Congenital Clubfoot (Talipes equinovarus)

Yasser

Alwabli

Introduction – definition

Developmental deformity of foot

described as:

◦ Equinus

◦ Inversion (HF varus)

◦ Cavus (FF pronation)

◦ Adduction

Introduction – definition

Epidemiology

1-2 in 1000

50% bilateral, Boys 2X

Associations (20%) - SP, CP, AG ? DDH (Paton RW, 2009)

Family studies:

◦ 30% in identical twins, one parent 3-4%

and two parents 30%

Etiology

Many theories:

◦ Mechanical, neuromuscular, vascular

deficiencies

◦ Polygenic multifactorial trait

◦ AD with incomplete penetrance

◦ Environmental – early amniocentesis,

maternal smoking

◦ Genetic – PITX1 gene

Pathoanatomy

Talocalcaneonavicular (TCN) joint

dislocation with soft tissue

contractures

Soft tissue contractures

Cavus (tight intrinsics, FHL, FDL)

Adductus (tight tibialis posterior)

Varus (tight tendoachilles, tibialis

posterior)

Equinus (tight tendoachilles)

Clinically

Small foot

Small calf

Tibia - shortened

Medial and posterior foot skin creases

Foot deformities:

◦ Hindfoot - Equinus + Varus

◦ Midfoot - Cavus

◦ Forefoot - Adduction

Imaging

Antenatally – US

X-Rays – not routinely done

Views - AP and lateral in stress dorsiflexion. ◦ On AP view: Talocalcaneal angle (30-55˚) and the talo-first

metatarsal angle (5-15˚).

◦ Lateral view: Talocalcaneal angle (10-40˚) and the tibiocalcaneal

angle (10-20˚).

Hindfoot parallelism

All of these angles are decreased.

Classification - Pirani’s

classification system (Pirani et al,

1995)

Classification - Dimeglio

classification (Dimeglio et al,

1995)

Classification - Dimeglio

classification (Dimeglio et al,

1995)

Classification - Dimeglio

classification (Dimeglio et al,

1995)

Treatment – Ponseti

technique Since 1950

POSNA members – 96.7% (2010)

Success rate – 90%

Timing – first weeks of life

Serial casting (average 4-5 casts)

Long leg cast

Dennis brown bar

Achilles tenotomy – 70%

Dennis brown bar

Treatment – Ponseti

technique

Treatment - French technique

74% success rate

Daily manipulation by physiotherapist followed by immobilization with adhesive taping to maintain the correction achieved with stretching.

Daily for 2 months then 3/week till age 6 months.

If successful in achieving correction, parents continue both the home exercises and night splints until the child reaches walking age.

Treatment – surgical options

Posteromedial soft tissue release: Resistant cases

Delayed presentation

Syndrome-associated clubfoot

Medial opening or lateral column-

shortening osteotomy, or cuboidal

decancellation – older children 3-10

years

Tripe arthrodesis – refractory cases

Talectomy – salvage procedure

Complications

With nonoperative treatment:

◦ Relapse

◦ Dynamic supination

With operative treatment:

◦ Residual cavus

◦ Pes planus

◦ Intoeing gait

◦ Dorsal bunion