Key Insights To Treating Talipes Equinovarus

Since the first recognition of talipes equinovarus (TEV), the only treatment options have been closed reduction through manipulation with immobilizing techniques and surgical correction. The goal of treatment is ensuring a painless, plantigrade, supple foot with good range of motion and normal function. However, there has been a significant evolution in the treatment of TEV over the years. In fact, there are over 2,600 literature references on the subject. TEV is an anatomically and etiologically complex condition. Understanding the morbid anatomy is crucial for successful conservative and surgical management. The principal lesion is peritalar malposition with downward, medial and proximal navicular displacement. The greatest distortion is in the talus.1 Although the body and trochlea are almost normal, the neck is short, deviated medially and downward. The articular surface for the navicular is plantar and medial on the neck. Plantarflexion of the talus in the ankle mortise produces ankle equinus. The navicular rotates so the forefoot becomes supinated and the navicular lies close to the tip of the medial malleolus. The calcaneus follows in the same direction while moving into varus around a rotational axis through its body with medial rotation in the transverse plane. The distal calcaneus is almost directly under the talar head. Its posterior portion elevates, goes into varus and moves laterally so that the superior and lateral surface come close to the fibular malleolus. The cuboid and the rest of the distal foot follow this rotation. The calcaneocuboid facet faces more medially, adding to the adductus of the forefoot. Articular surface remodeling with ligament, joint capsule and muscle contractures make the deformity rigid. It is a common misconception that the peritalar articulations are subluxed or dislocated.2 They are anatomically distorted in pathological positions, but are congruent and cohesive.2,3 Simple stretching will not relocate them. Correction requires shape change in the cartilage anlage. Studies of the morbid anatomy of idiopathic TEV reveal several other findings.1,4 The calf muscles are almost always decreased in bulk.5-7 The initial thought was that decreased calf muscle diameter resulted from cast immobilization and other therapies, but one may also see this among untreated children. There are no regularly occurring abnormalities in muscle or nerve. There often are abnormalities in the anterior tibial artery. In some cases, it does not pass onto the dorsum of the foot. In other cases, there are anomalies as proximal as the trifurcation. The tendo-Achilles may insert more medially on the posterior calcaneus or the medial fibers may be contracted.1 There are no brain or spinal cord abnormalities. A Review Of The Different Types Of TEV There is a tendency to lump all forms of TEV together, but there are prognostic and therapeutic merits in classification. Currently, there are four types of TEV. The idiopathic form is the most common. However, keep in mind that some studies suggest primary muscular and peripheral nerve etiologies in some cases of idiopathic TEV. There is also a polyallelic genetic component with severity influenced by the infant’s gender.8,9 Idiopathic TEV runs the spectrum from a mild flexible deformity to an extreme rigid deformity. The postural (positional) form includes all TEV caused by in utero positioning and occult neurological disturbances with muscle imbalance. Therefore, this is not a pure category. The prognosis depends on the underlying pathophysiology.10,11 The teratological (teratogenic) form includes all TEV associated with multiple bone and joint pathologies. It includes diastematomyelia, myelomeningocele, tethered cord, arthrogryposis multiplex congenita and Streeter’s dysplasia. The syndromic form includes all TEV associated with named syndromes in which TEV is a feature. Smith’s Recognizable Patterns of Human Malformation (although using the term generically) lists over 50 syndromes in which “clubfoot” is a regular or occasionally occurring feature.12 A Historical Perspective On Manipulation Techniques Kite recognized TEV was composed of forefoot adductus, heel varus and equinus. He noted foot and ankle equinus, and believed forefoot cavus and posterior ankle contracture made up total equinus.13-22 He did not identify subtalar supination as a third component of equinus. His method corrected each component separately. He corrected forefoot adductus first and proceeded to correct heel varus, which he understood as a single plane rotation around a longitudinal axis through the calcaneus. Then he addressed the equinus. Curiously, Kite’s own articles described correction of forefoot adductus and heel varus as a unit. His cast consisted of a slipper cast with a leg component for infants over age 1 and an above-knee portion for infants less than 1 year old. Ponseti made similar observations about the components of the deformity, but also noted plantarflexion of all or part of the medial column and forefoot supination as well as varus.3,23-27 His technique differs substantially from Kite’s technique. Ponseti began the casting sequence by supinating the forefoot even further as the adductus component is manipulated. Doing so places the entire foot distal to the talus on the same supinated plane. Using Ponseti’s technique, one would manipulate the forefoot adductus and heel varus together, allowing the calcaneus to rotate as the distal end moves up and lateral to the talar head while the posterior portion moves medial and down away from the fibula. Then Ponseti would manipulate the equinus. He used above knee casts with the knee flexed for all ages. If Ponseti achieved successful reduction, he placed the child in an externally rotated transverse bar and shoe apparatus in order to maintain reduction. He managed unyielding equinus via an Achilles tenotomy. How Surgical Reduction Of TEV Has Evolved Over The Years Modern surgical management of TEV probably begins with Turco.28-38 While he believed closed reduction of TEV was ideal, he knew it was not always possible. Dissatisfaction with conservative treatment and the results of isolated soft tissue procedures led him to a one-stage operation to completely correct the deformity.38 He recognized what Shaw referred to as the acetabulum pedis.7 The talocalcaneonavicular joint complex includes the talonavicular, anterior and middle talocalcaneal facets and the spring ligament. The talonavicular capsule, deltoids, tibialis posterior and bifurcate ligament make up the soft tissue constraints. The socket moves around the ball (the talar head). The soft tissue and fibrocartilage expand and contract the socket on demand. Turco noted dorsiflexion and plantarflexion of the foot occur both at the ankle and the talocalcaneonavicular complex. He observed rearfoot motion is triplane in nature and cannot be managed in isolation as Kite and many other authors had presumed.13 Turco identified three surgical compartments, each with its own set of structures and contractures. Posterior compartment contractures include the posterior ankle capsule, posterior subtalar joint capsule, tendo-Achilles, the posterior talofibular and calcaneofibular ligaments. Medial compartment contractures include the deltoid, spring ligament, talonavicular joint capsule, tibialis posterior, flexor digitorum longus and flexor hallucis longus. Subtalar joint contractures include the talocalcaneal interosseous and the bifurcate ligaments. Contractures of the plantar fascia, abductor hallucis, flexor digitorum and hallucis brevis and abductor digiti quinti produce cavus deformity, but Turco thought you would only see this among older children. Using a medial approach, Turco isolated the tibialis posterior, flexor digitorum longus, the neurovascular bundle, flexor hallucis longus and tendo-Achilles and released their sheaths along with the master knot of Henry. He proceeded to release the posterior compartment contractures and followed suit with the medial and subtalar compartment contractures. Surgical indications for Turco’s one-stage procedure included failed conservative treatment and recurring deformity. Complications included overcorrection, forefoot adduction deformity, wound dehiscence, loss of correction and postoperative stiffness. Factors influencing success included the patient’s age at operation, prior surgery and iatrogenic changes from manipulation. Crawford, et. al., adapted for TEV the Cincinnati incision which Giannestras initially used for vertical talus deformity.39 Although it gives excellent exposure, it is less than optimal for tendo-Achilles lengthening and closure because of perfusion issues if the skin is very tight. Many surgeons avoid this incision due to the fear of skin slough.32 Assessing McKay’s Contributions To The Literature McKay’s goal in treating TEV was to facilitate a foot that was completely normal in appearance and function.2,29,40 His contributions to non-operative and operative treatment were significant, particularly in advancing the anatomical understanding of the deformity and correcting the misconception that the joint surfaces are subluxed or dislocated. He pointed out that they are congruent and cohesive in abnormal positions of extreme equinus and varus. The whole foot is rotated inward on the talus at the talonavicular, talocalcaneal and calcaneocuboid joints. He stressed that motion is critical for function and the potential for motion is diminished by static unremitting pressure on the articular cartilage.2 He theorized the abnormal shape of the talus was due to abnormal growth at the articular ends.2 Since the cartilage was misplaced and abnormal, there was compromised longitudinal growth in all directions. He noted talocalcaneal joint abnormality results from three-plane motion around the talocalcaneal interosseous ligament. The distal calcaneus inverts around a coronal axis, rotates medially around a vertical axis and has sagital plantarflexion around a transverse axis. The distal calcaneus moves medially and the posterior body moves upward toward the posterior fibula. For McKay, the keys to treatment success were early corrective attempts to preserve articular cartilage and maintaining joint mobility.40 He performed manipulation by pressing his thumb in the medial arch against the medial side of the calcaneocuboid joint in order to push the calcaneus laterally at the same time that the calcaneus is pulled down out of equinus and moved medially away from the posterior fibula. McKay would follow this by applying a long leg cast with the knee at 90 degrees. For McKay, surgical intervention is indicated when conservative correction begun within the first six weeks of life fails or when the deformity recurs three times. Physical indications include: obvious rigid clubfoot deformity; walking on the lateral border of the foot with the heel in varus; a foot axis to bimalleolar line less than 76 degrees; and parallel talar and calcaneal bisections on both AP and lateral radiographs. Surgery must be comprehensive and complete since multiple small procedures do not accomplish the goal. McKay would begin by using the Cincinnati incision with the patient prone. He would proceed to lengthen the tendo-Achilles while preserving the anterior fibrofatty tissue for reattachment. McKay would subsequently perform lateral and posterior dissection through the peroneal retinaculum, which allows separation of the calcaneofibular ligament and the posterior talofibular ligament. McKay would proceed to release the lateral talocalcaneal ligament and capsule. If you opt to use this procedure, keep in mind that release of the extensor digitorum brevis, the cruciate crural ligament, dorsal calcaneocuboid joint and cuboidonavicular ligament might be needed. Medially, McKay would do a Z-lengthening of the tibialis posterior, using the distal portion as a guide to the talonavicular joint to facilitate complete release. He would proceed to dissect the tendon sheaths of flexor digitorum and hallucis longus, and sleeve them upward along the body of the talus. In his plantar dissection, he would release the long plantar ligament and the plantar and medial capsule of the calcaneocuboid joint. This leaves the following restraints: the posterior talofibular, deep deltoid, posterior tibiofibular and interosseous ligaments and the toe flexors. If the talus could not move back, McKay lengthened the posterior talofibular ligament and proceeded to do the same with the posterior portion of the deep deltoid, the toe flexors and the tibiofibular ligaments. It might be necessary to release the talocalcaneal interosseous ligament to correct horizontal rotation. He would pin the talonavicular and talocalcaneal joints (two pins for the latter). He used a uniquely constructed hinged cast for immobilization. How Simons Approached Surgical Treatment Of TEV Simons expanded the complete peritalar release with a standard posteromedial release and additional releases of the lateral part of the talonavicular joint, lateral subtalar joint, calcaneofibular ligament and the interosseous talocalcaneal ligament.28,32-34 Only the complete subtalar release accomplishes full calcaneal rotation in a single procedure.32,34 Simons believed that you should delay surgery until the foot is at least 8 cm long because size is more important than age. However, he noted that the child should be under 4 years of age. Definite contraindications include a flat-topped talus and severe restricted plantarflexion due to anterior capsule contractures. Relative contraindications include rocker-bottom deformity and marked pes planus. He recommends the Cincinnati incision for patients up to the age of 3.32 The complete release includes superficial and deep medial, posterior and lateral dissection. Keep in mind that calcaneocuboid capsulotomy, anterior calcaneal osteotomy and plantar release may also be needed.32 For Simons, his superficial medial dissection included the superficial origin of the abductor hallucis and isolation of the neurovascular bundle. He would move on to deep dissection, opening the sheath of flexor digitorum longus from its muscle fibers to the master knot of Henry. Simons performed a proximal Z-lengthening of the tibialis posterior. His posterior dissection included lengthening of tendo-Achilles; posterior ankle capsulotomy from the peroneal sheath to tibialis posterior; and subtalar capsulotomy from flexor hallucis longus to the peroneal sheaths. Simons would begin his lateral dissection by opening the peroneal tendon sheaths at the posterior subtalar joint and circumferentially cutting the sheaths. He proceeded to release the calcaneofibular and posterior talofibular ligaments. Then he carried the dissection distally to free the lateral aspect of the talonavicular joint. Simons subsequently opened the lateral part of the subtalar joint and incises the talocalcaneal interosseous ligament. Simons continued deep dissection of the medial side to the distal tendon sheath of tibialis posterior, which he preserved for future repair by making a small slit over a probe near the abnormal tibionavicular “articulation.” One can draw the distal portion of the previously lengthened tendon out of the sheath and use it as a guide to the navicular tuberosity. (Simons would replace it and repair the sheath after performing a talonavicular release.) He would section the superficial deltoid and incise the sheath of the flexor hallucis longus. Simons proceeded to release the talonavicular joint, using the tibialis posterior tendon as the guide. If he could not reduce the forefoot adduction, Simons released the calcaneocuboid joint, preserving the dorsal and lateral one-third of the capsule and ligaments as a hinge to prevent subluxation. One would release the remainder of the joint from the medial and plantar to correct the forefoot in infants and children less than 3 years old. When patients are over the age of 3, Simons recommended a distal calcaneal osteotomy. He did not think a plantar release was necessary in most cases. One can use a threaded Kirschner wire to fixate the talonavicular joint. You can place a talocalcaneal pin vertically through the interosseous ligament. The calcaneocuboid release (or osteotomy) is also fixated. After realignment, one needs to decide whether there is a need for lengthening of the flexor digitorum and hallucis longus. The final position is confirmed by intraoperative radiology.41 Simons’ technique differs from McKay’s in repositioning, the use of intraoperative X-rays and postoperative care. Additionally, Simons released the interosseous and posterior talofibular ligaments routinely. McKay rolled up the sheaths of flexor hallucis and digitorum longus. Simons’ technique preserves the distal portion of tibialis posterior sheath and uses the plantar release for persisting forefoot adduction and cavus deformity. What One Can Learn From The Evolution Of TEV Treatment In reviewing the evolution of TEV, there are a few key principles to remember. Obviously, treatment and prognosis depend on the type of TEV. Secondly, even idiopathic TEV will soon be divided into etiological and pathophysiological subtypes. Third, the individual anatomical components do not exist in a vacuum. They are dynamically interrelated and managing one requires manipulating all other components simultaneously. Fourth, the plantarflexed position of the foot on the tibia is the sum of plantarflexion of the talus in the ankle mortise plus plantarflexion produced by the malpositioned calcaneus in the sagittal plane and supination of the subtalar joint complex.42 Treatment has evolved through a period of manipulation and casting, followed by progressively more complicated surgery. In the last few years, however, the pendulum has swung back in the direction of manipulative therapy.10 Renewed interest in non-surgical therapy probably resulted because of the frequent complications from surgery. These include avascular necrosis of the talus, flat-topped talar dome, subluxations of the talonavicular joint, overcorrection and failure to achieve reduction.35 Current Concepts In Closed Reduction Currently, there is renewed interest in Ponseti’s method of closed reduction. Conservative treatment of TEV should begin as soon after birth as possible.9 A delay in starting treatment is detrimental since successful closed reduction is preferable to surgical reduction. Closed reduction often succeeds and has less morbidity than surgery. Even patients who don’t have a full response can still benefit from partial correction as it stretches nerves and blood vessels, and also mobilizes the skin.40 Surgical reduction should be regarded as a salvage procedure. There are a number of points that help closed reduction succeed. As noted earlier and pointed out by numerous authors, the joints are not subluxed or dislocated. If they were, stretching and surgical release would result in complete reduction to normal position. In fact, the articulations are cohesive and congruent, but malpositioned. If the joints are released, they become subluxed or dislocated when repositioned. Second, contracted ligaments and joint capsule are extremely tight and unyielding. Excessive force will permanently damage cartilage and possibly fracture bone. Third, most of the abnormality is in the talus. The body of the talus is near normal, but the neck is short and deviated medially and plantarly. There is additional medial and plantar deviation of the articular surface of the head. Correct manipulation requires that surgeons fully understand the anatomy of TEV. The talus is plantarflexed in the ankle mortise with much of the trochlear surface anterior. The medial and lateral tubercles are against the posterior lip of the tibia and are held there by the contracted posterior ankle capsule. The calcaneus is rotated in sagittal plantarflexion, coronal inversion and transverse adduction with the distal calcaneus and calcaneocuboid joint rotated into adduction and inversion under the talar head. The posterior calcaneus is dorsiflexed, laterally toward the fibula and in varus. The abnormal position is held posterolaterally by contracture of the peroneal retinaculum and the calcaneofibular ligament, posteriorly by the subtalar capsule, and anteriorly by displacement of the navicular in a plantar, medial and proximal direction. The calcaneus and cuboid must follow the navicular. The navicular is held in its abnormal position by the pathological talonavicular joint congruency, the contracted spring and tibionavicular ligament, the ligaments between the distal calcaneus, cuboid and navicular and the abnormal position of the cuboid on the calcaneus. The forefoot is initially in medial cavus and adduction. The entire forefoot is supinated as everything distal follows the abnormally positioned navicular and cuboid. How The Author Proceeds With Manipulation And Casting My manipulation and casting closely follows the technique of Ponseti with a few variations. Initially, the forefoot is supinated with some plantarflexion of all or part of the medial column. One would start manipulation by supinating the medial column even further to bring the entire forefoot to the same plane as the navicular and cuboid. Once this is accomplished, one would place longitudinal traction on the medial column and abduct the entire foot over the head of the talus.43 You would place counterpressure over the dorsolateral talar head only. One must avoid restraining the calcaneus proximolaterally. It’s important to allow triplane motion for the calcaneus so the distal end can rotate laterally from under the talar head, rotate out of varus and dorsiflex along the lateral side of the talar head and neck while the posterior calcaneus moves medially away from the posterior fibula, everts and moves downward. After each manipulation, one should maintain the foot in an above-knee cast with the knee flexed. This is necessary to prevent transverse rotation and stabilize the new position. Otherwise, you will lose the correction. Once you have restored the talocalcaneonavicular relationship, you can assess the full extent of equinus. It is treated by dorsiflexing the entire plantar foot while pulling the calcaneus downward with a plantar assist by a finger on the superior surface just anterior to the tendo-Achilles.This prevents inadvertent plantar rocker-bottom deformity. How To Address Resistance To Manipulation Keep in mind that equinus is often resistant to manipulation. For infants under six months of age, one can perform a simple tendo-Achilles tenotomy in the office under local anesthesia. When treating infants over six months, it is better to go with an open tendo-Achilles lengthening. This allows a limited posterior release, if indicated. One would subsequently use casting to maintain reduction. Once you have completed the casting, use an externally rotated Fillauer bar bent in V fashion with the apex plantar. Very rarely, an infant will not tolerate the bar and shoe combination. In these cases, I have used solid ankle-foot orthoses (AFOs). Although I have not done this often enough to develop data, I find the AFO less satisfactory than the Fillauer bar. Relapses are common and are treated by repeating manipulation and casting. Around the age of 4, some children have enough residual forefoot supination that they need either a split or complete lateral transfer of the tibialis anterior.23,44,45 This is most common in the subset of children who fail to develop adequate peroneal function. This same complication can follow surgical over-release. Some infants with idiopathic TEV are very resistant to treatment because they are too old or have a deformity that is too severe to respond to non-operative reduction. In my hands, the comprehensive release, as initially outlined by McKay and refined by Simons, works best. I also incorporate the concepts outlined by Carroll.46-51 I modify the techniques in four ways. First, I have never found it necessary to perform a distal calcaneal osteotomy at the first release, but I routinely release the calcaneocuboid joint. Second, I try to keep the talocalcaneal interosseous ligament intact. Third, I almost always do some plantar release. Fourth, I tailor the release to the deformity so that enough is done to correct it, but not past that point. This prevents the problems of overcorrection. It is easier to salvage an undercorrected TEV than a grossly overcorrected foot. In Conclusion TEV is a complex deformity that is best managed by surgeons who fully understand the pathological anatomy. Considerable skill is needed for manipulation as well as surgery. The success or failure is in the hands of the first therapist. Non-operative therapy is not an alternative to surgery and most cases require some operative intervention. This can be as simple as an Achilles tenotomy or as extensive as a full rearfoot release. Physicians treating TEV must be willing and have the surgical skills to complete the entire case. Since TEV may be associated with other conditions, the treating physician has the responsibility to identify and address these problems as well. Dr. Harris is a Clinical Associate Professor in the Department of Orthopaedics and Rehabilitation at the Loyola Medical Center in Maywood, Ill. He is a Fellow of the American College of Foot and Ankle Surgeons.
 

References:

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Carroll NC: Congenital clubfoot: pathoanatomy and treatment. Instr Course Lect 1987;36:117-121. 51. Carroll NC, Gross RH: Operative management of clubfoot. Orthopedics 1990;13:1285-1296. Additional References 52. Hauser EDW: “Congenital Clubfoot.” Springfield: Charles C. Thomas, 1966. 53. Lehman WB: “The Clubfoot.” Philadelphia: J. B. Lippincott Co., 1980. 54. LeNoir JL: “Congenital Idiopathic Talipes.” Springfield: Charles C. Thomas, 1966. 55. McCauley JC, Jr.: Clubfoot: History of the development and the concepts of pathogenesis and treatment. Clin Orthop 1966;44:51-63. 56. McCauley JC, Krida A: The early treatment of equinus in congenital clubfoot. Am J Surg 1933;22:491-499. 57. Velasco Polo de G, Lechtman CP: Surgical treatment of congenital talipes equinovarus adductus. Clin Orthop 1970;70:87-92. 58. Scarpa A: A memoir on the congenital club feet of children, and of the mode of correcting that deformity. 1818. Clin Orthop 1994:4-7. 59. Bleck EE, Minaire P: Persistent medial deviation of the neck of the talus: A common cause of in-toeing in children. J Pediatr Orthop 1983;3:149-159. 60. Tachdjian MO: “Pediatric Orthopedics.” Philadelphia: W. B. Saunders Company, 1990. 61. Lovell WW, Winter RB: “Pediatric Orthopaedics.” 1978.