Club Foot

Properly known as talipes equinovarus, club foot is a deformity of the foot involving also the entire lower leg. It is either positional (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, e.g. 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 1000 births.²
• 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 clubfoot and 20-30% chance for children of involved parents) and maternal smoking.³

• 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 hindfoot 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 - AP plus lateral standing or simulated-standing
• Ultrasound⁴

May be associated with other congenital disorders and particular associations include spina bifida, cerebral palsy, myelomeningocoele and arthrogryposis.

• Current management of congenital talipes equinovarus is moving away from surgery towards conservative treatment using the Ponseti regime of casting and manipulation (see eMedicine reference for full description).^5,6
• Management will depend on the degree of rigidity, associated abnormalities and secondary muscular changes.
• Serial plaster cast is the main form of non-surgical treatment with gentle manipulation of the foot towards the corrected position before cast 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 walking well.

Surgery

• If despite conservative management the hindfoot remains in an equinus position, then an operation is required to release the soft tissue responsible for shortening, e.g. release of tibialis posterior, abductor hallucis and achilles tendons.
• Complete soft tissue release performed between 6 and 12 months achieves satisfactory results in 80-90% 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
• Commonest 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 mid-tarsal and sub-talar joints, or calcaneal osteotomy and talectomy.

• Approximately 50-60% of clubfeet in newborns can be corrected non-operatively.¹
• About 20% of infants requiring surgery require further surgery at a later stage.⁷