Congenital Talipes Equinovarus (CTEV)
Congenital talipes equinovarus (CTEV), commonly known as clubfoot, is a fixed structural deformity of the foot characterized by four components: ankle equinus, hindfoot varus, forefoot adductus, and midfoot cavus, affecting approximately 1-2 per 1,000 live births with a male predominance of 2.25:1. 1, 2, 3
Clinical Presentation and Diagnosis
CTEV presents as a fixed structural deformity where the foot cannot be passively corrected to neutral position, distinguishing it from positional talipes which is fully correctable and occurs five times more commonly 2
The condition affects both feet in 50% of cases, with equal distribution between left and right sides when unilateral 2
Most cases (approximately 72%) occur in isolation, though 27.7% have syndromic associations requiring examination of hips for stability and spine for spina bifida stigmata 2
Diagnosis is typically made at early baby check or prenatal ultrasound, though some cases are initially mistaken for positional variants and may present later at the six-week check 2
Severity Assessment
The Pirani scoring system is the standard assessment tool, ranging from 0 to 6, where higher scores indicate more severe deformity 1, 4
Imaging modalities include radiography for bone anatomy and relationships, ultrasound for cartilaginous structures without radiation exposure, and MRI for comprehensive multiplanar evaluation of bones, cartilage, and soft tissues 3
Standard Treatment: The Ponseti Method
The Ponseti technique of manipulation and serial casting is the current standard treatment, having replaced extensive surgical releases over the past 25 years 2, 3, 5
Treatment Protocol
Serial manipulations and casts are applied weekly, with an average of 6.5 casts required for full correction 1
Percutaneous Achilles tenotomy is required in approximately 87% of cases to achieve full correction, guided by Pirani score 1
The Ponseti technique significantly improves foot alignment compared to the Kite technique, reducing average total Pirani scores by 1.15 points (95% CI -1.32 to -0.98) after 10 weeks of serial casting 5, 4
Compared to traditional techniques, the Ponseti method reduces Pirani scores by 1.50 points (95% CI -2.28 to -0.72) after serial casting and tenotomy 5, 4
Casting Materials
- Semi-rigid fibreglass may be as effective as plaster of Paris in the Ponseti technique, producing average total Pirani scores only 0.46 points higher (95% CI -0.07 to 0.99) 4
Accelerated Protocol
- An accelerated Ponseti technique may be as effective as standard weekly casting, showing no significant difference in Pirani scores (MD 0.31,95% CI -0.40 to 1.02) at completion of casting 5, 4
Post-Casting Management
Boots and bar splintage is a vital component of the Ponseti technique, as relapse is strongly correlated with non-compliance with orthotic wear 2
Management of Relapse
- Relapse following Ponseti treatment is more likely corrected with further serial casting (risk difference 25-50%), whereas relapse after the Kite technique more often requires major surgery 5, 4
Treatment Outcomes
The Ponseti technique significantly reduces need for invasive surgical procedures while being safe, effective, and affordable 1
Final Pirani scores improve dramatically, from an average of 4.8 at presentation to 0.055 after completion of casting 1
The technique provides a painless, plantigrade, cosmetically acceptable foot with higher functional outcomes and minimal complications 1
Adverse Events
Common complications during serial casting include cast slippage requiring replacement, plaster sores (pressure areas), and skin irritation 5, 4
Surgical procedures when required carry risks of infection and need for skin grafting 5, 4
Critical Clinical Pitfalls
Urgent referral to pediatric orthopaedics is warranted when CTEV is identified, as Ponseti treatment should be started early for optimal outcomes 2
Direct examination of the feet is essential to differentiate fixed CTEV from positional talipes, as the latter does not require casting or surgical treatment 2
Non-compliance with boots and bar splintage is the primary cause of relapse, requiring strong emphasis on adherence during family counseling 2