Clubfoot

Talipes Equinovarus, commonly known as Clubfoot, is a congenital deformity involving multiple musculoskeletal structures in the foot and ankle. It presents with a distinctive inward twisting of the foot and affects approximately 1 in 1,000 live births.

Epidemiology

Parameter Details
Gender Boys > Girls
Prevalence Higher in Polynesians and Black populations
Laterality 50% of cases are bilateral

Aetiology

Clubfoot’s causes are multifactorial, with several proposed theories:

  • Neurogenic: Muscle imbalance potentially leading to deformity
  • Myogenic: Anomalous muscles noted in clubfoot
  • Vascular: Often accompanied by a short limb and absent anterior tibial artery
  • Bone Abnormalities: Primarily affecting talus and calcaneus
  • Packaging Disorder: Association with developmental dysplasia of the hip (DDH) and metatarsus adductus
  • Genetic Predisposition: Family history increases risk
  • Associated Conditions: May present alongside hip and spinal issues (screen recommended)

Subtypes of Clubfoot

Subtype Description
Idiopathic No known associated conditions
Neuromuscular Related to conditions such as CP, polio, peroneal nerve palsy, spina bifida
Teratologic Associated with arthrogryposis and multiple joint contractures

Features of the Deformity

The deformity in clubfoot affects the ankle, subtalar, and midtarsal joints. Key components include:

  1. Ankle: Equinus position due to gastro-soleus involvement
  2. Hindfoot: Varus, inversion, and adduction caused by tibialis posterior contracture, and bony abnormalities in the talus and calcaneus
  3. Forefoot: Cavus, adduction, and plantarflexion involving the plantar fascia, adductor hallucis, and flexor hallucis

Classification: Pirani Score

Score Element Description
Posterior Folds Medial and posterior creases, linked to severity
Curvature Curvature of the lateral border
Calcaneus & Talus Palpability indicates severity
  • Scores range from 0 to 6, with higher scores indicating more severe and rigid deformities.

Clinical Presentation

  • Medial-facing sole
  • High-arched heel
  • Shortened limb on the affected side
  • Smaller calf and foot size
  • Screening advised for associated abnormalities (e.g., bone dysplasia, DDH, neurogenic markers)

Imaging Features

Imaging, although not always required for diagnosis, provides key insights:

View Key Indicators
Lateral (Turco’s) Talo-calcaneal angle is 0° in clubfoot
AP (Kite’s Angle) Talo-calcaneal angle less than 20° (normally 20-40°)

Management Approaches

Ponseti Method

  • Indications: First-line treatment for all clubfoot presentations
  • Process: 6-8 casts changed weekly, ending with Achilles tenotomy
  • Post-casting: Boot and bar used 23 hours daily for 3 months, then nightly until age 4
  • Correction Order (CAVE):
    • Cavus (dorsiflexion of the first ray)
    • Adductus (forefoot correction)
    • Varus (hindfoot correction)
    • Equinus (Achilles tenotomy)

Soft Tissue Release

Method Description
Cincinnati Circumferential release of all structures
A la Carte Posteromedial release tailored to specific structures
  • Complications: Scarring, stiffness, neurovascular risk, recurrence in resistant cases

Surgical Options

Technique Use Case Key Points
Tendon Transfer Residual recurrence in ages 3-4 Transfer TA to base of the 5th metatarsal
Ilizarov Method Severe, stiff, older cases Gradual correction with external fixation
Osteotomy Recalcitrant deformities, older children Calcaneus or lateral column shortening
Talectomy Rare, primarily in cases of arthrogryposis
Fusion Triple fusion in select cases to stabilize foot Concerns for future ankle degeneration

Bony Features of Clubfoot

  • Parallelism of talus and calcaneus on both views
  • Kite’s Angle < 20 degrees
  • Turco’s Angle 0 degrees in lateral dorsiflexion view

References

Miller M (2008) Review of Orthopaedics, 5th edition, Saunders.

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