CTEV (Congenital Talipes Equino Varus) Treatment

What is Clubfoot:

Club foot is also known as Talipes Equino Varus. It is a common condition, in which new born feet points medially and downward. This condition is diagnosed at birth. More common in males than females. Incidence is 1 per 1000 live birth.

Types of Clubfoot:

Club feet can be classified in three different ways –

Etiological:

1) idiopathic, 2) neurological 3) syndromic (related to an underlying syndrome)

Severity wise:

1. Postural CTEV 2. Structural CTEV

Idiopathic:

1-benign (postural) feet, 2- moderate feet 3- stiff feet 4- very sever stiff- stiff feet

Signs and Symptoms of Clubfoot:

1. One or both feet in new born
2. Stiff, rigid foot deformity
3. High heel due to short tendoachilis
4. Heel and fore foot both turned in with deep mid sole crease, small feet size
   

   Causes of Clubfoot:

   Most of the time, causes are not known. But sometimes, they can be a part of a syndrome in which many other systems of the body are affected. In mild variety, it may be due to intrauterine compression; otherwise, usually in moderate to severe variety is because of shortening of muscle, capsule, and bony deformity.

How to Prevent Clubfoot:

We can’t prevent the occurrence of ctev because it occurs because of unknown reasons and some time by genetic issues.

How to Treat Clubfoot:

A few decades back, many methods of treatment were in practice, but results were not so good, and recurrence was very common. Earlier, most of the club feet need surgery. This is because surgery in the club foot gives stiffness to the joint. With the invention of the Ponsetty concept of manipulation & plaster application, the success rate became much higher, chances of recurrence became less. Now irrespective of age, most CTEV feet can be managed successfully with the Ponsetty concept of plaster application. Now big surgery is needed rarely. Clubfeet, even in elder children, can be managed by the use of the Ponsetty plaster technique. If they need surgery, then they need minor surgery only.

• Ponsetty technique of Plaster Application: In the Ponsetty technique, we correct the deformity of the foot in a specific sequence. The first correction is varus, then adduction and equinus in the last. Four to six plasters are needed at 7-10 days intervals in most of the club foot. In the end, Tenotomy of heel card & 1-month plaster is needed to treat equinus deformity. After removal of plaster abduction, a specific foot brace is being given.

• Brace: After complete correction of foot deformity by Ponsetty plaster, we need to protect the foot from recurrence by a special brace. It keeps the foot in the outside direction of 60 degrees. For maintenance of this angle, both feet need to be fixed in the brace. Distance between both shoes will be equal to the distance between both shoulders of a child. This brace needs to be wear for 1.5 years to 2 years. Daily cleaning of shoes is mandatory. The brace needs to be changed as the child’s foot size increases. In this maintenance phase, massage, plantar stimulation, and some exercise have to be continued.

• Surgery: earlier most of the time, club feet need surgery, but results were not good due to recurrence and stiffness. Nowadays, with the use of the Ponsetty plaster technique, only minor surgery is needed in most cases.

• Percutaneous TA Tenotomy: In the Ponsetty concept of CTEV correction, we do percutaneous Tenotomy of heel card. This procedure is being done as an OPD procedure, and plaster will be given for four weeks. With this surgery, the heel position became better.

• Tibialis anterior tendon transfer: If the child has a recurrence of forefoot Varus, then the anterior tibialis transfer is being done. In this surgery tibialis anterior tendon releases from the base of 1st metatarsal base on the medial side and reattachs to the center of the foot. This tendon transfer balances the muscle power in the foot by which chances of recurrence decrease.

• Double osteotomy: If the front part of the foot has deviated medially. The length of the medial border of the foot is shorter than the lateral border. Then, in this case, bone is removed from the lateral side of the foot (cuboid) and placed on the medial side of the foot (medial cuneiform)

• Planter fasciotomy: If the plantar fascia is tight and there is severe caves deformity then release of the plantar fascia is required. This surgery is being utilized in elder children before applying plaster.

Complication of Clubfoot:

CTEV, as per say don’t cause crate any trouble except a progressive increase in deformity if not managed initially. If not managed, then the child will learn to stand and walk with a deformed foot. With an increase in age and weight, foot deformity can progress to extent that child can have pain, abnormal walking pattern, and shoe wear and tear

CTEV Treatment Options:

The main goal of ctev treatment is to correct the way your child’s foot looks and works before your child learns to walk. ctev treatment start as child born. In the past, very few ctev treatments were there to fix this condition.Postural CTEV is self revolving, but sometimes massage, stretching & manipulation may be required. Other stiff & rigid variety need manipulation and plaster application. Universal ctev treatment process is the Ponsetty methods of manipulation and repeated plaster application for 5-6 times at 7-10 days interval followed by Percutaneous tenotomy & plaster for 1 month. The child has to wear special shoes (Dennis brown splint) day and night till the age of 18 months. Some they need to wear for a longer time. Stretching exercise, planter stimulation, and oil massage are also advised to continue till the child start walking.

Final Outcome: 

Most of the CTEV can have completely normal feet if correct methods of manipulation, precaution, Longer and persistent use of brace with strict follow-up. Recurrences are common with very stiff and syndromic club feet & the feet of child where strict guideline of wearing shoes were not followed. Recurrence will be of a milder variety if reported early and again can be corrected with same methods of Ponsetty plaster technique. In some cases, these CTEV feet require surgery in the form of muscle joint release, but it is not preferred now due to fear of stiff foot post-operatively. Now a days recurrence are being manage by tendon transfer, osteotomy with before, and afterward plaster application.

Reference Links :

• https://en.wikipedia.org/wiki/Clubfoot
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1571059/
• https://www.mayoclinic.org/diseases-conditions/clubfoot/symptoms-causes/syc-20350860
• https://global-help.org/products/clubfoot_ponseti_management/

Frequently Asked Questions