Chapter 86: Club Feet

Patient Story

A 4-day-old baby boy is brought to the pediatrician’s office for their first visit after birth. The pregnancy was full-term and uneventful, except for that the baby was a breech birth. The baby’s mother has noticed that although both legs and feet appear a little “curved,” both feet are almost “sideways” and look abnormal (Figure 86-1). On examination of both feet the hindfoot is clearly inverted, the toes point medially, and the foot is plantar flexed. The deformity is somewhat correctible by forcing the foot into a more normal position, but not completely. The baby does not appear to be in pain. He has no other abnormalities, has a normal neurologic exam for his age, and appears to be otherwise healthy. The child is referred to a pediatric orthopaedic surgeon, who begins serial Ponseti casting within one to two weeks. After several weeks of weekly serial casting, the feet have a more normal appearance. The child is then splinted full-time using a special orthosis for approximately three months, after which he is only splinted at night until walking age, at which time splinting is discontinued. He has no residual deformity.

Introduction

Clubfeet is one of the most common congenital abnormalities of the lower extremities.¹ As with any congenital deformity, it can be very concerning to new parents. However, the current gold standard of early non-operative treatment, with surgery only if needed later in life, has led to generally excellent functional results long-term.²

Synonyms

Congenital Talipes Equinovarus.

Epidemiology

• Approximately 1.2 per 1000 live births in Caucasians.³

• Varies across cultures, with only 0.39 to 0.5 per 1000 live births in Asian nations to 7 per 1000 live births in the South Pacific.^1,3

• Two-to-one male predominance across all populations, with 50 percent of cases bilateral.⁴

Etiology and Pathophysiology

• Due to the numerous bones and joints in the foot, a great deal of very descriptive but complicated orthopaedic terminology is associated with understanding the normal and abnormal relationships within the foot. However, this knowledge becomes useful in deciphering and communicating how to correct the deformity.

• The pathophysiology in clubfoot is characterized by four fundamental deformities of the foot, remembered by the mnemonic CAVE:⁵

  • Cavus (a deformity describing a higher or cavitary arch of the foot).

  • Adductus of the forefoot (the rays of the toes abnormally point medially).

  • Varus of the hindfoot (the plantar aspect of the calcaneus points medially if looked at from behind the patient).

  • Equinus (the foot is relatively plantar flexed, usually with a tight Achilles ...