Congenital Talipes Equinovarus [CTEV] Or Club Foot
Club foot or CTEV is congenital foot deformity present since birth characterized by equinus of the hindfoot & adduction of the midfoot & forefoot with varus through the subtalar joint complex (foot turned inwards and facing upwards).
Cavus deformity usually accompanies most of the club foot and it occurs through the midfoot.
The exact cause is unknown; however, there are many proposed theories.
Multifactorial & modulated significantly by developmental aberration early in limb bud development.
The main proposed theories include arrest in embryonic development, myofibroblastic retractile tissue in the medial ligament, and primary germplasm defect in the cartilaginous talar anlage producing the dysmorphic neck and navicular subluxation.
Baby is brought by parents or caregivers to a pediatric orthopedic surgeon with deformity of unilateral or bilateral feet since birth.
It is important to examine the baby as the whole, not just extremity, to make a proper diagnosis of CTEV.
Foot lies in equinovarus but it is flexible and fairly easily corrected by manual pressure in postural CTEV whereas foot is a more rigid and partial or slight correction of the deformity is possible in other types of CTEV.
The severity of foot deformity is graded according to Pirani and Dimeglio score.
As in our resource-limited country child will not be brought to the hospital in the newborn period, the child will have callosities over the foot and walks on the lateral border of the foot.
The examination should include looking for spinal pathology, neurologic abnormality & any syndrome or associated condition
No specific investigation is needed to make the diagnosis of club foot.
There is no consensus on the role of radiography in the diagnosis & management of club foot.
Despite this limitation, x-ray evaluation of clubfeet is helpful in determining surgical planning & may also be helpful in the intraoperative evaluation of the correction of club foot deformity.
Treatment options depend on age at presentation to Pediatric Orthopedic Surgeon.
Treatment should be started as soon as possible after birth; earlier the treatment is begun the more likely that it will be successful because of the relative visco-elastic character of the newborn foot.
Non-operative means should be used to correct & immobilize the foot in the neonatal period.
Operative treatment is desirable if conservative means fail or in children too old to benefit from conservative treatment.
Conservative methods are the initial treatment of choice. Repeated passive stretching such as was first advocated by Hippocrates is both safe & effective and the correction obtained at each manipulation can be maintained by plaster cast or adhesive strapping, especially in the neonatal period. Non-operative treatment proposes to gradually correction of the deformity. Well established, time tested, and scientifically accepted Ponseti casting is followed.
According to at age presentation, treatment option can be categorized as follows –
From birth to 2 years – Serial Corrective plaster followed by brace application
3 to 5 years – Soft tissue release with a bony procedure
6 to 12 years – External fixator (Ilizarov or JESS) assisted correction
Above 12 years – Ilizarov assisted correction or triple arthrodesis
Recurrence of deformity is an important matter of concern.
Risk factors for recurrence of CTEV are non-compliance with brace, neurogenic, or syndromic CTEV.
Recurrence can be prevented by strict adherence to bracing protocol and regular follow up till skeletal maturity.
Otherwise, the child should lead a normal life.