Congenital Talipes Equinovarus
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Direct answer
Congenital talipes equinovarus is a present-at-birth foot deformity in which the forefoot is adducted and the hindfoot sits in equinus and varus. Treatment is primarily non-surgical, using the Ponseti method of serial manipulation and plaster casting started in the first weeks of life. Most feet are corrected by casting and a percutaneous Achilles tenotomy, then held with a foot abduction brace to prevent relapse.
What you must remember
- CAVE components: cavus (high arch), adductus (forefoot turned inward), varus (heel inverted) and equinus (ankle held in plantarflexion).
- Underlying defect: the talus is medially rotated and plantarflexed, so the navicular and calcaneus rotate around it.
- Sex and laterality: boys are affected more often than girls, and bilateral involvement is common.
- Ponseti method: weekly casts that correct the cavus first, then the forefoot adduction, and equinus last.
- Achilles tenotomy: a percutaneous release performed for residual equinus, usually before the final cast.
- Foot abduction brace: worn full time initially, then at night and during naps until about four years of age.
- Relapse: most often caused by poor brace compliance, and managed by repeat casting before surgery is considered.
A stepwise Ponseti pathway
The aim is a plantigrade, mobile foot without later surgery. Early and gentle correction works with the soft tissues while the foot is still pliable.
- Start early: begin casting in the first weeks of life, when the foot is more correctable and the tissues are more pliable.
- Correct the cavus: supinate the forefoot, with counter-pressure on the talar head, so the midfoot rotates around the talus without pronation.
- Abduct the forefoot: rotate the forefoot outward around the talar head to correct adduction while the heel is held steady.
- Address equinus last: dorsiflex the ankle gently, and perform a percutaneous Achilles tenotomy when dorsiflexion remains limited.
- Final cast and brace: hold the correction in a final cast for about three weeks, then start the abduction brace.
Serial casting is weekly, and the cast is changed as the foot improves. Surgery such as a posteromedial release is reserved for feet that fail to correct or relapse despite treatment.
Where the exam tries to catch you
Questions on this topic usually test the order of correction and the role of bracing.
- Trap: forcing the ankle into dorsiflexion before correcting the forefoot Correct: cavus and adduction are corrected first, and equinus is addressed last with tenotomy when needed.
- Trap: pronating the foot during casting Correct: the foot is supinated and abducted, because pronation worsens the deformity and can produce a rocker-bottom foot.
- Trap: stopping the brace once the casts are finished Correct: relapse is common without brace compliance, so maintenance bracing is essential.
- Trap: choosing surgery as first-line treatment in infancy Correct: Ponseti casting is first-line, and surgery is reserved for feet that fail to respond or relapse.
Frequently asked questions
What are the components of the deformity in congenital talipes equinovarus?
The components of the deformity in congenital talipes equinovarus are cavus, adductus, varus and equinus, remembered as CAVE. Cavus is a high arch, adductus turns the forefoot inward, varus inverts the heel and equinus holds the ankle in plantarflexion.
Why is the Ponseti method preferred for congenital talipes equinovarus?
The Ponseti method is preferred for congenital talipes equinovarus because serial casting corrects the deformity without extensive surgery in most infants. It works best when started in the first weeks of life and followed by a foot abduction brace to prevent relapse.
Which tendon is released in the Ponseti method?
The Achilles tendon is released in the Ponseti method when residual equinus persists after serial casting. The release is usually a percutaneous tenotomy performed before the final cast, which allows the ankle to dorsiflex to the required position.
How long is the foot abduction brace worn after clubfoot correction?
The foot abduction brace in congenital talipes equinovarus is worn full time at first, then at night and during naps until about four years of age. Compliance matters because relapse is common when the brace is not worn as prescribed.