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Synonym: club foot
Congenital talipes equinovarus is a common congenital orthopaedic condition. It is characterised by an excessively turned in foot (equinovarus) and high medial longitudinal arch (cavus). If left untreated it can result in long-term disability, deformity and pain. Interventions can be conservative (eg, splinting or stretching) or surgical.
Talipes equinovarus is either:
- Positional (a normal foot that has been held in a deformed position in the uterus). Postural talipes is correctable with gentle passive dorsiflexion of the foot. This positional variant occurs about five times more often than congenital talipes equinovarus.
- Congenital (fixed) talipes equinovarus, which may be either of below:
The rest of this article is about congenital talipes equinovarus.
In 20% of cases, club foot is associated with distal arthrogryposis, congenital myotonic dystrophy, myelomeningocele, amniotic band sequence, or other genetic syndromes such as trisomy 18 or chromosome 22q11 deletion syndrome. In the remaining cases the deformity is isolated and the exact aetiology is unknown.
Maternal associations with club foot include teratogenic agents, oligohydramnios and congenital uterus constriction rings.
- Although club foot is recognisable at birth, the severity of the deformity can vary from mild to an extremely rigid foot that is resistant to manipulation.
- 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; club foot correction during serial manipulation can be monitored using ultrasound.
The Pirani scoring system is often used to provide a forecast about the likely treatment for an individual foot but a low score does not exclude the possibility that a tenotomy may be required.
- Management will depend on the degree of rigidity, associated abnormalities and secondary muscular changes.
- Current management of congenital talipes equinovarus is moving away from surgery towards conservative treatment using immobilisation and manipulation.
- The Ponseti method and the French functional method are both effective in reducing the need for surgery.
- Ponseti method:
- When compared with surgical intervention, both the Ponseti method and surgery had a relatively high recurrence rate, but the Ponseti method was associated with significantly less revision surgery.
- The Ponseti method has an initial correction rate of around 90% in idiopathic feet. Non-compliance with bracing is the most common cause of relapse.
- In the Ponseti method, the reduction phase uses weekly casts followed by a percutaneous tenotomy of the Achilles tendon to correct the equinus. Twenty-four-hour then nighttime splinting in abduction is then maintained for a period of three to four years.
- The French functional method involves specialised physiotherapists. Daily manipulation is used with immobilisation by adhesive bandages and pads. There are basically three approaches: the Saint-Vincent-de-Paul, the Robert-Debré and the Montpellier method.
- 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, six months of life.
- 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.
Further reading & references
- Club Foot and the Ponseti Method; Ponseti International
- Gray K, Pacey V, Gibbons P, et al; Interventions for congenital talipes equinovarus (clubfoot). Cochrane Database Syst Rev. 2012 Apr 18;4:CD008602. doi: 10.1002/14651858.CD008602.pub2.
- Huntley JS; Optimising the management of congenital talipes. Practitioner. 2013 Oct;257(1765):15-8, 2.
- Werler MM, Yazdy MM, Mitchell AA, et al; Descriptive epidemiology of idiopathic clubfoot. Am J Med Genet A. 2013 Jul;161A(7):1569-78. doi: 10.1002/ajmg.a.35955. Epub 2013 May 17.
- Desai L, Oprescu F, DiMeo A, et al; Bracing in the treatment of children with clubfoot: past, present, and future. Iowa Orthop J. 2010;30:15-23.
- Dobbs MB, Gurnett CA; Genetics of clubfoot. J Pediatr Orthop B. 2012 Jan;21(1):7-9. doi: 10.1097/BPB.0b013e328349927c.
- Dobbs MB, Gurnett CA; Update on clubfoot: etiology and treatment. Clin Orthop Relat Res. 2009 May;467(5):1146-53. doi: 10.1007/s11999-009-0734-9. Epub 2009 Feb 18.
- Desai S, Aroojis A, Mehta R; Ultrasound evaluation of clubfoot correction during Ponseti treatment: a preliminary report. J Pediatr Orthop. 2008 Jan-Feb;28(1):53-9.
- Bridgens J, Kiely N; Current management of clubfoot (congenital talipes equinovarus). BMJ. 2010 Feb 2;340:c355. doi: 10.1136/bmj.c355.
- Dyer PJ, Davis N; The role of the Pirani scoring system in the management of club foot by the Ponseti method. J Bone Joint Surg Br. 2006 Aug;88(8):1082-4.
- Siapkara A, Duncan R; Congenital talipes equinovarus: a review of current management. J Bone Joint Surg Br. 2007 Aug;89(8):995-1000.
- 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.
- Richards BS, Faulks S, Rathjen KE, et al; A comparison of two nonoperative methods of idiopathic clubfoot correction: the Ponseti method and the French functional (physiotherapy) method. J Bone Joint Surg Am. 2008 Nov;90(11):2313-21. doi: 10.2106/JBJS.G.01621.
- Halanski MA, Davison JE, Huang JC, et al; Ponseti method compared with surgical treatment of clubfoot: a prospective J Bone Joint Surg Am. 2010 Feb;92(2):270-8.
- Jowett CR, Morcuende JA, Ramachandran M; Management of congenital talipes equinovarus using the Ponseti method: a systematic review. J Bone Joint Surg Br. 2011 Sep;93(9):1160-4. doi: 10.1302/0301-620X.93B9.26947.
- Bergerault F, Fournier J, Bonnard C; Idiopathic congenital clubfoot: Initial treatment. Orthop Traumatol Surg Res. 2013 Feb;99(1 Suppl):S150-9. doi: 10.1016/j.otsr.2012.11.001. Epub 2013 Jan 21.
- 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.
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Dr Colin Tidy
Dr Colin Tidy
Dr John Cox