CTEV

(ConGenital Talipes
EquinoVarus)
 CTEV (ConGenital Talipes EquinoVarus)
• talipes equinovarus : talipes (talus:ankle; pes:foot)
and equinus (horse-like), and varus (inverted or
adducted)
• The main clinical sign of  congenital talipus
equinovarus are:
– Equinus (plantar flexion of the foot in the ankle joint)
– Supination (the plantar surface of the foot is turned
inward)
– Forefoot adduction (the anterior part of the foot is
displaced medially)
• occur in one of every 1000 live births, more commonly
in males, and occurs bilaterally in nearly 50 percent of
all cases, deformity is readily recognized,
Etiology

• Idiopathic Clubfoot: If the cause of Clubfoot is not known,

• Mechanical Theory: The rise in intrauterine pressure forces the foot
against the wall of the uterus in the position of deformity.
• Ischemic Theory: Ischemia (restriction of blood supply) of calf muscles
during intrauterine life due to some factors results in contractures and
finally resulting in deformities in the foot.
• Secondary Clubfoot
• Paralytic Disorders: In cases where there is muscle imbalance in cases
such as Polio, Spina Bifida and Myelodysplasia,
• Arthrogryposis Multiplex Congenita: This is a disorder of defective
development of muscles and these muscles are fibrotic and results in
deformities in the foot.
Classification

• Isolated (idiopathic) clubfoot is the most common form of

the deformity and occurs in children who have no other
medical problems.
• Nonisolated clubfoot occurs in combination with various
health conditions or neuromuscular disorders, such as
arthrogryposis and spina bifida.
• The clubfoot may be more resistant to treatment, require a
longer course of nonsurgical treatment, or even multiple
surgeries.
Unilateral CTEV
• The affected foot is usually 1 to 1 1/2 sizes smaller and
somewhat less mobile than the normal foot.
• The calf muscles will also stay smaller, so your child may
complain of "sore legs" or getting tired sooner than peers.
• The affected leg may also be slightly shorter than the
unaffected leg, but this is rarely a significant problem
• Varus deformity of the heel
• Adduction of forefoot + some degree
plantarflexion and supination
• foot is fixed in a downward and inward
position.
• the talus is always deformed, with a
foreshortened talar neck that is always
medially and plantar deviated.
• The navicular also is medially and plantar
deflected.
• The joint capsules on the posteromedial portion of the foot
are contracted.
• The tendons on the posteromedial aspect of the foot
(Achilles tendon, flexor hallus longus, flexor digitorium
longus, abductor hallucis, posterior tibial tendon, plantar
fascia, and short toe flexors) are also contracted.
untreated clubfoot
• walk on the outer edge of the foot instead of the sole,
• develop painful calluses,
• be unable to wear shoes,
• and have lifelong painful feet that often severely limit
activity.
Diagnose
• Diagnosis is easy in cases where symptoms are evident
soon after the birth.
• Then the talocalcaneal angle (the angle between the bones
talus and calcaneum) is less than 35 degrees confirm by X
ray, it confirms the presence of Clubfoot.
The goal of treatment

• a foot that “looks” like a foot,

• “acts” like a foot,
pain-free foot with a substantial weight-bearing surface
(plantigrade) clubfoot will not get better on its own.
With treatment, → have a nearly normal foot, and he or she
can run and play and wear normal shoes.
Treatment
• There is no medication,
• stretching program, or orthotic that will overcome the stiffness in a
true congenital idiopathic clubfoot.
• Serial casting followed by orthotic control after correction, or
• casting + surgical releases with or without postoperative orthotics,
form the hallmark of treatment.
• With or without treatment the foot will always be smaller in size
and the calf will always be thinner than normal.
• clubfoot will not get better on its own. With treatment, children
should have a nearly normal foot, and he or she can run and play
and wear normal shoes.
 Ponseti treatment
• Manipulation and casting. foot is gently stretched and manipulated into
a corrected position and held in place with a long-leg cast (toes to thigh).
The displaced bones are gradually brought into correct alignment.
• Each week this process of stretching, re-positioning, and casting is
repeated until the foot is largely improved.
• weekly plaster changes, 5 to 8 casts are generally required.
Ponseti treatment
• The foot was markedly abducted up to 70 degrees without pronation
(combined movements of abduction, extension and eversion of the
foot) in the last cast, → complete correction and it prevent early
recurrence.
• If the varus deformity of the heel had been corrected and residual
equinus was observed after the adduction of the foot →percutaneous
Achilles tenotomy was performed
• After the tenotomy, an additional above knee cast with knee flexed in
90 degrees was applied and left in place for three weeks to allow for
healing of the tendon.
• After removal of the cast, a Denis-Browne bar and shoes (D-B splint)
was used to prevent relapse of the deformity.
Achilles tenotomy
• minor procedure to release continued tightness in the
Achilles tendon (heel cord) after manipulation and casting
• A new cast will be applied to the leg to protect the tendon
as it heals. This usually takes about 3 weeks.
• By the time the cast is removed, the Achilles tendon has
regrown to a proper, longer length, and the clubfoot has
been fully corrected.
Boots and bar
• To ensure that the foot will permanently stay in the correct
position, → need to wear a brace (commonly called "boots
and bar") for a few years.
• The brace keeps the foot at the proper angle to maintain
the correction →essential to prevent relapses.

The Markell Abduction Brace. The Mitchell Abduction Brace.

• connecting the feet horizontally at the desired angles to the
Sagittal plane
• “the desired angles,” : external rotations of 20-degrees for
unaffected feet and up to 90-degrees for club-feet.
• original brace included an L-shaped bracket to hold the foot,
“bending up one side to clear the external malleolus and
bear against the outer side of the leg.”
• The foot is also described by Browne to be held in significant
dorsiflexion, connected to the bar via “sticking-plaster” for
babies, and open-toe straight last boots for walking children.
• consists of two shoes connected by a bar.
• If the deformity is unilateral, the external rotation on the affected
foot should be set to 60/70° and on the unaffected foot to 30/40°.
• The bar should be of the length between the child's shoulders and
should be bent to allow for 10-15° of dorsiflexion.
• the bar can be lengthened over time as the child grows.
• The shoes should be comfortable and straight laced (no curves
and can fit both feet).
• To increase the ease and adherence of use, a brace with shoes
that can clip into and out of the bar seems to be preferred by the
parents.
Denis-Browne Bar (foot abduction
orthosis)
• The bar, not the shoes, is the main workhorse of this
treatment and must be used at all times.
• This is best accomplished with the feet in well-fitted, open-
toed, medial bar, high-top straight-last shoes attached to
Denis-Browne bar.
• The shoes allow for the bar to be attached to the feet so the
foot/feet can be rotated outward, maintaining the correct
alignment of the pre-bone cartilage as the foot grows.
• In treatment for rotation deformities, the length of the bar
should not exceed the width of the pelvis.
 Denis Browne Brace
• After a further 3 weeks in plaster, the feet must
then be held in an over-corrected position by a
‘boots and bar’ brace.
• consists of open-toed sandals connected by a
metal bar, with the feet held in a turned-out
position.
• The brace is worn continuously (day and night) /
for 23½ hrs per day for 3 months,
• The 30minutes without the boots and bar are for the
baby to have a bath and a kick around.
• then just at night (12 to 14hrs) until the child is
around 5 years old.
• The long-term success depends on how well the
boots and bar routine is followed
 types of braces

• all of which consist of shoes, sandals,

or custom-made footwear attached
to the ends of a bar.
• The bar can be solid (both legs move
together) or dynamic (each leg
moves independently).

The Dobbs Dynamic Abduction Brace.

The Iowa Orthopaedic Journal The University of IowaBRACING IN THE TREATMENT OF CHILDREN WITH
CLUBFOOT: PAST, PRESENT, AND FUTURE Lajja Desai, BSE, Florin Oprescu, MD, PhD,and Jose A
Morcuende, MD, PhD.
The Steenbeek brace
• developed in Uganda by Michiel Steenbeek and David Okello
• made with local tools (leather sewing machine, metal-working equipment,
welding tools) and materials (leather, lining, plywood, mild steel rod stock)
.
• The cost is under 10 US dollars and matches the recommendations
provided by Dr. Ponseti.
Kessler Brace
• follows the angles
recommended by the Ponseti
method,
• the bar has some flexibility to
allow the child some ability for
plantar flexion during kicking.
• The bar returns to the original
dorsiflexed position once the
child stops kicking
The ALFA-Flex shoe
• FAB produced in Europe
• large focus on the comfort and fit of the shoe.
• It uses non-toxic and biocompatible materials
• An “intelligent” foam mould for the shoe allows a close, firm fit for the
child's foot and provides proper distribution of pressure in the brace.
• The foam material has both viscous and elastic components. The shoes
are easy to put on due to step-in straps.
The Dobb's Dynamic Clubfoot Brace
• a bar that allows the child to
move both legs independently
and shoes that reduce heel
friction,
• however due to the articulation
design, dorsiflexion may be
difficult to achieve
• The bar component can also be
attached to Markell, Mitchell or
custom made shoes.
 CTEV shoes
• used once a child starts walking.
• -Straight inner border to prevent
forefoot adduction.
• -Outer shoes raise to prevent foot
inversion.
• -No heel to prevent equinus.
• This shoes are used until the child is
5 years old.
• Ctev shoes in the day, DB splint in
the night
How To USe
• Put the shoes on first and then attach the bar.
• Make sure the heel is down in the back of the shoe and then
fasten the strap securely. Check that the toes are not curled
underneath the foot.
• Make sure the laces fasten firmly all the way up the foot.
• If the baby manages to pull his/her heel out of the shoe, the toes
will be less visible. Remove the shoe and put it on again, making
sure that the heel is down and the strap and laces securely
fastened.
• The skin around the feet must be carefully checked and if blisters
or rubbing occur
Prevent Escapes
• In boots or sandals with a single strap, tighten it by one more hole,
using your thumb to hold the foot and tongue in place. In boots with
multiple straps, tighten the middle one first, using your thumb to hold
the foot and tongue in place.
• Try double socks. In boots with a removable insert, place one sock
directly over the foot, and a second sock over the insert to help take
up excess room.
• Remove the tongue of the shoe — this will not harm your child.
• Try lacing the shoes from top to bottom, so that the bow is by the toes.
• Use 40-inch round shoelaces.
• Try thinner or thicker cotton socks, or the ones with non-slip soles.