A 4-day-old baby boy is brought to the pediatrician’s office for their first visit after birth. The pregnancy was full-term and uneventful, except for that the baby was a breech birth. The baby’s mother has noticed that although both legs and feet appear a little “curved,” both feet are almost “sideways” and look abnormal (Figure 86-1). On examination of both feet the hindfoot is clearly inverted, the toes point medially, and the foot is plantar flexed. The deformity is somewhat correctible by forcing the foot into a more normal position, but not completely. The baby does not appear to be in pain. He has no other abnormalities, has a normal neurologic exam for his age, and appears to be otherwise healthy. The child is referred to a pediatric orthopaedic surgeon, who begins serial Ponseti casting within one to two weeks. After several weeks of weekly serial casting, the feet have a more normal appearance. The child is then splinted full-time using a special orthosis for approximately three months, after which he is only splinted at night until walking age, at which time splinting is discontinued. He has no residual deformity.

Clubfeet is one of the most common congenital abnormalities of the lower extremities.¹ As with any congenital deformity, it can be very concerning to new parents. However, the current gold standard of early non-operative treatment, with surgery only if needed later in life, has led to generally excellent functional results long-term.²

Congenital Talipes Equinovarus.

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  Approximately 1.2 per 1000 live births in Caucasians.³

  
  
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  Varies across cultures, with only 0.39 to 0.5 per 1000 live births in Asian nations to 7 per 1000 live births in the South Pacific.^1,3

  
  
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  Two-to-one male predominance across all populations, with 50 percent of cases bilateral.⁴

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  Due to the numerous bones and joints in the foot, a great deal of very descriptive but complicated orthopaedic terminology is associated with understanding the normal and abnormal relationships within the foot. However, this knowledge becomes useful in deciphering and communicating how to correct the deformity.

  
  
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  The pathophysiology in clubfoot is characterized by four fundamental deformities of the foot, remembered by the mnemonic CAVE:⁵

  
  
  
  
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    Cavus (a deformity describing a higher or cavitary arch of the foot).

    
    
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    Adductus of the forefoot (the rays of the toes abnormally point medially).

    
    
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    Varus of the hindfoot (the plantar aspect of the calcaneus points medially if looked at from behind the patient).

    
    
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    Equinus (the foot is relatively plantar flexed, usually with a tight Achilles tendon).

  
  
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  Another useful descriptive term for the forefoot is supination (a combination of inversion and adduction).

  
  
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  The deformity can vary from mild and very flexible to severe and rigid.¹

  
  
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  The etiology is thought to be multifactorial but may include:¹

  
  
  
  
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    Genetic factors.

    
    
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    Environmental exposure, for example, cigarette smoke.

    
    
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    Vascular deficiencies.

    
    
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    Abnormal function of the neuromuscular unit.

    
    
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    Late-term in utero positioning was historically thought to be a factor, but the evidence appears less likely that it plays a major role in the development of clubfoot.

  
  
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  May be associated with syndromes such as arthrogryposis, constriction bands (Streeter dysplasia), prune belly, tibial hemimelia, Möbius syndrome, Freeman-Sheldon syndrome, diastrophic dwarfism, Larsen syndrome, Opitz syndrone, and Pierre Robin syndrome.⁶

Clinical Features

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  Clubfoot has a very typical appearance.

  
  
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  After birth clubfoot is primarily a clinical diagnosis based on physical examination showing foot equinus with some degree of cavus, varus, and adductus.⁶

  
  
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  Frequently the involved calf is smaller in circumference.

  
  
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  Examination of the skin creases around the foot and ankle can aid in diagnosis.

  
  
  
  
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    The involved side tends to have a single heel crease, versus multiple on the uninvolved side.⁶

    
    
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    The depth of the medial skin crease indicates the severity of the deformity.

  
  
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  Numerous classification schemes exist, with none entirely prognostic. The system described by Deméglio is most popular to describe severity and track progress of treatment.⁵

Imaging

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  Radiographs can be performed but their role is unclear as the bones of the foot of a newborn are mostly cartilage with ossification centers that are not centered, making the images difficult to interpret.

  
  
  
  
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    As the bones ossify, classic changes seen include parallelism of the angle made between the long axis of the talus and calcaneus on AP and lateral radiographs when compared to the normal foot (Figure 86-2).

    
    
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    Clubfoot can be visualized on prenatal ultrasound.

    
    
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    Other modalities after birth such as MRI, and CT have been used but are not essential.

  
  
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  Radiographs can be useful in cases of tibial hemimelia, or for surgical planning if and when intervention is considered.

  
  
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  There is a high incidence of associated disorders and syndromes; therefore a full neurologic examination as well as assessment of all joints and the spine is important.^3,6