3. Talipes Equinovarus

Talipes Equinovarus

This PatientPlus article is written for healthcare professionals so the language may be more technical than the condition leaflets. You may find the abbreviations list helpful.

Synonym: club foot

Talipes equinovarus, club foot, is a deformity of the foot also involving the entire lower leg. It is either positional (a normal foot that has been held in a deformed position in the uterus) or fixed.[1]

  • Fixed talipes equinovarus may be congenital (usually an isolated abnormality) or teratological (associated with a neuromuscular disorder, eg myodysplasia, arthrogryposis multiplex congenita or as part of a syndrome complex).
  • The cause of congenital clubfoot is unknown and most infants who have clubfoot have no identifiable cause.
  • Associations with club foot include teratogenic agents, oligohydramnios and congenital constriction rings.
  • There is an autosomal recessive pattern of clubfoot inheritance; genetic associations also include diastrophic dwarfism and some syndromes involving chromosomal deletion.
  • The incidence is approximately 1 in 1,000 births.[2]
  • The congenital form is responsible for about three quarters of all cases. There are no other congenital abnormalities.
  • The male-to-female ratio is 2:1.
  • Bilateral involvement is found in 30-50% of cases.
  • Risk factors include family history (there is a 10% chance of a subsequent child being affected if the parents already have a child with a club foot and 20-30% chance for children of involved parents) and maternal smoking.[3]
  • It most often presents in neonates. Postural talipes is correctable with gentle passive dorsiflexion of the foot.
  • The calf muscle and the foot may be smaller than normal.
  • The hind foot is in rigid equinovarus (foot is turned inward and downward) and the forefoot is short, wide, adducted and supinated. The sole of the foot points medially.
  • The heel is high, with the fibula prominent.
  • In an adult with residual deformity there is adduction of the forefoot, shortening of the Achilles tendon and a small foot.
  • X-rays - anteroposterior (AP) plus lateral standing or simulated-standing.
  • Ultrasound.[4]

It may be associated with other congenital disorders and particular associations include spina bifida, cerebral palsy, myelomeningocele and arthrogryposis.

  • Current management of congenital talipes equinovarus is moving away from surgery towards conservative treatment using Ponseti's regime of casting and manipulation.[5][6]
  • Management will depend on the degree of rigidity, associated abnormalities and secondary muscular changes.
  • Serial plaster cast is the main form of nonsurgical treatment with gentle manipulation of the foot towards the corrected position before the cast is applied and changed every 1-2 weeks.[3]
  • If clinical and X-ray correction are achieved by 3 months of age, then holding casts are used for a further 3-6 months with orthoses/corrective shoes until the patient is walking well.

Surgery

  • If, despite conservative management, the hind foot remains in an equinus position, then an operation is required to release the soft tissue responsible for shortening, eg release of the tibialis posterior, abductor hallucis and Achilles tendons.
  • Complete soft-tissue release performed between 6 and 12 months achieves satisfactory results in 80-90% of cases. A recent study found that results of surgery were better if performed in the second, rather than the first, 6 months of life.[7]
  • The most common residual abnormality is dynamic pes varus and this is corrected with centralisation of the tibialis anterior tendon.
  • Further corrective surgery may be required later in childhood. This may include wedge excision of the calcaneocuboid bone, fusion of the midtarsal and subtalar joints, or calcaneal osteotomy and talectomy.
  • Approximately 50-60% of club feet in newborns can be corrected non-operatively.[1]
  • About 20% of infants requiring surgery need further surgery at a later stage.[7]
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Further reading & references

  1. Patel M et al; Clubfoot, eMedicine, Feb 2010
  2. Danielsson LG; Incidence of congenital clubfoot in Sweden. 128 cases in 138,000 infants 1946-1990 in Malmo. Acta Orthop Scand. 1992 Aug;63(4):424-6.
  3. Cummings RJ, Davidson RS, Armstrong PF, et al; Congenital clubfoot. Instr Course Lect. 2002;51:385-400.
  4. Aurell Y, Johansson A, Hansson G, et al; Ultrasound anatomy in the neonatal clubfoot. Eur Radiol. 2002 Oct;12(10):2509-17. Epub 2002 May 14.
  5. Siapkara A, Duncan R; Congenital talipes equinovarus: a review of current management. J Bone Joint Surg Br. 2007 Aug;89(8):995-1000.
  6. Shack N, Eastwood DM; Early results of a physiotherapist-delivered Ponseti service for the management of idiopathic congenital talipes equinovarus foot deformity. J Bone Joint Surg Br. 2006 Aug;88(8):1085-9.
  7. Templeton PA, Flowers MJ, Latz KH, et al; Factors predicting the outcome of primary clubfoot surgery. Can J Surg. 2006 Apr;49(2):123-7.
Original Author: Dr Colin Tidy Current Version:
Last Checked: 21/01/2011 Document ID: 665  Version: 22 © EMIS

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