Clubfoot (congenital talipes equinovarus)

Question 1

What is the epidemiology of clubfoot?

Answer 1

1) More common in males
2) MC congenital disorder 1:250 to 1:1000
3) half are bilateral
4) familial occurence in 25%

Question 2

What are the muscle imbalances that lead to the deformity (CAVE) in clubfoot?

Answer 2

C: midfoot Cavus (tight intrinsics, FDL, FHL)
A: forefoot Adductus (tight posterior tibialis)
V: hindfoot Varus (tight posterior tibialis, achilles)
E: hindfoot Equinus (tight achilles)

Question 3

What are the boney deformities a/w clubfoot?

Answer 3

1) talar neck is medially and plantarly deviated
2) calcaneus is in varus and rotated medially around talus
3) navicular and cuboid are displaced medially

Question 4

What radiographic abnormalities are present in clubfoot?

Answer 4

dorsiflexed (Turco) view: 1) talus and calcaneus can show parallelism
2) talocalcaneal angle less than 20 deg

Question 5

What is the success rate with Ponsetti casting?

Answer 5

90%

Question 6

What are the treatment options for clubfoot deformity?

Answer 6

1) Ponsetti casting
2) Posteromedial soft tissue release; resistant feet in children, done at 9-10 months; degree of soft tissue release correlates with outcome
3) Medial column lengthening or lateral column shortening; age 3-10
4) Triple arthrodesis; refractory clubfeet age 8-10; contraindicated in insensate feet
5) Talectomy; salvage procedure for child 8-10 with insensate foot

Question 7

What is the general schedule for Ponsetti method?

Answer 7

Months 1-4: Weekly casting with knee 90°; cavus corrected by supinating forefoot; correct adduction and varus by rotating calcaneus and forefoot (abduction) around talus; Achilles tenotomy done at 8 weeks
Months 4-8: forefoot adduction orthotic 23hrs/day for 3 months; done once forefoot is abducted to 70°
2-4yrs: 20% may need tibialis anterior tendon transfer w/wo repeat TAL; if dynamic intoeing

Question 8

How are non-operative complications managed for clubfoot deformities?

Answer 8

Relapse:
if 20yo repeat casting trial and/or TA transfer with TAL
Dynamic supination: whole TA tendon transfer; preferred over split TA transfer

Question 9

What are some operative complications of clubfoot deformity?

Answer 9

1) residual varus: result of placement of navicular in dorsally subluxed position
2) pes planus: from overcorrection
3) osteonecrosis of the talus
4) dorsal bunion

Question 10

What are key points in the Ponsetti method?

Answer 10

1) keeping the forefoot supinated
2) applying lateral pressure to the talar neck only
3) weekly long leg casts
4) percutaneous achilles tenotomy before final cast application to address any residual equinus deformity

Question 11

5-year-old boy has a history of being treated with the Ponseti technique for a unilateral clubfoot. What muscle most commonly causes a dynamic deformity in the swing phase of gait following Ponseti casting?

Answer 11

tibialis anterior

Question 12

Residual cavus after surgical correction of a clubfoot deformity with comprehensive clubfoot release and pinning is caused by what technical error?

Answer 12

Placement of navicular in dorsally subluxed position