الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Congenital talipes equinovarus (clubfoot) is a complex, congenital, contractural malalignment of the bones and joints of the foot and ankle that is difficult to correct, The individual deformity has four components: Equinus of the hindfoot, Varus (or inversion) at the midtarsal joint complex, Cavus (plantar flexion of the forefoot on the hindfoot), and Adductus of the forefoot on the midfoot.(1)
Congenital talipes equinovarus (CTEV) is one of the most common congenital anomalies encountered in pediatric orthopedics .Its incidence is approximately one in every 1000 live births. It and may be unilateral or bilateral. Bilateral deformities occur in 50% of patients. Boys are affected twice as often as girls.(2)
The true etiology of idiopathic congenital talipes equinovarus is still unknown. Several theories have been proposed regarding the cause; one of the most accepted theories is that a primary germ plasm defect in the talus causes continued plantar flexion and inversion of this bone, with subsequent soft-tissue changes in the joints and musculotendinous complexes.(3)
The talipes equinovarus deformity is classified into congenital and acquired. The congenital is further classified into idiopathic and non-idiopathic types. The idiopathic type is typically an isolated skeletal anomaly, usually bilateral, has a higher response rate to conservative treatment and a tendency towards a late recurrence. The causes of the non-idiopathic type include deformity occurring in genetic syndromes, teratologic anomalies, neurological disorders of known (e.g., spina bifida), arthrogryposis, absent bone; fibula or tibia and unknown etiology and myopathies. The non-idiopathic type is characterized by presence of other anomalies and a poor response to conservative or operative treatment. Acquired equinovarus has neurogenic causes (e.g., poliomyelitis, meningitis, sciatic nerve damage) and vascular causes.(92)
Radiographs should be included as part of the evaluation of clubfoot, before, and after treatment. Standard radiographs include anteroposterior and stress dorsiflexion lateral radiographs of both feet. If the deformity is unilateral, the normal foot can be used as a control to determine radiographic correction. (70)
Radiological assessment of the correction must be done with clinical evaluation. Properly taken radiographs avoid a false clinical impression of an apparent correction. Clinically, the heel varus may appear to be corrected because manipulations have displaced the heel pad laterally, whereas radiographs will demonstrate an abnormal tarsal relationship between the Calcaneus and talus, thus confirming the fact that one is dealing with a spurious correction. In the unilateral deformity, the clubfoot should be compared to the normal foot. (71)
The initial treatment of clubfoot, regardless of its severity or rigidity, is nonoperative by serial manipulation and casting that should begin as early as possible after birth (7 to 10 days). Historically, the treatment consists of Forcible Serial Manipulation by correcting all the deformity simultaneously with fulcrum at the calcaneo-cuboid joint as describe by Kite. The efficacy of manipulation and casting is attributable to the viscoelastic, or rate-dependent, behavior of the ligaments and tendons. (107)
Over the past decade Ponseti management has become accepted throughout the world as the most effective and least expensive treatment of clubfoot. The Ponseti technique corrects the deformity by gradually rotating the foot around the head of the talus over approximately period of 6 weeks by weekly manipulations followed by plaster cast applications. At the time of the final cast, most infants require percutaneous achilles tenotomy to gain adequate lengthening of the achilles tendon. When the final cast is removed, the infant is placed in a brace that maintains the foot in its corrected position (foot abduction orthosis). (7)