A 5-year-old female was admitted to the inpatient service after a cuneiform to cuboid wedge surgery for recurrent talipes equinovarus on the left foot. The past medical history showed bilateral congenital clubfoot that was treated by the Ponseti method of serial casting and application of nightime foot orthosis for 2 years. Since that time the parents had noted an increase in left foot adduction and pain. The pertinent physical exam showed a healthy appearing female who was sleeping post-op. The left foot was in a plaster cast that had some sanguinous fluid on the cast at the heel. There was good capillary refill and mild swelling of the toes. The diagnosis of post-operative recurrent talipes equinovarus was confirmed. Overnight, the patient’s clinical course revealed that her pain was well-controlled with oral medication. The next day, physical therapy was able to get the patient up on crutches and she was sent home to followup in 6 weeks with orthopaedics.
Figure 104 – AP radiographs of both feet show a persistent metatarsus adductus deformity in the left foot. There is a dysplastic appearing medial cuneiform bone with associated widening at the first tarsal-metatarsal joint.
Newborn foot deformities are relatively common with an incidence of ~4.2%. About 75% of these are due to metatarsus adductus. Talipes equinovarus, calcaneovulgus foot and vertical talus are the other most common abnormalities.
Congenital talipes equinovarus or clubfoot deformity occurs in 1-2/1000 births. The mneumonic CAVE identifies the major findings of Cavus, forefoot Adduction, hindfoot Varus and Equinus. Clubfoot can be mild to severe with the more severe forms being associated with other problems.
The Ponseti method is currently considered the main treatment method with better short-term outcomes compared to other techniques. Dr. Ignatio Ponseti at the University of Iowa developed a technique of serial casting of the feet. Most patients require 5-7 casts changed weekly with longer treatment for more severely affected feet. A period of stabilization with ankle-foot orthoses (AFOs) is required to maintain the desired outcome. Sometimes a tendon transfer is also necessary.
Originally, Dr. Ponsetti had a 50% relapse rate with his early patients, but later this was decreased to 7% by overcorrection of the initial deformity with the initial casting and use of the night AFO splinting.
Overall initial correction of deformity is as high as 93-100% of cases, but there can be persistent or recurrent deformity. Persistent deformity is one that has been incompletely corrected initially before being placed into the AFO. Recurrent deformity is one that was initially corrected, properly placed and maintained in the AFO, but recurs months to years later. Overall relapse rates range from 4-41%. Of patients that are compliant with AFO use, this is decreased from 0-21%.
There are 3 main reasons for relapse:
- Non-compliance with the AFO use – caregivers fail to understand the importance of consistent use of the AFO. Incidence of non-compliance with AFO use is 0-51%
- Increased risk – underlying disorder such as arthrogryposis, unrecognized or known neuropathy (e.g. Charot-Marie Tooth, myasthenia gravis, myotonic dystrophy, meningomyelocoele), and syndromes (e.g. Larsen syndrome).
Non-idiopathic clubfeet have a higher rate of relapse; from 24-56% depending on the population.
Treatment of relapse includes repeated casting and/or tenotomy, tibialis anterior tendon transfer and other surgical techniques depending on the specific area of deformity.
Questions for Further Discussion
1. What is the difference between calcaneovalgus foot and posteromedial bowing of the tibia?
2. How is metatarsus adductus treated?
- Symptom/Presentation: Foot Pain
- Specialty: Orthopaedic Surgery and Sports Medicine | Radiology / Nuclear Medicine / Radiation Oncology
- Age: School Ager
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Sankar WN, Weiss J, Skaggs DL. Orthopaedic conditions in the newborn. J Am Acad Orthop Surg. 2009 Feb;17(2):112-22.
Jowett CR, Morcuende JA, Ramachandran M. Management of congenital talipes equinovarus using the Ponseti method: a systematic review. J Bone Joint Surg Br. 2011 Sep;93(9):1160-4.
Gray K, Pacey V, Gibbons P, Little D, Frost C, Burns J. Interventions for congenital talipes equinovarus (clubfoot). Cochrane Database Syst Rev. 2012 Apr 18;4:CD008602. doi: 10.1002/14651858.CD008602.pub2.
Chu A, Lehman WB. Persistent clubfoot deformity following treatment by the Ponseti method. J Pediatr Orthop B. 2012 Jan;21(1):40-6.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital