CTEV (Clubfoot): Ponseti Method, CAVE Deformity & Rehab MCQs

Congenital Talipes Equino Varus (CTEV)

CTEV, or Clubfoot, is one of the most common congenital orthopedic anomalies. It is a complex 3D deformity of the foot involving the ankle, subtalar, and midtarsal joints.

1. The CAVE Deformities

The deformity consists of four components, which must be corrected in a specific order:

• C - Cavus (High arch) - Forefoot pronation relative to hindfoot.
• A - Adductus - Forefoot deviates medially.
• V - Varus - Heel (Calcaneus) is turned inward.
• E - Equinus - Ankle is fixed in plantarflexion (Tight Achilles).

2. Pathoanatomy

• Primary Pathology: Medial and Plantar deviation of the Talar Neck. The Talus is smaller and deformed.
• Soft Tissue: Medial and Posterior ligaments/tendons (Tibialis Posterior, FHL, FDL, Achilles) are tight and shortened.

3. Management (The Ponseti Method)

The Ponseti Method is the Global Gold Standard (Success rate >95%).

1. Manipulation & Casting: Serial casting (weekly) to correct Cavus, Adductus, and Varus (in that order). The foot is abducted around the Talar head (fulcrum).
2. Tenotomy: Percutaneous Tendo-Achilles Tenotomy is required in 90% of cases to correct the final Equinus deformity.
3. Bracing (Maintenance): Dennis Brown Splint (Foot Abduction Brace) worn 23 hours/day for 3 months, then at night until age 4 to prevent recurrence.

25 Practice MCQs

Q1. The acronym CAVE stands for:

Answer: A). The order of correction is C -> A+V -> E.

Q2. The fulcrum for manipulation in the Ponseti method is:

Answer: A). Never touch the Calcaneus directly; abduct the forefoot to correct the heel.

Q3. Which deformity is corrected LAST?

Answer: D). Corrected by Tenotomy after the midfoot is unlocked.

Q4. Cavus is corrected by:

Answer: A). Paradoxical supination aligns the forefoot.

Q5. The Pirani Score is used to:

Answer: A). Higher score = more severe.

Q6. Rocker Bottom Foot (Vertical Talus) is a complication of:

Answer: A). Attempting to correct Equinus before Varus/Adductus leads to spurious correction.

Q7. Dennis Brown (DB) Splint maintains:

Answer: A). Shoes set at 70 degrees abduction.

Q8. Which tendon is primarily tight and contributes to Varus/Adductus?

Answer: A). The main inverter of the foot.

Q9. Tenotomy is indicated when:

Answer: A). Usually after 4-6 casts.

Q10. The primary goal of Ponseti treatment is:

Answer: A). Function > Anatomy.

Q11. CTEV is associated with:

Answer: A). Part of "packaging disorders".

Q12. "Kite's Angle" on X-ray (Talocalcaneal angle) in CTEV is:

Answer: A). Normal is 20-40; in Clubfoot < 20.

Q13. Tibialis Anterior Transfer (TATT) is done for:

Answer: A). Moves the insertion to the middle/lateral cuneiform to act as dorsiflexor.

Q14. Recurrence is most commonly due to:

Answer: A). Parents stop using the boots/bar too early.

Q15. Which part of the foot is adducted?

Answer: A). Hindfoot is in Varus.

Q16. Post-tenotomy cast remains for:

Answer: A). Allows the tendon to heal in the lengthened position.

Q17. Is CTEV painful at birth?

Answer: B). It is a painless deformity initially.

Q18. Secondary changes in bone occur:

Answer: A). Bones change shape to accommodate the deformity.

Q19. The navicular bone is displaced:

Answer: A). Subluxates medially off the talar head.

Q20. French Method of treatment involves:

Answer: A). Alternative to Ponseti, labor intensive.

Q21. Complex Clubfoot is characterized by:

Answer: A). "Atypical" clubfoot requiring modified Ponseti.

Q22. Male to Female ratio is:

Answer: A). Opposite of DDH (which is female dominant).

Q23. Turco's operation is:

Answer: A). Used for resistant cases (extensive open surgery).

Q24. Bilateral involvement occurs in:

Answer: A). Very common.

Q25. Which structure is NOT tight in CTEV?

Answer: D). Peroneals (Evertors) are weak and overstretched, not tight.