synonyms: congenital talipes equinovarus, clubfoot
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.
- 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
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
- 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