Congenital Talipes Equinovarus

Definition of the disease A clubfoot, Giles Smith syndrome [1] or talipes equinovarus (TE !, is a birth defect" TE is classified into # $roups% &ostural TE or Structural TE " 'ithout treatment, persons afflicted

often appear to (al) on their an)les, or on the sides of their feet" *t is a common birth defect, occurrin$ in about one in every 1,+++ live births" Appro,imately -+. of cases of clubfoot are bilateral" *n most cases it is an isolated dysmelia" This occurs in males more often than in females by a ratio of #%1" /lubfoot is a con$enital foot abnormality" *t is one of the most common pediatric orthopedic conditions" The heel tilts in and do(n, and the forefoot is also turned in" 'ithout treatment,a patient (ith a clubfoot (ill (al) on the outside of the foot (hich may produce pain and0or disability" A clubfoot is usually smaller than an unaffected (normal! foot" TE is associated (ith 1oint la,ity, con$enital dislocation of the hip, tibial torsion, ray

anomalies of the foot (oli$odactyly!, absences of some tarsal bones and a history of other foot anomalies in the family

Etiology The e,act cause of the clubfoot is un)no(n" *t cannot be prevented, but it is treatable" A child (ith a clubfoot should still $ro( and develop normally and be able to (al), run and play sports.

'hile there is no conclusive proof that talipes is hereditary, statistics indicate that there is a three to four percent probability that a child (ill develop it if one parent has this deformity" This percenta$e increases to 1- percent if both parents are affected" 2or normal parents (ho have a child (ith this problem, there is a t(o to five percent chance that their ne,t child (ill have talipes" Additionally, male babies are t(ice as li)ely to be afflicted (ith this condition than female babies" Structural TE is caused by% $enetic factors, a $enetic defect (ith three copies of

chromosome 13" Gro(th arrests at rou$hly 4 (ee)s and compartment syndrome of the affect limb are also causes of Structural TE " Genetic influences increase dramatically (ith family history" *t (as previously assumed that postural TE could be caused by e,ternal influences in

the final trimester such as intrauterine compression from oli$ohydramnios or from amniotic band syndrome" 5o(ever, this is countered by findin$s that TE usual (hen the intrauterine space is restricted" The cause of talipes is the abnormal position of the feet and limited space in the (omb durin$ fetal development, (hich can result in malformed tendons, muscles and bones" 2urthermore, the lac) of amniotic fluid in the sac surroundin$ the fetus, or oli$ohydramnios, can increase pressure on the feet, leadin$ to talipes as (ell" Clinical Manifestations /linical manifestation observed in each patients included the follo(in$% contracture of the heel6cord triceps surae7 contracture of the posterior tibial, fle,or hallucis lon$us, and fle,or di$itorum lon$us tendons% contracture of the posterior capsule includin$ the tibiotalar and fibulotalar articulations (the posterior talocalcaneal 1oint (as not opened!7 contracture of the
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does not occur more frequently than

deltoid li$ament, involvement of the anterior tibiotalar li$ament because of the for(ard sublu,ation of the talus7 fi,ation of the scaphoid to the medial malleolus (ith contracture of the talonavicular and talocalcaneal li$aments7 the anterior tibial tendon (as moderately shortened, and the cuboid (as displaced medially and the calcaneocuboid 1oint (as moderately distorted" The combination of navicular displacement and medial and posterior an)le and foot contractures (as associated (ith internal rotation of the talus in the an)le mortise and the calcaneus (ith the talus" Pathophysiology
Environment factors smoking Genetic factors Chromosome 18 Uterine position

9-12 weeks to gestation

Development of Lower lim s are misrepresente!

Lower lim s are !eforme!

Genetic and ecolo$ical factors are important in the pahophysiolo$y of TE " There is substantiation that maturity of bone, 1oint, connective tissue, innervation, vasculature and muscle may each be implicated in the pathophysiolo$y" annoyance of the overall process of medial rotation of the fetal foot may be the common path(ay lin)ed to all these aspects of development"
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*t is li)ely there is more than one different reason, and at least in some cases the phenotype may occur as a result of a threshold effect of different factors actin$ to$ether" &atholo$y observed in each of the three feet at operation included the follo(in$% (1! contracture of the heel6cord triceps surae7 (#! contracture of the posterior tibial, fle,or hallucis lon$us, and fle,or di$itorum lon$us tendons% (8! contracture of the posterior capsule includin$ the tibiotalar and fibulotalar articulations (the posterior talocalcaneal 1oint (as not opened!7 (9! contracture of the deltoid li$ament, involvement of the anterior tibiotalar li$ament because of the for(ard sublu,ation of the talus7 (-! fi,ation of the scaphoid to the medial malleolus (ith contracture of the talonavicular and talocalcaneal li$aments7 (:! the anterior tibial tendon (as moderately shortened, and (;! the cuboid (as displaced medially and the calcaneocuboid 1oint (as moderately distorted" (3! The combination of navicular displacement and medial and posterior an)le and foot contractures (as associated (ith internal rotation of the talus in the an)le mortise and the calcaneus (ith the talus" The articular surface of the head of the talus (as covered medially by the scaphoid and the body of the talus (as turned in(ard as far as the medial border of the talus (ould allo(" A portion of the head of the talus (as uncovered laterally" &arado,ically, it appeared to point laterally but actually (as pointin$ medially in relation to the an)le 1oint" *ndentation of the medial malleolus on the body of the talus is readily visuali<ed once the li$aments have been released" 'hen the talus and calcaneus are derotated laterally as a unit, the area of medial compression on the body of the talus due to inversion and internal rotation becomes evident, and

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(hen these conditions are corrected a space appears bet(een the talus and the medial articular surface of the medial malleolus"

Diagnostic Test 1" =6 >ay #" ?a$netic >esonance *ma$in$ Medical Intervention There are t(o (ell6)no(n non6sur$ical methods to treat talipes% a! The &onseti method

A special splint called the @enis6Aro(ne splint is put in place" This splint is made of t(o hi$h6top, open6toed shoes connected by a bar, (hich is ad1usted accordin$ to the correct position of the feet" The splint is (orn full6time for t(o to three months and then only at ni$ht for the ne,t t(o to four years" @eveloped by @r" *$nacio &onseti of *o(a, the &onseti method be$ins (ith a series of $entle manipulations and toe6to6thi$h cast placements for the first five to seven (ee)s" The heel6 cord is cut to complete the correction of the foot before the last cast is applied" Then, the last cast is placed for three (ee)s, by (hich time the heel6cord has healed properly"
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b! 2rench ?ethod This treatment requires daily one6hour therapy (ith a qualified physical therapist" *t consists of $entle stretchin$ of the feet, follo(ed by tapin$ to maintain their improved position" At ni$ht, the taped feet are connected (ith a machine that allo(s for a continuous passive motion to ma,imi<e stretchin$" 2or t(o hours every day, the tape is removed to air the s)in" &hysical therapy sessions continue daily for as lon$ as three months, and tapin$ is discontinued once the child be$ins (al)in$" *n stretchin$ and castin$ therapy the doctor chan$es the cast multiple times over a fe( (ee)s, $radually stretchin$ tendons until the foot is in the correct position of e,ternal rotation" The heel cord is released (percutaneous tenotomy! and another cast is put on, (hich is removed after three (ee)s" To avoid relapse a corrective brace is (orn for a $radually reducin$ time until it is only at ni$ht up to four years of a$e" Surgical Intervention The operative procedure includes% (1! B6len$thenin$ of the heel cord (ith release of the medial fibers distally7 (#! capsulorrhaphy of the tibiotalar and fibulotalar 1oints complete7 (8! capsulorrhaphy of the deltoid li$ament and plantar calcaneonavicular li$ament maintainin$ a small ton$ue of capsule attached to the tibia7 (9! capsulorrhaphy of the talonavicular li$aments% (-! capsulorrhaphy of the anterior tibiotalar li$ament from medial to lateral malleolus" (The talocalcaneal li$ament and the posterior compartment fo the foot should be avoided"! (:! The talus is then rotated laterally in the an)le mortise and the calcaneus (ith it" *f derotation is not complete and if the scaphoid does not $lide readily to the lateral side, a second incision is made

laterally, openin$ the calcaneocuboid 1oint and the cuboid metatarsal 1oints" The sinus tarsi is entered and the lateral talonavicular and calcaneonavicular li$aments are released, as are the tibulotalar li$aments laterally" This procedure usually allo(s full e,ternal rotation of the talus and the calcaneus as a unit and reestablishes the lateral border of the foot 6 the calcaneocuboid an$le bein$ chan$ed from conve, to neutral" The relationship bet(een the talus and the calcaneus is reestablished and the foot is then lined up (ith the fibula and medial malleolus" (;! The anterior tibial tendon is detached from the first metatarsal on the medial side and transferred to the dorsum of the first metatarsal (here it is reinserted into soft tissue and periosteum in the infant, or into a hole in the first cuneiform in the older patient" All tendons that have been len$thened are resutured and none is resected" The posterior tibial tendon should be saved and every effort should be made to maintain its ori$inal action on the hindfoot" At this point in the operation, e,cessive correction or the creation of heel val$us is readily possible, particularly in the foot of a child under one year of a$e" >esuture of a portion of the deltoid li$ament and the medial tendons (ill avoid e,cessive correction and allo( active forces to be applied to the medial border of the foot as the child $ro(s" The tourniquet is released, the bleedin$ points are coa$ulated, and the s)in is closed (ith absorbable suture" *n the infant, fi,ation pins are usually unnecessary to maintain the relationship bet(een the scaphoid and talus but may he required in the older child" E,cessive abduction of the forefoot should be avoided and the relationship bet(een the talus and the scaphoid, and the talus and an)le 1oint, should approach that seen in the physiolo$ic position" *f the s)in is ti$ht after closure, the foot should be inverted sli$htly and the tension ta)en off the s)in"
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&rimary healin$ should be sou$ht" 2luffed $au<e and pads are applied, sheet cotton is used and split so that there is no pressure on the s)in, and the cast is applied (ith the foot at ri$ht an$les and in neutral position in relationship to the malleoli, (ith the )nee at ri$ht an$les" This cast is chan$ed at 1+ to 19 dayCs so that repositionin$ can be accomplished if there (as tension on the s)in initially" At this time the initial internal rotation of the foot and the apparent, but usually none,istent, tibial torsion have been corrected" *n over 4+ percent of the clubfeet treated, the internally rotated position has been corrected by derotatin$ the talus in the an)le mortise" *n the authorCs opinion the li$amentous contracture, the position of the talus in the an)le mortise, and the relationship of the ad1acent tarsal bones to the talus constitute the primary patholo$y in con$enital talipesequinovarus" *f all aspects of the deformity are not corrected, then recurrent clubfoot is the rule" Dperative correction must be made from both the medial and lateral sides of the an)le 1oint and the midfoot in order to fullyC correct the internal rotation of the talus and the medial positionin$ of the scaphoid, as (ell as the distortion of the calcaneocuboid 1oint" Any procedure that attempts to do this (ithout correctin$ the talus may be successful only because the total deformity (as very mild" Severe clubfeet (ill not be corrected permanently if the an)le 1oint is not released" Total subtalar release (ill not be successful in the severe foot and (ill result eventually in a distorted tibiotalar 1oint (ith a foot that is apparently corrected by e,ternal rotation but (hich eventually (ill either revert to varus or (ill be placed in a val$us position in overcorrection" Nursing Intervention

This treatment for talipes require nursin$ care (hich consists of $entle manipulations to move the feet as much as possible to(ards the correct position and to hold this correction (ith a plaster cast" Splints are then used as a follo(6up treatment" These are fle,ible, as they can be used at various times durin$ the treatment and can be (orn #9 hours a day or only at ni$ht" Shoes used (ith splints should be strai$ht laced shoes (ith a strai$ht medial border"