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Talipes Equinovarus / Clubfoot

- Discussion:
    - congenital clubfoot is a structural foot deformity that is present at birth;
    - there is in utero malalignment of the talocalcaneal, talonavicular and calcaneocuboid joints;
    - articular malalignments are fixed by contracted joint capsules, ligaments, and contracted foot and ankle tendons;
    - may be bilateral in up to 50%;
    - occurs in about 1 out of 800 births;
    - more common in males than females; 
    - ref: Club Foot: Rising Incidence—Why
    - pathoanatomy:
    - genetic tendency;
           - if both parents are normal w/ affected child, risk of next child having clubfoot is 2-5%;
           - w/ one affected parent and one affected child, then risk of next child having clubfoot is about 10-25%;
           - in some syndromes such as diastrophic dwarfism, there is autosomal recessive inheritance;
           - references:
                  - Family studies and the course of congenital clubfoot, talipes equinovarus, talipes calcaneovalgus, and metatarsus varus. 
                  - The Genetics of Idiopathic Clubfoot.  
    - diff dx:
           - myotonic muscular dystrophy
           - arthrogryposis multiplex congenita
           - myelomeningocele club foot
           - poliomyelitis
           - cerebral palsy
           - peroneal type of progressive muscle atrophy

- Radiographic Assessment of Club Foot

- Treatment Options
    - clubfoot casting:
    - surgical options:
           - circumferential release: "cincinati incision"
           - Goldner four quadrant approach:
           - medial release
           - posterior release
           - posteromedial release
           - tendon transfers
           - salvage procedures:
                  - combined soft-tissue and bone procedures;
                  - arthrodesis / osteotomy: (triple arthrodesis)
                  - forefoot adduction deformity:
                          - in the report by Lourenco AF, et al, the author performed a closing wedge osteotomy of the cuboid and opening 
                                 wedge osteotomy of the medial cuneiform in 39 feet;
                          - clinical and radiographic improvement was seen in all patients, and no complications were seen;
                          - surgery is advocated in children older than age 4, or when the medial cuneiform ossific nucleus is well developed;
                          - ref: Treatment of Residual Adduction Deformity in Clubfoot: The Double Osteotomy
           - talectomy:
                  - in the report by Legaspi J, et al, the authors reviewed 24 feet in 15 patients who had undergone talectomy for recurrent
                          equinovarus deformity;
                  - 21 were associated with arthrogryposis multiplex congenita, two with myelomeningocele and one with idiopathic
                          congenital talipes equinovarus;
                  - good results were achieved in eight feet (33%) in which further surgery was not needed and  walking was painless;
                  - a fair result was obtained in ten feet (42%) in which further surgery for recurrence of a hindfoot deformity had been
                          necessary but walking was painless;
                  - remaining six feet (25%) were poor, with pain on walking;
                  - all patients wore normal shoes and could walk independently, except one who was wheelchair bound because of other
                            joint problems.
                  - recurrent deformity, the development of tibiocalcaneal arthritis and spontaneous fusion of the  tibia to the calcaneum were
                            all seen in these patients;
                  - ref: Talectomy in patients with recurrent deformity in club foot. A long term followup study

Clubfoot References

Current management of idiopathic clubfoot questionnaire: a multicentric study.