TEXTBOOK READING

CONGENITAL TALIPES
EQUINOVARUS (CTEV)
Presented by:
Mala Alawiyah Bakrie
Adeh Mahardika
Siti Hardiyanti O. H.
Anggiat Humusor Ulina

Advisor :
dr. Fendy
dr. Benny Murtaza
Orthopaedic and Traumatology
Department
Medical Faculty of Hasanuddin
University

Introduction
The term talipes is derived from talus

(Latin = ankle bone) and pes (Latin = foot).

In the full-blown equinovarus deformity the
heel is in equinus, the entire hindfoot in
varus and the mid and forefoot adducted
and supinated.
Apleys System of Orthopaedics and Fracture, 2010 Solomon, Warwick,
Nayagam

PathologicalAnatom y
The neck of the talus points downwards and deviates

medially, whereas the body is rotated slightly outwards

in relation to both the calcaneum and the ankle
mortise.
The posterior part of the calcaneum is held close to
the fibula by a tight calcaneo-fibular ligament, and is
tilted into equinus and varus; it is also rotated medially
beneath the ankle.
Apleys System of Orthopaedics and Fracture, 2010 Solomon, Warwick,
Nayagam

Pathologicalanatom y
The navicular and entire forefoot are shifted

medially and rotated into supination (the composite

varus deformity).
The skin and soft tissues of the calf and the medial
side of the foot are short and underdeveloped.
If the condition is not corrected early, secondary
growth changes occur in the bones; these are
permanent. Even with treatment the foot is liable to
be short and the calf may remain thin.
Apleys System of Orthopaedics and Fracture, 2010 Solomon, Warwick,
Nayagam

Anatom y

Apleys System of Orthopaedics and Fracture, 2010 Solomon, Warwick,

Nayagam

Anatom y

Apleys System of Orthopaedics and Fracture, 2010 Solomon, Warwick,

Nayagam

Apleys System of Orthopaedics and Fracture, 2010 Solomon, Warwick,

Nayagam

Incidence
The incidence ranging from

Apleys System of Orthopaedics and Fracture, 2010 Solomon, Warwick,

Nayagam

Etiology
The exact cause is not known, although the

resemblance to other disorders suggests several

possible mechanisms.
It could be a germ defect, or a form of arrested
development.
Its occurrence in neurological disorders and neural
tube defects (e.g. myelomeningocele and spinal
dysraphism) points to a neuromuscular disorder.
Apleys System of Orthopaedics and Fracture, 2010 Solomon, Warwick,
Nayagam

Clinicalfeatures
The foot is both turned and twisted inwards so

that the sole faces posteromedially.

The ankle is in equinus, the heel is inverted and
the forefoot is adducted and supinated;
The foot also has a high medial arch (cavus),
and the talus may protrude on the dorsolateral
surface of the foot.
Apleys System of Orthopaedics and Fracture, 2010 Solomon, Warwick,
Nayagam

Clinicalfeatures
The heel is usually small and high, and deep

creases appear posteriorly and medially.

In a normal baby the foot can be dorsiflexed and
everted until the toes touch the front of the leg.
In club-foot this manoeuvre meets with varying
degrees of resistance and in severe cases the
deformity is fixed.

Apleys System of Orthopaedics and Fracture, 2010 Solomon, Warwick,

Nayagam

Talipes equinovarus (club-foot) (a) True club-foot is a fi

xed deform ity,unlike (b)
posturaltalipes,w hich is easily correctable by gentle passive m ovem ent.(c,d) W ith true
club-foot,the poorly developed heelis higherthan the forefoot,w hich points dow nw ards and
inw ards (varus).
Apleys System of Orthopaedics and Fracture, 2010 Solomon, Warwick,
Nayagam

X-rays
The anteroposterior film is taken with the foot 300 plantarflexed

and the tube likewise angled 300 perpendicular.

Lines can be drawn through the long axis of the talus parallel to
its medial border and through that of the calcaneum parallel to
its lateral border; they normally cross at an angle of 2040
degrees (Kites angle) but in club-foot the two lines may be
almost parallel.
Incomplete ossification makes it difficult to decide exactly where
to draw these lines and this means that there is a considerable
degree of interobserver variation.

Apleys System of Orthopaedics and Fracture, 2010 Solomon, Warwick,

Nayagam

X-rays
The lateral film is taken with the foot in forced

dorsiflexion.
Lines drawn through the midlongitudinal axis of the
talus and the lower border of the calcaneum should
meet at an angle of about 40 0.
Anything < 200 shows that the calcaneum cannot be
tilted up into true dorsiflexion; the foot may seem to be
dorsiflexed but it may actually have broken at the
midtarsal level, producing the socalled rocker-bottom
deformity.
Apleys System of Orthopaedics and Fracture, 2010 Solomon, Warwick,
Nayagam

Review of Orthopaedics 5th edition, Saunders Elsevier 2008, Miller, Mark, D.

Review of Orthopaedics 5th edition, Saunders Elsevier 2008, Miller, Mark, D.

Apleys System of Orthopaedics and Fracture, 2010 Solomon, Warwick,

Nayagam

Treatm ent
The aim of treatment is to produce and

maintain a plantigrade, supple foot that will

function well.
There are several methods of treatment
but relapse is common, especially in
babies with associated neuromuscular
disorders.
Apleys System of Orthopaedics and Fracture, 2010 Solomon, Warwick,
Nayagam

Conservative Treatm ent

Treatment should begin early,

preferably within a day or two of birth.

This consists of repeated manipulation
and adhesive strapping that maintains
the correction.

Apleys System of Orthopaedics and Fracture, 2010 Solomon, Warwick,

Nayagam

Conservative Treatm ent

A, Technique of a nonoperative Ponseti correction of clubfoot. B, The thumb is

positioned over the lateral aspect of the head of the talus and the fingers correct
the forefoot. No counterpressure should be applied at the calcaneocuboid joint
because the entire foot must be abducted under the talus. The cavus and
adduction are corrected by slight supination of the forefoot in relation to the
hindfoot.
The forefoot is never everted; rather, it is displaced as a unit.
Tachdjian's Pediatric Orthopaedics, 4th edition, 2008, Herring,J. A. MD

O perative Treatm ent

The objectives of club-foot surgery are:

(1) the complete release of joint tethers

(capsular and ligamentous contractures
and fibrotic bands);
(2) lengthening of tendons so that the foot
can be positioned normally without undue
tension.
Apleys System of Orthopaedics and Fracture, 2010 Solomon, Warwick,
Nayagam

Congenitaltalipes equinovarus treatm ent Firstline treatm entis non-operative.This m ay be by

m anipulation and strapping (a) or serialcasting (b). Ifinsuf c
i
fientcorrection is achieved,a form alopen
release m ay be needed (c).Severe relapses need m ore radicalform s oftreatm entsuch as the Ilizarov
fi
xator (d).A fter successfulcorrection ofdeform ity,relapses m ay be prevented by using Dennis Brow ne
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LATE O R RELAPSED CLU B-FO O T

Late presenters often have severe deformities with

secondary bony changes, and the relapsed clubfoot is complicated by scarring from previous
surgery.
Calcaneal osteotomies, in the form of lateral closing
wedges or lateral translations, improve heel varus.
The distorted anatomy makes triple arthrodesis a
real challenge but it is possible to end up with a
plantigrade, stable and pain-free foot.
Apleys System of Orthopaedics and Fracture, 2010 Solomon, Warwick,
Nayagam

Thank You