Congenital talipes equinovarus

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Congenital talipes equinovarus is considered the most common anomaly affecting the feet diagnosed on antenatal ultrasound.

Terminology

While some use talipes equinovarusand clubfoot synonymously, in certain publications, the term clubfoot is considered a more general descriptive term that describes three distinct abnormalities:

talipes equinovarus(adduction of the forefoot, inversion of the heel and plantar flexion of the forefoot and ankle)
talipes calcaneovalgus (dorsal flexion of the forefoot with the plantar surface facing laterally)
metatarsus varus (inversion and adduction of the forefoot alone)

Epidemiology

It carries an estimated incidence of 0.5-5% of live births ⁴. Some reports suggest a male predilection with a male to female ratio of 2:1. The condition is bilateral in more than half of cases.

Associations

There is an immense number (estimated at 200) ⁸ of associations which include:

chromosomal anomalies
other syndromic conditions
renal anomalies
- prune belly syndrome
- renal agenesis
connective tissue disorders
- Marfan syndrome
- Ehlers-Danlos syndrome
spinal anomalies
skeletal dysplasias
- diastrophic dysplasia

Pathology

The deformity involves both ankle and subtalar joints. The malalignment is fixed by joint, ligamentous and tendinous contractures.

There may be a familial predilection in ~15% of cases ⁹. If detected antenatally, a careful search for other associated anomalies is recommended.

Radiographic features

Plain radiograph

Assessment requires weight bearing DP and lateral radiographs. Where weight bearing is not possible, it should be simulated.

Talipes equinovarus consists of four elements ⁷:

hindfoot equinus: lateral talocalcaneal angle ~~less than 35~~<35º
hindfoot varus: talocalcaneal angle ~~less than 20~~<20º
metatarsus adductus: adduction and varus deformity of the forefoot; talus to first metatarsal (Meary's) angle ~~greater than 15~~ >15º
talonavicular subluxation: medial subluxation of the navicular on the talus

Ultrasound

~~Approximately~~ 10-20% of individuals with prenatally diagnosed clubfoot may have a normal foot or positional foot deformity requiring minimal treatment. Conversely, 10-13% of prenatally diagnosed individuals with isolated clubfoot will have complex clubfoot postnatally, dependent on the presence of additional structural or neurodevelopmental abnormalities ^13-15.

Sonographic features may vary depending on severity. Both the tibia and fibula may be in the same image as the medially deviated foot and the foot may additionally appear plantar flexed.

Treatment and prognosis

Many (at least 50%) require orthopaedic intervention ⁸. The Ponseti method is a manipulative technique that corrects congenital clubfoot without invasive surgery. Therapeutic options range from casting and manipulation, through to surgical release. The most common surgical complication is overcorrection resulting in a "rockerbottom" flat foot deformity. Overall prognosis will often depend on other associated condition. Isolated condition may be treated successfully ⁸.

~~-<a title="Connective tissue disorders" href="/articles/connective-tissue-disease">connective tissue disorders</a><ul>~~
+<a href="/articles/connective-tissue-disease">connective tissue disorders</a><ul>
~~-<a href="/articles/hindfoot-equinus">hindfoot equinus</a><strong>:</strong> <a href="/articles/lateral-talocalcaneal-angle">lateral talocalcaneal angle</a> less than 35º</li>~~
+<a href="/articles/hindfoot-equinus">hindfoot equinus</a><strong>:</strong> <a href="/articles/lateral-talocalcaneal-angle">lateral talocalcaneal angle</a> <35º</li>
~~-<a href="/articles/hindfoot-varus">hindfoot varus</a><strong>:</strong> <a href="/articles/talocalcaneal-angle">talocalcaneal angle</a> less than 20º</li>~~
+<a href="/articles/hindfoot-varus">hindfoot varus</a><strong>:</strong> <a href="/articles/talocalcaneal-angle">talocalcaneal angle</a> <20º</li>
~~-<a href="/articles/metatarsus-adductus">metatarsus adductus</a>: adduction and varus deformity of the forefoot; talus to first metatarsal angle greater than 15º</li>~~
+<a href="/articles/metatarsus-adductus">metatarsus adductus</a>: adduction and varus deformity of the forefoot; <a title="Meary's angle" href="/articles/mearys-angle">talus to first metatarsal (Meary's) angle</a> >15º</li>
-</ul><h5>Ultrasound</h5><p>Approximately 10-20% of individuals with prenatally diagnosed clubfoot may have a normal foot or positional foot deformity requiring minimal treatment. Conversely, 10-13% of prenatally diagnosed individuals with isolated clubfoot will have complex clubfoot postnatally, dependent on the presence of additional structural or neurodevelopmental abnormalities <sup>13-15</sup>.</p><p>Sonographic features may vary depending on severity. Both the tibia and fibula may be in the same image as the medially deviated foot and the foot may additionally appear plantar flexed.</p><h4>Treatment and prognosis</h4><p>Many (at least 50%) require orthopaedic intervention <sup>8</sup>. The Ponseti method is a manipulative technique that corrects congenital clubfoot without invasive surgery. Therapeutic options range from casting and manipulation, through to surgical release. The most common surgical complication is overcorrection resulting in a "<a href="/articles/rocker-bottom-foot">rockerbottom</a>" flat foot deformity. Overall prognosis will often depend on other associated condition. Isolated condition may be treated successfully <sup>8</sup>.</p>
+</ul><h5>Ultrasound</h5><p>10-20% of individuals with prenatally diagnosed clubfoot may have a normal foot or positional foot deformity requiring minimal treatment. Conversely, 10-13% of prenatally diagnosed individuals with isolated clubfoot will have complex clubfoot postnatally, dependent on the presence of additional structural or neurodevelopmental abnormalities <sup>13-15</sup>.</p><p>Sonographic features may vary depending on severity. Both the tibia and fibula may be in the same image as the medially deviated foot and the foot may additionally appear plantar flexed.</p><h4>Treatment and prognosis</h4><p>Many (at least 50%) require orthopaedic intervention <sup>8</sup>. The Ponseti method is a manipulative technique that corrects congenital clubfoot without invasive surgery. Therapeutic options range from casting and manipulation, through to surgical release. The most common surgical complication is overcorrection resulting in a "<a href="/articles/rocker-bottom-foot">rockerbottom</a>" flat foot deformity. Overall prognosis will often depend on other associated condition. Isolated condition may be treated successfully <sup>8</sup>.</p>

References changed:

1. Koulouris G & Morrison W. Foot and Ankle Disorders: Radiographic Signs. Semin Roentgenol. 2005;40(4):358-79. <a href="https://doi.org/10.1053/j.ro.2005.01.018">doi:10.1053/j.ro.2005.01.018</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/16218553">Pubmed</a>
2. Thapa M, Pruthi S, Chew F. Radiographic Assessment of Pediatric Foot Alignment: Review. AJR Am J Roentgenol. 2010;194(6 Suppl):S51-8. <a href="https://doi.org/10.2214/AJR.07.7143">doi:10.2214/AJR.07.7143</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/20489117">Pubmed</a>
3. Wainwright A, Auld T, Benson M, Theologis T. The Classification of Congenital Talipes Equinovarus. J Bone Joint Surg Br. 2002;84(7):1020-4. <a href="https://doi.org/10.1302/0301-620x.84b7.12909">doi:10.1302/0301-620x.84b7.12909</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/12358365">Pubmed</a>
4. Bromley B & Benacerraf B. Abnormalities of the Hands and Feet in the Fetus: Sonographic Findings. AJR Am J Roentgenol. 1995;165(5):1239-43. <a href="https://doi.org/10.2214/ajr.165.5.7572511">doi:10.2214/ajr.165.5.7572511</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/7572511">Pubmed</a>
5. Allen S, Harvey C, O'Regan D. Interpretation of Ankle and Foot Radiographs. Br J Hosp Med (Lond). 2006;67(1):M8-11. <a href="https://doi.org/10.12968/hmed.2006.67.Sup1.20336">doi:10.12968/hmed.2006.67.Sup1.20336</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/16447403">Pubmed</a>
6. Tillett R, Fisk N, Murphy K, Hunt D. Clinical Outcome of Congenital Talipes Equinovarus Diagnosed Antenatally by Ultrasound. J Bone Joint Surg Br. 2000;82(6):876-80. <a href="https://doi.org/10.1302/0301-620x.82b6.9777">doi:10.1302/0301-620x.82b6.9777</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/10990315">Pubmed</a>
7. Adam Greenspan. Orthopedic Imaging. (2004) ISBN: 9780781750066 - <a href="http://books.google.com/books?vid=ISBN9780781750066">Google Books</a>
8. Michael Entezami, Ursula Knoll, Matthias Albig et al. Ultrasound Diagnosis of Fetal Anomalies. (2004) ISBN: 9781588902122 - <a href="http://books.google.com/books?vid=ISBN9781588902122">Google Books</a>
9. Eberhard Merz. Ultrasound in Obstetrics and Gynecology. (2005) ISBN: 9781588901477 - <a href="http://books.google.com/books?vid=ISBN9781588901477">Google Books</a>
10. Bar-On E, Mashiach R, Inbar O, Weigl D, Katz K, Meizner I. Prenatal Ultrasound Diagnosis of Club Foot: Outcome and Recommendations for Counselling and Follow-Up. J Bone Joint Surg Br. 2005;87(7):990-3. <a href="https://doi.org/10.1302/0301-620X.87B7.16076">doi:10.1302/0301-620X.87B7.16076</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/15972918">Pubmed</a>
11. Keret D, Ezra E, Lokiec F, Hayek S, Segev E, Wientroub S. Efficacy of Prenatal Ultrasonography in Confirmed Club Foot. J Bone Joint Surg Br. 2002;84(7):1015-9. <a href="https://doi.org/10.1302/0301-620x.84b7.12689">doi:10.1302/0301-620x.84b7.12689</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/12358364">Pubmed</a>
12. Malone F, Marino T, Bianchi D, Johnston K, D'Alton M. Isolated Clubfoot Diagnosed Prenatally: Is Karyotyping Indicated? Obstet Gynecol. 2000;95(3):437-40. <a href="https://doi.org/10.1016/s0029-7844(99)00582-7">doi:10.1016/s0029-7844(99)00582-7</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/10711559">Pubmed</a>
13. Lauson S, Alvarez C, Patel M, Langlois S. Outcome of Prenatally Diagnosed Isolated Clubfoot. Ultrasound Obstet Gynecol. 2010;35(6):708-14. <a href="https://doi.org/10.1002/uog.7558">doi:10.1002/uog.7558</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/20069547">Pubmed</a>
14. Viaris de le Segno B, Gruchy N, Bronfen C et al. Prenatal Diagnosis of Clubfoot: Chromosomal Abnormalities Associated with Fetal Defects and Outcome in a Tertiary Center. J Clin Ultrasound. 2016;44(2):100-5. <a href="https://doi.org/10.1002/jcu.22275">doi:10.1002/jcu.22275</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/26179848">Pubmed</a>
15. Glotzbecker M, Estroff J, Spencer S et al. Prenatally Diagnosed Clubfeet: Comparing Ultrasonographic Severity with Objective Clinical Outcomes. J Pediatr Orthop. 2010;30(6):606-11. <a href="https://doi.org/10.1097/BPO.0b013e3181e78e4e">doi:10.1097/BPO.0b013e3181e78e4e</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/20733428">Pubmed</a>
1. Koulouris G, Morrison WB. Foot and ankle disorders: radiographic signs. Semin Roentgenol. 2005;40 (4): 358-79. <a href="http://dx.doi.org/10.1053/j.ro.2005.01.018">doi:10.1053/j.ro.2005.01.018</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/16218553">Pubmed citation</a><div class="ref_v2"></div>
2. Thapa MM, Pruthi S, Chew FS. Radiographic assessment of pediatric foot alignment: review. AJR Am J Roentgenol. 2010;194 (6): S51-8. <a href="http://dx.doi.org/10.2214/AJR.07.7143">doi:10.2214/AJR.07.7143</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/20489117">Pubmed citation</a><div class="ref_v2"></div>
3. Wainwright AM, Auld T, Benson MK et-al. The classification of congenital talipes equinovarus. J Bone Joint Surg Br. 2002;84 (7): 1020-4. <a href="http://dx.doi.org/10.1302/0301-620X.84B7.12909">doi:10.1302/0301-620X.84B7.12909</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/12358365">Pubmed citation</a><div class="ref_v2"></div>
4. Bromley B, Benacerraf B. Abnormalities of the hands and feet in the fetus: sonographic findings. AJR Am J Roentgenol. 1995;165 (5): 1239-43. <a href="http://www.ajronline.org/cgi/content/abstract/165/5/1239">AJR Am J Roentgenol (abstract)</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/7572511">Pubmed citation</a><div class="ref_v2"></div>
5. Allen SD, Harvey CJ, O'regan D. Interpretation of ankle and foot radiographs. Br J Hosp Med (Lond). 2006;67 (1): M8-11. - <a href="http://www.ncbi.nlm.nih.gov/pubmed/16447403">Pubmed citation</a><div class="ref_v2"></div>
6. Tillett RL, Fisk NM, Murphy K et-al. Clinical outcome of congenital talipes equinovarus diagnosed antenatally by ultrasound. J Bone Joint Surg Br. 2000;82 (6): 876-80. <a href="http://dx.doi.org/10.1302/0301-620X.82B6.9777">doi:10.1302/0301-620X.82B6.9777</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/10990315">Pubmed citation</a><div class="ref_v2"></div>
7. Greenspan A. Orthopedic imaging, a practical approach. Lippincott Williams & Wilkins. (2004) ISBN:0781750067. <a href="http://books.google.com/books?vid=ISBN0781750067">Read it at Google Books</a> - <a href="http://www.amazon.com/gp/product/0781750067?ie=UTF8&tag=radiopaediaor-20&linkCode=as2&camp=1789&creative=9325&creativeASIN=0781750067">Find it at Amazon</a><div class="ref_v2"></div>
8. Entezami M, Albig M, Knoll U et-al. Ultrasound Diagnosis of Fetal Anomalies. Thieme. (2003) ISBN:1588902129. <a href="http://books.google.com/books?vid=ISBN1588902129">Read it at Google Books</a> - <a href="http://www.amazon.com/gp/product/1588902129?ie=UTF8&tag=radiopaediaor-20&linkCode=as2&camp=1789&creative=9325&creativeASIN=1588902129">Find it at Amazon</a><div class="ref_v2"></div>
9. Merz E, Bahlmann F. Ultrasound in obstetrics and gynecology. Thieme Medical Publishers. (2005) ISBN:1588901475. <a href="http://books.google.com/books?vid=ISBN1588901475">Read it at Google Books</a> - <a href="http://www.amazon.com/gp/product/1588901475?ie=UTF8&tag=radiopaediaor-20&linkCode=as2&camp=1789&creative=9325&creativeASIN=1588901475">Find it at Amazon</a><div class="ref_v2"></div>
10. Bar-On E, Mashiach R, Inbar O, Weigl D, Katz K, Meizner I. Prenatal ultrasound diagnosis of club foot: outcome and recommendations for counselling and follow-up. The Journal of bone and joint surgery. British volume. 87 (7): 990-3. <a href="https://doi.org/10.1302/0301-620X.87B7.16076">doi:10.1302/0301-620X.87B7.16076</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/15972918">Pubmed</a> <span class="ref_v4"></span>
11. Keret D, Ezra E, Lokiec F, Hayek S, Segev E, Wientroub S. Efficacy of prenatal ultrasonography in confirmed club foot. The Journal of bone and joint surgery. British volume. 84 (7): 1015-9. <a href="https://www.ncbi.nlm.nih.gov/pubmed/12358364">Pubmed</a> <span class="ref_v4"></span>
12. Malone FD, Marino T, Bianchi DW, Johnston K, D'Alton ME. Isolated clubfoot diagnosed prenatally: is karyotyping indicated?. Obstetrics and gynecology. 95 (3): 437-40. <a href="https://www.ncbi.nlm.nih.gov/pubmed/10711559">Pubmed</a> <span class="ref_v4"></span>
13. Lauson S, Alvarez C, Patel MS, Langlois S. Outcome of prenatally diagnosed isolated clubfoot. Ultrasound in obstetrics & gynecology : the official journal of the International Society of Ultrasound in Obstetrics and Gynecology. 35 (6): 708-14. <a href="https://doi.org/10.1002/uog.7558">doi:10.1002/uog.7558</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/20069547">Pubmed</a> <span class="ref_v4"></span>
14. Viaris de le Segno B, Gruchy N, Bronfen C, Dolley P, Leporrier N, Creveuil C, Benoist G. Prenatal diagnosis of clubfoot: Chromosomal abnormalities associated with fetal defects and outcome in a tertiary center. Journal of clinical ultrasound : JCU. 44 (2): 100-5. <a href="https://doi.org/10.1002/jcu.22275">doi:10.1002/jcu.22275</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/26179848">Pubmed</a> <span class="ref_v4"></span>
15. Glotzbecker MP, Estroff JA, Spencer SA, Bosley JC, Parad RB, Kasser JR, Mahan ST. Prenatally diagnosed clubfeet: comparing ultrasonographic severity with objective clinical outcomes. Journal of pediatric orthopedics. 30 (6): 606-11. <a href="https://doi.org/10.1097/BPO.0b013e3181e78e4e">doi:10.1097/BPO.0b013e3181e78e4e</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/20733428">Pubmed</a> <span class="ref_v4"></span>

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