CHAPTER I

Congenital Talipes Varus Equino (CTEV) which is also known as the 'clubfoot' is a developmental disorder in the lower extremities that are often encountered,
but still rarely studied. CTEV included in the term "syndromic" if this case is found in
conjunction with other clinical features as a part of a genetic syndrome. CTEV can
occur alone without the presence of other clinical features, and is often referred to as
CTEV "idiopathic". CTEV syndromic often accompanies neurological and
neuromuscular disorders, such as spina bifida or spinal muscular atrophy. But the
most common form is CTEV "idiopathic", which in this second form of the superior
limb in normal circumstances.

Club-foot found in Egyptian hieroglyphs and described by Hippocrates in 400

BC. Hippocrates suggested treatment by manipulating the feet gently and then fitted
bandage. Until now, modern treatments still rely on manipulation and immobilization.
Manipulation and immobilization serially performed carefully followed the
installation of gypsum is a modern non-operative treatment methods. Possible
mechanisms of mobilization which is currently the most effective is the Ponseti
method, where the use of this method can reduce the need for surgery. However, there
are many cases that require operative therapy.

CHAPTER II
2.1 Definition
Congenital Talipes Varus Equino is fixation of the foot in the position of
adduction, supination and varus. Calcaneus bone, navicular and cuboid terrotasi
medial direction towards the talus, and stuck in a position of adduction and inversion
by ligaments and tendons. In addition, the first metatarsal bone over the plantar
flexion of the area

2.2 Epidemilogy
Incidents of CTEV vary, depending on race and gender. CTEV incident in the
United States by 1-2 in the case of 1000 live births. Comparing the case of men and
women is 2: 1. Bilateral involvement was found in 30-50% of cases.
.
2.3 CLASIFICATION
There are many classifications in CTEV division, but yet there is a
classification that is used universally. The division that is often used is postural or
positional, and fixed rigid. Clubfeet postural or positional not an actual clubfeet.
While the types of fixed or rigid clubfeet can be classified into types of flexible (can
be corrected without surgery) and resistant (requiring operative therapy, although this
is not entirely true by experience dr. Ponseti)
.
Several other types of classifications that can be found, among others:
a. Pirani
b. Goldner
c. In Miglio
d. Hospital for Joint Diseases (HJD)
e. Walker

2.4 Etiology
Etiology of actual CTEV not known with certainty. But a lot of theories about
the etiology CTEV, among others:
a.mechanical factors intra uterine
is the oldest and theory first proposed by Hippocrates. It is said that the baby's
feet were arrested in equinovarus position because of external compression of the
uterus. Parker (1824) and Browne (1939) stated that the occurrence of the
oligohydramnios emphasis from the outside because of the limited movement of the
fetus.
b. neuromuscular defects
some researchers believe that CTEV always due neuromuscular defects, but
many studies have shown that there is no histological abnormalities and
eektromiografik
c. The primary defect in plasma cells
Irani and Sherman have to do surgery on a 11-foot and 14-foot CTEV normal.
It found that in the case of CTEV neck of the talus is always short, followed by a
rotation towards the anterior medial and plantar. They argued that the hypothesis in
this case because of a defect in plasma cell primary.
d. fetal development stunted
e. Hereditary
Wynne and Davis argued that the polygenic factors facilitate fetal exposure to
external factors (Rubella infection, use Talidomide)

f. vascular hypothesis
Atlas et al (1980), found abnormalities in the vasculature cases CTEV.
Obtained the blocking vascular sinus floor tarsalis. In infants with CTEV got the
muscle wasting in the ipsilateral, where it is likely due to decreased perfusion of the
anterior tibial artery during the developmental period.
2.5 PATOFISIOLOGY
Some theories that support the pathogenesis of CTEV, among others:
a. impaired fetal development in phase fibular
b. lack of network kartilagenosa talus
c. neurogenic factor
have found abnormalities in the histochemical peroneal muscle groups in
patients CTEV. This is expected because of changes in intrauterine innervation for
neurological diseases, such as stroke. This theory is supported by the incident CTEV
in 35% of infants with spina bifida.
d. Fibrosis retraction secondary to an increase in fibrous tissue in muscles and
ligaments.
In postmortem studies, Ponsetti found a very loose collagen network and can
be stretched in all the ligaments and tendons structures (except Achilees). In contrast,
the Achilles tendon is made of a very dense network of collagen and can not be
stretched. Zimny et al, found that there mioblast the medial fascia using electron
microscopy. They menegemukakan hypothesis that this is what menyebaban medial
contracture.
e. Anomalies in the tendon insertion
Inclan hypothesize that CTEV due to anomalies in the tendon insertion. But
this is not supported by other studies. This is due to the distortion in the anatomical

position CTEV which makes visible visible abnormalities in the tendon insertion.
f. Climatic variations
Robertson noted the relationship between climate change and the incidence of
occurrence CTEV epidemiology. This is consistent with a similar variation in the
incidence of poliomyelitis cases in the community. CTEV said the sequelae of
prenatal poliolike state condition. This theory is supported by the change in the motor
neurons in the spinal cord anterior babies.
2.6 CLINICAL MANIFESTASION
Find CTEV or a history of neuromuscular disease in the family. Perform
overall examination in order to identify the presence or absence of other
abnormalities. Check the baby's legs in a state prone, so it can be seen part of plantar.
Check also the infant supine position to evaluate their internal rotation and varus.
Similar deformity seen in myelomeningocele and arthrogryposis. Ankle and
foot in equinus position is in the supine position (varus) and adduction.
Navicular bone and cuboidal shifted toward more medially. Soft tissue
contractures occur in the medial plantar pedis section. Calcaneus bone not only be in
the equinus position, but anteriorly suffered medial rotation in the direction of
rotation along the lateral direction on the posterior.
Heel seemed small and empty. At the touch heel will feel soft (like cheek). In
line with the approach taken, the heel will repopulate and on touching it is harder
(like touching the nose or chin).
Because the lateral section is not closed, then the neck of the talus can be
easily felt in the sinuses tarsalis. Normally covered by navikular talus neck and body
of the talus. Medial malleolus becomes difficult palpable and generally stick to
navikular. Normal distance there is between navikular and malleolus disappeared.
Tibia often have internal rotation.
2.7 IMAGING DIAGNOSTIC

Radiological features of CTEV is the alignment between the talus and

calcaneus bone. The position of the foot during a radiological image capture has very
important meaning. Position anteroposterior (AP) taken with the foot plantar flexion
of the tube at 30 and 30 position of the vertical state. The position taken by the
foot lateral plantar flexion against at 30.
AP and lateral picture can also be taken on the position of foot dorsiflexion
and plantar flexion full. This position is important to know the relative position of the
talus and calcaneus.
Measuring the angle talokalkaneal of AP and lateral position. AP line drawn
through the center of the talus bone axis (parallel to the medial border) and through
the center of the calcaneus bone axis (parallel to the lateral boundary). Value is
normally between 25-40 . If found any angle less than 20A is said to be abnormal.
Talokalkaneus anteroposterior line nearly parallel to the case CTEV. Along
with the treatment given, either by casting or surgery, then the calcaneus bone will
rotate in the direction of the external, followed by talus are also experiencing derotasi.
That way it will form an adequate talokalkaneus corner.
The lateral line is drawn through the midpoint between the head and the body
of the talus bone and along the base of the calcaneus bone. Normal values between
35-50 , were on CTEV nialinya ranged from negative 35A and 10A .
The angle of these two sides (AP and lateral) are added to determine the index
talokalkaneus, where the feet that have been corrected will have a value of more than
40A .
AP and lateral line midway through the normal talus bone navikular and first
metatarsal.
Lateral radiological image capture with foot dorsiflexion was detained at the
maximum position is the most reliable method for diagnosing CTEV uncorrected.
2.8 Therapy
2.8.1 Medication Therapy

The goal of medical therapy is to correct existing deformity and maintain the
correction has been done until the cessation of bone growth.
Traditionally, CTEV categorized into two kinds, namely:
CTEV which can be corrected by manipulation, casting and installation of
gypsum.
CTEV resistant which gives a minimal response to the stylist carrying on with
the installation of gypsum and may relapse ccepat although it did successfully
with manipulative therapy. In this category are required operative
intervention.
Currently there is an assessment system designed by prof. dr. Shafiq Pirani, an
expert ortopaedist in England. This system is called The Pirani Scoring System. By
using this system, we can identify the severity and monitor the progress of a case
CTEV for correction performed.
The system consists of six categories, each of the hindfoot and midfoot 3. For
the hindfoot, the category is divided into the posterior protrusion / posterior crease
(PC), void heel / emptiness of the heel (EH), and the degree of dorsiflexion is
happening / degree of dorsiflexion (DF). As for the category of the midfoot, divided
into the curvature of the lateral border / curvature of the lateral border (CLB), a bulge
in the medial / medial crease (MC) and the exposure of the lateral head of the talus /
uncovering of the lateral head of the talus (LHT).
The way to calculate the Pirani Score is as follows:
a.

Curvature

of

the

lateral

border

of

the

foot

(CLB)

Lateral limits of normal leg straight. The limits curved legs that appear indicating the
presence of medial contracture.

Look at the plantar pedis and put bars / ruler in the lateral part of the foot.
Normally, the lateral border of the foot appears straight, starting from the heels up to
the head of the fifth metatarsal. If the lateral border of the foot is obtained straight,
the score given is 0

At the foot of the abnormal, the lateral boundary appears away from the straight line.
Lateral border appear curved yanng mild rated 0.5 (arch seen in the distal part of the
foot on the metatarsal area).

The curvature of the lateral border of the foot which is obvious given the value of 1
(the curvature of the joints appear to be as high as kalkaneokuboid).

B. Medial crease of the foot (MC)

In normal circumstances, the skin on the soles of the feet area will show fine
lines. Folds of the skin may indicate the presence of contractures in the medial region.
Hold the foot and pull gently while checking out.

Look at the arch of the medial border of the foot. Normally be seen the fine lines on
the skin of the soles of the feet which do not alter the contour of the medial arch. In
these circumstances, the value of MC is 0.

At the foot of abnormal, it will appear to have one or two folds in the skin. If this is
not too much influence the medial arch contour, then the MC is equal to 0.5.

c. Posterior crease of the ankle (PC)

In normal circumstances, the skin on the posterior heel will show multiple skin folds
smooth. If there is any deeper skin folds, then it shows the possibility of a more
severe posterior contracture. Pull gently feet while checking.

Examining look into the patient's heel. Normally be seen the fine lines that do
not alter the contour of the heel. This causes the folds of the skin can adapt, so it can
be stretched when the foot in dorsiflexion. In this condition, then the value for the PC
is 0

At the foot of abnormal, it will get one or two folds in the skin. If these folds tidaak
too affects the contour of the heel, then the value of the PC is at 0.5.

If the inspection found that the skin folds in the heel area and the changing contours of
the heel, then the value of the PC is 1.
D. Lateral part of the Head of the Talus (LHT)
In case CTEV untreated, the examiner can feel the head of the Talus in the
lateral section. With the correction of deformity, the bone will navikular down
over the head of the talus, then it will make it more difficult palpable, and in
the end can not be felt at all. Sign "navikular downs over the head of the
talus" is measuring the amount of contractures in the medial region.

With traditional non-operative management, the installation splint starts in infants

aged 2-3 days. The sequence of the correction to be made are as follows:
1. Adduction of the forefoot

2. Supination forefoot
3. Equinus
Attempts to correct the equinus position at the beginning of the correction can
break the legs of patients, and resulted in rockerbottom foot. Should not be forced
when making corrections. Place the foot in the best position can be obtained, then
maintain this position by using a "strapping" which changed every few days, or
maintained using a cast that replaced a few weeks. This continued until full correction
can be obtained or until it can no longer do the next correction.
The position of the feet that have been corrected is then maintained for several
months. Operative action should be done as soon as possible when the apparent
failure of conservative therapy, which, among others, characterized by persistent
deformity, deformity or return the form rockerbottom foot deformity correction
stopped soon after
After control for 6 weeks can usually known types of deformity CTEV,
whether including an easy corrected or resistant type. This was confirmed by using
X-ray and the comparison calculation bone orientation. From the report found that the
success rate using this method amounted to 11-58%.
Ponseti Method
This method was developed by dr. Ignacio Ponseti at the University of Iowa.
This method was developed from cadaveric studies and clinical observations
performed by dr. Ponseti. measures to be taken are as follows:
1. The primary deformity in the case CTEV is the calcaneus bone rotation
toward intenal (adduction) and plantar flexion pedis. Feet are in a position of
adduction and plantar flexion pedis experience at the subtalar joint. The first
goal is to make the foot in abduction and dorsiflexion position. To obtain
optimal correction foot CTEV the case, then the calcaneus bone must be
freely rotated down the talus. The correction is done through the normal arch
of joints subtalus. This can be done by putting a finger the index provider in

the medial malleolus to stabilize the foot and then lift the thumb and placed in
the lateral part of the head of the talus, while we do the forefoot abduction
with supination direction.
2. Cavus foot will increase when the forefoot is in the prone position. If found
adany cavus, the first step in the correction of foot is by gently lifting the first
metatarsal, to correct cavusnya. After cavus corrected, it can be positioned
forefoot abduction as it is written in the first step.
3. When the foot is placed in the prone position, it may cause the calcaneus bone
is under the talus. If this is the case, then the calcaneus bone can not rotate and
settle in varus position. As written in the second step, the cavus will increase.
This can cause tejadinya bean-shaped foot. At the end of the first step, the foot
will be at a maximum abduction but never pronation.
4. The manipulation is done in a special room after the baby is breastfed. Once
the foot is manipulated, then the next step is to install long leg casts to
maintain the correction has been made. The cast should be installed with a
minimum bearing, but still adequate. The next step is to spray benzoin tincture
to attach the legs to the feet with bearing cast. Dr Ponsetti prefer to install
additional padding along the border of the medial and lateral leg, so safe to
use scissors when removing plaster casts. The cast should not be installed
until tapping your toes or mengobliterasi transverse arch. The position of the
knee at an angle of 90A for long casts installation. Parents can soak casts
this baby for 30-45 minutes before released. Dr Ponsetti choose to release
casts by using oscillating saws (rotating). The cast is split into two and
removed, and then put back together. This is done to determine the
development of the forefoot abduction, then this can be used to determine the
dorsiflexion and megetahui correction has been achieved by foot ekuinus.
5. There is an effort to correct CTEV with coercion against tight Achilles tendon
can result in fracture of the midfoot and ends with the formation of such
rockerbottom foot deformity. Abnormal curvature of the foot (cavus) should

be treated separately, as described in the second step, while ekuinusnya

position must be corrected without causing breakage midfoot.
In general it takes 4-7 times to get the cast mounting foot maximum
abduction. The cast is changed every week. Corrections made (attempt to make the
foot in abduction position) can be considered adequate if the axis of the thigh and leg
at 60A
After the abduction of the foot can be reached a maximum, most cases of
percutaneous tenotomy membutukan done on the Achilles tendon. This is done in a
state aspetis. Local area anesthetized with a combination of topical and local
infiltration of lignocaine minimal use of lidocaine. Tenotomy is done by making use
of a knife slices Beaver (rounded edges). Postoperative wound is then closed with a
single suture using a thread that can be absorbed. Installation is done with the cast last
leg positioned at maximum dorsiflexion, then casts maintained up to 2-3 weeks.
6. The next step after the installation of the cast is the use of shoes attached to
the slab Dennis Brown. Problematic foot is positioned in abduction (extreme
rotation) to 70A . with the unaffected foot set at 45A of abduction. These
shoes also have a bearing on the heel to prevent the foot tucked out of the
shoe. These shoes are used 23 hours a day for 3 months, then used at nap time
and night for 3 years.
7. In approximately 10-30% of cases, the tendon of the anterior titbialis can
move to the lateral cuneiform current 3 year old child. This makes the
correction may last longer legs, preventing metatarsal adduction and inversion
of the foot. This procedure is indicated in children aged 2-2.5 years, by means
of dynamic foot supination. Before the operation, the pair of long leg cast for
several weeks.

2.8.2 Operative Therapy

a. Incision
Several options for incision,to others:
Cincinnati:
This type of form transverse incision, starting from the anteromedial
(navikular-cuneiform joints) feet to the anterolateral side (distal and medial part of
the tarsal sinus), proceed to the back of the ankle joint as high as tibiotalus.
Turco curvilineal incision medial or posteromedial: This incision can cause open
wounds, especially in the vertical angle and medial leg. To avoid this, some operators
choose several roads, among others:
Three separate incision - vertical incision posterior, medial, and lateral
Two separate incision - Curvilinear medial and posterolateral
Many approaches can be done to get the operative therapy in all quadrants. Some of
the options that can be taken, among others:

Plantar: Plantar fascia, abductor hallucis, flexor digitorum brevis, long and short plantar
ligaments
Medial: medial structures, tendon sheaths, talonavicular and subtalar release, posterior
tibial, FHL, and elongation FDL
Posterior: kapsulotomi feet and subtalar joints, particularly the release of the posterior
talofibular and tibiofibular ligament, and ligaments kalkaneofibular
Lateral: structures lateral peroneal sheath, pesendian kalkaneokuboid, and ligaments
talonavikular and subtalar release

Whichever approach is taken should be able to produce adequate exposure. Structures

to be removed or stretched is as follows:
Achilles Tendon
Upholstery tendons of the muscles that pass through the subtalar joint.
Posterior ankle capsule and ligaments Deltoid.
Inferior tibiofibular ligament
Ligaments fibulocalcaneal
Capsule of the joint and the subtalar talonavikular.
Pedis plantar fascia and intrinsic muscles
Longitudinal axis of the talus and calcaneus should be separated approximately 20A
of lateral projection. Correction is done then maintained with the wiring in the joints
talokalkaneus, or talonavikular or both. It can also be done using a cast. Postoperative
wound that occurs should not be shut down by force. The wound may be left open so
as to form granulation tissue or even later can be a skin graft.

Management of the operation must consider the age of the patient:

1. In children less than 5 years, then the correction can be done only through the soft
tissue procedures.
2. For children over 5 years, then it is in need of reshaping bone / bony reshaping (eg,
excision of joints kalkaneokuboid dorsolateral [procedure Dillwyn Evans] or
calcaneus bone osteotomy to correct varus).
3. If the child is older than 10 years, it can be done tarsektomi lateral or arthrodesis.).
Be aware of the state of post-operative wounds. If the skin closure after
surgery is difficult, it is better to wound is left open so that the reaction can occur
ganulasi, to then allow the primary or secondary healing.
Can also do a skin graft to cover the wound defect after surgery. The bandage
should only be fitted loose and should be checked regularly.
Follow-up of patients
Pin for this fiksator usually removed after 3-6 weeks. Satelah it remains
necessary mounting bandage boots paired with Dennis Brown for 6-12 months.

2.9 COMPLICATION
Infection (rare)
Stiffness and limitation of motion: stiffness that appears at the beginning
associated with unfavorable outcomes.
Avascular necrosis of the talus: approximately 40% incidence of avascular
necrosis of the talus appear on technique combined medial and lateral release.

Can occur overkoreksi which may be due to:

- The release of the interosseous ligaments of the joints subtalus
- Navikular excessive bone displacement laterally
- An extension of the tendon
2.10 DIFFERENTIAL DIAGNOSTIC

Postural clubfoot - due to the position of the fetus in the uterus. Type of foot

abnormalities such as these can be corrected manually by the examiner. Postural

clubfoot gave a good response to the installation of serial casts and rarely relapse.

Metatarsus adductus (or varus) - is a deformity of the metatarsal bones alone.

Forefoot leads to the midline of the body, or in apposition addkutus pad. These
abnormalities can be corrected by manipulation and installation of serial casts.
2.11 PROGNOSTIC
-

Approximately 50% of cases CTEV in newborns can be corrected without

operative action. Dr. Ponseti reported a success rate of 89% by using the technique
(including the Achilles tendon tenotomy). Other researchers reported the average
success rate of 10-35%. Most cases reported satisfaction levels as high as 75-90%, in
terms of both appearance and function of the foot.

Satisfactory results were obtained in approximately 81% of cases.The main

factors affecting functional outcome is the range of movement of the movement of

the foot, where it is influenced by the degree of flattening of the dome of the talus
bone. Thirty-eight percent of patients with CTEV cases requiring further operative
actions (nearly 2/3 of his is a procedure to reshape the bone).

The mean rate of recurrence of deformity reached 25%, with a range between

10-50%.

The best results are obtained in children operated on at the age of 3 months

(usually with a size of more than 8 cm).

LITERATURE

1.

Meidzybrodzka, Z. 2002. Congenital Talipes Eqinovarus (clubfoot): disorder of the foot but
not the hand. www.anatomisociety.com [29 juli 2008].

2.

Patel, M. 2007. Clubfoot. www.emedicine.com [29 juli 2008].

3.

Harris, E. 2008. Key Insight To Treating Talipes Equinovarus.

www.podiatry.com [29 juli

2008].
4.

Nordin,

S.

2002.

Controversies

In

Congenital

Clubfoot:

Literature

Review.

www.mjm.com [29 juli 2008].

5.

Pirani, S. 1991. A Relible & Valid Method of Assesing the Amount of Deformity in the
Congenital Clubfoot Deformity. www.ubc.com [2 juli 2008].

6.

Anonym. 2006. Brith Defect Risk Factor Series: Talipes Equinovarus (clubfoot).

www.statehealth.com [2 juli 2008].

7.

Anonym. 2005. Clubfoot Deformity. www.dubaibone.com [5 juli 2008].

8.

Hussain, S. et al. 2007 Gomal Journal of Medical Sciences July Dec 2007, Vol. 5, No. 2.
Turcos Postero Medial Release for Congenital Talipes Equinovarus.

www.gjm.com [5

juli 2008].
9.

Soule, R. E. 2008. Treatment of Congenital Talipes Equinovarus in Infancy and Early

Chlidhood. www.jbjs.com [5 juli 2008].

10. Kler, J. et al. 2005 Treatment Methods of Congenital Talipes Equinovarus-three case reports.

www.jpn-online.com [7 juli 2008].

11.

Yeung EHK. et al. 2005 Radiografic Assesment of Congenital Talipes Equinovarus:

Strapping versus Forced Dorsoflexion. www.jos.com [7 juli 2008].