2. CLUBFOOT
 VAGUETERM USEDTO DESCRIBE A
NUMBER OF DIFFERENTABNORMALITIES
INTHE SHAPE OFTHE FOOT
 NOW IT HAS COMETO BE SYNONYMOUS
WITH THE COMMONEST CONGENITAL
FOOTABNORMALITY i.e., CTEV

3. ANATOMY

5. ANATOMY-JOINTS
 ANKLE JOINT :TIBIA ANDTALUS
 SUBTALAR JOINT :TALUS AND CALCANEUM
 TALONAVICULAR JOINT
 CALCANEO- CUBOID JOINTS

6. ANATOMY
 TENDONS
 TIBIALIS POST
 FLEXOR DIG. LONGUS
 FLEXOR HALLUSIS LONGUS

7. ANATOMY
 LIGAMENTS
 DELTOID L. : MEDIAL COLLATERAL LIG. OF ANKLE
 SPRING L. : CALCANIUM – NAVICULAR
 CAPSULAR L. :T – N , N – C , C – M
 PLANTAR L. :LONGITUDINAL ARCH OF FOOT

8. NOMENCLATURE
Planus: flatfoot
Cavus: highly arched foot
Varus: heal going towards
the midline
Valgus: heel going away
from the midline
Adduction: forefoot going
towards the midline
Abduction: forefoot going away
From the midline

9. CLUB FOOT

10. CLUB FOOT
Definitions
Talipes: Talus = ankle
Pes = foot
Equinus: (Latin = horse)
Foot that is in a position of
planter flexion at the ankle,
looks like that of the horse.
Calcaneus: Full dorsiflexion at the ankle

11. CLUB FOOT
Types
 Idiopathic (Unknown Etiology) :
 CongenitalTalipes Equino-Varus CTEV
 Acquired, Secondary to :
 CNS Disease : Spina bifida, Poliomyelitis
 Arthrogryposis Multiplex Congenita
 Absent Bone : fibula / tibia

12. CTEV
 MOST COMMON CONGENITAL FOOT DISORDER
 MALES
 1/1000 LIVES BIRTHS

13. TYPES
 OSSEOUS : absent tibia / fibula
 MUSCULAR : AMC
 NEUROPATHIC : spina bifida
 IDIOPATHIC
 CLASSIFICATION : Ponsetti
 Supple
 Rigid
 Teratologic

14. CLASSIFICATION
 EXTRINSIC
 FLEXIBLEWITH ABNORMAL BONE RELATION
 WITHOUT MARKED FIBROSIS
 CONSERVATIVETREATMENT
 INTRINSIC
 RIGIDWITH ABNORMAL BONE RELATION
 MARKED FIBROSIS
 OPERATIVETREATMENT

15. THEORIES OF CTEV
 TURCO’S : medial displacement of navicular and
calcaneous around talus
 BROCKMAN’S : congenital atresia of theT – N joint
 Mc- KAY’s :3-D bony deformity of the subtalar complex
 INTRAUTERINE:compression by malpositon of fetus in utero
 Germ plasm theory
 Soft tissue theory
 Prenatal muscle imbalance theory

16. PATHO-ANATOMY
 BONES AND JOINTS
 CALCANEUS : INVARUS POSITION
 TALUS : DISPLACED MEDIAL AND PLANTARWARDS
 NAVICULAR : MEDIALLY DISPLACED AND ROTATED
 CUBOID : DISPLACED MEDIALLY AND ARTICULATES
WITHTHE NON-ARTICULAR SURFACE
OF CALCANEUM ( CUBOID SIGN /
LOCKED CUBOID )
 METATARSALS : DEVIATES MEDIALLY ATT-M JOINTS
 DISLOCATION OFTALOCALCANEAL ARTICULATION
 TIBIA – MEDIALTORSION

17. PATHO-ANATOMY
 BONESAND JOINTS
 EQUINUS - ANKLE JOINT
 INVERSION - SUBTALAR JOINT
 FOREFOOT ADDUCTION - MIDTARSAL JOINTS
 FOREFOOT CAVUS – EXCESSIVE ARCHING
AT MIDTARSAL JNTS

18. PATHO-ANATOMY
 MUSCLES CAPSULESAND LIGAMENTS
STRCTURES CONTRACTED ONTHE MEDIAL SIDE
3 MUSCLES
• AHL
• TP
• FHL
3 LIGAMENTS
• DELTOID
• SPRING
• PLANTAR
3 CAPSULES OF
• SUBTALAR
• TARSAL
• TARSOMETATARSAL

19. 2 MUSCLES
• TIBIALIS POST.
• TENDO-ACHILLES
2 LIGAMENTS
• TALOFIBULAR
• CALCANEOFIBULAR
2 CAPSULES OF
• ANKLE JNT
• SUBTALAR JNT
PATHO-ANATOMY
 MUSCLES CAPSULESAND LIGAMENTS
STRCTURES CONTRACTED ONTHE POSTERIOR SIDE

20. 1 MUSCLE
• TIBIALIS ANT.
1 LIGAMENT
• SUPERIOR
PARONEAL
RETINACULA
1 CAPSULES
• CALCANEO-
CUBOID JNT
PATHO-ANATOMY
 MUSCLES CAPSULESAND LIGAMENTS
STRCTURES CONTRACTED ONTHE ANTERIOR SIDE

21. PATHO-ANATOMY
 SKIN
 Adapts shortening on the medial side
 Deep creases on the medial side
 Dimples on the lateral aspect
 SECONDARY CHANGES
 Occurs when the child starts walking-exaggerates the
deformity
 Callosities and bursae

22. CLINICAL FEATURES
 COMMON PRESENTATIONS
 Detected at birth
 Infancy and early child hood
 Late childhood

23. CLINICAL FEATURES
 Short Achilles tendon
 High and small heel
 No creases behind Heel
 Abnormal crease in middle of the foot
 Foot is smaller in unilateral affection
 Callosities at abnormal pressure areas
 Internal torsion of the leg
 Calf muscles wasting
 Deformities don’t prevent walking

24. CLINICAL FEATURES
 Seek a detailed family history of clubfoot or
neuromuscular disorders, and perform a general
examination to identify any other abnormalities.
 Similar deformities are seen with myelomeningocele
and arthrogryposis.Therefore, always examine for
these associated conditions.

25. CLINICAL FEATURES
 DORSIFLEXION TEST :
 PLUMBLINETEST : tibial torsion
 child is made to sit on a table with both LL hanging from the
edge.
 Line drawn from the centre of the patella to the tibial tubercle
when extended down should cut the foot at 1st or 2nd
intermetatarsal space normally.- PLUMBLINE
 In CTEV , with medial rotation of tibia it cuts through 4th or 5th
space
 SCRATCHTEST – INFANTS
 MEDIAL SCRACTHTEST : FOOT EVERTS - PERONEALS
 LATERAL SCRACTHTEST: FOOT INVERTS - INVERTORS

26. INVESTIGATIONS
 RADIOGRAPHY
 APVIEW :angle formed b/w
 talus and calcaneum ( NORMAL 30-35) REDUCED
 Talus and metatarsals ( NORMAL 5 -15 )  -VE
Helps to asses angle of varus and forefoot adduction

27. RADIOGRAPHY
 LATERALVIEW - ANGLE FORMED B/W
 TIBIA AND CALCANEUM ( NORMAL 5- 15 )  -VE
 TALUS AND CALCANEUM ( NORMAL 20- 50) 
TO KNOWTHE EXTENTOF EQINUSANDVARUS DEFORMITY
 CT , MRI , ARTHROGRAPHY

28. MANAGEMENT
The goal of treatment for clubfoot is to obtain a plantigrade foot
that is functional, painless, and stable
A cosmetically pleasing appearance is also an important goal
 CONSERVATIVE
 SURGICAL
 EXTERNAL FIXATORS

29. CONSERVATIVE
 INFANTS (< 6 MONTHS)
 1ST 6WEEKS : SERIAL MANIPULATION AND CASTING
 Corrective casting
 First correction of adductus of midfoot
 Folowed by correction of inversion
 Finally correction of the equinus

30. Conservative management
Weekly serial manipulation and casting
Every weekly for 1st 6 week
Fortnightly till 6 months
Correction acheived Correction not achieved
Splint
day time
Phelp’s Brace
night time
Dennis Brown Splint
For 6 – 18 mothhs
CTEV shoes
( upto 4 years )
SURGERY EXT. FIXATOR
<4YRS STR
>4YRS STR+BONY
PROCEDURE

31. SURGICAL TRATMENT
Indications
 Late presentation, after 6 months of age
 Complementary to conservative treatment
 Failure of conservative treatment
 Residual deformities after conservative treatment
 Recurrence after conservative treatment

32. SURGICAL TREATMENT
 Soft tissue operations
 Release of contractures
 Tendon elongation
 Tendon transfer
 Restoration of normal bony relationship
 Bony operations
Usually accompanied with soft tissue operation
Types:
 - Osteotomy, to correct foot deformity or int. tibial torsion
 - Wedge excision
 - Arthrodesis (usually after bone maturity)
 one or several joints
 - Salvage operation to restore shape

33. P M S R
POSTERO MEDIAL SOFTTISSUE RELEASE ( 6-12 months )
 TURCO’S PROCEDURE
 On the posterior Side
 Z- plasty of tendo – Achilles
 Posterior capsulotomy of ankle and subtalar jnt
 Release of posterior talo-fibular and calcaneo-fibular lig
 On the medial side
 Lenghtening ofTP , FHL, FDL
 Release of talonavicular lig., spring lig., superficial part of
deltoid lig.
 Release of interossious talocalcaneal lig, capsules of naviculo-
cuniform and 1st metatarsao-cuniform jnts

34. P M S R
 On the plantar side
 Plantar fascia release
 Release of AH , FDB
 Post – op regimen
 Change cast at 2 weeks
 Remove K wire at 6 weeks
 Long leg cast for 3 months
 Ankle foot orthoses for 6- 9 months

35. LIMITED SOFT TISSUE RELEASE
 When only one component present
 Equinus – posterior release
 Adduction – medial release
 Cavus – plantar release

36. CIRCUMFERENTIAL RELEASE
 McKAY’s
 All structures on PMSR + lateral structures
 Superior peroneal retinaculam
 Inferior extensor retinaculam
 Dorsal calcaneo-cuboid lig.
 12 – 36 months
 Passively correctable deformity resulting from muscle
imbalance

37. RESISTANT CLUBFOOT
• >5YR. METATARSAL OSTEOTOMY
METATARSUS
ADDUCTUS
• <2- 3YR .modified McKey”s procedure
• 3- 10 yr
• Dwyer osteotomy
• Dilwyn –Evans operation
• 10-12 yr tripple arthrodesis
HIND FOOT
VARUS
• TendoAchillus lengthening + posterior capsulotomy sub
talar and ankle joint
• Lambrunidis triple arthrodesis
EQINUS

38. OPERATIONS
 TRIPPLE ARTHRODESIS(>10YRS)
 Lateral closed wedge osteotomy through subtalar and
midtarsal joints is done to fuse
 SUBTALAR
 TALONAVICULAR
 CALCANEOCUBOID
 TALECTOMY
 Severe uncorrected club-foot
 SURGERY FOR CORRECTION OFTIBIALTORSION
 >15deg should be corrected by derotation osteotomy

39. DILWYN-EVANS OPERATION
 Soft tissue release and calcaneocuboid fusion
 1st three stages : extensive soft tissue release
 Finally calcaneaocuboid wedge is excised
 Neglected or recurred foot in children of 4-8 yrs

40. EXTERNAL FIXATORS
 ILIZAROV’S EXTERNAL FIXATOR FRAME
 JOSHI’S EXTERNAL FIXATOR FRAME
 Allows gradual distraction
 Transfixing wires through
 Tibia, calcaneum ad metatarsals
 Distractors positioned
 Posteriorly, medially and laterally
 Frame completed by
interconnecting the components

41. TREATMENT IN ADULT PATIENT
 CUNIFORMTARSECTOMY
 Vertical wedge of bone , with its base laterally is
removed from
 Calcaneus – behind the metatarsal joints
 Cuboid – infront of the joint
 Curved wedge , with its base upwards and laterally
 from head and neck of talus

42. RETENSION OF CTEV CORRECTION
 DENIS BROWN SPLINT
 PHELP’S BRACE
 BELOW KNEEWALKING CALIPERS
 CTEV SHOES