Basics
Description
Clubfoot is a congenital or neuromuscular deformity in which the hindfoot is fixed in equinus (plantar flexion) and varus (toward the midline) and the forefoot is fixed in varus, equinus, and often cavus (high midfoot arch with overextension). á
Epidemiology
- Risk of deformity increases by 20-30 times when there is an affected 1st-degree relative.
- Male > female (2:1)
Incidence
Incidence is 1-1.4/1,000 live births but can vary among different ethnic groups. á
Pathophysiology
- Many anatomic abnormalities have been postulated as causing clubfoot:
- Anomalous or deficient muscles, myoblasts, mast cells, abnormal primary bone formation, joint and muscle contractures, vascular anomalies (absent dorsalis pedis artery), and nerve anomalies
- Abnormalities of the fibrous connective tissue
- Interruption of embryonic foot development has also been suggested.
Etiology
- Most cases are idiopathic (multifactorial inheritance pattern with significant environmental influence).
- Infrequently, neuromuscular imbalance may underlie the deformity (cerebral palsy, myelomeningocele, lipomas of the cord, caudal or sacral agenesis, polio, arthrogryposis, fetal alcohol syndrome).
- Rapid recurrence should prompt a thorough examination for possible underlying etiologies.
Diagnosis
History
- Family history of clubfoot (3%)
- Onset of deformity (congenital or developmental)
Physical Exam
- Careful examination of
- The neuromuscular system for neuromuscular etiologies such as lumbosacral sinuses, dimples, and lipomas as well as spasticity, asymmetry, and muscle imbalance
- The hips for hip dysplasia
- The neck for torticollis
- Physical exam trick
- Push the foot into a corrected position. Is the deformity fully correctable? Overcorrectable?
- About 1 in 15 idiopathic clubfeet have rigid equinus, midfoot (metatarsal) plantarflexion, a deep heel crease at the posterior ankle, a transverse midsole or midfoot crease, and a short hyperextended hallux. This appearance for these feet may not be apparent until after 1-3 casts. They have been called "complex idiopathic clubfoot"Ł and are more difficult to treat.
Diagnostic Tests & Interpretation
Lab
- The diagnosis is established clinically.
- Radiographs (after 3 months of age) may confirm bone position but cannot make the diagnosis.
- At 3-6 months of age, anteroposterior and lateral radiograph films in dorsiflexion (maximal correction) may help in defining residual deformity. The beam should be focused on the hindfoot for both the anteroposterior and lateral radiographs as the measured angles will be hindfoot angles.
- Decreased talocalcaneal angle on the anteroposterior and lateral views (ÔëĄ25 degrees) confirm persistent deformity.
- Medial displacement of the cuboid on the calcaneus and persistent plantar flexion of the forefoot on the hindfoot (talar to 1st metatarsal angle) indicate more complex deformities.
Differential Diagnosis
Distinguish other deformities of the foot: á
- Metatarsus adductus or varus (heel is in neutral position, no fixed equinus)
- Calcaneovalgus (foot is in valgus, no fixed heel equinus)
- Vertical talus (foot is in valgus, heel in equinovalgus)
- Many children with clubfoot also have tibial torsion, which is a normal variant that rarely requires treatment.
Treatment
Additional Treatment
General Measures
- Ponseti method (casting and bracing) and its variations have become the standard of initial treatment.
- Initial treatment:
- Care can begin in the 1st week after birth, although later treatment is generally successful as well.
- Initial treatment is serial (weekly) manipulation and casting with long leg casts first correcting abduction, then rotation, then dorsiflexion. The talar head is stabilized with the casting physician's thumb while the contralateral hand manipulates the foot.
- Taping may be useful for treatment of the infant requiring ICU care; access to the feet should be maintained for blood tests.
- Surgical intervention should be done if manipulation cannot correct the deformity completely within 8-12 weeks of casting.
- Long leg serial casting by the Ponseti technique improves results so that in most clubfeet, little more than heel cord lengthening and possibly posterior ankle release is required. The operated foot is stabilized for healing for 1 month in a Ponseti-type cast.
- Following surgery, bracing with bars and shoes for 3 months full time and then 3 years nights and naps is an integral part of the Ponseti method.
- With the Ponseti method, 30-45% of patients may have various forms of recurrence requiring repeated casting and/or surgical release through maturity.
- Treatment of complex idiopathic clubfoot require up to 5 additional casts to abduct the forefoot at the midfoot, laterally rotating the anterior tuberosity of the calcaneus under the head of the talus. Recurrence of deformity is more common in this type.
Ongoing Care
Follow-up Recommendations
Patient Monitoring
- Realignment of the deformity is the goal and should be achieved with casting and surgery.
- Most surgeons cast the feet for 1 month postoperatively.
- With the Ponseti method, bars and shoes are recommended full time for 3 months and nights for 3 years to maintain the correction.
- Remember, the cause of the deformity is not corrected. Only the alignment of the bones and lengthening of the soft tissues are corrected.
- Depending on the severity of the deformity, all corrected clubfeet can be expected to demonstrate varying amounts of calf narrowing and weakness, ankle and subtalar stiffness, a difference between the feet of 1-2 shoe sizes, and even a leg length discrepancy, usually <2 cm.
- There also will be decreased ankle and subtalar motion as compared to normal.
- Adolescent children with clubfeet often will get leg cramps and tire easily while doing sports.
- Recurrence of heel cord tightness is common, especially during periods of rapid growth.
- Additional heel cord stretching and casting and, infrequently, additional surgery may be needed.
- All true recurrences should lead to further evaluation for neuromuscular or syndromic causes that might have been undiagnosed in the infant.
Additional Reading
- Hamel áJ, Becker áW. Sonographic assessment of clubfoot deformity in young children. J Pediatr Orthop B. 1996;5(4):279-286. á[View Abstract]
- Ponseti áIV, Zhivkov áM, Davis áN, et al. Treatment of the complex idiopathic clubfoot. Clin Orthop Relat Res. 2006;451:171-176. á[View Abstract]
- Roye áBD, Hyman áJ, Roye áDP Jr. Congenital idiopathic talipes equinovarus. Pediatr Rev. 2004;25(4):124-130. á[View Abstract]
- Scher áDM. The Ponseti method for treatment of congenital club foot. Curr Opin Pediatr. 2006;18(1):22-25. á[View Abstract]
- Scherl áSA. Common lower extremity problems in children. Pediatr Rev. 2004;25(2):52-62. á[View Abstract]
- Yamamoto áH, Muneta áT, Morita áS. Nonsurgical treatment of congenital clubfoot with manipulation, cast, and modified Denis Browne splint. J Pediatr Orthop. 1998;18(4):538-542. á[View Abstract]
Codes
ICD09
- 754.7 Talipes, unspecified
- 754.71 Talipes cavus
- 754.79 Other deformities of feet
ICD10
- Q66.89 Other specified congenital deformities of feet
- Q66.7 Congenital pes cavus
- Q66.0 Congenital talipes equinovarus
SNOMED
- 397932003 Talipes equinovarus (disorder)
- 205091006 Congenital pes cavus (disorder)
- 42162004 Congenital varus deformity of foot (disorder)
FAQ
- Q: How can a rigid clubfoot be distinguished from a positional clubfoot?
- A: During initial evaluation of the child, it is important to assess the amount of flexibility in a clubfoot. This can be most easily done by flexing the hip to 90 degrees, flexing the knee to 90 degrees, and then gently trying to turn the forefoot into a straight position lined up with the thigh. If the foot easily spins around into a normal position, it can be assumed that this is a flexible or positional clubfoot. If deformity persists, this is a rigid deformity. If possible, the examining physician should palpate the heel to see if the os calcis comes out of its equinus position filling the heel pad. In some children, particularly with a rocker-bottom sole, the heel pad looks as if it is in the correct position, but the os calcis remains in equinus with the posterior aspect of the os calcis proximal to the heel pad.
- Q: What percentage of clubfeet are successfully treated by casting?
- A: To some extent, the amount of success depends on how much correction is desired. Occasionally, cast correction will provide a partial correction. Some feet, after casting, can be held in the corrected position, only to spin back to the clubfoot deformity when released. Positional clubfeet are likely to improve with casting in perhaps 98% of cases. Rigid clubfeet are much less likely to be corrected by casting. The success rate with casting alone in the rigid feet is likely to be ~10%. It is important to remember that casting and surgery cannot make the clubfoot normal.
- Q: What will be the permanent disability of a congenital clubfoot deformity?
- A: Although casting and surgical correction of a congenital clubfoot can realign the bones, the surgery does little to correct the underlying neuromuscular problems. As a result, all children with rigid clubfeet are likely to have a leg length inequality (usually <1.5 inches), a smaller foot (usually 1-2 sizes), calf narrowing that cannot be significantly improved with exercise, and joint stiffness (ankle, subtalar, and midfoot). Even children with optimal realignment of the deformity will notice their inability to perform gymnastic activities or running activities requiring normal range of motion of the ankle and foot. Many will complain of the inability to keep up with their peer group during adolescent and young adult sports activities.
- Q: How soon should an infant with congenital clubfoot be referred to an orthopedic surgeon?
- A: Casting begins within the 1st-2nd week of life. Medical and life-threatening conditions should take precedence over the treatment of the clubfoot. Access to the feet for IV or blood studies will interfere with a casting regimen. Casting should begin as soon as is practical. It may even be possible to begin taping of the foot as an alternative to casting, which will still allow IV access to the feet. Referral to an orthopedic surgeon should, therefore, follow as soon as is practical. Studies have shown that excellent results can be obtained from the Ponseti method even when initiated after the 1st year of life.