Congenital talipes equinovarus (CTEV)

What is congenital talipes equinovarus (CTEV)?

Congenital talipes equinovarus (CTEV) is a foot deformity that a child is born with. It is also known as ‘clubfoot’ or ‘talipes’. CTEV is a common condition that occurs in approximately 1 in 1,000 births.

There is an hereditary influence which means that if there is a close relative with clubfoot the likelihood of having CTEV is 3 to 10 percent.

It is more common in boys and can affect one or both feet. The most common type of clubfoot is idiopathic meaning ‘no known cause’ but secondary CTEV can occur with other neurological conditions or syndromes such as spina bifida and arthrogryposis.

What is the treatment for CTEV?

The Ponseti method is the internationally recognised gold standard treatment for children with CTEV. The goals of treatment are to achieve a functional, pain-free foot, the ability to wear normal shoes and the avoidance of permanent disability. There are two phases which are ‘corrective’ and ‘maintenance’. We would hope to begin treatment at your first consultation.

Corrective phase

This involves weekly manipulation of the foot or feet as well as cast application. These treatments are provided by a specialist physiotherapist and a trained paediatric orthopaedic casting practitioner. There are usually 6 to 8 sequential manipulations and cast application required to achieve full correction.

Each week, your child will have their cast taken off with a cast saw and will get weighed without their cast on. During the weeks that the casts are applied, we advise that you do not bath your child at home. The cast is not waterproof so you cannot get it wet. However, you will be given the opportunity to bathe your child in clinic when the cast is removed each week.

Here is an example of the first cast

The cast is taken off with the cast saw each week

Tenotomy

As part of this phase your child will usually need a tenotomy (division) of the Achilles tendon. This is the case in around 80 percent of children and this is because the Achilles tendon is tight in CTEV. This will usually be performed by the surgeon in the clinic using local anaesthetic. However, if your child is over 3 months old we would expect to perform this surgery in theatre under anaesthetic.

After the tenotomy, we would expect the cast to remain in place for 3 weeks. When this 3 weeks is over your child’s corrective phase is complete.

Maintenance phase

This part of the Ponseti method is crucial and the advice given must be followed as instructed.

When the final cast is removed, your child is ready to be fitted with boots and bar on the same day. The boots and bars are to be worn for 23 hours per day for 3 months.

After this initial period, your child will wear the boots and bar at night and for nap times only. This will mean approximately 14 hours per day. This will not affect your child’s development and they will learn to walk in the normal way and within the normal timescales.

Your child will be reviewed at regular intervals by the orthotist and orthopaedic team. Your child will usually be expected to follow the boots and bar regime until they are 4 years old.

If your child does not wear the boots and bar as instructed, the correction will have a 90 percent chance of failing before the age of 2.

An example of the boots and bars used in the Ponseti method to treat talipes

What do I need to know about the cast?

Do

• Keep cast clean and dry (if nappy leaks, wipe cast with baby wipes)
• Check for any cracks or breaks
• Check for cast slips – can you see all of your child’s toes?
• Check for circulation – are toes normal colour and warm
• Support the cast when lifting or putting your child into a car seat

Don’t

• Take the cast off under any circumstances
• Put powder or lotions down the cast as these increase the risk of it slipping

Please contact us if you notice any of the following:

• Increased swelling at the top of the cast or in the toes
• Fluid or bad smell coming from the cast
• Toes are not normal colour or cold
• Any redness or rubbing the skin from the cast
• You cannot see all of the toes, for example they have slipped back in the cast and are moving away from the edge of the foot plate
• The cast is soft or cracked
• The cast is too tight around the top of the leg (you should be able to get your index finger down the top)
• Your baby kicks the cast off
• Your baby has an unexplained high temperature or is very grizzly and unable to settle for feeding or sleep

Example of a cast slip – the toes are inside the cast

How do I contact you?

Ring the plaster room and speak to one of the team. We may ask you to send us a photograph by email so that we can assess whether we need you to come into hospital or if you are more local, we may ask you to come straight in.

Please do not email us without ringing first as the email is not always checked regularly.

If out of hours, please attend your local Emergency Department for help and advice.

Who will I see in the team?

Please visit our Trust website to see all the professionals that will be involved with your child’s care, including their Orthopaedic Consultant, Physiotherapist, Casting Practitioner and Orthotist.
www.sheffieldchildrens.nhs.uk/services/orthopaedics/talipes

You can also visit the STEPS charity website for further information
www.steps-charity.org.uk/conditions/talipes-clubfoot