Club Foot(Congenital talipes equinovarus)

Club Foot also is known as Giles Smith Syndrome, Congenital talipes equinovarus (CTEV), or talipes equinovarus (TEV). The Word “Talipes Equinovarus” comes from Latin: Talus (ankle) + pes (foot). Equino– indicates the heel is elevated (like a horse’s)  varus- indicates it is turned inward. The foot is turned in sharply, and the person seems to be walking on their ankle.

Club Foot

What does Club Foot mean?

It is a congenital deformity (present at birth) in which the affected foot appears rotated internally at the ankle – the foot points down and inwards and the soles of the feet face each other.

Club foot vs normal

Types of Club Foot.

Structural Club FootPostural Club Foot
Structural TEV is caused by genetic factors, such as Edwards syndrome, a genetic defect with three copies of chromosome 18. Growth arrest at roughly 9 weeks and compartment syndrome of the affected limb are also causes of Structural TEV. Genetic influences increase dramatically with family history.Postural TEV could be caused by external influences in the final trimester such as intrauterine compression from oligohydraminos or from amniotic band syndrome. However, this is countered by findings the TEV does not occur more frequently than usual when the intrauterine space is restricted.
Types of club foot.

Epidemiology :

1 in every 1000 live births each year. Males are affected twice as often as females. Association(20%) with spina bifida ,myelomeningocele.Half of the cases are bilateral. Familial Studies: 30%in identical twins, one parent 3%-4%, both parents 30%.

Etiology

The most common cause is idiopathic.

Enviromental etiology: Early amniocentesis, maternal smoking.

Genetic Etiology is strongly suggested. Familial occurance is 25%.

Mechanical, neuromuscular, vascular deficiency.

Recent link to PITX1 gene, transcription factor critical for limb development (Paired Like Homeodomain 1 is a Protein Coding gene).

Deformity

Talocalcaneonavicular (TCN) joint dislocation with soft tissue contractures. A complex joint in which the head of talus articulates with calcaneus & plantar calcaneonavicular ligament (spring ligament) below & the navicular in front.

Deformity in Club Foot

Soft tissue contrature:

Cavus (tight intrinsics, Flexor Hallusis Longus , Flexor digitorum longus).

Adductus (tight tibialis posterior).

Varus (tight tendoachilles).

Equinus (tight tendoachilles, tibialis posterior).

Clinically:

Small foot .
Small calf .
Tibia – shortened .
Medial and posterior foot skin creases.

Foot deformities:

  ◦ Hindfoot – Equinus + Varus

  ◦ Midfoot – Cavus

  ◦ Forefoot – Adduction

TREATMENT OPTIONS:

Stretching and casting (Ponseti Method).

Stretching and taping (French Method).

Surgery.

Brace.

Stretching and casting (Ponseti method):

Success rate about 90%. This treatment entails manipulating the foot into a correct position and then placing it in a cast to maintain that position. Repositioning and recasting occurs every week for several weeks. After the shape of the foot is realigned, it is maintained through stretching exercises, special shoes or splinting with braces at night for up to three years. For this method to work effectively, you’ll need to apply your child’s braces according to your doctor’s specifications so that the foot doesn’t return to its original position.

Stretching and casting (Ponseti method)
Pirani scoring system
pirani score

Stretching and taping (French method):

It has a 74% success rate. Daily manipulation by physiotherapist followed by immobilization with adhesive taping to maintain the correction achieved with stretching. Daily for 2 months then 3/week till age 6 months. If successful in achieving correction, parents continue both the home exercises and night splints until the child reaches walking age.

Stretching and taping (French method)

 Dennis Brown Brace:

Used when long leg cast is removed after 3 weeks of treatment. The bar is fit shoulder-width apart and worn full time for the 1st two months.

 Dennis Brown Brace:

Surgical Treatment for Club foot:

Posteromedial soft tissue release:
Resistant cases , Delayed presentation
Syndrome-associated clubfoot .

Medial opening or lateral column shortening osteotomy, or cuboidal decancellation (older children 3-10 years).

Triple arthrodesis – refractory cases .

Talectomy – salvage procedure.

Surgical method for Club Foot
Percutaneous Achilles tenotomy
Surgical treatment for Club Foot
Before and Surgery for Club foot
Surgical method for Club Foot

Complications:

With non-operative treatment:

 ◦ Relapse
◦ Dynamic supination

With operative treatment:

 ◦ Residual cavus
 ◦ Pes planus
 ◦ Intoeing gait
 ◦ Dorsal bunion

For more information visit www.thenepalidoctor.com