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

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