Talipes Equinovarus

Talipes Equinovarus, clinical photograph of congenital talipes equinovarus
Clinical photograph of congenital talipes equinovarus. Image by OpenStax College, Wikimedia Commons, CC BY 3.0.

Definition

Congenital deformity of the foot with

  • Equinus & varus deformity of heel
  • Forefoot adduction
  • Midfoot supination

Epidemiology

  • Commonest of the congenital orthopaedic abnormalities
  • 1.5:1000 live births
  • Males>Females – 2:1
  • 30-50% bilateral
  • Much more common in Polynesian & Maori & lower in Asians
  • Wynne-Davies suggests that has polygenic inheritance
  • Tachdjian suggests that
  • Patient with CTEV that has one child affected then 25% chance of another affected
  • If both parents are normal & have affected child then chance of another is 5%

Classification

  • Idiopathic or Secondary
  • Idiopathic
    • Multifactorial
    • Polygenic
    • Environmental
    • Multifactorial inheritance patterns
    • 0.5% if one 2nd degree relative (aunt, uncle) has CTEV
    • 2% if one parent has CTEV
    • 5% if one child has CTEV
    • 25% if one parent & one child has CTEV
    • Environmental
    • Uterine constriction (Oligohydramnios, Constriction Band)
    • Drugs/ Chemicals (Aminopterin, Tubocurarine)
  • Secondary
    • Genetic
    • Part of syndromes with Mendelian Inheritance
    • Craniofacial dysplasia
    • Diastrophic dwarfism
    • Larsens syndrome
    • Pierre-Robin
    • Neuromuscular
    • Associated with
    • Spina Bifida
    • Cerebral Palsy
    • Arthrogryposis
    • Muscular Dystrophies
    • Spinal Muscular Atrophy

Pathogenesis

  • Unknown at this stage
  • Various theories
  • Irani & Sherman 1972 – suggest abnormal cartilage anlage in anterior aspect of talus secondary to germ cell defect
  • Isaacs in 1977 – found histochemical muscle abnormalities under EM but not detectable on EMG
  • Atlas 1980 – found abnormal vascular abnormalities with ischaemic area in sinus tarsi region & this suggests an abnormality with blood supply to tarsal neck region
  • Dietz 1983 – Posterior tibial tendon sheaths have significantly less cellular & cytoplasmic volume than those anteriorly
  • Zimmy et al 1988 – found regional differences in the cellular nature of the fascia in clubfoot – medial fascia contained cells resembling myofibroblasts & mast cells
  • Victoria-Diaz 1984 – there may be defect in tibial growth phase & so production of clubfoot deformity
  • In summary » Postulated to be due to
  • Primary germ plasm defect
  • Cartilage anlage arrest
  • Abnormal myofibroblasts
  • Abnormal neuromuscular junction
  • Retracting fibrosis
  • Anomalous tendon insertions
  • Ischaemia
  • Packaging defect (oligohydramnios)

Pathology

  • All tissues around the foot are abnormal
  • Bones
  • All the bones of foot abnormal
  • No internal tibial torsion
  • Femur, Tibia & the fibula especially often shorter
  • Talus
  • Head & neck deviated medially & plantarward
  • Body rotated externally in the ankle mortise
  • Body extruded anteriorly
  • Smaller than normal
  • Calcaneum
  • In equinus
  • Rotated medially
  • Means that long axis of talus & calcaneum parallel
  • Smaller than normal
  • Navicular
  • Subluxed medially towards the medial malleolus
  • Cuboid
  • Subluxed medially
  • Forefoot
  • Adducted & Supinated
  • Cavus deformity may occur
  • Lateral Malleolus
  • Located posterior near the calcaneus
  • Muscles
  • Atrophy & contracture
  • Triceps Surae
  • Tibialis Posterior
  • FHL
  • FDL
  • Tendon sheaths thickened around
  • Tibialis Posterior
  • Peroneals
  • Ligaments & Fascia
  • Shortening of
  • Calcaneofibular ligament
  • Posterior Talofibular ligament
  • Deltoid
  • Long & Short plantar ligaments
  • Spring
  • Bifurcate
  • Plantar fascia
  • Tendo Achilles with more medial insertion on the calcaneum » ↑ varus
  • Joint Capsules
  • Contracture of capsules of
  • Posterior ankle joint
  • Posterior subtalar joint
  • Talonavicular joint
  • Calcaneocuboid joint

Clinical Features

  • Clubfoot
  • 1. Deformity
    • Heel equinus
    • Heel varus
    • Midfoot supination
    • Forefoot adduction
    • Maybe cavus
  • 2. Features
    • Curved lateral border of foot
    • Devil’s thumbprint over the lateral malleolus
    • Medial & Lateral skin creases
    • Navicular fixed to medial malleolus
    • Os calcis fixed to the lateral malleolus
    • Heel small & high
  • 3. General
    • Calf atrophy
    • Calf shortening
    • Other Conditions
    • Should all be excluded
    • Spinal Dysraphism
    • Arthrogryposis
    • Neuromuscular Disorders
    • When examining patient for first time assessment made of the degree of correction able to be achieved
    • Mild
    • Able to correct past neutral
    • Postural Form of deformity
    • 10% require surgery
    • Moderate
    • Correction within 20° of neutral
    • Structural Form
    • 50% require surgery at some stage
    • Severe
    • Correction to < 20° of neutral
    • Severe structural abnormalities – Teratogenic
    • 90% require surgery

Radiology

  • Can assess prior to treatment with A-P & Lateral of foot
  • Calcaneal & Talar ossification centres are present at birth with the cuboid appearing by 6 months
  • Navicular will not appear until 2-4 years
  • Simons CORR 1978 – suggested standard radiographic assessment
  • Anteroposterior View
  • Kite’s angle – Anteroposterior Talocalcaneal angle
  • Ankle dorsiflexed 15° & tube at 30° from vertical
  • Talocalcaneal angle normally 20-40°
  • Less than 20° suggests the talus & calcaneum are becoming more parallel
  • Suggested that with nonoperative management the correction of equinus should be delayed until the Kite angle is normalised to avoid breaking midfoot
  • First Metatarsal-Tarsal Angle
  • Line through the long axis of first metatarsal & the talus respectively allows evaluation of the degree of forefoot adduction
  • Normal angle is 0-20°
  • Lateral View
  • Lateral Talocalcaneal Angle
  • Angle formed by line drawn through the long axis of talus & line along the plantar aspect of the calcaneum
  • Normally is 35-55°
  • < 35° indicates hindfoot equinus
  • Talocalcaneal Index
  • Addition of the Talocalcaneal angles in A-P & Lateral
  • Normally > 40°

Treatment

  • Initially non operative & starts on Day One of life » “as the feet exit the birth canal”
  • Aims of treatment
    • Correct deformity early
    • Correct fully
    • Maintain in corrected position until foot stops growing
    • Remember two types of club foot – Attenborough 1966
    • Easy
    • Resistant
    • The resistant form identified by
    • Thin calf
    • Small high heel
    • Medial crease
    • Devil’s thumb print laterally
    • (ie seen with Arthrogryposis)
  • 1. Non operative Treatment
    • The First Cast
    • Correct the heel varus & forefoot adduction first – avoid breaking the midfoot
    • One hand on knee & one on toes & manipulate into neutral position
    • Then apply firm SLPOP over the holders fingers & apply knob at the end for ease of removal
    • Moulding until sets
    • Repeat these second daily until the forefoot adduction is neutral – usually at 1 week
    • First LLPOP
    • Heel equinus corrected with this
    • SLPOP applied with gentle correction of equinus – push calcaneus upwards & heel downwards & avoid pushing on midfoot
    • Then extend as LLPOP with knee flexion & slight ER
    • Subsequent casts applied at 3 days then weekly depending on progress
    • This is repeated until the forefoot adduction & heel equinus corrected beyond neutral – ie Overcorrect
    • Usually at 3 week time
    • The last cast applied in full correction for further 3 weeks
    • Then strapping & manipulation by the physiotherapists up to 12 weeks
    • Splintage
    • Bivalved AFO (front-back boots) & Dennis-Browne bar used full-time until walking age
    • Removed to learn walking
    • Applied when resting only up to 18 months
    • Review
    • See serially up to 8 years
    • Outcome
      • 50% of the feet are corrected by 6 weeks at end of casting
      • 90% of mild
      • 50% of moderate
      • 10% of the severe
    • If no correction then surgery required & no further non op treatment until surgery
  • 2. Surgical Treatment
    • Indications
      • Failure of serial casting at 6 weeks
      • Failure of subsequent splintage & strapping
      • Timing
      • Variable timing in literature
      • Probably average is 3-9 months
    • Advantage of
      • Prior to fixed bony deformity & contractures
      • Prior to walking
      • There is literature to support later surgery at one year as anatomy more able to be recognised
  • Goals
    • Release of all soft tissue restraints to allow proper positioning of the tarsal bones
  • Approaches
    • 1. Turco
      • Posteromedial incision – curved
      • From the base of first MT above the posterior tubercle of calcaneus to the TA
      • The disadvantages include
      • Crosses medial skin creases
      • Difficult to explore the plantar fascia
      • Difficult to explore the posterolateral corner
      • May need a separate lateral incision particularly in older child
    • 2. Cincinnati
      • Posterior U shaped incision from the navicular medially curved posteriorly in the skin crease & ending at the calcaneocuboid joint
      • Lateral exposure available with this approach
      • Disadvantages
      • Fear of loss of the posterior skin flap
      • Exposure of the plantar fascia difficult
      • Difficult to expose the proximal TA
    • 3. Norris-Carrol
      • Two incisions performed
      • Curved incision from centre of os calcis to the talonavicular joint
      • Second incision halfway between the TA & the lateral malleolus
      • The disadvantage is two incisions
  • Surgical Procedures
    • Identify the N-V bundle & protect
    • Posteromedial Release
    • Z lengthening of the TA
    • Posterior capsulotomy of
    • Ankle joint
    • Subtalar joint
    • Release the Posterior tibiofibular ligament & the Calcaneofibular ligament
    • FHL – intermuscular recession if the hallux flexes when foot dorsiflexed
    • FDL – Z-lengthening if the lesser toes flex when foot dorsiflexed
    • The above done at end of procedure if required
    • Often the above is all that required
    • Medial release follows if there is persistent varus
    • Z-lengthening of the Tibialis Posterior & release of sheath
    • Follow to the navicular insertion & this is guide to T-N joint
    • The capsule of the T-N joint released
    • The superficial fibres of the Deltoid ligament & the Spring ligament released
    • At this stage usually able to reduce the navicular – if not then lateral release often required
    • Plantar Release
    • Usually if resistant cavus
    • Able to reflect the Abductor Hallucis
    • Release the
    • Knot of Henry
    • Long plantar ligament
    • Plantar Fascia
    • FDB from the calcaneum
    • The calcaneocuboid capsule
    • Medial ST joint released
    • Lateral Release
    • Usually severe forms where complete correction of the forefoot adduction not correctable with medial release
    • Release the
    • Bifurcate ligament
    • Calcaneocuboid capsule
    • Interosseous ligament
    • Allows the calcaneocuboid joint to reduce independently to the talonavicular joint & correct the forefoot adduction & supination of midfoot
    • Supplemental Fixation
    • K-wire fixation across the
    • Talonavicular joint
    • Calcaneocuboid joint
    • Subtalar joint
    • Maybe required to hold position
    • Postoperative Care
    • LLPOP – in equinus if Cincinnati to protect the skin
    • Neutral if other incisions
    • ROS & take out wires at 2 weeks
    • Then cast until 6 weeks
    • Splintage as per non op treatment then
    • Results
    • Ponsetti 1963 – 71% good or excellent results
    • Turco 1979 – 84% good or excellent results with posteromedial release
    • Recurrence/ Failure
    • 15% of operated clubfoot
    • Not really recurrence rather
    • Undercorrection
    • Failure to maintain correction
    • Prevented by
    • Explanation preop about need for ongoing care
    • Adequate initial correction
    • Postoperative vigilance
    • Suspect early with tight TA & stiff ST joint
    • Usually see
    • Forefoot adductus
    • Hindfoot varus
    • Curved lateral border of foot
    • Cavus
    • Younger than 2-3 years then can repeat the release
    • Difficult +++
    • Relatively high risks
    • Benefits ↓ with advancing age
    • May need to add lateral release or lateral column shortening
    • If > 5 years then may need bony procedures to realign the forefoot or os calcis
    • Forefoot Adductus
    • Dynamic
    • Correctable passively
    • Best seen in swing phase
    • Correct with SPLATT
    • Transfer the lateral 1/2 of the Tibialis Anterior to lateral cuneiform or cuboid (via drill hole & pull-through with button in sole of foot)
    • Fixed
    • Bony procedure required
    • May require MT osteotomies or Heyman-Herndon release
    • Best procedure is Cuboid Decancellation
    • Lateral incision & release of the C-C joint & reduction of it
    • Then remove wedge of bone from the middle of the cuboid
    • Other procedures to shorten the lateral column include
    • Dillwyn-Evans procedure
    • Shorten anterior process of calcaneus
    • Medial soft tissue release
    • Lichtblau osteotomy
    • Hindfoot Varus
    • Correction with calcaneal osteotomy
    • Oblique sliding osteotomy best
    • Slide the calcaneum laterally
    • Can also perform Dwyer
    • Lateral closing wedge calcaneal osteotomy
    • Salvage Procedure
    • Triple arthrodesis
    • Best option for failed or resistant clubfoot
    • Especially. if child > 12 years
    • Choices are
    • Standard triple arthrodesis
    • Lambranudi arthrodesis if fixed equinus
    • Plantargrade foot achieved with 95% good results but progressive Osteoarthritis (Ponsetti)
    • Talectomy
    • Reserved for the resistant arthrogrypotic club foot
    • Poor results
    • Complications
    • Neurovascular injury
    • Loss of foot (10% have atrophic dorsalis pedis artery bundle)
    • Undercorrection
    • Overcorrection (esp with Cincinatti)
    • Forefoot adductus
    • Hindfoot varus

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.