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)
| 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 |
The deformity in clubfoot affects the ankle, subtalar, and midtarsal joints. Key components include:
- Ankle: Equinus position due to gastro-soleus involvement
- Hindfoot: Varus, inversion, and adduction caused by tibialis posterior contracture, and bony abnormalities in the talus and calcaneus
- 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 |
- 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.