eMedicine Specialties > Orthopedic Surgery > Foot & Ankle

Clubfoot: Workup

Author: Minoo Patel, MBBS, MS, FRACS, Senior Lecturer, Monash University; Director, Centre for Limb Reconstruction and Deformities, Epworth Centre, Melbourne, Australia; Orthopaedic Adult/Pediatric Surgeon, Epworth Hospital, Melbourne, Australia; Consulting Adult/Pediatric Orthopedic Surgeon, Department of Orthopedic Surgery, Monash Medical Center, Australia
Coauthor(s): John Herzenberg, MD, FRCSC, Head of Pediatric Orthopedics, Director of International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore
Contributor Information and Disclosures

Updated: Feb 9, 2010

Workup

Imaging Studies

  • Imaging studies generally are not required to understand the nature or the severity of the deformity. Radiographs, however, are a useful baseline prior to and following surgical correction of the feet, closed Achilles tenotomy, or a limited posterior release. Radiographs show the true gain in foot (ankle) dorsiflexion and confirm the appearance of an iatrogenic rockerbottom foot should one result. Occasionally, radiographs are necessary to diagnose clubfeet associated with tibial hemimelias.
  • Radiographs
    • Talocalcaneal parallelism is the radiographic feature of clubfeet. Simulated weight-bearing x-rays are used for infants who have not commenced walking. Positioning for foot x-rays is very important. The anteroposterior (AP) view is taken with the foot in 30° of plantar flexion and the tube at 30° from vertical. The lateral view is taken with the foot in 30° of plantar flexion.
    • AP and lateral views also can be taken in full dorsiflexion and plantar flexion. This is especially important when measuring the total amount of dorsiflexion achieved at the end of treatment, as well as the relative position of the talus and calcaneum.
    • Measure the talocalcaneal angle in the AP and lateral films. AP lines are drawn through the center of the long axis of the talus (parallel to the medial border) and through the long axis of the calcaneum (parallel to the lateral border), and they usually subtend an angle of 25-40°. Any angle less than 20° is considered abnormal.
    • The AP talocalcaneal lines are almost parallel in clubfeet. As the feet correct with casting or surgery, the calcaneus rotates externally, and the talus reciprocally also derotates to a lesser degree to give a convergent talocalcaneal angle.
    • Lateral lines are dawn through the midpoint of the head and body of the talus and along the bottom of the calcaneum, usually 35-50° Clubfoot ranges between 35° and negative 10°.
    • The lateral talocalcaneal lines are almost parallel in clubfeet. As the feet correct with casting or surgery, the calcaneum dorsiflexes relative to the talus to give a convergent talocalcaneal angle.
    • These 2 angles (AP and lateral) are added to derive the talocalcaneal index, which in a corrected foot should be more than 40°.
    • The AP and lateral talar lines normally pass through the center of the navicular and the first metatarsal.
    • In older children, a flat top talus can be demonstrated radiologically if the talus is sufficiently calcified, but care is required for positioning of the foot.
    • A lateral film with the foot held in maximal dorsiflexion is the most reliable method of diagnosing an uncorrected clubfoot, since the absence of calcaneal dorsiflexion is evidence that the calcaneus is still locked in varus angulation under the talus.

More on Clubfoot

Overview: Clubfoot
Workup: Clubfoot
Treatment: Clubfoot
Follow-up: Clubfoot
Multimedia: Clubfoot
References
Further Reading
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References

  1. Docker CE, Lewthwaite S, Kiely NT. Ponseti treatment in the management of clubfoot deformity - a continuing role for paediatric orthopaedic services in secondary care centres. Ann R Coll Surg Engl. Jul 2007;89(5):510-2. [Medline].

  2. Ippolito E, Ponseti IV. Congenital club foot in the human fetus. A histological study. J Bone Joint Surg Am. Jan 1980;62(1):8-22. [Medline].

  3. Scher DM. The Ponseti method for treatment of congenital club foot. Curr Opin Pediatr. Feb 2006;18(1):22-5. [Medline].

  4. Hussain FN. The role of the Pirani scoring system in the management of club foot by the Ponseti method. J Bone Joint Surg Br. Apr 2007;89(4):561; author reply 561-2. [Medline].

  5. Lejman T, Kowalczyk B. [Results of treatment of congenital clubfoot with modified Goldner's technique]. Chir Narzadow Ruchu Ortop Pol. 2002;67(4):351-5. [Medline].

  6. Kaewpornsawan K, Khuntisuk S, Jatunarapit R. Comparison of modified posteromedial release and complete subtalar release in resistant congenital clubfoot: a randomized controlled trial. J Med Assoc Thai. May 2007;90(5):936-41. [Medline].

  7. Parker SE, Mai CT, Strickland MJ, Olney RS, Rickard R, Marengo L, et al. Multistate study of the epidemiology of clubfoot. Birth Defects Res A Clin Mol Teratol. Aug 20 2009;[Medline].

  8. Steinman S, Richards BS, Faulks S, Kaipus K. A comparison of two nonoperative methods of idiopathic clubfoot correction: the Ponseti method and the French functional (physiotherapy) method. Surgical technique. J Bone Joint Surg Am. Oct 1 2009;91 Suppl 2:299-312. [Medline].

  9. Parada SA, Baird GO, Auffant RA, Tompkins BJ, Caskey PM. Safety of percutaneous tendoachilles tenotomy performed under general anesthesia on infants with idiopathic clubfoot. J Pediatr Orthop. Dec 2009;29(8):916-9. [Medline].

  10. Celebi L, Muratli HH, Aksahin E, Yagmurlu MF, Bicimoglu A. Bensahel et al. and International Clubfoot Study Group evaluation of treated clubfoot: assessment of interobserver and intraobserver reliability. J Pediatr Orthop B. Jan 2006;15(1):34-6. [Medline].

  11. Paton RW, Freemont AJ. A clinicopathological study of idiopathic CTEV. J R Coll Surg Edinb. Apr 1993;38(2):108-9. [Medline].

  12. Zimny ML, Willig SJ, Roberts JM, D'Ambrosia RD. An electron microscopic study of the fascia from the medial and lateral sides of clubfoot. J Pediatr Orthop. Sep-Oct 1985;5(5):577-81. [Medline].

  13. Inclan. Anomalous tendon insertions theory, though other studies have not supported this; the distorted anatomy can make it appear that tendon insertions are anomalous. J Bone Joint Surg Am. 1958;40:159.

  14. Robertson. CORR Prenatal polio-like condition; epidemiological evidence,seasonal variation.

  15. 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. Aug 2006;88(8):1082-4. [Medline].

  16. Cummings RJ. The effectiveness of botulinum A toxin as an adjunct to the treatment of clubfeet by the Ponseti method: a randomized, double blind, placebo controlled study. J Pediatr Orthop. Sep 2009;29(6):564-9. [Medline].

  17. Hsu WK, Bhatia NN, Raskin A, Otsuka NY. Wound complications from idiopathic clubfoot surgery: a comparison of the modified Turco and the Cincinnati treatment methods. J Pediatr Orthop. Apr-May 2007;27(3):329-32. [Medline].

  18. Singh BI, Vaishnavi AJ. Modified Turco procedure for treatment of idiopathic clubfoot. Clin Orthop Relat Res. Sep 2005;438:209-14. [Medline].

  19. Bensahel H, Csukonyi Z, Desgrippes Y, Chaumien JP. Surgery in residual clubfoot: one-stage medioposterior release "à la carte". J Pediatr Orthop. Mar-Apr 1987;7(2):145-8. [Medline].

  20. Bensahel H, Jehanno P, Delaby JP, Themar-Noël C. [Conservative treatment of clubfoot: the Functional Method and its long-term follow-up]. Acta Orthop Traumatol Turc. 2006;40(2):181-6. [Medline].

  21. Ferreira RC, Costa MT, Frizzo GG, Santin RA. Correction of severe recurrent clubfoot using a simplified setting of the Ilizarov device. Foot Ankle Int. May 2007;28(5):557-68. [Medline].

  22. Freedman JA, Watts H, Otsuka NY. The Ilizarov method for the treatment of resistant clubfoot: is it an effective solution?. J Pediatr Orthop. Jul-Aug 2006;26(4):432-7. [Medline].

  23. Ferreira RC, Costa MT, Frizzo GG, Santin RA. Correction of severe recurrent clubfoot using a simplified setting of the Ilizarov device. Foot Ankle Int. May 2007;28(5):557-68. [Medline].

  24. Graham GP, Dent CM. Dillwyn Evans operation for relapsed club foot. Long-term results. J Bone Joint Surg Br. May 1992;74(3):445-8. [Medline].

  25. Morcuende JA, Abbasi D, Dolan LA, Ponseti IV. Results of an accelerated Ponseti protocol for clubfoot. J Pediatr Orthop. Sep-Oct 2005;25(5):623-6. [Medline].

  26. Ponseti IV. Relapsing clubfoot: causes, prevention, and treatment. Iowa Orthop J. 2002;22:55-6. [Medline].

  27. Ponseti IV. Clubfoot management. J Pediatr Orthop. Nov-Dec 2000;20(6):699-700. [Medline].

  28. Haft GF, Walker CG, Crawford HA. Early clubfoot recurrence after use of the Ponseti method in a New Zealand population. J Bone Joint Surg Am. Mar 2007;89(3):487-93. [Medline].

  29. Dobbs MB, Corley CL, Morcuende JA, Ponseti IV. Late recurrence of clubfoot deformity: a 45-year followup. Clin Orthop Relat Res. Jun 2003;(411):188-92. [Medline].

  30. Simons GW. Calcaneocuboid joint deformity in talipes equinovarus: an overview and update. J Pediatr Orthop B. 1995;4(1):25-35. [Medline].

  31. Simons GW. A standardized method for the radiographic evaluation of clubfeet. Clin Orthop Relat Res. Sep 1978;(135):107-18. [Medline].

  32. Schlegel UJ, Batal A, Pritsch M, Sobottke R, Roellinghoff M, Eysel P, et al. Functional midterm outcome in 131 consecutive cases of surgical clubfoot treatment. Arch Orthop Trauma Surg. Aug 4 2009;[Medline].

  33. Cooper DM, Dietz FR. Treatment of idiopathic clubfoot. A thirty-year follow-up note. J Bone Joint Surg Am. Oct 1995;77(10):1477-89. [Medline].

  34. Wallander H, Larsson S, Bjönness T, Hansson G. Patient-reported outcome at 62 to 67 years of age in 83 patients treated for congenital clubfoot. J Bone Joint Surg Br. Oct 2009;91(10):1316-21. [Medline].

  35. Bohm. Arrest of fetal development in the fibular stage. J Bone Joint Surg Am. 1929;11:229.

  36. Bor N, Herzenberg JE, Frick SL. Ponseti management of clubfoot in older infants. Clin Orthop Relat Res. Mar 2006;444:224-8. [Medline].

  37. Cowell HR, Wein BK. Genetic aspects of club foot. J Bone Joint Surg Am. Dec 1980;62(8):1381-4. [Medline].

  38. Faulks S, Luther B. Changing paradigm for the treatment of clubfeet. Orthop Nurs. Jan-Feb 2005;24(1):25-30; quiz 31-2. [Medline].

  39. Irani RN, Sherman R. Defective cartilaginous anlage of the talus. J Bone Joint Surg Am. 1963;45A:45.

  40. Isaacs H, Handelsman JE, Badenhorst M, Pickering A. The muscles in club foot--a histological histochemical and electron microscopic study. J Bone Joint Surg Br. Nov 1977;59-B(4):465-72. [Medline].

  41. Noonan KJ, Richards BS. Nonsurgical management of idiopathic clubfoot. J Am Acad Orthop Surg. Nov-Dec 2003;11(6):392-402. [Medline].

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Keywords

clubfoot, congenital talipes equinovarus, CTEV, rockerbottom foot, rockerbottom deformity, foot deformity, clubfeet, clubfoot surgery

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Contributor Information and Disclosures

Author

Minoo Patel, MBBS, MS, FRACS, Senior Lecturer, Monash University; Director, Centre for Limb Reconstruction and Deformities, Epworth Centre, Melbourne, Australia; Orthopaedic Adult/Pediatric Surgeon, Epworth Hospital, Melbourne, Australia; Consulting Adult/Pediatric Orthopedic Surgeon, Department of Orthopedic Surgery, Monash Medical Center, Australia
Minoo Patel, MBBS, MS, FRACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, AO Foundation, Australian Association of Surgeons, Australian Medical Association, Australian Orthopaedic Association, Bombay Orthopedic Society, Indian Orthopedic Association, Orthopaedic Research Society, Orthopaedics Overseas, and Royal Australasian College of Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

John Herzenberg, MD, FRCSC, Head of Pediatric Orthopedics, Director of International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore
John Herzenberg, MD, FRCSC is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine, American Academy of Orthopaedic Surgeons, Limb Lengthening and Reconstruction Society ASAMI-North America, and Pediatric Orthopaedic Society of North America
Disclosure: Smith and Nephew, EBI, Orthofix Educational Grant None

Medical Editor

John S Early, MD, Foot/Ankle Specialist, Texas Orthopaedic Associates, LLP; Co-Director, North Texas Foot and Ankle Fellowship Baylor University Medical Center
John S Early, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association, and Texas Medical Association
Disclosure: Zimmer Inc Consulting fee Consulting; Smith Nephew Consulting fee Consulting; AO North America Honoraria Speaking and teaching; Osteotech Consulting fee Consulting; Stryker Consulting fee Consulting

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Shepard R Hurwitz, MD, Executive Director, American Board of Orthopaedic Surgery
Shepard R Hurwitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for the Advancement of Science, American College of Rheumatology, American College of Sports Medicine, American College of Surgeons, American Diabetes Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Association for the Advancement of Automotive Medicine, Eastern Orthopaedic Association, Orthopaedic Research Society, Orthopaedic Trauma Association, and Southern Orthopaedic Association
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Jason H Calhoun, MD, FACS, Frank J Kloenne Chair in Orthopedic Surgery, Professor and Chair, Department of Orthopedics, The Ohio State University Medical Center
Jason H Calhoun, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Diabetes Association, American Medical Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Missouri State Medical Association, Musculoskeletal Infection Society, Southern Medical Association, Southern Orthopaedic Association, Texas Medical Association, and Texas Orthopaedic Association
Disclosure: Nothing to disclose.

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