Summary

Congenital Talipes Equinovarus (CTEV), or Clubfoot, is the most common congenital deformity of the foot (1:1000). It is a complex 3D deformity characterised by CAVE (Cavus, Adductus, Varus, Equinus). The pathology lies in the medial dislocation of the navicular and calcaneus around the talus, held tight by contracted posteromedial soft tissues. Treatment has been revolutionised by the Ponseti Method (Serial manipulation and casting), which is >95% successful and avoids extensive surgery. Maintenance involves wearing "Boots and Bar" bracing until age 4. [1,2]

Key Facts

• Definition: Fixed deformity of Cavus, Adductus, Varus, and Equinus.
• Incidence: 1 per 1000 live births.
• Gender: Male > Female (2:1).
• Laterality: 50% Bilateral. If unilateral, the affected foot is always slightly smaller.
• Treatment: Ponseti Method (Gold Standard).

Clinical Pearls

"CAVE": The order of the deformity AND the order of correction.

1. Cavus (High arch). Corrected by supinating the forefoot (Lifting the 1st Metatarsal).
2. Adductus (Forefoot in).
3. Varus (Heel in). (Adductus and Varus are corrected together by Abduction).
4. Equinus (Ankle down). Corrected LAST by Tenotomy.

"Don't Touch the Heel": In the Ponseti method, you NEVER touch or squeeze the heel (calcaneus). You apply correction by pushing the head of the talus (lateral side) and abducting the forefoot. The heel corrects itself automatically.

"Golden Period": Treatment should start within 1-2 weeks of birth while the ligaments are stretchy (maternal relaxin effect). However, Ponseti can work even in older children/neglected cases.

"Rule out Neurological": A unilateral, rigid clubfoot can be the first sign of Spina Bifida (tethered cord). Always examine the spine!

        DIAGNOSIS (Confirm Idiopathic)
                    ↓
        WEEKLY CASTING (Ponseti)
    1. Elevate 1st Ray (Correct Cavus)
    2. Abduct around Talus (Correct Add/Varus)
       (Usually 4-6 casts per week)
                    ↓
        IS DORSIFLEXION POSSIBLE?
        ┌───────────┴───────────┐
      YES (>10 deg)            NO
       │                        ↓
       │            TENOTOMY (Percutaneous)
       │            (Cut Achilles Tendon)
       │            (+ Final Cast 3 Weeks)
       │                        │
       └───────────┬────────────┘
                   ↓
        FOOT ABDUCTION BRACE (FAB)
        (Boots and Bars)
        - 23hr/day for 3 months
        - Night/Nap for 4 years

The Ponseti Technique (Step-by-Step)

1. First Cast: Supinate the forefoot! This aligns the forefoot with the varus hindfoot (unlocks the midfoot). It looks like you are making the deformity worse, but you are correcting the Cavus.
2. Subsequent Casts: Abduct the foot while putting counter-pressure on the Lateral Talar Head. This rotates the calcaneus out of varus.
3. Achilles Tenotomy: Performed under local anaesthetic in clinic. A tiny nick into the tendon. It snaps (audible). A cast is applied immediately in full dorsiflexion. The tendon heals in the elongated position (Gap fills with tendon tissue, not scar) in 3 weeks.

Orthotics (Boots and Bar)

• Purpose: Prevents recurrence (the soft tissues want to shrink back).
• Protocol: 23 hours a day for 3 months. Then nights/naps until age 4.
• Compliance: The #1 cause of failure. If they don't wear it, it comes back (90% recurrence).

Surgical Options (If Ponseti Fails)

• Posteromedial Release (PMR): "Turco Procedure". Extensive soft tissue release. High risk of stiffness and pain later in life. Rarely done now.
• Tibialis Anterior Transfer (TAT): If the child relapses at age 3-4 (Dynamic Supination). The tendon is moved to the middle of the foot to act as a dorsiflexor.

Before Ponseti (1990s), most clubfeet had big operations (PMR). Long term studies showed these feet became stiff, painful, and arthritic by age 30. Ponseti proved that gradual stretching induces biological remodelling of the collagen (Creep), resulting in a supple, pain-free foot. Surgery is now considered a failure of treatment.

Key Studies

1. Ponseti (1963): Determining the correct kinematics.
2. Dobbs et al. (2004): Long term follow up showing Ponseti feet function better than Surgical feet.
3. Pirani: Validated the scoring system.

What is Clubfoot?

The tendons on the inside and back of the foot are too short and tight. They pull the foot inwards and downwards.

Will my baby walk?

Yes! With proper treatment, your child will run, play sports, and wear normal shoes. You won't even notice the limp.

Do we need surgery?

No. We use a series of plaster casts to gently stretch the tight ligaments. It's like straightening a crooked tree sapling - gentle pressure over time works better than chopping it.

Why the boots?

The foot has a "memory". It wants to curl back up. The boots hold it straight while the foot grows. It is harder for you (the parents) than the baby - they get used to it. Sticking to the boots is the most important thing you can do.