- Congenital malformation in which either one foot or both are rotated inward and downward
Epidemiology
- Most common musculoskeletal birth defect
- More common in males
- More common in developing countries
- 50% of cases are bilateral
Etiology/Risk factors
- Idiopathic
- Early amniocentesis increases risk of clubfoot
- Genetics
- Mutations in MYH3, TPM2
- Possibly linked to the PITX1-TBX4 transcriptional pathway
- Associated with other conditions – Arthrogryposis , Ehlers-Danlos syndrome, myelodysplasia etc.
Pathophysiology
- Characteristic deformities: CAVE – with their respective muscle contractures in brackets
- CAVE – a high arch (tight FHL and FDL )
- Adductus of the forefoot – forefoot curves inwards towards the big toe (tight tibialis posterior)
- Varus – heel is inverted, forcing patient to walk on the outside of the foot (tight Achilles tendon, tibialis posterior and tibialis anterior)
- Equinus – foot is pointed downwards, forcing patient to walk on tiptoes (tight Achilles tendon)
Clinical features
- Affected foot and leg may be smaller than the other
- Foot skin creases
- Pain and difficulty walking
- Visible deformities
- Hindfoot in equinus and varus
- Midfoot in cavus
- Forefoot in adduction
Diagnosis
- Mostly made through physical exam – imaging rarely needed
- X-RAY – long axis of talus and calcaneus are parallel
- Ultrasound – for prenatal diagnosis
Treatment
Non-operative
- Ponseti method of serial casting – gold standard (Goal is to rotate foot laterally around fixed talus)
- Order of correction: cavus → adductus → varus → equinus
Operative
- Posteromedial soft tissue release and tendon lengthening (indicated when Ponseti has failed)
- Several tendons and plantar fascia are cut (released) or lengthened; midfoot is aligned with the hindfoot (navicula aligned with talus)
- Wires are then placed across the joints to hold them in position
- Post operative casting is needed
- Talectomy – indicated in severe, rigid recurrent clubfoot in children with arthrogryposis