Talipes equinovarus deformity

(Clubfoot )
• Is a common deformity of the foot
• Incidence of1:1000 live births world wide
• Higher incidence in east Africa
• 50% are bilateral
• M :F 3:1
• Tends to be severe in females
 Aetiology
• Primary germ plasm defect in the talus
with subsequent soft tissue changes
• Primary but local dysplasia of all soft
tissues of the affected extremity
• Neuromyogenic imbalance involving the
peroneals
• Arrest of fetal development
 Pathoanatomy
• Talus is dimorphic with 50% of its articular
surface out of the ankle joint ,medially
rotated and plantar flexed leading to talo-
navicular dislocation
• Calcaneus adducted and inverted locked
under the talus ,subtalar in varus
• Forefoot adducted and inverted
• Cavus due to the plantarflexion of the first
metatarsal
 Pathoanatomy….
• Soft tissue abnormality is manifested by
-calf atrophy
-contracture of
tendons ,capsules ,ligaments and Achilles
tendon
- atrophy of anterior tibial artery
-weakness of the peroneals
 Components of clubfoot
.cavus due to plantar flexion of first
metatarsal
.adduction of the fore foot
.varus of the heel
.equinus of the ankle joint
 Classification
• Idiopathic accounts for 90% ,the child
apart from the deformity of the foot is
otherwise normal
• Syndromic /Neuropathic account for 10%
of clubfeet ,the child has other associated
abnormalities as well
spina bifida ,arthrogryphosis multiplex
congenita
 Physical examination
• General examination of the patient to rule out :
.Other gross abnormalities ,congenital
deficiencies of femur or tibia
.Arthrogryphosis multiplex congenita: multiple
contractures of the joints with absence of skin
creases
. Spine ,tuft of hair ,dimple ,swelling
Meningomyelocele
 Normal foot
• Symmetrical calf size
• Heel is full size ,in neutral postion
• Creases are fine and multiple on the
posterior ankle and midfoot
• Supple ankle joint
• Straight lateral border
 Pirani scoring system
Assesment of degree of severity (0-3)
Hind foot contracture
• Posterior crease
• Empty heel
• Rigid equinus
Mid foot contracture
• Medial crease
• Lateral curvature of the foot
• Lateral aspect of the head of the talus
 Differential diagnosis
• Postural clubfoot
• Metatarsus adductus
• Calcaneovalgus
joints are supple ,deformities can be
corrected by manipulation and stretching
.congenital vertical talus : rigid foot caused
by dorsolateral dislocation of the navicular
pushing the talus down ward
 Treatment
• The goal of treatment should be to produce
painfree, plantigrade ,mobile and fits into a
normal shoe and maintains lasting correction
• Gentle manipulation to correct the deformities
using Ponseti method
• Serial casting which extends to the groin with
knee flexion 90 degree
• Subcutaneous lengthening of the Achilles
tendon is performed in 80% of the patients
• Denis brown splint ,shoes attached to a bar
• Denis brown splint
 Natural history
Recurrent and Resistant clubfoot
• Surgical treatment (soft tissue release) is
recommended in resistant cases,complex
and recurrent ones
• Calf atrophy remains throughout life
• Asymmetry of foot size
• Limitation of subtalar joint
• Pes planus ,forefoot adduction