Congenital club-foot

Club foot represents a disruption of complex relationships between bone, ligament and muscle of the foot.

The most common type of club foot is congenital talipes equinovarus.

• clubfoot, also known as congenital talipes equinovarus, is a developmental deformity of the foot
  • one of the most common birth deformities with an incidence of 1.2 per 1000 live births each year in the white population (1,2)
  • clubfoot is twice as common in boys and is bilateral in 50% of case
  • most often idiopathic but may be associated with other conditions in around 20% of cases
  • most common associated conditions are spina bifida (4.4% of children with clubfoot), cerebral palsy (1.9%), and arthrogryposis (0.9%)
  • a prospective study did not reveal an association with developmental dysplasia of the hip (3)
    
    
• diagnosis
  • clubfoot is most commonly diagnosed postnatally during the routine baby check
    • foot points downwards at the ankle (equinus) the heel is turned in (varus), the midfoot is deviated towards the midline (adductus), and the first metatarsal points downwards (plantar flexion)
    • deep creases may be present behind the heel or on the medial side of the foot. The deformity in club foot is not passively correctable by the examiner (1)
    • foot and calf muscles are smaller than the unaffected side in unilateral clubfoot
      
      
• preferred treatment for clubfoot is the Ponseti method
  • detailed method of manipulation and casting without major surgical releases, and it is the treatment of choice of most orthopaedic surgeons worldwide (1,2)
    • method has become the standard of care and completely eliminates the need for extensive operative correction in over 98% of patients if applied correctly
    • treatment involves manipulation, a series of castings, percutaneous achilles tenotomy and foot bracing
    • with correct application of the procedure and appropriate patient adherence, complete correction can be achieved in as little as 16 days with an accelerated casting protocol (2)
  • if diagnosis and referral to an orthopaedic surgeon does not occur prenatally or in the first few days after birth, the baby must be referred urgently when the deformity is first noticed
    • earlier Ponseti treatment is started (ideally around one to two weeks), the easier correction is to achieve

All neonates should be screened for club foot and if it is discovered, a full neurological examination should be carried out.

Notes:

• positional clubfoot (postural talipes): the foot assumes the same position as in congenital clubfoot but the deformity is correctable. This is probably a normal variant (1)

Reference:

• Bridgens J, Kiely N. Current management of clubfoot (congenital talipes equinovarus). BMJ. 2010 Feb 2;340:355.
• Desai L et al. Bracing in the treatment of children with clubfoot: past, present, and future. Iowa Orthop J. 2010;30:15-23.
• Paton RW, Choudry Q. Neonatal foot deformities and their relationship to developmental dysplasia of the hip: an 11-year prospective, longitudinal observational study. J Bone Joint Surg Br 2009; 91-B:655-8.