Congenital talipes equinovarus (CTEV), more commonly known as clubfoot, is a congenital condition that affects the foot and ankle of newborns, where the foot is abnormally rotated inward. It is a developmental deformity that can cause lifelong disability if not treated properly. The condition can affect one or both feet and is characterized by a combination of foot misalignments, including adduction (the foot pointing inward), supination (the sole facing upwards), and varus (the foot tilted towards the inside). The severity and specifics of the deformity can vary, but in its most extreme form, it can lead to difficulty in walking and require long-term medical intervention.
Understanding the Deformity
In CTEV, the foot’s bones and soft tissues are malformed, causing the foot to be fixed in an abnormal position. The calcaneus, navicular, and cuboid bones in the foot are medially rotated in relation to the talus, and the tendons and ligaments surrounding these bones tighten, further contributing to the deformity. The foot is supinated, meaning the outer edge of the foot is higher than the inner edge, but the toes may still turn inwards. This condition can lead to difficulty with normal mobility and can affect the child’s overall foot development.
Although CTEV is often a standalone condition (idiopathic), it can also be associated with other genetic or neurological disorders, which is known as syndromic CTEV. Syndromic CTEV is less common but can be more severe, often requiring more aggressive treatment approaches. In most cases, however, the upper limb and other parts of the body are unaffected.
Causes and Risk Factors
The precise cause of CTEV remains unclear, but research suggests a combination of genetic and environmental factors. Studies have indicated that there may be a hereditary component, with a family history present in about 24–50% of cases, depending on the population. Genetic studies suggest that CTEV follows a complex inheritance pattern, possibly involving a single gene with major effects against a polygenic background. Environmental factors, such as maternal smoking during pregnancy, have also been identified as contributing to the development of CTEV, indicating an interplay between genetics and external conditions.
In some cases, intrauterine positioning may also play a role in the development of CTEV. Studies have shown that the mildest cases of CTEV could be associated with restricted fetal movement, which might result from insufficient amniotic fluid (oligohydramnios) or abnormal uterine positioning.
Diagnosis and Treatment
CTEV is typically diagnosed at birth, but more advanced imaging techniques, such as ultrasound, can detect the condition in utero as early as 12 weeks of gestation. The primary goal of treatment is to correct the foot’s alignment and ensure proper functionality without the need for permanent disability.
Non-Surgical Treatments
The Ponseti method is the most widely used non-surgical treatment for CTEV. This technique involves serial casting, where the foot is manipulated into a corrected position and casted in place. The casts are changed weekly, and the procedure may last for six to eight weeks. In most cases, an Achilles tenotomy, a procedure where the tight Achilles tendon is cut to allow the foot to be positioned more normally, is required. After the casting period, the child wears a brace (commonly a foot-abduction orthosis) to maintain the corrected position.
Another widely used technique is the Kite method, which also involves casting but differs in the approach to manipulation. While effective, the Kite method often requires a longer casting period and more frequent surgical interventions.
Surgical Treatments
In cases where non-surgical methods fail, surgery may be necessary. Surgical interventions typically involve lengthening or releasing tendons, ligaments, or muscles that are restricting the foot’s mobility. Procedures such as Achilles tendon lengthening, tibialis anterior tendon transfer, and soft tissue releases are common. These surgeries aim to restore proper alignment and function to the foot, though they often come with higher risks of relapse and complications than non-surgical methods.
Outcomes and Challenges
With prompt and appropriate treatment, most children with CTEV can achieve normal foot function, though some may experience relapses. These relapses often require additional intervention, such as more casting or even surgery. The Ponseti technique has been shown to produce excellent long-term outcomes, with studies indicating that more than 90% of cases avoid major surgery. However, in some cases, the deformity may return, necessitating further treatments.
Relapse is particularly common if the child does not adhere to the bracing regimen after the casting phase, which highlights the importance of early and consistent intervention. Research continues to explore the best ways to reduce relapse rates and improve overall outcomes, including new techniques and the use of additional therapeutic agents like botulinum toxin.
Conclusion
Congenital talipes equinovarus is a complex condition that requires careful and timely intervention. While the exact cause remains poorly understood, advances in treatment, particularly the Ponseti method, have significantly improved the prognosis for most children. Early diagnosis and consistent follow-up care are critical in ensuring that children with clubfoot can lead active, healthy lives. Parents and caregivers should be informed about the treatment options and the importance of adherence to post-treatment protocols, such as wearing the prescribed braces, to minimize the risk of relapse.
Do you have more questions?
Q. What is congenital talipes equinovarus (CTEV)?
A. Congenital talipes equinovarus, also known as clubfoot, is a congenital deformity where one or both feet are twisted out of shape or position.
Q. How common is congenital talipes equinovarus?
A. It occurs in about 1 in every 1,000 live births and is more common in boys than girls.
Q. What causes clubfoot?
A. The exact cause of clubfoot is unknown, but it is believed to involve both genetic and environmental factors.
Q. Is clubfoot painful for infants?
A. Clubfoot itself is not painful for infants, but if left untreated, it can lead to significant disability and discomfort as the child grows.
Q. What are the visible signs of clubfoot?
A. The foot is usually turned inward and downward, and the calf muscles on the affected leg are often underdeveloped.
Q. Can both feet be affected by clubfoot?
A. Yes, clubfoot can affect one or both feet, with bilateral involvement being common.
Q. How is clubfoot diagnosed?
A. Clubfoot is typically diagnosed at birth through physical examination, and it can sometimes be detected through prenatal ultrasound.
Q. What is the initial treatment for clubfoot?
A. The Ponseti method, which involves gentle manipulation and casting, is the most common initial treatment.
Q. How many casts are usually needed in the Ponseti method?
A. Usually, 5 to 7 casts are required to correct the deformity gradually.
Q. Is surgery required for all clubfoot cases?
A. Most cases respond well to the Ponseti method, but some may require a minor surgical procedure to release the Achilles tendon.
Q. What happens after the casting phase?
A. After casting, the child typically wears a brace to maintain correction and prevent recurrence.
Q. How long does a child need to wear the brace after treatment?
A. The brace is worn full-time for the first few months and then during naps and nighttime for several years.
Q. What if clubfoot is not treated?
A. Untreated clubfoot can lead to permanent disability, pain, and difficulty with walking.
Q. Can children with treated clubfoot lead normal lives?
A. Yes, with proper treatment, most children with clubfoot can walk, run, and participate in regular activities without limitations.
Q. Is recurrence of clubfoot possible after treatment?
A. Yes, recurrence can happen, especially if bracing is not followed properly, which is why regular follow-up is important.
Q. Are there long-term complications of clubfoot?
A. With successful treatment, long-term complications are minimal, though some children may have slightly smaller or less flexible feet.
Q. Does clubfoot have any impact on intelligence or brain development?
A. No, clubfoot is a structural condition of the foot and does not affect brain development or intelligence.
Dr. Mo Athar
