Clubfoot

Clubfoot aka Congenital Talipes Equinovarous

Idiopathic Most common birth defect 1:250 - 1:1000 (depending on population) M>F 50% bilateral 25% familial occupancy PITX1 = transcription factor critical for limb development

AnatomyCharacteristic deformity consisting of Forefoot Adductus Midfoot Cavus Hindfoot Equinus Hindfoot Varus Caused by muscle deformities FHL, FDL & intrinsic all tight - > Forefoot Adductus Tib Post tightness - > Midfoot Cavus Tendo-Achilles tightness - > Hindfoot Equinus Tib Ant, Rib Post & Tendoachilles tightness - > Hindfoot Varus Develop honey deformity Talar neck ; medial & plantar deviation Calcaneus ; Varus & medically rotated (around talus) Navicular & Cuboid displaced medially

Physical Exam Small foot & calf Short tibia Medial & posterior foot skin creases Foot deformities: Forefront AdductusMidfoot CavusHindfoot Equinus & Varus Differentiate from more common positional deformities by rigid Equinus & therefore resistance to passive correction

RadiographsDorsiflexion lateral = Turco view Hindfoot parallelism Talus & Calcaneus Talocalcaneal angle <35deg (normal >35deg) Flat talar head AP view Talocalcaneal (kite) angle <20deg (normal 20-40deg) Talus-1st MT angle is negative (norm 0-20deg) Can also show Hindfoot parallelism US Prenatal high false positive rate (10.5%)

Treatment Non-op Vs Op - modern trends towards Non-opNon-op = Serial manipulation & casting aka Ponseti method 90% success rateOperative = Posteromedial soft tissue release & tendon lengthening Medial column lengthening or lateral column-shortening osteotomy, or Cuboid decancellation Triple arthrodesis Talectomy Multiplanar Supramalleolar osteotomy

Clubfoot Management

Non-Operative= serial manipulation with Ponseti method (long leg casting) Goal = Laterally rotate foot around fixed talus Order of correction = CAVE Midfoot CavusForefoot AdductusHindfoot VarusHindfoot EquinusPonseti MethodMonth 1-4 Weekly serial casting (knee in 90deg flexion)Tendoachilles lengthening (TAL) @ 8/52 needed in 80%Month 4-8 Foot abduction orthosis (FAO) 23hrs/day x 3/12 after correction, then night & nap time only until age 4Years 2-4 Tibialis anterior tendon transfer (usually at 2years, required in 10-20%)

Operative