CTEV (Congenital Talipes Equinovarus) — 10 Marks

Definition

• Cavus (high medial longitudinal arch)
• Adductus of the forefoot
• Varus of the hindfoot
• Equinus of the ankle (Miller's Review of Orthopaedics, p. 8086)

Etiology (Multifactorial)

1. Idiopathic (most common, ~80%) — polygenic/multifactorial inheritance
2. Neurogenic — spina bifida, myelomeningocele, arthrogryposis
3. Syndromic — e.g., Larsen syndrome, diastrophic dysplasia
4. Positional/intrauterine — oligohydramnios, mechanical crowding
5. Associated with an absent or diminutive anterior tibial artery in true idiopathic clubfoot (Miller's Review, p. 8086)

Pathoanatomy

• Medial and posterior soft tissue contracture (tendo-Achilles, tibialis posterior, flexor tendons, deltoid and spring ligaments)
• Talus in equinus with medial deviation of its neck
• Navicular displaced medially and subluxated on the talar head
• Calcaneus in varus and equinus, rotated medially beneath the talus
• Forefoot adducted and supinated relative to the hindfoot

Clinical Features

• Present at birth; foot cannot be passively corrected to neutral
• Hindfoot varus and equinus, forefoot adduction/supination, deep medial crease, small heel that is difficult to palpate
• Calf atrophy (present even after correction)
• Foot appears shorter and internally rotated ("hooked" appearance)
• Assess for associated syndromes/neurological deficit — always examine the spine and hips

Severity Scoring

• Pirani score (0–6): six clinical signs (curved lateral border, medial crease, talar head coverage, posterior crease, rigid equinus, empty heel), each scored 0/0.5/1 — used to monitor progress with Ponseti casting
• Dimeglio score: more detailed, predicts number of casts required and difficulty

Investigations

• Largely clinical diagnosis
• Antenatal ultrasound can detect it in utero
• Radiographs (AP and lateral, in maximum correction) are of limited use in infants due to unossified epiphyses, but talocalcaneal angle (Kite's angle) can be assessed
• MRI/spinal imaging if an underlying neurogenic cause is suspected

Treatment

1. Conservative — Ponseti Method (Gold Standard)

• Started as early as possible, ideally within first 1-2 weeks of life
• Weekly gentle manipulation and serial above-knee plaster casting, correcting deformities in the CAVE sequence: cavus → adductus → varus → equinus (equinus last)
• Most cases require a percutaneous Achilles tenotomy at the end of casting to correct residual equinus (Miller's Review, p. 8086)
• After correction, a foot abduction brace (Denis Browne splint, boots and bar) is critical — worn full-time for ~3 months, then nights/naps until age 4-5 years, to prevent relapse (Miller's Review, p. 8086)
• Relapse is treated with a trial of recasting +/- repeat tenotomy before considering surgery

2. French (Physiotherapy) Method

• Daily manipulation, stretching, taping/strapping, and continuous passive motion using a machine; less commonly used, requires daily therapist input

3. Surgical Treatment (Reserved for resistant/relapsed/neglected cases)

• Indicated for failed conservative treatment, neglected clubfoot presenting late, or syndromic/neurogenic rigid clubfoot
• Posteromedial soft tissue release (Turco procedure) — releases tendo-Achilles, posterior ankle capsule, tibialis posterior, and medial structures
• Complete subtalar release (Carroll/McKay)
• In older neglected children: Ilizarov correction, Dillwyn Evans procedure (lateral column shortening + medial release), or triple arthrodesis in adolescents/adults with severe fixed deformity
• Tendon transfers (e.g., tibialis anterior transfer to lateral cuneiform) for dynamic supination deformity/relapse in older children

Complications

• Relapse/recurrence (most common — usually due to non-compliance with the abduction brace)
• Overcorrection ("rocker-bottom" or flat-top talus deformity)
• Residual forefoot adduction or supination
• Stiffness, pain, and degenerative changes in adulthood if untreated (neglected clubfoot)
• Growth disturbance from extensive surgical release (scarring, avascular necrosis of talus)

Prognosis

• Excellent with early Ponseti treatment and brace compliance — >90% success rates reported
• Neglected/untreated clubfoot in adults leads to significant disability, callosities over the dorsolateral foot (weight-bearing surface), and difficulty with footwear