Clubfoot (congenital talipes equinovarus)

Introduction

Idiopathic deformity of the foot of unclear etiology

Epidemiology
o

hand anomalies (Streeter dysplasia)

diastrophic dysplasia

arthrogryposis

tibial hemimelia

myelodysplasia

prune-belly syndrome

demographics

most common birth defect

1:250 to 1:1000 depending on

population

Anatomy

highest prevalence in Hawaiians and

Maoris

more common in males

Muscles contractures lead to the characteristic deformity

that includes (CAVE)

location

Associated conditions

half of cases are bilateral

Genetics
o

genetic etiology is strongly suggested

familial occurrence in 25%

recent link to PITX1, transcription factor

critical for limb development

common genetic pathway may exist with

congenital vertical talus

o
o

midfoot Cavus (tight intrinsics, FHL, FDL)

forefoot Adductus (tight tibialis posterior)

hindfoot Varus (tight tendoachilles, tibialis

posterior)
Simple Deformities

Deformity

Strong Muscle

calcaneus is in varus and rotated medially

around talus

navicular and cuboid are displaced medially

Weak Muscle

equinus

gastrocnemius-soleus complex

dorsiflexors

cavus

plantar fascia, intrinsics

dorsiflexors

varus

posterior tibialis and anterior

tibialis

peroneal brevis

supination

anterior tibialis

peroneus longus

flatfoot

peroneus brevis

posterior tibialis

Table of foot deformity muscle imbalances

Complex Deformities
equinovarus
+ supination

gastroc-soleus complex,
posterior tibialis, anterior
tibialis

peroneus brevis & longus

equinovalgus

gastroc-soleus complex,
peroneals

posterior tibialis, anterior

tibialis

calcaneovalg
us

foot dorsiflexors/evertors (L4 and

L5)

plantar flexors /inverters

(S1 and S2)

hindfoot Equinus (tight tendoachilles)

Bony deformity consists of

o talar neck is medially and plantarly deviated

Presentation

Physical exam
o inspection

small foot and calf

shortened tibia
medial and posterior foot skin creases
foot deformities
hindfoot in equinus and varus
differentiated from more common
positional foot deformities by rigid

equinus and resistance to passive

correction
midfoot in cavus
forefoot in adduction

Imaging

Radiographs
o recommended views

shows hindfoot parallelism between the

talus and calcaneus

Ultrasound
o

dorsiflexion lateral (Turco view)

helpful in prenatal diagnosis (high false positive

rate)

Treatment

Nonoperative
o

will see talocalcaneal angle < 35 and

flat talar head (normal is talocalcaneal
angle >35)

AP

talus-first metatarsal angle is negative

(normal is 0-20)
also shows hindfoot parallelism

serial manipulation and casting (Ponseti

method)
indications
there has been a trend away
from surgery and towards the
nonoperative Ponseti method
due to improved long term
results
outcomes
Ponseti method has 90%
success rate

talocalcaneal (Kite) angle is < 20

(normal is 20-40)

Operative
o posteromedial soft tissue release and
tendon lengthening
indications

resistant feet in young children

"rocker bottom" feet that
develop as a result of serial
casting

syndrome-associated clubfoot
delayed presentation >1-2
years of age
performed at 9-10 months of
age so the child can be
ambulatory at one year of age
outcomes
requires postoperative casting
for optimal results
extent of soft-tissue release
correlates with long-term
function of the foot and
patient
medial opening or lateral columnshortening osteotomy, or cuboidal
decancellation
indications
older children from 3 to 10
years

triple arthrodesis
indications
in refractory clubfoot at 8-10
years of age
contraindicated in insensate
feet due to rigidity and
resultant ulceration
talectomy
indications

salvage procedure in older

children (8-10 yrs) with an
insensate foot
gradual correction by means of ring fixator (Taylor
Spatial Frame) application
complex deformity resistant to
standard methods of treatment

Techniques

Serial manipulation and casting (long leg cast)

o

goal is to rotate foot laterally around a fixed talus

order of correction (CAVE)

1. midfoot cavus
2. forefoot adductus
3. hindfoot varus
4. hindfoot equinus