PES EQUINOVARUS –
(PEV)
[Link] Doğan , MD
Ankara Yıldırım Beyazıt University,
Orthopaedics and Traumatology Dept.
[Link] Doğan, MD
Pes Equinovarus - PEV
PES EQUINOVARUS
Congenitally deformed foot(club foot)
pes equinovarus
talipes equinovarus
Varus
Adduktus Eqinus
[Link] Doğan, MD
Pes Equinovarus - PEV
1) Fixed plantar flexion of ankle
plantar fleksiyon (equinus),
2) Inversion and axially internal
rotation of subtalar joint (varus),
3) Medial subluxation of
talonavicular and calcaneocuboid
joint (adductus)
[Link] Doğan, MD
Pes Equinovarus - PEV
ETIOLOGY
• Controversial
• Many causes were suspected especially neuromuscular
causes
• Even being hereditary has solid proofs, poligenetic
characteristics of pes equinovarus makes it unknown
[Link] Doğan, MD
Pes Equinovarus - PEV
EPIDEMIOLOGY
• Frequency; 1-2 cases in a thousand live
• % 50 bilateral
• Male/female ratio:2/1
• Pedigree investigation is %10 positive
• If the kid has deformed mother or father, the second kid’s
probability having deformity is %10-25
• If mother and father is normal second kid’s probability
having deformity is %2-5
[Link] Doğan, MD
Pes Equinovarus - PEV
PATHOLOGY
• Leg’s posterior and
medial
muscles(especially Calf
muscles and tibialis
posterior) are extremely
shortened, fibrous
capsules of deformed
joints are thickened and
deformity’s concave
side is contracted
[Link] Doğan, MD
Pes Equinovarus - PEV
Pathoanatomy
• Calcaneus turns inferiorly and
internally that makes it paralel to
talus
• Calcaneus posterior touches fibula
because of strained
calcaneofibular ligament
• Plantar fascia and spring ligament
are short
• Achilles, TP, FHL, FDL are shortened
• Ankle and talocalcaneal joint’s
posterior capsule are strained
[Link] Doğan, MD
Pes Equinovarus - PEV
Pathoanatomy
• Head of Talus is short, and
turned medially and
plantarily
• Varus deformity in distal of
calcaneus
• Subtalar joint is in inversion
and plantar flexion
[Link] Doğan, MD
Pes Equinovarus - PEV
Main patology is in talus and talonavicular joint
[Link] Doğan, MD
Pes Equinovarus - PEV
Pathoanatomy
Muscles
• Especially peroneal group of
leg muscles are atrophic
• Fibril counts are normal but
fibrils’ size are short
• Arterial pathology exists ( A.
Tibialis Anterior hypoplasia)
[Link] Doğan, MD
Pes Equinovarus - PEV
DIAGNOSIS
CLINICAL:
• Slight deformities must be differentiated from positional
equinovarus
• Positional equinovarus cause is bad position in uterus and
it can be passively fixed
• Severe deformities must be differentiated from rarely seen
but severe ongoing teratological pes equinovarus
• Teratological types are mostly seen with spina bifida or
artrogriposis(amioplasia congenita) like syndromes
[Link] Doğan, MD
Pes Equinovarus - PEV
CLINICAL
EXAMINATION
[Link] Doğan, MD
Pes Equinovarus - PEV
• Cavus
• Adduktus
• Varus
• Eqinus
• Tibial internal rotation
•C– A – V – E Varus
Adduktus Eqinus
Grant, Am J Ortho, 1995
[Link] Doğan, MD
Pes Equinovarus - PEV
[Link] Doğan, MD
Pes Equinovarus - PEV
RADIOLOGICAL:
• Because of non ossified bones of
newborn direct radiography is not
significant. After 4-5. months
radiological evaluation can be
made. Ankle and posterior of foot
are on plantarflexion
• Angle relation between talus and
calcaneus is deformed(normally
angle is 25-40 degrees), subjectively
parallelity occured
• Navicular bone according to talus
and cuboid bone according to
calcaneus subluxated medially and
deplaced
[Link] Doğan, MD
Pes Equinovarus - PEV
Radiographic examination
• Reliability in diagnosis and treatment is
controversial
• Small ossification center
• Talus’s ossification center is not in it’s central core
• Ossification of navicula begins in the age of 3-4
[Link] Doğan, MD
Pes Equinovarus - PEV
AP Radiography
NORMAL
• A-Kite angle 20-40
• B-talo-first metatarsal angle 0–15
• Calcaneus - cuboid and 5. metatars
are on the same plane
[Link] Doğan, MD
Pes Equinovarus - PEV
Lateral Radiography
• Talocalcaneal angle 35-50
[Link] Doğan, MD
Pes Equinovarus - PEV
• A- Kite angle <20
• B- TMT angle increases
• Cuboid slides medially
and the line that is drawn
from calcaneus passes
laterally
[Link] Doğan, MD
Pes Equinovarus - PEV
Classification
• İdiopathic
• Postural
• Neurogenic
• Syndromic
[Link] Doğan, MD
Pes Equinovarus - PEV
Classification
Soft
Soft-hard
Hard
[Link] Doğan, MD
Pes Equinovarus - PEV
DEFINITIVE
NEUROMUSCULAR
SYNDROMIC Myelomeningocele
Larsen Syndrome
Poliomyelitis
Artrogriposis Multiplex
congenita Cerebral Palsy
Myotonic muscular
DIAGNOSOSIS dystrophy
[Link] Doğan, MD
Pes Equinovarus - PEV
TREATMENT
[Link] Doğan, MD
Pes Equinovarus - PEV
Treatment
1) CASTING: PONSETİ Management
• The order of fixing deformities are:
1) Cavus
2) Adduction of anterior of foot and varus of heel
3) Equinus.
• The last component of fixation in a deformed foot is equinus.
• Percutaneous tenotomy may be needed
• (CAVE)
This management’s complications are:
a)İncreased cavus deformity
b)Rocker-bottom deformity
c)Flattening of proximal side of Talus
d)Lateral rotaiton of ankle
e)İncreased stiffness in ankle and ligaments.
[Link] Doğan, MD
Pes Equinovarus - PEV
• Long leg cast is applied and
changed in 5-7 days
• The order of fixing deformities:
• Cavus,
• Adduktus,
• Varus
• Equinus
• Percutaneous achilles tenotomi
and cast application after 3
weeks Denis-Browne splint
• 4 months continuous
• Nights before 4 year-old
[Link] Doğan, MD
Pes Equinovarus - PEV
Fırst Cavus Then Metarsus Adductus Must Be Fıxed
[Link] Doğan, MD
Pes Equinovarus - PEV
Complıcatıons:
• Cast wound
• Detachment of cast
from foot
• Rocker-bottom foot
• Deformity may
reoccur
[Link] Doğan, MD
Pes Equinovarus - PEV
Do Not Forget!!!!
You Have One Chance In Treatment
[Link] Doğan, MD
Pes Equinovarus - PEV
SURGICAL TREATMENT
• All strained soft tissue loosened, normal relation
between talus and calcaneus tried to be provided,
tendons are extended
• There are
a) medial
b) posterior
c) posteromedial
d) Complete subtalar loosening managements
Because of most of the deformities can be fixed with
Ponseti management, surgical treatment is rarely used
according to past. Surgery mostly favoured in late
diagnosed and very rigid cases
[Link] Doğan, MD
Pes Equinovarus - PEV
Aım Of Treatment
• Can press sole of foot,
• Can wear shoes,
• Sufficient function,
• Normal shaped,
• A foot without pain
Normal Anatomy
Thank You…
[Link] Doğan , MD
Ankara Yıldırım Beyazıt University,
Orthopaedics and Traumatology Dept.
