Definition: Congenital
clubfoot, talipes equinovarus, is a musculoskeletal deformity of the foot. Clubfeet
are considered flexible if they are correctable without surgery and resistant
if surgical release is required for correction.
Incidence: Clubfoot is
present in approximately 1 in 1000 live births in the United States. The percentage
of clubfoot varies greatly with ethnicity.
Age:
Clubfoot is congenital. It is observable at
birth and ultrasound may be used to diagnose it prenatally.
Gender: Clubfoot is
more common in males with the male-to-female ratio at approximately 2.5:1.
Etiology and Pathophysiology: The exact
cause of clubfoot is unproved; however, it has a genetic component. There are
several theories including defective talus cartilaginous anlage, fetal developmental
disturbances in the fibular stage, abnormal tendon insertions, neurogenic
causes, and retracting fibrosis.
Clinical Presentation: Clubfoot
may be bilateral or unilateral. The midfoot is adducted and supinated while the
internally rotated heel is in varus and the ankle is in equinus. The foot is unable
to reach dorsiflexion greater than 90 degrees. Clubfeet are usually shorter and
wider than normal feet and may have creases at the midfoot and ankle. Clubfoot
results in atrophy of the calf. Palpation reveals a small and soft heel and a
talar neck that is laterally uncovered.
Pathology: Clubfoot
consists of bone deformity and soft tissue contracture. It has several tissue abnormalities,
including muscle and cartilage anomalies, bone primary germ plasm defects, and vascular
abnormalities such as hypoplasia/absence of the anterior tibial artery.
Diagnostic Procedures: Radiographs
can be used to determine the extent of deformities. For optimal radiographs,
the foot should be weight bearing and placed in the best possible correction.
However,
incomplete ossification of bones in young patients as well as positioning problems
of the foot may lead to radiographic difficulties.
Treatment: Clubfoot is
initially treated by nonoperative means. Flexible clubfeet may be treated with
serial manipulation, casting, and splinting in order to lengthen ligaments and
tendons. If nonoperative treatment fails, surgery may be necessary. Surgical
correction includes medial plantar release and posterior release. The subtalar
joint should be internally rotated. Lateral
release is often
required to allow for the calcaneus to rotate outwardly.
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