CONGENTINAL TALIPES EQUINOVARUS

Congenital Talipes Equinovarus (CTEV/ Clubfoot) is the commonest orthopaedic birth defect. It occurs with a frequency of 1 in 1000 live births. In this condition, the newborn’s foot is turned inwards and downwards. Clubfoot is bilateral (affecting both feet) in 50% cases.

Various theories have been proposed to explain the causation of Clubfoot including genetic cause, germ plasm defect, arrest of growth of feet within the womb, overcrowding in the womb, etc. However, the exact cause is still not known and Clubfoot is though to have a multifactorial cause.

Ultrasonography during pregnancy may be able to detect Clubfoot in the unborn baby in only about 70% cases after 16 weeks of pregnancy. In 30% cases, the Ultrasonography may fail to detect Clubfoot.

Clubfoot is of three main types:

  • Postural: This type of clubfoot is due to chronic posturing of the baby’s foot within the uterus. Postural clubfoot can be easily corrected and it usually resolves within one or two months with simple manipulation and physiotherapy
  • diopathic: Majority clubfeet are of this variety. This type of clubfoot is more severe and rigid than postural clubfoot, however apart from the foot deformity the child has no other deformity/ anomaly. Idiopathic Clubfoot is treated by Ponseti protocol.
  • Syndromic: This is the severest form of clubfoot and in this type the child may have multiple other anomalies. Syndromic clubfoot is also treated by Ponseti protocol, but open extensive surgeries are often needed.

Idiopathic Clubfoot is now treated by Ponseti protocol which is the gold standard treatment the world over. Open surgeries are now reserved for only the rare severe rigid syndromic clubfeet which fail to respond to Ponseti protocol.

Ponseti protocol is a revolutionary minimally invasive method of treatment of Clubfoot which has become the gold standard method of treatment of Clubfoot since the late 1990s. It was described by Professor Ignacio Ponseti from Iowa, USA. Before Ponseti method became popular, extensive open surgeries used to be performed for correction of clubfoot.

Treatment of Clubfoot by the Ponseti protocol consists of different stages:

In the first stage, the deformity is gradually corrected by serial manipulation and application of plaster casts by a specific technique elaborately described by Prof Ponseti. The plaster cast is changed every weekly till the midfoot deformity is overcorrected. On an average, about six plaster casts are needed to reach this stage, though the number may vary depending on the severity and rigidity of the deformity.Most of the times, even after the midfoot deformity is corrected, the child still has residual hindfoot equinus deformity due to tight Achilles tendon at the back of the heel. Once this stage is reached, the child then undergoes a minimally invasive surgery called Achilles tendon tenotomy in which the tight tendon is percutaneously cut and the hindfoot equinus deformity is corrected. A plaster cast is then applied in the overcorrected position for a period of three weeks.

CTEV Before Casting

CTEV Cast

CTEV after 6 casts Midfoot deformity corrected Hindfoot equinus persists

Equinus correction after TendoAchilles tenotomy

After this plaster cast is removed, a special brace called the Dennis Brown brace is applied to maintain the corrected position. This brace consists of shoes in both feet (even if only one foot is affected) and a metal rod connecting the two shoes. This brace is applied fulltime (23 hours a day) for three months and thereafter sleeptime till the age of four years

CTEVStenbeek Brace

CTEV After Correction

The Ponseti protocol of treatment yields excellent results and most children with Clubfeet walk independently by the age of 12 to 18 months. Long term studies have shown that children with Clubfeet can lead a perfectly normal life and most of them can walk, run, play, jump, etc. There are examples of children with clubfeet who have grown up to become famous athletes.

Even after Clubfoot deformity is corrected, there is a high tendency of the deformity to recur if the brace is not worn as recommended. Hence it is extremely important to wear the brace even after the deformity is corrected. Other factors responsible for recurrence after initial correction are syndromic clubfeet and rigid clubfeet which needed more than the average number of plaster casts to achieve correction.

Treatment of a clubfoot recurrence depends on the type of recurrence. In some cases, repetition of serial plaster casting is needed. In some children, the TendoAchiles tenotomy surgery may need to be repeated. In some cases where there is muscular imbalance, a rebalancing surgery called Tibialis Anterior tendon transfer surgery is needed to restore the position of the foot