Talipes Equinovarus (Clubfoot)
Talipes Equinovarus (Clubfoot)
Talipes Equinovarus is one of the most common congenital foot deformities, occurring in approximately 1 in 1000 live births. The condition is characterized by a complex three-dimensional deformity of the foot and ankle.
Key Components of Deformity (CAVE):
- C - Cavus: High medial longitudinal arch
- A - Adductus: Forefoot adduction
- V - Varus: Hindfoot varus
- E - Equinus: Ankle plantarflexion
Epidemiology
- Male:Female ratio = 2:1
- Bilateral in 50% of cases
- Increased incidence with family history
- Environmental factors: Early amniocentesis, smoking during pregnancy
Pathoanatomy
- Medial and plantar soft tissue contractures
- Abnormal talocalcaneal relationship
- Medial displacement of navicular
- Medial displacement of cuboid
- Associated muscle abnormalities in gastrocnemius-soleus complex
Clinical Presentation
- Rigid foot deformity present at birth
- Smaller calf size on affected side
- Shortened foot
- Posterior heel crease
- Poor ankle mobility
Classification
Diméglio Classification:
- Grade I (Soft-soft): <20% - Benign, fully reducible
- Grade II (Soft-stiff): 20-50% - Reducible but partially resistant
- Grade III (Stiff-soft): 50-90% - Resistant but partially reducible
- Grade IV (Stiff-stiff): 90-100% - Severe, rigid
Diagnostic Imaging
- Initial Assessment: Clinical examination sufficient for diagnosis
- Radiographs: Not typically needed in infants but useful for monitoring treatment
- Anteroposterior view: Talocalcaneal angle
- Lateral view: Tibiocalcaneal angle
- Advanced Imaging: Reserved for complex cases or surgical planning
- MRI: Rarely indicated
- CT: Sometimes used for complex revision cases
Associated Conditions and Syndromes
- Neuromuscular Conditions:
- Arthrogryposis Multiplex Congenita
- Myelomeningocele
- Spinal Muscular Atrophy
- Genetic Syndromes:
- Trisomy 18 (Edwards Syndrome)
- DiGeorge Syndrome
- Moebius Syndrome
- Freeman-Sheldon Syndrome
- Skeletal Dysplasias:
- Diastrophic Dysplasia
- Larsen Syndrome
Genetic Considerations
- PITX1 gene mutations
- TBX4 gene mutations
- HOXD gene cluster variations
- Increased risk in first-degree relatives
Treatment Approach
Ponseti Method (Gold Standard):
- Phase 1: Correction
- Weekly casting (5-7 casts typically)
- Sequential correction of cavus, adductus, and varus
- Percutaneous Achilles tenotomy (80-90% of cases)
- Final cast for 3 weeks post-tenotomy
- Phase 2: Maintenance
- Foot Abduction Brace (FAB)
- 23 hours/day for 3 months
- 12-14 hours/day until age 4-5 years
- Foot Abduction Brace (FAB)
Surgical Management
- Limited Surgery:
- Anterior tibial tendon transfer
- Repeat percutaneous tenotomy
- Comprehensive Release: Reserved for resistant cases
- Posteromedial release
- Comprehensive subtalar release
Monitoring and Follow-up
- Regular monitoring during casting phase (weekly)
- Close follow-up during initial bracing
- Quarterly visits in first year
- Annual monitoring until skeletal maturity
