Clubfoot

Also know as congenital talipes equinovarus
Commonest congenital and ankle deformity in UK
Should be differentiated from
- Talipes calcaneovalgus
- Postural talipes equinovarus
Affects about 3 per 1000 live births
Male to female ratio is 3 to 1
40% cases are bilateral
Low incidence in far east asians and Polynesians
High incidence in black South Africans
Genetic factors seem to important in its aetiology
Most cases are idiopathic
Occasionally associated with neuromuscular disorders
Aetiological factors include
- Developmental arrest or delay
- Intrauterine moulding
- Retracting fibrosis
- Neuromuscular factors

Many cases are diagnosis with prenatal ultrasound
Ultrasound can not assess the severity of the condition
The anatomical features of talipes equinovarus include:
- Equinus deviation in the sagital plane
- Varus deviation in the frontal plane
- Adduction of the forefoot in the horizontal plane
- Deviation of the whole foot with respect to the talus
The severity of the deformity can be graded
- Grade 1 - foot can be held in neutral position
- Grade 2 - fixed equinus or varus deformity of less then 20 degrees
- Grade 3 - fixed equinus or varus deformity of more than 20 degrees
Surgery is required in:
- 10% patients with Grade 1 deformity
- 50% patients with Grade 2 deformity
- 90% patients with Grade 3 deformity

Treatment should be begun within the first week of life
Initial management should involve conservative therapy involving
- Manipulation and serial casting
- Continuous physical therapy
With both methods the deformities are addressed in the following order
- Forefoot adduction and cavus deformity
- Whole foot varus deformity
- Equinus deformity
False correction of deformity can occur
Leads to 'rocker-bottom foot'

By 3 months of age it is usually clear whether conservative management will be effective
Timing of surgery is controversial
Most surgeons recommend surgery between 9 and 12 months of age
Plaster can then be removed at the time the child begins to walk
Aim of surgery is release all the tight structures and lengthen muscles
Structures that may need to be divided include:
- Plantar fascia
- Tendon sheaths of tibialis posterior, flexor hallucis longus, flexor digitorum longus
- Posterior part of deltoid ligament
- Posterior part of ankle joint and subtalar joint capsules
- Fibulocalcaneal and fibulotalar ligaments
- Peroneal tendon sheaths
- Talonavicular joint capsule
Tendons that may require lengthening include:
- Achilles tendon
- Tendon of flexor digitorum longus
- Tendon of flexor hallucis longus
- Tendon tibialis posterior
Percutaneous wires may be need to maintain correction
Foot is kept in plaster for about 6 weeks
Following plaster removal a splint is required until the child is walking normally
Late problems following surgery include
- Dynamic forefoot adduction and varus
- Recurrent deformity
- Overcorrection
Most children undergoing surgery achieve a plantigrade foot
Most can wear normal shoes

Macnicol M F. The management of clubfoot: issues for debate. J Bone Joint Surg Br 2003; 85: 167-170.

Noonan K J. Richards B S. Nonsurgical management of idiopathic clubfoot. J Am Acad Orth Surg 2003; 11: 392-402.

Scher D M. The Ponseti method for the treatment of congenital club foot. Curr Opin Pediatr 2006; 18: 22-25.