Congenital talipes equinovarus
Congenital talipes equinovarus (CTEV) is considered the most common anomaly affecting the feet diagnosed on antenatal ultrasound.
While some use CTEV and club foot (CF) synonymously, in certain publications term clubfoot is considered a more general descriptive term that describes three distinct abnormalities:
- talipes equinovarus (adduction of the forefoot, inversion of the heel and plantar flexion of the forefoot and ankle)
- talipes calcaneovalgus (dorsal flexion of the forefoot with the plantar surface facing laterally)
- metatarsus varus (inversion and adduction of the forefoot alone)
It carries an estimated incidence of 0.5-5% of live births 4. Some reports suggest a male predilection with a male to female ratio of 2:1. The condition is bilateral in more than half of cases.
There may be a familial predilection in ~15% of cases 9. If detected antenatally, a careful search for other associated anomalies are recommended.
There is an immense number (estimated at 200) 8 of associations which include:
- chromosomal anomalies
- other syndromic conditions
- renal anomalies
- connective tissue disorders
- spinal anomalies
- skeletal dysplasias
Talipes equinovarus consists of four elements 7:
- hindfoot equinus: lateral talocalcaneal angle less than 35º
- hindfoot varus: talocalcaneal angle less than 20º
- metatarsus adductus: adduction and varus deformity of the forefoot; talus to first metatarsal angle greater than 15º
- talonavicular subluxation: medial subluxation of the navicular on the talus
Approximately 10-20% of individuals with prenatal diagnosed clubfoot may have a normal foot or positional foot deformity requiring minimal treatment. Conversely, 10-13% of prenatally diagnosed individuals with isolated clubfoot will have complex clubfoot postnatally, dependent on the presence of additional structural or neurodevelopmental abnormalities 13-15.
Sonographic features may vary dependent on severity. Both the tibia and fibula may be on the same image as the medially deviated foot and the foot may additionally appear plantar flexed.
Treatment and prognosis
Many (at least 50%) require orthopaedic intervention 8. The Ponseti method is a manipulative technique that corrects congenital clubfoot without invasive surgery. Therapeutic options range from casting and manipulation, through to surgical release. The most common surgical complication is overcorrection resulting in a "rockerbottom" flat foot deformity. Overall prognosis will often depend on other associated condition. Isolated condition may be treated successfully 8.
- 1. Koulouris G, Morrison WB. Foot and ankle disorders: radiographic signs. Semin Roentgenol. 2005;40 (4): 358-79. doi:10.1053/j.ro.2005.01.018 - Pubmed citation
- 2. Thapa MM, Pruthi S, Chew FS. Radiographic assessment of pediatric foot alignment: review. AJR Am J Roentgenol. 2010;194 (6): S51-8. doi:10.2214/AJR.07.7143 - Pubmed citation
- 3. Wainwright AM, Auld T, Benson MK et-al. The classification of congenital talipes equinovarus. J Bone Joint Surg Br. 2002;84 (7): 1020-4. doi:10.1302/0301-620X.84B7.12909 - Pubmed citation
- 4. Bromley B, Benacerraf B. Abnormalities of the hands and feet in the fetus: sonographic findings. AJR Am J Roentgenol. 1995;165 (5): 1239-43. AJR Am J Roentgenol (abstract) - Pubmed citation
- 5. Allen SD, Harvey CJ, O'regan D. Interpretation of ankle and foot radiographs. Br J Hosp Med (Lond). 2006;67 (1): M8-11. - Pubmed citation
- 6. Tillett RL, Fisk NM, Murphy K et-al. Clinical outcome of congenital talipes equinovarus diagnosed antenatally by ultrasound. J Bone Joint Surg Br. 2000;82 (6): 876-80. doi:10.1302/0301-620X.82B6.9777 - Pubmed citation
- 7. Greenspan A. Orthopedic imaging, a practical approach. Lippincott Williams & Wilkins. (2004) ISBN:0781750067. Read it at Google Books - Find it at Amazon
- 8. Entezami M, Albig M, Knoll U et-al. Ultrasound Diagnosis of Fetal Anomalies. Thieme. (2003) ISBN:1588902129. Read it at Google Books - Find it at Amazon
- 9. Merz E, Bahlmann F. Ultrasound in obstetrics and gynecology. Thieme Medical Publishers. (2005) ISBN:1588901475. Read it at Google Books - Find it at Amazon
- 10. Bar-On E, Mashiach R, Inbar O, Weigl D, Katz K, Meizner I. Prenatal ultrasound diagnosis of club foot: outcome and recommendations for counselling and follow-up. The Journal of bone and joint surgery. British volume. 87 (7): 990-3. doi:10.1302/0301-620X.87B7.16076 - Pubmed
- 11. Keret D, Ezra E, Lokiec F, Hayek S, Segev E, Wientroub S. Efficacy of prenatal ultrasonography in confirmed club foot. The Journal of bone and joint surgery. British volume. 84 (7): 1015-9. Pubmed
- 12. Malone FD, Marino T, Bianchi DW, Johnston K, D'Alton ME. Isolated clubfoot diagnosed prenatally: is karyotyping indicated?. Obstetrics and gynecology. 95 (3): 437-40. Pubmed
- 13. Lauson S, Alvarez C, Patel MS, Langlois S. Outcome of prenatally diagnosed isolated clubfoot. Ultrasound in obstetrics & gynecology : the official journal of the International Society of Ultrasound in Obstetrics and Gynecology. 35 (6): 708-14. doi:10.1002/uog.7558 - Pubmed
- 14. Viaris de le Segno B, Gruchy N, Bronfen C, Dolley P, Leporrier N, Creveuil C, Benoist G. Prenatal diagnosis of clubfoot: Chromosomal abnormalities associated with fetal defects and outcome in a tertiary center. Journal of clinical ultrasound : JCU. 44 (2): 100-5. doi:10.1002/jcu.22275 - Pubmed
- 15. Glotzbecker MP, Estroff JA, Spencer SA, Bosley JC, Parad RB, Kasser JR, Mahan ST. Prenatally diagnosed clubfeet: comparing ultrasonographic severity with objective clinical outcomes. Journal of pediatric orthopedics. 30 (6): 606-11. doi:10.1097/BPO.0b013e3181e78e4e - Pubmed