Clubfoot (congenital talipes equinovarus)

Topic updated on 07/31/16 12:44pm
  • Idiopathic deformity of the foot of unclear etiology
  • Epidemiology
    • demographics
      • most common birth defect
      • 1:250 to 1:1000 depending on population
      • highest prevalence in Hawaiians and Maoris
      • more common in males
    • location
      • half of cases are bilateral
  • Genetics
    • genetic etiology is strongly suggested
    • unaffected parents with affected child have 2.5% - 6.5% chance of having another child with a clubfoot
    • familial occurrence in 25%
    • recent link to PITX1, transcription factor critical for limb development
    • common genetic pathway may exist with congenital vertical talus  
  • Associated conditions
    • hand anomalies (Streeter dysplasia) 
    • diastrophic dysplasia  
    • arthrogryposis  
    • tibial hemimelia 
    • myelodysplasia  
    • amniotic band syndrome
    • Pierre Robin syndrome
    • Opitz syndrome
    • Larsen syndrome
    • prune-belly syndrome
  • Muscles contractures lead to the characteristic deformity that includes (CAVE)     
    • midfoot Cavus (tight intrinsics, FHL, FDL)
    • forefoot Adductus (tight tibialis posterior)
    • hindfoot Varus (tight tendoachilles, tibialis posterior, tibialis anterior)
    • hindfoot Equinus (tight tendoachilles)
  • Bony deformity consists of
    • talar neck is medially and plantarly deviated
    • calcaneus is in varus and rotated medially around talus
    • navicular and cuboid are displaced medially
  • Table of foot deformity muscle imbalances 
  • Physical exam
    • inspection
      • small foot and calf 
      • shortened tibia
      • medial and posterior foot skin creases
      • foot deformities
        • hindfoot in equinus and varus
          • differentiated from more common positional foot deformities by rigid equinus and resistance to passive correction
        • midfoot in cavus
        • forefoot in adduction
  • Radiographs
    • recommended views
      • dorsiflexion lateral (Turco view)
        • shows hindfoot parallelism between the talus and calcaneus 
        • will see talocalcaneal angle < 35° and flat talar head (normal is talocalcaneal angle >35°)
      • AP
        • talocalcaneal (Kite) angle is < 20° (normal is 20-40°) 
        • talus-first metatarsal angle is negative (normal is 0-20°)
        • also shows hindfoot parallelism
  • Ultrasound 
    • helpful in prenatal diagnosis (high false positive rate)
    • can be diagnosed as early as 12 weeks of gestational age 
  • Nonoperative
    • serial manipulation and casting (Ponseti method)    
      • indications
        • there has been a trend away from surgery and towards the nonoperative Ponseti method due to improved long term results
      • outcomes
        • Ponseti method has 90% success rate
  • Operative 
    • posteromedial soft tissue release and tendon lengthening
      • indications
        • resistant feet in young children
        • "rocker bottom" feet that develop as a result of serial casting 
        • syndrome-associated clubfoot
        • delayed presentation >1-2 years of age
        • performed at 9-10 months of age so the child can be ambulatory at one year of age
      • outcomes
        • requires postoperative casting for optimal results
        • extent of soft-tissue release correlates with long-term function of the foot and patient 
    • medial column lenthening or lateral column-shortening osteotomy, or cuboid decancellation
      • indications
        • older children from 3 to 10 years
    • triple arthrodesis
      • indications
        • in refractory clubfoot at 8-10 years of age
        • contraindicated in insensate feet due to rigidity and resultant ulceration
    • talectomy
      • indications
        •  salvage procedure in older children (8-10 yrs) with an insensate foot
    • multiplanar supramalleolar osteotomy  
      • indications
        • salvage procedure in older children with complex, rigid, multiplanar clubfoot deformities that have failed conventional operative management
    • gradual correction by means of ring fixator (Taylor Spatial Frame) application
      • complex deformity resistant to standard methods of treatment
  • Serial manipulation and casting (long leg cast)  
    • goal is to rotate foot laterally around a fixed talus
    • order of correction (CAVE)
      1. midfoot cavus
      2. forefoot adductus
      3. hindfoot varus
      4. hindfoot equinus
Ponseti Method
Month 1-4 Weekly serial casting (with knee in 90° of flexion )

• First correct cavus while forefoot remains supinated (NOT pronation) by aligning the plantar-flexed 1st MT with the remaining metatarsals (forcible pronation would increase cavus deformity as the 1st MT is plantar-flexed further) 
• Secondly correct adduction and heel varus by rotating calcaneus and forefoot around talus (head of talus acts as a fulcrum)

Tendoachilles lengthening (TAL) at week 8 required in 80%

• Equinus correction last with tendinoachilles lengthening (TAL)
• Perform when foot is 70° abducted and heel is in valgus   
• Ponseti method uses a complete transverse cut of achilles
• Cast in maximal dorsiflexion after TAL

Month 4-8 Foot abduction orthosis (FAO) 
• 23 hours a day for 3 months after correction 
• night time/nap time only until age 4 years

• With Denis-Brown bar in external rotation (70° in clubfoot and 40° in normal foot) 
• Fit FAO on day of TAL

2-4 years Tibialis anterior tendon transfer (TA transfer) q at 2 yrs of age (10-20% will require)

• 10-20% will need TA transfer with or without repeat TAL for recurrent supination, varus, and/or equinus
• Indicated if the patient demonstrates supination of the foot during dorsiflexion (a dynamic intoeing gait)

  • Complications with nonoperative treatment
    • deformity relapse
      • relapse in child < 2 years
        • early relapse usually the result of noncompliance with FAO
        • treat with repeat casting
      • relapse in child > 2 years
        • treat initially with casting
        • consider TA tendon transfer to lateral cuneiform (can only perform if lateral cuneiform is ossified)
        • consider repeat TAL
    • dynamic supination
      • treat with whole anterior tibial tendon transfer (preferred in OITE question over split anterior tibial tendon transfer)    
  • Complications with surgical treatment 
    • residual cavus
      • result of placement of navicular in dorsally subluxed position q
    • pes planus
      • results from overcorrection
    • undercorrection
    • intoeing gait
    • osteonecrosis of talus
      • results from vascular insult to talus resulting in osteonecrosis and collapse
    • dorsal bunion   
      • caused by dorsiflexed first metatarsal (FHB and abductor hallucis overpull secondary to weak plantar flexion) and overactivity of anterior tibialis
      • treat with capsulotomy, FHL lengthening, and FHB flexor to extensor transfer at MTP joint


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Qbank (16 Questions)

(OBQ11.214) A 19-year-old female presents with metatarsalgia and difficulty with wearing closed-toe shoes on her left foot. She is found to have a muscular strength imbalance between the anterior tibialis and peroneus longus on the left side. A clinical image and lateral foot radiograph are shown in Figures A and B, respectively. Which congenital condition most likely contributed to the development of the current foot deformity? Topic Review Topic
FIGURES: A   B        

1. Congenital calcaneonavicular coalition
2. Congenital vertical talus
3. Congenital oblique talus
4. Congenital talipes equinovarus
5. Calcaneovalgus foot

(OBQ10.122) A 3-week-old infant presents with the unilateral foot deformity displayed in Figure A. All of the following are key concepts for treatment of this deformity with manipulation and serial casting EXCEPT: Topic Review Topic
FIGURES: A          

1. Forefoot is supinated and not pronated during correction
2. Forefoot abduction with lateral pressure on the talus
3. Percutaneous achilles tenotomy done before final cast application for residual equinus
4. Weekly cast changes
5. The last cast is applied with the foot in 30 degrees of abduction

(OBQ10.157) A 16-year-old female complains of foot pain with ambulation. She previously underwent clubfoot soft tissue releases at 5 months of age. Each of the following are complications or late deformities associated with clubfoot surgery EXCEPT: Topic Review Topic

1. Dorsal bunion
2. Osteonecrosis of the talus
3. Rigid pes planus
4. Intoeing gait
5. Tarsal tunnel syndrome

(OBQ10.266) Which of the following photographs is most consistent with pediatric clubfoot deformity? Topic Review Topic
FIGURES: A   B   C   D   E  

1. Figure A
2. Figure B
3. Figure C
4. Figure D
5. Figure E

(OBQ09.62) A 3-year-old boy has been treated in the past with Ponseti casting now presents with dynamic supination during gait. You're planning to perform an anterior tibialis transfer to the lateral cuneiform. All of the following are true EXCEPT: Topic Review Topic

1. This transfer is required in 10-20% of children who undergo the Ponseti treatment
2. Weak peroneals are counteracted by overpull of the anterior tibialis
3. Grade 4 or 5 strength of the anterior tibialis is needed prior to transfer
4. Subtalar rigidity supplements the transfer
5. Dynamic supination includes foot supination during swing phase and landing on the lateral foot border during stance phase

(OBQ09.174) In patients with clubfeet treated with soft-tissue release, which of the following variables shows the greatest correlation with long-term functional impairment. Topic Review Topic

1. Extent of soft-tissue release
2. Subtalar joint function
3. Ankle joint function
4. Peroneal muscle function
5. Duration of cast treatment

(OBQ07.31) A 4-year-old boy demonstrates excessive supination occuring during the swing phase of gait following Ponseti casting for an isolated right clubfoot. Which of the following sites identified in Figure A shows the correct destination for the transferred tendon in order to balance the foot and eliminate the supination? Topic Review Topic
FIGURES: A          

1. A
2. B
3. C
4. D
5. E

(OBQ07.245) Which of the following components of the clubfoot deformity should be addressed first when using the Ponseti method? Topic Review Topic

1. Cavus
2. Equinus
3. Pronation
4. Hindfoot alignment
5. Metatarsal adduction

(OBQ06.255) A 5-year-old boy has a history of being treated with the Ponseti technique for a unilateral clubfoot. What muscle most commonly causes a dynamic deformity in the swing phase of gait following Ponseti casting? Topic Review Topic

1. Tibialis Posterior
2. Tibialis Anterior
3. Gastrocnemius
4. Peroneus Longus
5. Peroneus Brevis

(OBQ05.31) Residual cavus after surgical correction of a clubfoot deformity with comprehensive clubfoot release and pinning is caused by what technical error? Topic Review Topic

1. Inadequate Achilles tendon lengthening
2. Failure to correct hindfoot valgus
3. Failure to perform a posteromedial imbrication
4. Placement of the navicular in a dorsally subluxated position
5. Failure to perform a lateral column lengthening

(OBQ05.123) A tibialis anterior transfer is appropriate for which of the following patients with clubfoot? Topic Review Topic

1. Newborn with forefoot adduction
2. 3-year-old with a foot that supinates when he dorsiflexes
3. 6-month-old residual equinus after casting
4. 5-year-old boy with a fixed hindfoot varus
5. 2-year-old with a foot that pronates when he plantarflexes

(OBQ05.129) Figure A shows a lateral radiograph of an 9-month old's dorsiflexed foot. What is the first line treatment for this condition? Topic Review Topic
FIGURES: A          

1. Observation
2. Serial casting
3. Manipulation under anesthesia followed by a single casting
4. Surgical re-alignment
5. Serial manipulation and casting followed by surgical release and talonavicular reduction with pinning

(OBQ04.35) A 6-week-old boy presents with bilateral lower extremity deformities shown in Figure A. All of the following are true regarding the Ponseti technique for correction of this congenital deformity EXCEPT: Topic Review Topic
FIGURES: A          

1. Weekly manipulation and application of long leg casts
2. Achilles tenotomy is indicated for residual equinus before final cast application
3. Pronation of the foot during initial cast correction
4. Abduction of the foot with counterpressure at the talus
5. Correction of adduction deformity prior to equinus

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