Congenital Talipes Equinovarus

Definition

Congenital talipes equinovarus (CTEV, clubfoot) is a common congenital deformity in which the foot is turned downwards and inwards and cannot be passively corrected to normal. It may be idiopathic (the majority), syndromic/teratologic (associated with conditions such as arthrogryposis or spina bifida), or postural (a mild, fully correctable positional deformity). It is commoner in boys and is bilateral in about half of cases.

Components of the Deformity

The deformity has four components, remembered as ‘cave’: Cavus (a high medial longitudinal arch), forefoot Adductus, hindfoot Varus (inverted heel), and ankle Equinus (fixed plantarflexion). The calf is often thin and the foot smaller than normal.

The four components of clubfoot — Cavus, Adductus, Varus and Equinus (‘cave’).

Clinical Assessment

The diagnosis is clinical at birth. The key distinction is between a rigid true CTEV (cannot be passively over-corrected) and a flexible postural deformity (fully correctable). Severity is graded (e.g. The Pirani or Dimeglio score) to guide and monitor treatment. Examine for associated abnormalities (spine, hips) that suggest a syndromic cause.

Management — the Ponseti Method

Treatment should begin soon after birth while the tissues are supple. The gold standard is the Ponseti method: serial weekly manipulation and casting that sequentially corrects the deformity in a set order (cavus, then adductus and varus, and finally equinus), usually followed by a percutaneous Achilles tenotomy to correct the residual equinus. Correction is then maintained with a foot abduction (boots-and-bar) brace for several years to prevent relapse. Neglected, relapsed or resistant (often syndromic) feet may need soft-tissue release or bony surgery.

Complications & Outcome

With early, well-conducted Ponseti treatment the outlook is excellent: most children achieve a supple, plantigrade, painless and functional foot that fits normal footwear. The principal problem is relapse, usually from inadequate bracing, which is managed by repeat casting and, if a dynamic supination persists, a tibialis anterior tendon transfer. Neglected clubfoot presenting late, and rigid syndromic feet (e.g. Arthrogryposis), are much harder to treat and may require extensive soft-tissue release or bony surgery, sometimes with gradual correction using an Ilizarov frame.

• Foot turned down and in; components ‘cave’: Cavus, Adductus, Varus, Equinus.
• Distinguish rigid true CTEV from a correctable postural deformity.
• Idiopathic (commonest), syndromic/teratologic, or postural; often bilateral.
• Gold standard = Ponseti serial casting + Achilles tenotomy, then boots-and-bar bracing.
• Relapse usually from poor brace compliance; neglected/resistant feet may need surgery.