Introduction
Background
Clubfoot, or talipes equinovarus, is a congenital deformity consisting of hindfoot equinus, hindfoot varus, and forefoot varus. The deformity was described as early as the time of Hippocrates. The term talipes is derived from a contraction of the Latin words for ankle, talus, and foot, pes. The term refers to the gait of severely affected patients, who walked on their ankles.1,2
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Pathophysiology
This deformity is associated with myelomeningocele, arthrogryposis multiplex congenita, and tibial hemimelia. Most cases of congenital talipes equinovarus are idiopathic. The pathophysiology of the more common isolated form is not known and is the subject of controversy. Possible contributing factors include the following: defective cartilage with ligamentous laxity, muscle imbalance, abnormal intrauterine position, central nervous system anomaly, and persistence of a normal fetal relationship.
Various theories about the pathophysiology and pathoanatomy focus on primary deformities of the subtalar joint, tibiotalar joint, and talus and on the excessive length of the lateral column relative to that of the medial column.
The long-standing controversy regarding the pathophysiology and pathoanatomy has spawned a multitude of varied, sometimes contradictory, surgical approaches. Advances in imaging may someday enhance the understanding of the deformity and help guide surgical treatment.
Frequency
United States
Clubfoot is common, with an incidence of 1-4 cases per 1000 live births among whites. The risk increases 30-fold in individuals who have a first-degree relative with the condition.
Mortality/Morbidity
If untreated or incompletely treated, clubfoot causes an abnormal gait, and stress changes may occur on the lateral (fibular) side of the foot due to preferential weight bearing.
Sex
A slight male predominance may exist, with a male-to-female ratio of 2-3:1.
Anatomy
Talipes equinovarus mainly consists of hindfoot equinus, hindfoot varus, and forefoot varus (inversion or supination). It is a complex deformity involving many bones, articulations, and soft-tissue structures.
Besides the major components mentioned above, other anomalies are present. Muscle shortening is present on the medial side of the foot and leg. The talus is abnormally small, and its dome is less convex than normal. The talar neck is hypoplastic, medially deviated, and plantar flexed so that its articular surface faces medially. The navicular is often subluxed medially. The calcaneus is also small and displaced into a varus, equinus, and internally rotated position. As a result, the calcaneocuboid joint lies beneath, rather than beside, the talonavicular joint.
Other aspects of the pathoanatomy are controversial and not well understood.
Presentation
Clinically, the foot is extremely plantar flexed, with the forefoot swung medially and the sole facing inward. The deformity can be unilateral or bilateral.
Preferred Examination
The standard radiologic method of evaluation is plain radiography. The equipment required is inexpensive and readily available. Evaluation should include the acquisition of only weight-bearing images because the stress involved is reproducible. In infants, weight bearing can be simulated with the application of dorsal flexion stress.
The standard views are the dorsoplantar (DP) and lateral views. For the DP view, the beam is angled 15° toward the heel to prevent overlap of the structures of the lower leg. The lateral view should include the ankle, and not the foot, for proper depiction of the talus.
Other methods of imaging are not routinely used in the evaluation of clubfoot, and experience with these is limited.3
Limitations of Techniques
Plain radiography has the disadvantage of exposing the patient to ionizing radiation. Additionally, proper positioning can be difficult. Improper positioning can simulate deformities. Further, because clubfoot is a congenital condition, the lack of ossification in some of the involved bones is another limitation. In neonates, only the talus and calcaneus are ossified. The navicular does not ossify until the child is aged 2-3 years.
Differential Diagnoses
Other Problems to Be Considered
Congenital vertical talus and spastic or paralytic deformities can also cause hindfoot equinus.
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References
Manaster BJ. Congenital foot anomalies. In: Handbook of Skeletal Radiology. 1996: 338-49.
Ozonoff MB. The foot. In: Pediatric Orthopaedic Radiology. 1992: 416-23.
Offerdal K, Jebens N, Blaas HG, Eik-Nes SH. Prenatal ultrasound detection of talipes equinovarus in a non-selected population of 49 314 deliveries in Norway. Ultrasound Obstet Gynecol. Nov 2007;30(6):838-44. [Medline].
Prasad P, Sen RK, Gill SS, Wardak E, Saini R. Clinico-radiological assessment and their correlation in clubfeet treated with postero-medial soft-tissue release. Int Orthop. Sep 4 2007;[Medline].
Tarraf YN, Carroll NC. Analysis of the components of residual deformity in clubfeet presenting for reoperation. J Pediatr Orthop. Mar-Apr 1992;12(2):207-16. [Medline].
Johnston CE, Hobatho MC, Baker KJ. Three-dimensional analysis of clubfoot deformity by computed tomography. J Pediatr Orthop B. 1995;4(1):39-48. [Medline].
Downey DJ, Drennan JC, Garcia JF. Magnetic resonance image findings in congenital talipes equinovarus. J Pediatr Orthop. Mar-Apr 1992;12(2):224-8. [Medline].
Cahuzac JP, Baunin C, Luu S. Assessment of hindfoot deformity by three-dimensional MRI in infant club foot. J Bone Joint Surg Br. Jan 1999;81(1):97-101. [Medline].
Wang C, Petursdottir S, Leifsdottir I. MRI multiplanar reconstruction in the assessment of congenital talipes equinovarus. Pediatr Radiol. Apr 1999;29(4):262-7. [Medline].
Chami M, Daoud A, Maestro M. Ultrasound contribution in the analysis of the newborn and infant normal and clubfoot: a preliminary study. Pediatr Radiol. 1996;26(4):298-302. [Medline].
Coley BD, Shiels WE 2nd, Kean J, Adler BH. Age-dependent dynamic sonographic measurement of pediatric clubfoot. Pediatr Radiol. Nov 2007;37(11):1125-9. [Medline].
Hamel J, Becker W. Sonographic assessment of clubfoot deformity in young children. J Pediatr Orthop B. Fall 1996;5(4):279-86. [Medline].
Shiels WE 2nd, Coley BD, Kean J, Adler BH. Focused dynamic sonographic examination of the congenital clubfoot. Pediatr Radiol. Nov 2007;37(11):1118-24. [Medline].
Ramseier LE, Schoeniger R, Vienne P, Espinosa N. Treatment of late recurring idiopathic clubfoot deformity in adults. Acta Orthop Belg. Oct 2007;73(5):641-7. [Medline].
Ikeda K. Conservative treatment of idiopathic clubfoot. J Pediatr Orthop. Mar-Apr 1992;12(2):217-23. [Medline].
McKay DW. New concept of and approach to clubfoot treatment: section I-principles and morbid anatomy. J Pediatr Orthop. Oct 1982;2(4):347-56. [Medline].
Further Reading
Keywords
talipes equinovarus, hindfoot equinus, hindfoot varus, forefoot varus, myelomeningocele, arthrogryposis multiplex congenita, tibial hemimelia
