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Congenital talipes equinovarus

Classification

  • Postural
Postural or positional talipes can be passively fully corrected or even overcorrected
  • Fixed
  1. Flexible - correctable with non-operative treatment
  2. Resistant - surgery

Incidence

  • 1:1000 live births caucasians
  • 3:1000 live births polynesians
  • Male : Female 2:1
  • 50% Bilateral
  • 10% chance of subsequent child being affected if positive family history
  • 2.3% if no family history

Aetiology

The true aetiology of congenital club foot is unknown. Most infants who have clubfoot have no identifiable genetic/ syndromal/ extrinsic cause

Associations:

Extrinsic causes:

  • Teratogenic agents eg sodium aminopterin
  • Oligohydramnios
  • Congenital constriction bands/rings
 

Genetic causes:

  • Mendelian inheritance: eg Diastrophic dwarfism- get an autosomal recessive pattern of club foot inheritance.
  • Cytogenetic abnormalities- CTEV can be seen in syndromes involving chromosomal deletion.
  • Multifactorial inheritance- it has been proposed that idiopathic CTEV in otherwise normal infants are the result of a multifactorial system of inheritance. Evidence for this:
  • incidence in
    • general pop= ~ 1/1000 live births
    • 1st deg rels= ~ 2%
    • 1 affected child - next child 2-5%
    • affected parent and affected child 10-25%
    • 2nd deg rels= 0.6%
    • If one monozygotic twin has CTEV- the 2nd twin has a 32% chance of also having CTEV
 

Theories of pathogenesis

  • Arrest of foetal development in the fibular stage ( Bohm JBJS 11: 229, 1929)
  • Defective cartilaginous anlage of the talus ( Irani and Sherman JBJS 45A: 45, 1963)
  • Neurogenic factor- histochemical abnormalities have been found in posteromedial and peroneal muscle groups of CTEV pts- thought due to innervation changes in intrauterine life ( Isaacs etal JBJS 59B: 465,1977
  • Neurological imbalance deformity - The incidence of varus and equino-varus deformity in spina bifida is about 35%
  • Retracting fibrosis- increased fibrous tissue in muscles and ligaments
  • Myoblasts in medial fascia- found on EM studies-postulated to cause medial contracture

Pathology

Bone

  • Femur, tibia and fibula
    • the entire lower limb can be shorter
      fibular shortening most common
  • Talus
    • all relationships of the talus are abnormal- including:
      - anterior extrusion of the body of the talus
      - ER of the body in the ankle mortise, equinus
      - medial and plantar deviation of the neck of the talus
  • Os calcis
    • medial rotation, equinus
  • Navicular
    • medial subluxation
  • Cuboid
    • medial subluxation
  • Forefoot
    • adducted and supinated, severe cases have cavus also

Muscle

Atrophy of the leg especially in peroneal group - number of fibres is normal , fibres are smaller in size
Triceps surae, Tib post, FDL,FHL are contracted

Other soft tissues

  • Tendon sheaths
    • frequently thickened, esp. about Tib post and perinea
  • Joint capsules
    • resistant CTEV - contractures of ankle, subtalar, talonavicular, calcaneocuboid jts
  • Ligaments
    • Resistant CTEV - contractures of calcaneofibular + talofibular ligs, deltoid lig, long and short plantar ligs, spring lig, long plantar lig. (bifurcate lig)
  • Fascia
    • Contracture of fascial planes and of plantar fascia


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