CONGENITAL TALIPES EQUINOVARUS (CTEV)

Mayank Pushkar. BPT, MSAPT*

INTRODUCTION Congenital telipesequinovarus (CTEV) is a common congenital limb deformity involving one foot or both1. Congenital means a deformity that is present at birth, Telipes means simply the foot and ankle, and Equinovarus refers to position of the foot, which points downward and inward. CTEV is also known as Clubfoot. An estimated 30000 children born with CTEV every year in India2, although a rate of 1.24 or greater have been reported in UK. It is a common birth defect, occurring in about 1/1000 live births. Almost half of the cases of CTEV are bilateral. Male children are more affected than female children with a ratio of approximately 2:13. PATHOANATOMY The true clubfoot is characterized by different
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deformities- Equinus, Varus, Adductus and cavus4. The equinus deformity is present at the ankle joint, TCN joint and forefoot. The varus component occurs primarily at TCN joint and the hind foot is rotated inward. The adductus deformity takes place at the talonavicular and the anterior subtalar joints. The cavus component involves forefoot plantar flexion, which contributes to the composite equinus.

Fig- 1- Showing CTEV in both the foot. AETIOLOGY Genetic factors play an important role in

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inheritance of CTEV as a polygenic multifactorial trait5. Maternal Hyperthermia is also one of the causes for CTEV6, as maternal hyperthermia acts as adverse environmental factor in the sensitive period of intrauterine development. Mainly there are 3 broad categories responsible for CTEV deformity in newborn71. NEUROLOGICAL DAMAGE 2. MUSCULO-SKELETAL DEFORMITY 3. POSTURAL DEFORMITY 1.NEUROLOGICAL DAMAGE: Spina bifida overta with failure of development of the sacral part of the spinal cord but normal proximal development can results in an equinovarus deformity of the foot. 2. MUSCULO-SKELETAL DEFORMITY:

neural tube defect are some of the other causes of structural CTEV4. 2. POSTURAL CTEV: This type of CTEV is caused due to the compression in utero with the feet held in equionovarus position in final trimester. CLINICAL FEATURES OF CTEV Idiopathic clubfoot is characterized by a beanshaped foot prominence of the head of Talus, medial plantar cleft, deep posterior cleft, absence of normal creases over the insertion of tendon achilies, calcaneal tuberosity situated at a higher level and atrophy of calf muscle4. Three major components of deformities, those are, equinous, varus and adducts, are obvious on examination. Presence of other anomalies implies a non-idiopathic type of clubfoot. Hypertrophy of calf muscle is present and dorsiflexion and eversion are limited. Lateral malleolus is very prominent while the medial malleolus is buried in a depression because of the inversion at the subtalar joint. There is also exaggeration of longitudinal arch of the foot. ASSESSMENT OF CTEV

CTEV can results because of composite intrinsic pathology of muscle and the bone. There are varieties of other conditions which affectthe peripheral musculoskeletal tissues and cause an equinovarus deformity. 3. POSTURAL DEFORMITY: Some children born with equinovarus deformity of the feet, if they have been tightly packed in the utero with the feet fixed in an equinovarus position for some week prior to birth. TYPES OF CTEV

ANTENATAL DIAGNOSIS: The clubfoot can be diagnosed at 18-20 weeks of gestation with the advert of Ultrasound. Amniocentesis is made at < 20 weeks to check for the high incidence of associated genetic anomalies7,8. POSTNATAL DIAGNOSIS: The child as well as

1. STRUCTURAL CTEV: This type of CTEV is caused by genetic factors such as- a genetic defect with 3 copies of chromosome 18, which is known an Edward Syndrome. Compartment syndrome,

foot must be carefully assessed at birth. The early assessment of CTEV can be carried out by two methords9: 1. Photographic Assessment
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Larsens syndrome, congenital heart defect and

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2. Radiological Assessment 1.PHOTOGRAPHIC ASSESSMENT: Photograph of resting forefoot supination is recommended at birth. The focus of the camera is centred at the level of the ankle joint and an assistant holds the knee between finger and thumb and rotates the leg outward until the forefoot is superimposed upon the line of tibia. From the photograph it is then possible to measure an angle subtended by the forefoot on the line of the tibia (Fig. 2). Children with more than 90
0

CTEV is the correction of the deformity followed by maintenance of the in the corrected position. The management of CTEV can be conservative (Non-operative) method as well as operative depending on the severity of deformity and age of child. CONSERVATIVE TREATMENT The conservative method comprises of

manipulation with or without strapping or corrective plaster casts. The goal of physiotherapy management of CTEV consisted of short term and long term goals14. The short term goal is to correct the

of resting forefoot supination at birth were more resistant to surgical correction.

deformity so that ankle assumes plantigrade positioning by the time the child would be 3 months. The long term goal is to maintain the corrected ankle in the situ and follow up the maintained correction until the child start walking. MEANS OF PHYSIOTHERAPY

MANAGEMENT 1. Rhythmic and repeated gentle

manipulation10 Fig. 2- Showing the measurement of angle. 2.RADIOGRAPHIC ASSESSMENT: A standard lateral soft tissue radiograph of the lower leg can be used for the assessment of CTEV. But X-Rays are not routinely prescribed at birth as few bones in the foot are ossified4. Also there is not much of clinical use of radiographic assessment as it does not make any difference in management of CTEV. MANAGEMENT OF CTEV The main principle of the management of
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2. Strapping and Plaster of Paris 3. Education and instruction to the mother and/ or parents10 1. RHYTHMIC AND REPEATED GENTLE MANIPULATION: To provide gentle manipulation, the PT placed the knee at 900 of flexion to prevent the damage to the lower end of tibia and fibular epiphysis and the ankle joint. To correct the adduction, the soft tissue of foot is passively stretched as- the forefoot is uncurled so that it moves away from epsilateral heel i.e. forefoot

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abduction. To correct the inverted foot, the foot is turned such that the sole face outward i.e. eversion. Finally, to correct the equinus, the heel is cupped with the one hand from the front of the foot and an upward pressure is applied, which brings the ankle into dorsiflexion. The entire procedure is repeated 34 times in each foot. 2. STRAPPING AND PLASTER OF PARIS: This can be useful for fairly mild cases and should be started at birth. Strips of adhesive strapping are passed around the foot, up the side of legs, and over the top of the knee, to hold the foot in a corrected position. This is usually done weekly, followed by some manipulation by the physiotherapist. According to the International Clubfoot Study Group (2003), Kites, Ponsetis and Bensabels techniques have been approved as the standardized conservative regimes for the management of CTEV11. Kites Technique4: This technique was derived from the concept of three-point pressure. In this method, the manipulation can be started soon after birth. The forefoot is grasped and distracted while the other hand holds the heel. The counterpressure is applied over calcaneocuboid joint and the navicular is pushed laterally. The heel is everted as the foot is abducted. This is followed by application of slipper cast, which is extended to below the knee with the foot everted with gentle external rotation. Once the adduction and varus are corrected, then the foot is pushed into dorsiflexion to correct the equinous. The casts are changed every week. Following full correction, the foot are placed in a Denis Brown Bar. The average number of cast required for
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correction by this technique is 20.4. Ponsetis Technique4: In Ponsetis technique, first 2 casts are applied with the supination of forefoot so as to bring into alignment with the hind foot12. The third cast is applied with the forefoot abducted and simultaneous counterpressure over the head of talus. In the fourth cast, the forefoot is further abducted. Before the application of fifth cast, the degree of dorsiflexion is assessed and if the dorsiflexion is not possible beyond neutral, then a Percutaneous AchiliesTenotomy is required, this is done under local anaesthesia. The casts are changed weekly intervals, before tenotomy, while the cast after the tenotomy is removed at the end of 3 weeks. After the removal of cast the patient is placed in modified Foot Abduction Orthosis (FAO). FAO is initially used 23 hrs.a day for 4 months and then subsequently for night-time for 3 years13. The average number of casts required with this technique is 5.4. French Technique4: This technique involves daily manipulation of the childs clubfoot by

Physiotherapist for 30 minutes,

followed by

stimulation of muscles (especially Peroneal muscle) around the foot and then adhesive strapping is applied. Daily treatment is required for

approximately 2 months and then reduced to 3 sessions per week for an additional six months. Tapping is continued until the patient is ambulatory. Once the child starts ambulation, then night-time splint is given for additional 2 to 3 years. 3. EDUCATION AND INSTRUCTION TO THE MOTHER: The mother should be assured and reassured that with her co-operation, consistency and

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compliance to treatment, the deformity could be corrected. She should be taught how to mobilize the feet in the absence of strap10. She is advised to take care and observed every time when a fresh strapping or plaster is applied and also to prevent the plaster or strapping from being wet or soiled either by water or any other fluid. SURGICAL/ OPERATIVE MANAGEMENT The operative treatment is required once the conservative treatment fails or the chance of correction of deformity with conservative

prevent stiffness, which can be done with following physiotherapy interventions15. Movement of toe, hip and knee in the plaster cast only, by tickling or by holding child high in suspension. To improve strength and stability gradual active non-weight bearing and resisted foot and ankle exercises are given, followed by progression to weight-bearing exercises. To maintain the correction and avoid recurrence, Night splint are provided. Some of the splints used in the management of CTEV are-

management is very less. Different operative procedures are performed based on the age of child. At 9 months 3 years: A Postero-medial soft tissue release (PMR), which was introduced by Turco14 is performed and followed by Dennis Brown splint for 2 years. In this technique, the correction of the abnormal tarsal relationship is prevented by rigid pathological soft tissue contracture. At 3 years- 8 years: At this age, soft tissue release along with Wedge Osteotomy of cuboid bone, which is known as EVANS is performed. At 8- 12 years: At this age, the Wedge Osteotomy of calcaneum (Dwyers Operation) along with wedge osteotomy of tarsal bone is performed. Above 12 years: A triple arthrodesis of 3 joints of foot (i.e. subtalar, calcaneo-cuboid and talonavicular joint) is performed. POST-OPERATIVE MANAGEMENT The main objective of physiotherapy after surgical procedure is to keep the other joints mobile and
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1. CTEV Splint 2. Dennis Brown Splint (Fig-4) 3. CTEV Shoes (Fig-5) Gait training with proper foot position is taught to the patient. Special CTEV shoes are given to the patients. The shoes got straight inner borer, which prevents forefoot adduction, outer shoe raise to prevent inversion and no heel to avoid equinus. An effective training is given to the mother or both parents for home care programme to maintain the correct position of the limb and how to give the exercise in correct way.

PHYSIOTHERAPY

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Fig-3- CTEV Splint Fig-5- CTEV Shoes Splint

Fig-4- Dennis Brown

REFRENCES 1.Macnicol M. F.The management of Clubfoot: Issues for debate. J Bone Joint Surg[Br],2003;167-170. 2. Global clubfoot initiative. Last assessed on 15th May 2012 at: http://globalclubfoot.org/countries/india/ 3. Macnicol M. F. and Murray A. W. Changing Concepts in the management of congenital talipesequinovarus.Paedetrics and child health,2008; 272-277. 4. Anand, A. and Sala, D.A. Clubfoot: Etiology and treatment. Indian J Orthop,2008;42:22-28. 5. Lehman, W.B. The clubfoot. JB Lippincott: New York; 1996 6. Edwards, M.J. The experimental production of clubfoot in guinea pigs by maternal hyperthermia during gestation. J Pathol, 1971;103:49-53. 7. Katz K, Meizner I, Mashiach R, Soudry M. The contribution of prenatal sonographic diagnosis of clubfoot to preventive medicine.J Pediatr Orthop,1999;19:5-7 8. Roye, B.D., Hyman J., Roye, D.P. Jr. Congenital idiopathic talipesequinovarus. Pediatr Rev, 2004;25:124-30. 9. Porter, R. Club foot. The foot,1997;7: 181-193. 10.Ezeukwu, A.O. and Maduagwu, S.M. Physiotherapy management of an infant with bilateral congenital talipesequinovarus. African Health Science, 2011;11(3): 444-448.

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11. Bensahel, H., Guillaume, A., Czukonyi, Z. andDesgrippes, Y. Results of physical therapy for idiopathic clubfoot: A long term8follow up study. J Pediatr Orthop,1990;10:189-92. 12. Ponseti IV, Campos J. Observations on pathogenesis and treatment of clubfoot. ClinOrthop, 1972;84:50-60. 13. Ponseti IV. Congenital clubfoot: Fundamentals of treatment. Oxford University Press: Oxford, England; 1996. 14. Turco VJ. Clubfoot. Churchill Livingstone: New York; 1981. 15. Goel RN. Goels Physiotherapy.Shubham Publication- Bhopal, Vol II, 2000.

CORRESPONDING AUTHOR: * Email: physio.mayank.pushkar@gmail.com

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