Table of Contents
Clubfoot (talipes equinovarus (TEV)) and metatarsus adductus are congenital anomalies in the pediatric population that become apparent at birth. In both disorders, the foot is inwardly turned and kidney-shaped. The tendons and ligaments are stiff, resulting in a restricted foot that cannot maintain the normal range of movements. Severe untreated TEV leads to the development of a foot with a club-like appearance. Talipes equinovarus can be either congenital or acquired.
Congenital talipes equinovarus (CTEV) causes an individual to walk on the ankle. It is the most common congenital foot disorder, affecting 1.2 children per 1,000 live births. It is mostly bilateral. Acquired talipes equinovarus (ATEV) results from diseases such as polio or cerebral palsy. It is usually unilateral.
Metatarsus adductus is a congenital deformity that results in an inward turning of the forefoot. It is also called metatarsus varus and is the most common foot deformity in infants. It occurs in 1 in 1,000 live births and is more common among first-born children. Metatarsus adductus is associated with torticollis or developmental dysplasia of the hip (from a tight uterine environment).
The exact etiology is still unknown. Most cases are idiopathic. Clubfoot and metatarsus adductus can be isolated or associated with other congenital anomalies such as arthrogryposis multiplex congenita, myelodysplasia, spina bifida, and other defects.
Disorders of the nervous system constitute the 2nd-largest percentage of etiological factors for clubfoot, including myelomeningocele and arthrogryposis. Interestingly, any part of the muscle, nerve, brain, or spinal cord can be affected. There are many theories regarding the idiopathic causes of these conditions.
Genetic factors account for almost 25% of total cases. Environmental factors, including various procedures such as early amniocentesis, or amniotic fluid problems such as oligohydramnios, are also indicated. Maternal factors such as cigarette smoking and viral infections have also been studied. The positioning of the baby in utero is also cited as a cause, especially breech position. Abnormal insertions of muscles have also been implicated.
Several theories have been put forward to explain the etiology of TEV, leading to its classification into 4 types:
Metatarsus adductus is classified into:
- Skew foot
- Serpentine foot (complex skew foot)
Pathology and Features
These diseases affect joints and bones of the foot, leading to the development of secondary soft tissue contractures. Similarly, they may affect the surrounding soft tissue, causing the development of secondary changes in bone.
Involved bone deformities include:
- Varus deformity
- Forefoot abduction
- Internal tibial torsion
Secondary soft tissue changes include:
- Reduced foot size
- Tight skin over the dorsum of the foot
- Callosities over the dorsum
- Hypertrophy of the anterior tibial artery
- Atrophy of the muscles and tendons of the posterior compartment of the leg
- Concave medial border of the foot and a convex lateral border
If left uncorrected, these deformities can lead to anatomical abnormalities and stumbling gait, among other issues, and should, therefore, be corrected before they become permanent.
Both disorders are painless conditions unless complications such as fracture or inflammation occur on the affected side. Symptoms include:
- Clubfoot: The ankle is curved inward and the foot is pointed downward. The heel of the affected foot is smaller. The condition can be unilateral or bilateral.
- Metatarsus adductus: The front of the foot is bent toward the middle. It is often bilateral. The affected foot is shorter than normal. Shoes do not fit and the child cannot enjoy normal playing activities due to a narrow range of motion.
Clubfoot and metatarsus adductus can be easily diagnosed by following a simple protocol. Ultrasound scanning in utero can detect these conditions, although they are usually diagnosed at birth.
During physical examination, the doctor observes the foot and the movements that can be made. Taking a complete birth history and family history are also important, as genetic factors play a significant role. Diagnostic procedures such as X-rays can visualize the structures of the foot in detail.
A treatment option is selected based on certain factors:
- The child’s age, other congenital anomalies, and medical history
- Extent and severity of the condition
- The child’s ability to tolerate various procedures and medications
- The expected duration of a specific treatment option
- The preferred option of the parents or guardians
Metatarsus adductus resolves spontaneously in 90% of cases by 4 years of age, with a further 5% resolving upon the commencement of walking. Thus, the disease rarely needs aggressive management.
Management of metatarsus adductus takes the following approach:
- Observation: No treatment is needed for deformities that are actively corrected.
- Serial stretching: This is recommended for deformities that are only passively corrected.
- Casting: This is recommended for rigid deformities, with the goal of obtaining a straight lateral foot.
- Surgery: If the above treatments have failed, operative management is the next resort, using procedures such as:
- Tarsometatarsal capsulotomies
- Open metatarsal osteotomies
- Opening wedge or closing wedge osteotomies for serpentine deformities
- Multiple metatarsal osteotomies with forefoot pinning and tarsometatarsal capsular release (Hamen procedure)
The management of TEV takes 2 forms: conservative or surgical.
Conservative Treatment Methods
Kite and Lovell
Kite and Lovell is the method of choice for children younger than 6 months of age and should begin soon after birth. It involves weekly serial manipulation by the caregiver during diaper changes for about 6 months, and placement of above-knee casts up to 6 weeks.
If a correction is achieved during the first 6 months, maintenance is done through the use of a Phelps brace during the day and Denis Browne splint during the night for 6–18 months, after which a below-knee walking caliper is used until the age of 4 years. After this period, this active intervention is replaced by serial check-ups.
The Ponseti method has several advantages over other conservative methods:
- Higher success rates (up to 98%)
- Can be used for older children up to the age of 2 years
It is also advantageous over surgical methods in that it:
- Results in a more flexible foot, and thus is more effective in later life
- Is less intensive
This method should be initiated as soon as possible, with weekly stretching of the foot by a medical practitioner and long-leg cast installation every 1–2 weeks.
Tenotomy for Achilles tendon release and lengthening are done before the last cast is put on, and maintained for 3 weeks. The deformity should be reversed by 6 weeks. The maintenance phase follows, with corrective foot orthosis administered 23 hours a day for 3 months and later only at night, up to 4 years of age.
Soft tissue procedures
These are done for recurrent cases before the age of 4 years. They include Turco’s procedure for the correction of posterior foot abnormalities, such as:
- Lengthening of the Achilles tendon
- Capsulotomy for the ankle and subtalar joint
- Release of the posterior talofibular and calcaneofibular joints
A plantar procedure such as:
- Release of the plantar fascia
- Release of abductor hallucis and flexor digitorum brevis
Medial procedure such as:
- Lengthening of the tibialis posterior and flexor digitorum longus
- Release of the talonavicular, superficial part of the deltoid ligament and spring ligament
Used for patients older than 4 years of age and include:
- Dwyer’s lateral closed wedge osteotomies
- Use of external fixators
Both of these conditions carry an excellent prognosis, provided that treatment begins as early as possible. Management should be started soon after birth, as the tissues are softer and manipulation is much easier at that time.