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