Idiopathic congenital talipes equinovarus

The etiology of idiopathic congenital talipes equinovarus is unknown, and there is no consensus as to the best treatment. Increasingly, ultrasound is being used to diagnose the condition prenatally, but the diagnosis remains clinical postnatally. Radiographs can help confirm the diagnosis and ascertain the severity of the condition. There are many classification schemes, but none offers adequate prognostic value. The mainstay of treatment is manipulation and casting, usually followed by soft-tissue release. However, some patients have been successfully treated with intensive physiotherapy instead of surgery.     

Primary treatment of talipes equinovarus

Our primary club foot therapy consists of a combination of plaster cast manipulation, physiotherapy and surgical correction. The initial plaster cast method of 4 to 6 weeks is followed by a functional mobilisation of the foot. The main aim being the reduction of the malpositioned talus in the ankle mortise. If there is residual deformity surgery is planned after six month. We use the Cincinnati approach with the possibility of the dorsal, medial and lateral release, enabling a correction of the hind-, mid- and forefoot. The main part of postoperative care is seen in the functional rehabilitation of the foot by physiotherapy, in order to achieve a cosmetic foot with good functions. Physiotherapy is advised until the child enters school in order to preserve function and form into adult life. A high frequency of satisfactory results can be expected using this protocol.     

Bilateral congenital idiopathic talipes equinovarus in twins

A case of twins with bilateral congenital idiopathic talipes equinovarus is reported. This specific presentation is rare, and no specific measures of incidence are presently registered. Both patients are currently undergoing serial follow-up. The cases discussed here support a genetic basis for the condition and suggest that chromosomal/genetic studies may prove informative in such incidences.     

Distal calcaneal osteotomy in resistant talipes equinovarus

In resistant talipes equinovarus deformity, posterior medial release alone may be inadequate. Procedures involving the lateral column are sometimes necessary. Thirty-nine patients were treated by a distal calcaneal osteotomy and plantar fasciotomy. Good results were obtained in 30 of 39 patients; two had fair results and seven of 39 had poor results. Of the lateral column procedures, distal calcaneal osteotomy avoids the articular surfaces and provides for easier rotational positioning and correction of the forefoot. Older patients who have had multiple operations and, potentially, more severe pathology do not do well with this procedure. Preoperative evaluation of certain radiographic parameters is important in patient selection for these procedures.     

The classification of congenital talipes equinovarus

e have assessed the reliability of four classification systems for club foot. Four observers evaluated nine children (18 feet) at different stages in the first six months of life, a total of 180 examinations. Each observer independently assessed all feet according to the classification systems described by Catterall, Diméglio et al, Harrold and Walker, and Ponseti and Smoley. The variation between observers was assessed using the kappa test which for no more agreement than chance has a value of 0, and for complete agreement between observers a value of 1. The kappa values varied between 0.14 and 0.77 depending on which classification system was used. The system of Diméglio et al was found to have the greatest reliability. Our findings suggest that current classification systems for the analysis of congenital talipes equinovarus are not entirely satisfactory.     

Wound problems in surgery for talipes equinovarus

The traditional treatment for talipes equinovarus (TEV) has been open surgery in many units around the world. The complication rates for primary corrective surgery are relatively small but may affect outcome significantly. The complications of surgery in relapsed TEV are more frequent than for primary surgery, and problems relating to wound healing present difficult challenges to the treating surgeon. An overview of the approaches to management of this still challenging condition are presented, and the factors involved in wound healing problems and strategies for their prevention and treatment are presented. In particular, the belated but rapid spread worldwide of the Ponseti nonoperative approach to treating talipes is the most important factor in reducing the rates of surgery and therefore the complications that may ensue.     

Seasonal variation in the incidence of congenital talipes equinovarus

A review of 77 neonates who presented with congenital talipes equinovarus over a seven-year period revealed an increase in the condition amongst babies born in the winter quarter. This finding was particularly apparent among the less severe cases of club-foot. Possible reasons for this seasonal variation are discussed.     

Use of the Cincinnati incision in congenital talipes equinovarus

A series of 16 patients (24 feet) with idiopathic congenital talipes equinovarus (CTEV) corrected by a Cincinnati incision is presented. Minimum follow-up was 2 years. This series demonstrated that the incision does not adversely affect the outcome, since 75% of these feet had a good or excellent correction. No significant wound problems were encountered. The advantages of the Cincinnati incision, together with the fact that no adverse sequelae resulted from its use, mean that it can be recommended for future use and should be taught to other physicians.     

Histological abnormalities of the calcaneum in congenital talipes equinovarus

Six calcaneal fragments from patients aged 2, 3, 4, and 5 years with relapsed talipes, and two normal feet from a 40-week-old stillborn fetus were studied. All tissue was sectioned in the sagittal or coronal plane and stained using alcian blue and sirius red to distinguish cartilage and bone. Immunocytochemistry was performed to illustrate collagen types I and II. Within the clubfoot calcaneum, there were fewer chondrocytes and a diminished number of cartilage canals. Although a growth plate was present, the zones of differentiated chondrocytes were not apparent and the chondrocytes were smaller and flatter. The alcian blue staining within the spherical physis was paler than normal, suggesting that the amount of extracellular proteoglycans was reduced. Overall, the growth plate region of the talipes calcaneum resembled that of a permanent cartilage, like articular cartilage. Abnormalities were also seen in the ossification center. Cartilage spicules were rare, and developing bone frequently abutted directly onto the growth plate cartilage. The relative absence of a primary spongiosa suggested that the physis was virtually inactive and endochondral bone formation was retarded. These findings are consistent with the hypothesis that an intrinsic primary growth disorder causes the formation of a small hypoplastic bone and, subsequently, a smaller foot. Received: February 21, 2001 / Accepted: June 12, 2001     

Lack of seasonal variation in idiopathic talipes equinovarus

BACKGROUND: One proposed etiology of idiopathic talipes equinovarus is an in utero enterovirus infection. Enterovirus infections demonstrate seasonal variation in temperate climates. METHODS: We collected data on 1202 children with idiopathic talipes equinovarus born in the Northeastern United States, Midwestern United States, and the United Kingdom to investigate a seasonal variation in this congenital deformity. Birth date, gestational age at the time of delivery, gender, race, and laterality were tabulated and subjected to univariate and bivariate analyses. RESULTS: There were 774 boys and 428 girls with idiopathic talipes equinovarus. The birth location was the United Kingdom (458 children), the Midwestern United States (426 children), and the Northeastern United States (318 children). No significant differences were detected among the geographic groups with respect to gender, race, or laterality, and no variation in month of birth or month of conception was noted. CONCLUSIONS: This study does not support an in utero enterovirus infection as an etiology of idiopathic talipes equinovarus in industrialized populations.     

Relapse in staged surgery for congenital talipes equinovarus

Between 1988 and 1995, we studied 91 club feet from a series of 120 recalcitrant feet in 86 patients requiring surgical treatment. There were 48 boys and 20 girls. The mean age at operation was 8.9 months. Surgery consisted of an initial plantar medial release followed two weeks later by a posterolateral release. This strategy was adopted specifically to address the problems of wound healing associated with single-stage surgery and to ascertain the rate of relapse after a two-stage procedure. Immobilisation in plaster was used for three months followed by night splintage. The feet were classified preoperatively and prospectively into four grades according to the system suggested by Dimeglio et al. Grade-1 feet were postural and did not require surgery. All wounds were closed primarily. One superficial wound infection occurred in a grade-4 foot and there were no cases of wound breakdown. The rate of relapse was 20.4% in grade-3 and 65.4% in grade-4 feet. Two-stage surgery for the treatment of club foot seems to be effective in the reduction of wound problems but does not appear to give significantly better results in terms of relapse when performed for more severe deformities.