Ctev

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CTEV (Congenital Talipes Equinovarus) is clubfoot - a common congenital deformity characterized by plantar flexion (equinus), inversion (varus), and adduction of the foot. Let me search the medical library for detailed coverage.

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CTEV - Congenital Talipes Equinovarus (Clubfoot)

Definition

CTEV is a congenital deformity of the foot characterized by a combination of four components, remembered by the mnemonic CAVE:

Component	Description
C - Cavus	High arch (plantar flexion of forefoot on hindfoot)
A - Adductus	Adduction of the forefoot
V - Varus	Varus of the hindfoot
E - Equinus	Plantar flexion at the ankle

Epidemiology

Boys affected twice as often as girls
50% of cases are bilateral
Incidence: ~1-2 per 1,000 live births

Etiology

Majority idiopathic - genetic cause strongly suggested
Key genetic pathway: PITX1-TBX4 transcriptional pathway
Associated conditions:
- Arthrogryposis
- Myelomeningocele
- Diastrophic dwarfism
- Prune-belly syndrome
- Tibial hemimelia
- Streeter dysplasia (hand anomalies)
- Other neuromuscular/syndromic conditions

Pathoanatomy

Talar neck deformity - medial and plantar deviation of the talar neck
Medial rotation of calcaneus
Medial displacement of navicular and cuboid
Shortening/contracture of:
- Intrinsic foot muscles
- Achilles tendon
- Tibialis posterior
- Flexor hallucis longus (FHL)
- Flexor digitorum longus (FDL)
- Joint capsules, ligaments, and fascia
Associated with absence or diminutive anterior tibial artery

Radiographic Findings

Radiographs are of limited use in infants due to minimal ossification. When used:

Radiographic evaluation of clubfoot - note parallelism of talus and calcaneus in B (clubfoot) vs. normal foot in A

Fig. 3.20 - (A) Normal foot. (B) Clubfoot showing "parallelism" of talus and calcaneus.

Measurement	Normal	Clubfoot
Talocalcaneal angle (AP/Kite angle)	20-40°	< 20° (parallelism)
Talocalcaneal angle (lateral/Turco - dorsiflexion view)	~35°	< 35°
Talus-1st metatarsal angle (AP)	0-20°	Negative

The key X-ray finding is parallelism of the talus and calcaneus (normally they diverge).

Treatment

1. Ponseti Method (Gold Standard - First Line)

Serial weekly manipulation and casting using long-leg plaster casts.

Order of correction follows CAVE (same mnemonic, but correction sequence):

Cavus - corrected first by supinating the forefoot and dorsiflexing the first ray
Adductus - corrected using lateral pressure on distal talar head as a fulcrum
Varus - corrected simultaneously with adductus
Equinus - addressed last (after varus is fully corrected to avoid rocker-bottom deformity)

Key steps:

~90% of patients require percutaneous Achilles tendon lengthening (tenotomy) to address hindfoot equinus
Last cast placed in 70° of abduction
Treatment typically complete in 1-5 months

2. Foot Abduction Brace (FAB) - Mandatory Post-Casting

Full-time wear for 3 months post-casting
Then during naps and nighttime for 3 years
Brace non-compliance is the #1 cause of recurrence
No impairment in athletic ability after successful treatment

Complications of Treatment

Complication	Cause
Recurrence / undercorrection	Most common; strongly associated with brace non-compliance
Rocker-bottom deformity	Attempting to dorsiflex hindfoot before varus is corrected
Flat-top talus	Aggressive dorsiflexion causing flattening of the talar dome
Dorsal bunion	After clubfoot surgery; tibialis anterior + FHB/abductor hallucis

Operative Treatment

Reserved for only ~5% of idiopathic clubfeet (resistant/refractory cases):

Posteromedial soft tissue release (PMSTR): tendon lengthening + subtalar, tibiotalar, and talonavicular release
- Must protect posterior tibial artery (dorsalis pedis often insufficient)
- Used in severe disease or when treatment initiated after 9 months of age
Older children (3-10 years): medial opening-wedge or lateral column-shortening osteotomy, or cuboidal decancellation for persistent adductus
Late presentation: Triple arthrodesis
- Contraindicated in insensate feet (risk of ulceration from rigidity)

Recent Evidence (2024-2026)

Recent systematic reviews confirm the Ponseti method as the standard of care:

A 2024 systematic review (PMID 39365806) found Ponseti method is also effective for myelodysplastic (non-idiopathic) clubfoot.
A 2026 meta-analysis (PMID 40888800) compared Plaster of Paris vs. semirigid fiberglass casting - POP remains the reference standard.
A 2024 systematic review (PMID 39134994) examined anterior tibial tendon transfer fixation techniques for dynamic supination relapse.

Sources: Miller's Review of Orthopaedics, 9th Ed., p. 282; Schwartz's Principles of Surgery, 11th Ed., p. 1946

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