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Club Foot

clubfoot picture 

clubfoot picture

clubfoot xray picture

clubfoot xray picture

synonyms: congenital talipes equinovarus, clubfoot

Clubfoot ICD-9

Clubfoot Etiology / Epidemiology / Natural History

  • Foot deformity with the hindfoot equinus, midfoot varus, and forefoot adductus or talipes equinovarus.
  • Etiology unknown
  • 1/1000 live births, M/F=3/1, 40% bilateral, highest incidence in polynesians
  • Genetic predisposition: incidence is 10x higher in families with an affected individual.
  • May be congenital or acquired secondary to cerebral palsy, myelomeningocele, polio, amniotic band syndrome.
  • Natural History: generally function well as children, but as body weight increases, lateral forefoot wear becomes painful and shoe wear difficult.

Clubfoot Anatomy

  • The talar neck is deviated in a medial and plantar direction; calcaneous is rotated medially, Navicular is displaced medially; cuboid displaced medially.
  • CAVE: cavus, adductus, varus and equinus.

Clubfoot Clinical Evaluation

  • Forefoot adductus and suppination; hindfoot equinos and varus.
  • Medial crease
  • Lateral head of talus
  • Empty heal
  • Posterior crease
  • RE
  • CLB

Clubfoot Xray / Diagnositc Tests

  • A/P view
    -Talocalcaneal (Kite's) angle: 20-40° is normal; <20° = clubfoot. Lines drawn throught the long axis of the talus and os calcis.
    -Talus-1st metatarsal angle (0-20° = normal, <0° = clubfoot. Lines drawn through the long axis of the talus and the 1st metatarsal.
  • Lateral view
    -Talocalcaneal angle: typically <25°. Lines drawn through the long axis of the talus and inferior margin of the calcaneous.
  • Dorsiflexion lateral (Turco's) view; measure the talocalcaneal angle (>35° is normal: <35° with flat talar head = clubfoot).

Clubfoot Classification / Treatment

  • Position vs idiopathic vs tertologic
  • Ponsetti Method (manipulation and serial casting) 
    -Treatment should be started within the first month of life. Success rate without surgery is less if started later, but warrants consideration withn first @8 months.
    -First cavus is corrected by supination of forefoot and 1st ray dorsiflexion, then abduct forefoot with talar head as fulcrum.  Once foot is abducted under the talus to 69° outward rotation and dorsiflexion is attempted.  Ponsetti methods corrects the components of the clubfoot in the order of cavus, forefoot adductus, hindfoot varus, and equinus. 
    -Usually 6-8wks of weekly long-leg groin-to-toe casts.
    -Generally requires percutaneous Achilles lengthening or posterior capsular release if equines is rigid.
  • Surgery done at 6-12months if deformity fails to correct with serial casting.
  • Delayed presentation: 3-10yrs old, generally require: medial opening or lateral column shortening osteotomy or cuboidal decancelliation indicated.
  • Delayed presentation / refractory clubfoot: >10yrs old, generaly treated with triple arthrodesis. Consider talectomy for pts with insensate feet.

Clubfoot Surgical Technique

  • Cincinnati incision
  • Carefully protect posterior tibial artery.
  • Achilles, posterior tibialis, FHL lengthening
  • Talotibial, calcaneotibial, talonavicular, subtalar  +/-calcaneocuboid capsular release.
  • Equinus deformity: Achilles Z-lengthengin, posterior tibiotalar and talocalcaneal capsulotomy.
  • Hindfoot varus: posteromedial talocalcaneal capsulotomy +/- complete subtalar release.
  • Midfoot adduction: abductor hallucis and talonavicular joint release +/- calcaneal cuboid joint release or decancellation of the cuboid.
  • Cavus: plantar fascia release.
  • Recurrent deformition after surgical release=15-50%

Clubfoot Associated Anomalies / Differential Diagnosis

Clubfoot Complications

  • Cast sore
  • Wound breakdown

Clubfoot Follow-up Care

  • Weekly cast change for 6-8 wks
  • Denis-Browne bar worn at night for up to 3 yrs
  • May require anterior tibialis transfer for residual supination.
  • Ir recurrence occurs repeat casting / abduction orthosis is often successful. Surgical release should include only the affected extrinsic areas: generally posterior subtalar, ankle and talonavicular joints. Medial subtalar joint and interosseous ligament generally do not require release.

Clubfoot Review References

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