Overview
Definition:
Clubfoot, also known as congenital talipes equinovarus (CTEV), is a common congenital birth defect characterized by inversion and adduction of the forefoot and midfoot, and equinus of the hindfoot, resulting in a foot that is twisted inward and downward.
Epidemiology:
It affects approximately 1-2 per 1000 live births worldwide, with higher incidence in males (2:1 ratio)
It can be isolated (idiopathic) or associated with underlying neuromuscular or genetic syndromes
Bilateral involvement occurs in about 50% of cases.
Clinical Significance:
Untreated clubfoot can lead to significant functional impairment, pain, difficulty with weight-bearing, and social stigma
Early and appropriate management is crucial for achieving a functional, pain-free foot and promoting normal development, making it a high-yield topic for pediatric and orthopedic examinations.
Clinical Presentation
Symptoms:
The primary "symptom" is the appearance of the deformed foot at birth
Parents typically note the foot's abnormal posture
There are usually no associated symptoms unless clubfoot is part of a broader syndrome
Diagnosis is usually evident on physical examination.
Signs:
The foot is characterized by a combination of hindfoot equinus (plantarflexion), varus (adduction) of the midfoot, and forefoot supination
The heel may appear smaller and wider
The calf muscles are often atrophied
The degree of deformity varies, with some cases being flexible and others rigid.
Diagnostic Criteria:
Clubfoot is primarily a clinical diagnosis based on physical examination findings of hindfoot equinus, varus deformity of the midfoot, and forefoot adduction
Radiographic criteria are typically not required for diagnosis but can be used to assess severity and treatment response in older children.
Diagnostic Approach
History Taking:
Key history points include family history of congenital anomalies, presence of other congenital defects or syndromes (e.g., meningomyelocele, arthrogryposis), gestational age, and mode of delivery
Absence of these associated factors suggests idiopathic clubfoot.
Physical Examination:
A systematic examination of the foot and ankle is crucial
Assess for hindfoot equinus (normal dorsiflexion is around 20 degrees), midfoot varus, forefoot adduction, and the overall rigidity of the deformity
Palpate for an accessory navicular bone
Assess the child's overall development and for other congenital anomalies
Assess the range of motion of all joints, particularly the subtalar joint.
Investigations:
For idiopathic clubfoot, routine laboratory investigations are not required
Imaging is typically not needed for diagnosis in newborns
Radiographs (AP and lateral views of the foot and ankle with the child's weight on the foot if possible) may be obtained to assess severity, especially in older children or if associated syndromes are suspected
Key radiographic measurements include the talocalcaneal angle and the talometatarsal angle.
Differential Diagnosis:
Other conditions that can mimic clubfoot include metatarsus adductus (forefoot adduction without hindfoot equinus or varus), positional foot deformities (often correctable with passive manipulation), and syndromic foot deformities (e.g., associated with arthrogryposis or neuromuscular disorders)
Distinguishing features include the degree of rigidity and the presence of other congenital anomalies.
Management
Initial Management:
The cornerstone of management for idiopathic clubfoot is the Ponseti method, a serial manipulation and casting technique
This method aims to gradually correct the deformity before definitive treatment
Early intervention is key, ideally starting within weeks of birth.
Ponseti Casting:
The Ponseti method involves weekly gentle manipulation and casting
The manipulation aims to correct the deformity sequentially: first, abduction of the forefoot
second, eversion of the midfoot
and third, dorsiflexion of the hindfoot by stretching the Achilles tendon and posterior structures
A long leg cast is applied with the knee in flexion to prevent external rotation of the femur and maintain correction
Typically, 5-7 casts are required over several weeks to achieve correction.
Achilles Tenotomy:
If residual equinus deformity persists after 5-7 casts, a percutaneous Achilles tenotomy may be performed
This is a minor surgical procedure where the Achilles tendon is partially or completely sectioned under local anesthesia or light sedation
Following tenotomy, a final cast is applied in maximum passive dorsiflexion for 3 weeks
This procedure allows for complete correction of the hindfoot equinus.
Bracing:
After successful casting and/or tenotomy, a dynamic orthotic brace (e.g., Denis Browne bar with shoes or specialized ankle-foot orthoses) is essential for maintaining correction
Bracing is typically worn full-time for the first 3-6 months, then at night and during naps until 2-3 years of age to prevent recurrence
Proper fit and adherence to the bracing regimen are critical for long-term success.
Complications
Early Complications:
Potential early complications include skin irritation or breakdown under the cast, pressure sores, nerve compression (e.g., peroneal nerve palsy), and vascular compromise
In the case of tenotomy, minor bleeding or infection at the incision site are possible but rare.
Late Complications:
The most common late complication is recurrence of the deformity, particularly the equinus component, if bracing compliance is poor
Inadequate correction may lead to chronic pain, gait abnormalities, and difficulty with footwear
Untreated or inadequately treated clubfoot can lead to severe functional disability and osteoarthritis later in life.
Prevention Strategies:
Meticulous attention to cast application, regular monitoring for signs of neurovascular compromise, and ensuring proper fit and wear of the post-casting brace are key to preventing complications
Patient and family education regarding the importance of the bracing regimen is paramount.
Prognosis
Factors Affecting Prognosis:
The prognosis for clubfoot managed with the Ponseti method is generally excellent, with over 90% achieving a good to excellent outcome
Factors influencing prognosis include early initiation of treatment, adherence to the Ponseti method, and consistent use of post-correction bracing
Associated syndromes, rigidity of the deformity, and patient compliance can affect outcomes.
Outcomes:
With appropriate Ponseti casting and tenotomy, most children achieve a plantigrade foot with good function, minimal pain, and satisfactory cosmetic appearance
They can participate in normal activities and sports
Long-term follow-up is important to monitor for recurrence.
Follow Up:
Regular follow-up appointments with the orthopedic specialist are necessary during the casting phase, after tenotomy, and throughout the bracing period
After the bracing phase, periodic check-ups are recommended until skeletal maturity to detect any signs of recurrence early
Families should be educated to recognize early signs of relapse.
Key Points
Exam Focus:
The Ponseti method is the gold standard for idiopathic clubfoot
Understand the sequential correction principles: abduction, external rotation, and dorsiflexion
The role of Achilles tenotomy is for persistent equinus after casting
Bracing is crucial for preventing recurrence.
Clinical Pearls:
Grasp the talar head during manipulation to lock the midfoot in abduction
Use a dorsal thumb pad to push the talar head into abduction and external rotation
Ensure adequate dorsiflexion in the final cast after tenotomy to prevent residual equinus
Compliance with bracing is non-negotiable.
Common Mistakes:
Over-reliance on traditional surgery without attempting Ponseti method for idiopathic clubfoot
Inadequate manipulation leading to incomplete correction
Poorly applied casts that slip or cause skin breakdown
Insufficient duration or inconsistent use of post-correction bracing, leading to high recurrence rates
Misdiagnosing positional deformities as true clubfoot and delaying appropriate treatment.