Mayank Pushkar. Congenital Talipes Equinovarus (CTEV) SRJI Vol- 2, Issue- 1, Year- 2013

35

CONGENITAL TALIPES EQUINOVARUS (CTEV)

Mayank Pushkar. BPT, MSAPT*

INTRODUCTION

Congenital telipesequinovarus (CTEV) is a

common congenital limb deformity involving one

foot or both1. “Congenital” means a deformity that is

present at birth, “Telipes” means simply the foot and

ankle, and “Equinovarus” refers to position of the

foot, which points downward and inward. CTEV is

also known as “Clubfoot”. An estimated 30000

children born with CTEV every year in India2,

although a rate of 1.24 or greater have been reported

in UK. It is a common birth defect, occurring in

about 1/1000 live births. Almost half of the cases of

CTEV are bilateral. Male children are more affected

than female children with a ratio of approximately

2:13.

PATHOANATOMY

The true clubfoot is characterized by different

deformities- Equinus, Varus, Adductus and cavus4.

The ‘equinus’ deformity is present at the ankle joint,

TCN joint and forefoot. The ‘varus’ component

occurs primarily at TCN joint and the hind foot is

rotated inward. The ‘adductus’ deformity takes place

at the talonavicular and the anterior subtalar joints.

The ‘cavus’ component involves forefoot plantar

flexion, which contributes to the composite equinus.

Fig- 1- Showing CTEV in both the foot.

AETIOLOGY

Genetic factors play an important role in

ISSN: 2277-1700 ● Website: http://www.srji.info.ms ● URL Forwarded to: http://sites.google.com/site/scientificrji

36

inheritance of CTEV as a polygenic multifactorial

trait5. Maternal Hyperthermia is also one of the

causes for CTEV6, as maternal hyperthermia acts as

adverse environmental factor in the sensitive period

of intrauterine development.

Mainly there are 3 broad categories responsible

for CTEV deformity in newborn7-

1. NEUROLOGICAL DAMAGE

2. MUSCULO-SKELETAL DEFORMITY

3. POSTURAL DEFORMITY

1.NEUROLOGICAL DAMAGE: Spina bifida

overta with failure of development of the sacral part

of the spinal cord but normal proximal development

can results in an equinovarus deformity of the foot.

2. MUSCULO-SKELETAL DEFORMITY:

CTEV can results because of composite intrinsic

pathology of muscle and the bone. There are

varieties of other conditions which affectthe

peripheral musculoskeletal tissues and cause an

equinovarus deformity.

3. POSTURAL DEFORMITY: Some children

born with equinovarus deformity of the feet, if they

have been tightly packed in the utero with the feet

fixed in an equinovarus position for some week prior

to birth.

TYPES OF CTEV

1. STRUCTURAL CTEV: This type of CTEV is

caused by genetic factors such as- a genetic defect

with 3 copies of chromosome 18, which is known an

“Edward Syndrome”. Compartment syndrome,

Larsen’s syndrome, congenital heart defect and

neural tube defect are some of the other causes of

structural CTEV4.

2. POSTURAL CTEV: This type of CTEV is

caused due to the compression in utero with the feet

held in equionovarus position in final trimester.

CLINICAL FEATURES OF CTEV

Idiopathic clubfoot is characterized by a bean-

shaped foot prominence of the head of Talus, medial

plantar cleft, deep posterior cleft, absence of normal

creases over the insertion of tendon achilies,

calcaneal tuberosity situated at a higher level and

atrophy of calf muscle4. Three major components of

deformities, those are, equinous, varus and adducts,

are obvious on examination. Presence of other

anomalies implies a non-idiopathic type of clubfoot.

Hypertrophy of calf muscle is present and

dorsiflexion and eversion are limited. Lateral

malleolus is very prominent while the medial

malleolus is buried in a depression because of the

inversion at the subtalar joint. There is also

exaggeration of longitudinal arch of the foot.

ASSESSMENT OF CTEV

ANTENATAL DIAGNOSIS: The clubfoot can be

diagnosed at 18-20 weeks of gestation with the

advert of Ultrasound. Amniocentesis is made at < 20

weeks to check for the high incidence of associated

genetic anomalies7,8.

POSTNATAL DIAGNOSIS: The child as well as

foot must be carefully assessed at birth.

The early assessment of CTEV can be carried out by

two methords9:

1. Photographic Assessment

Scientific Research Journal of India ● Volume: 2, Issue: 1, Year: 2013

37

2. Radiological Assessment

1.PHOTOGRAPHIC ASSESSMENT: Photograph

of resting forefoot supination is recommended at

birth. The focus of the camera is centred at the level

of the ankle joint and an assistant holds the knee

between finger and thumb and rotates the leg

outward until the forefoot is superimposed upon the

line of tibia. From the photograph it is then possible

to measure an angle subtended by the forefoot on the

line of the tibia (Fig. 2). Children with more than 900

of resting forefoot supination at birth were more

resistant to surgical correction.

Fig. 2- Showing the measurement of angle.

2.RADIOGRAPHIC ASSESSMENT: A standard

lateral soft tissue radiograph of the lower leg can be

used for the assessment of CTEV. But X-Rays are

not routinely prescribed at birth as few bones in the

foot are ossified4. Also there is not much of clinical

use of radiographic assessment as it does not make

any difference in management of CTEV.

MANAGEMENT OF CTEV

The main principle of the management of

CTEV is the correction of the deformity followed by

maintenance of the in the corrected position.

The management of CTEV can be conservative

(Non-operative) method as well as operative

depending on the severity of deformity and age of

child.

CONSERVATIVE TREATMENT

The conservative method comprises of

manipulation with or without strapping or corrective

plaster casts. The goal of physiotherapy management

of CTEV consisted of short term and long term

goals14. The short term goal is to correct the

deformity so that ankle assumes plantigrade

positioning by the time the child would be 3 months.

The long term goal is to maintain the corrected ankle

in the situ and follow up the maintained correction

until the child start walking.

MEANS OF PHYSIOTHERAPY

MANAGEMENT

1. Rhythmic and repeated gentle

manipulation10

2. Strapping and Plaster of Paris

3. Education and instruction to the mother

and/ or parents10

1. RHYTHMIC AND REPEATED GENTLE

MANIPULATION: To provide gentle

manipulation, the PT placed the knee at 900 of

flexion to prevent the damage to the lower end of

tibia and fibular epiphysis and the ankle joint. To

correct the adduction, the soft tissue of foot is

passively stretched as- the forefoot is uncurled so

that it moves away from epsilateral heel i.e. forefoot


38

abduction. To correct the inverted foot, the foot is

turned such that the sole face outward i.e. eversion.

Finally, to correct the equinus, the heel is cupped

with the one hand from the front of the foot and an

upward pressure is applied, which brings the ankle

into dorsiflexion. The entire procedure is repeated 3-

4 times in each foot.

2. STRAPPING AND PLASTER OF PARIS: This

can be useful for fairly mild cases and should be

started at birth. Strips of adhesive strapping are

passed around the foot, up the side of legs, and over

the top of the knee, to hold the foot in a corrected

position. This is usually done weekly, followed by

some manipulation by the physiotherapist.

According to the “International Clubfoot Study

Group (2003)”, Kite’s, Ponseti’s and Bensabel’s

techniques have been approved as the standardized

conservative regimes for the management of

CTEV11.

Kite’s Technique4: This technique was derived from

the concept of three-point pressure. In this method,

the manipulation can be started soon after birth. The

forefoot is grasped and distracted while the other

hand holds the heel. The counterpressure is applied

over calcaneocuboid joint and the navicular is

pushed laterally. The heel is everted as the foot is

abducted. This is followed by application of slipper

cast, which is extended to below the knee with the

foot everted with gentle external rotation. Once the

adduction and varus are corrected, then the foot is

pushed into dorsiflexion to correct the equinous. The

casts are changed every week. Following full

correction, the foot are placed in a “Denis Brown

Bar”. The average number of cast required for

correction by this technique is 20.4.

Ponseti’s Technique4: In Ponseti’s technique, first 2

casts are applied with the supination of forefoot so

as to bring into alignment with the hind foot12. The

third cast is applied with the forefoot abducted and

simultaneous counterpressure over the head of talus.

In the fourth cast, the forefoot is further abducted.

Before the application of fifth cast, the degree of

dorsiflexion is assessed and if the dorsiflexion is not

possible beyond neutral, then a “Percutaneous

AchiliesTenotomy” is required, this is done under

local anaesthesia. The casts are changed weekly

intervals, before tenotomy, while the cast after the

tenotomy is removed at the end of 3 weeks. After the

removal of cast the patient is placed in modified

“Foot Abduction Orthosis (FAO)”. FAO is initially

used 23 hrs.a day for 4 months and then

subsequently for night-time for 3 years13. The

average number of casts required with this technique

is 5.4.

French Technique4: This technique involves daily

manipulation of the child’s clubfoot by

Physiotherapist for 30 minutes, followed by

stimulation of muscles (especially Peroneal muscle)

around the foot and then adhesive strapping is

applied. Daily treatment is required for

approximately 2 months and then reduced to 3

sessions per week for an additional six months.

Tapping is continued until the patient is ambulatory.

Once the child starts ambulation, then night-time

splint is given for additional 2 to 3 years.

3. EDUCATION AND INSTRUCTION TO THE

MOTHER: The mother should be assured and

reassured that with her co-operation, consistency and


39

compliance to treatment, the deformity could be

corrected. She should be taught how to mobilize the

feet in the absence of strap10. She is advised to take

care and observed every time when a fresh strapping

or plaster is applied and also to prevent the plaster or

strapping from being wet or soiled either by water or

any other fluid.

SURGICAL/ OPERATIVE MANAGEMENT

The operative treatment is required once the

conservative treatment fails or the chance of

correction of deformity with conservative

management is very less. Different operative

procedures are performed based on the age of child.

At 9 months – 3 years: A Postero-medial soft tissue

release (PMR), which was introduced by Turco14 is

performed and followed by “Dennis Brown splint”

for 2 years. In this technique, the correction of the

abnormal tarsal relationship is prevented by rigid

pathological soft tissue contracture.

At 3 years- 8 years: At this age, soft tissue release

along with Wedge Osteotomy of cuboid bone, which

is known as EVANS is performed.

At 8- 12 years: At this age, the Wedge Osteotomy

of calcaneum (Dwyer’s Operation) along with

wedge osteotomy of tarsal bone is performed.

Above 12 years: A triple arthrodesis of 3 joints of

foot (i.e. subtalar, calcaneo-cuboid and talo-

navicular joint) is performed.

POST-OPERATIVE PHYSIOTHERAPY

MANAGEMENT

The main objective of physiotherapy after surgical

procedure is to keep the other joints mobile and

prevent stiffness, which can be done with following

physiotherapy interventions15.

• Movement of toe, hip and knee in the plaster

cast only, by tickling or by holding child

high in suspension.

• To improve strength and stability gradual

active non-weight bearing and resisted foot

and ankle exercises are given, followed by

progression to weight-bearing exercises.

• To maintain the correction and avoid

recurrence, Night splint are provided. Some

of the splints used in the management of

CTEV are-

1. CTEV Splint

2. Dennis Brown Splint (Fig-4)

3. CTEV Shoes (Fig-5)

• Gait training with proper foot position is

taught to the patient.

• Special CTEV shoes are given to the

patients. The shoes got straight inner borer,

which prevents forefoot adduction, outer

shoe raise to prevent inversion and no heel

to avoid equinus.

• An effective training is given to the mother

or both parents for home care programme to

maintain the correct position of the limb and

how to give the exercise in correct way.


40

Fig-3- CTEV Splint

Fig-4- Dennis Brown

Fig-5- CTEV Shoes Splint

REFRENCES

1.Macnicol M. F.The management of Clubfoot: Issues for debate. J Bone Joint Surg[Br],2003;167-170.

2. Global clubfoot initiative. Last assessed on 15th May 2012 at: http://globalclubfoot.org/countries/india/

3. Macnicol M. F. and Murray A. W. Changing Concepts in the management of congenital

talipesequinovarus.Paedetrics and child health,2008; 272-277.

4. Anand, A. and Sala, D.A. Clubfoot: Etiology and treatment. Indian J Orthop,2008;42:22-28.

5. Lehman, W.B. The clubfoot. JB Lippincott: New York; 1996

6. Edwards, M.J. The experimental production of clubfoot in guinea pigs by maternal hyperthermia during

gestation. J Pathol, 1971;103:49-53.

7. Katz K, Meizner I, Mashiach R, Soudry M. The contribution of prenatal sonographic diagnosis of clubfoot to

preventive medicine.J Pediatr Orthop,1999;19:5-7

8. Roye, B.D., Hyman J., Roye, D.P. Jr. Congenital idiopathic talipesequinovarus. Pediatr Rev, 2004;25:124-30.

9. Porter, R. Club foot. The foot,1997;7: 181-193.

10.Ezeukwu, A.O. and Maduagwu, S.M. Physiotherapy management of an infant with bilateral congenital

talipesequinovarus. African Health Science, 2011;11(3): 444-448.


41

11. Bensahel, H., Guillaume, A., Czukonyi, Z. andDesgrippes, Y. Results of physical therapy for idiopathic

clubfoot: A long term8follow up study. J Pediatr Orthop,1990;10:189-92.

12. Ponseti IV, Campos J. Observations on pathogenesis and treatment of clubfoot. ClinOrthop, 1972;84:50-60.

13. Ponseti IV. Congenital clubfoot: Fundamentals of treatment. Oxford University Press: Oxford, England; 1996.

14. Turco VJ. Clubfoot. Churchill Livingstone: New York; 1981.

15. Goel RN. Goel’s Physiotherapy.Shubham Publication- Bhopal, Vol II, 2000.

CORRESPONDING AUTHOR:

* Email: [email protected]

Documents

Mayank Pushkar. Congenital Talipes Equinovarus (CTEV) SRJI Vol- 2, Issue- 1, Year- 2013