Clubfoot (Congenital talipes equinovarus)

by Stewart Dix-Peek & Japie de Wet

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Introduction

Clubfoot (congenital talipes equinovarus) is an idiopathic deformity of the foot of unclear aetiology. It is the most common musculoskeletal congenital disability with an overall incidence of 1:1000. The male: female ratio is approximately 2:1, and 50% of the cases are bilateral. A genetic component is strongly suggested with a familial occurrence of 25%

Applied anatomy

Soft tissue and bony deformities contribute to the characteristic deformity noted in a clubfoot.

Muscle contractures (CAVE)

Midfoot

• Cavus (tight intrinsics, flexor hallucus longus, flexor digitorum longus).

Forefoot

• Adductus of the forefoot (tight tibialis posterior).

Hind foot

• Equinus (tight Achilles tendon).
• Varus (tight Achilles tendon, tibialis posterior and tibialis anterior).

Bony deformity

The talar neck is displaced medially and deviated plantarly. The calcaneus (hind foot) is in varus and rotated medially. The navicular and cuboid bones are displaced medially

Clinical findings

History

• Birth history: Normal vs Caesarean section, duration of pregnancy, pre- or perinatal complications.
• Developmental history and milestones.
• Family history: Spinal defects, clubfoot in the family.
• Previous treatment: conservative (casting) or surgery.

Examination

Look

• Syndromic features: Facial, disproportionality.
• Spinal defects.
• Lower limbs: affected limb smaller and atrophied.
• Foot: smaller posterior and medial crease
  
  • Hind foot equinus and varus
  • Midfoot cavus
  • Forefoot adduction

Feel

• Palpable talus head (uncovered).
• Empty heel.

Move

• Mobile or rigid.
• Correction of adduction and equinus.
• Anterior tibialis and abductor response.
• Record ROM for plantar flexion and abduction.

Note: A deformity that completely corrects into abduction and dorsiflexion is positional/postural and not a true clubfoot deformity (intra-uterine position).

Neurovascular

Standard lower limb neurovascular examination.

Special investigations

• Radiology: X-rays usually not needed.
• Clubfoot deformity can be diagnosed intra-uterine with ultrasound.

Commonly associated conditions

• Arthrogryposis
• Myelodysplasia

Management

Non-surgical

Ponseti method, including serial casting correcting in sequence the cavus, adductus, varus and equinus. This may include an Achilles tenotomy. Follow-up with foot abduction braces or Dennis Brown boots is also necessary.

Surgical

Soft tissue

• Posterior medial release, Achilles tendon lengthening, Tibialis anterior transfer

Bone

• Medial column lengthening and lateral column shortening
• Talectomy
• Triple arthrodesis