot treatment :


Section III- Evaluation and results . J. Pediatr. Orthop 1983 ; Vol 3 No 2 :
141-148

12.

Otremski I, Salam R , Khermosh O and Weintroub S . Residual adduction


of the forefoot . J. Bone Joint Surgery 1987 ; 69-B : No 5 : 832-834

13.

Waisbrod H . Congenital Clubfoot. An Anatomical Study . J Bone Joint


Surgery 1973; Vol 55 No 4 : 796-801

14.

Yamamoto H and Furuya K. Treatment of Congenital Clubfoot with a


modified Denis Brown Splint. J. Bone Joint Surgery 1990; Vol 72-B , No 3 :
460-463

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