Summary

Clubfoot (congenital talipes equinovarus, CTEV) is a congenital foot deformity affecting 1 in 1,000 live births, making it one of the most common musculoskeletal birth defects. The deformity involves four components remembered by the mnemonic CAVE: Cavus, Adductus, Varus, and Equinus. The Ponseti method of serial casting and percutaneous Achilles tenotomy has revolutionised treatment, with success rates exceeding 95%. Boots-and-bar bracing for 4 years after correction is essential to prevent relapse.

Key Facts

• Definition: Congenital foot deformity with forefoot adduction, hindfoot varus and equinus
• Incidence: 1 per 1,000 live births (varies by ethnicity)
• Sex Ratio: Male:Female 2:1
• Laterality: Bilateral in 50% of cases
• Treatment:Ponseti method is gold standard (95%+ success rate)
• Key to Success: Brace compliance (boots-and-bar for 4 years)

Clinical Pearls

"CAVE" Mnemonic: The four deformity components in order of correction are: Cavus (high arch), Adductus (forefoot adducted), Varus (hindfoot inverted), Equinus (ankle plantarflexed). Correct CAVE in order — C-A-V first with casting, E last with tenotomy.

Tenotomy in 90%: Approximately 90% of clubfeet require percutaneous Achilles tenotomy after casting to correct the equinus. This is done in clinic under local anaesthesia and is definitive.

Relapse is Parent-Dependent: Relapse occurs in 40% if bracing is not used correctly. The single biggest predictor of relapse is brace non-compliance. Educate parents extensively.

Why This Matters Clinically

Clubfoot, if untreated, leads to permanent disability, painful walking on the outer edge of the foot, and difficulties with footwear. The Ponseti method has transformed outcomes — with appropriate treatment, children achieve normal functional feet. Early referral to a Ponseti-trained specialist is essential.

Structured Approach

General:

• Full newborn examination (exclude syndromic features)
• Spine examination (sacral dimple, tuft of hair)
• Hip examination (Barlow/Ortolani for DDH)
• Both feet and legs examined

Specific Clubfoot Examination:

• Assess each CAVE component
• Test passibility of deformity (flexible vs rigid)
• Compare to contralateral side (if unilateral)
• Assess calf size (typically smaller on affected side)

Special Tests

Pirani Scoring System

Hindfoot (3 points):

• Posterior crease severity (0-1)
• Emptiness of heel (0-1)
• Rigidity of equinus (0-1)

Midfoot (3 points):

• Medial crease severity (0-1)
• Lateral border curvature (0-1)
• Head of talus coverage (0-1)

Total: 0 (normal) to 6 (severe)

Natural History

Untreated clubfoot leads to walking on the lateral border of the foot, painful calluses, difficulty with footwear, and significant disability. With proper Ponseti treatment, outcomes are excellent.

Outcomes with Treatment

Prognostic Factors

Good Prognosis:

• Idiopathic clubfoot
• Early treatment
• Good brace compliance
• Supple deformity

Poor Prognosis:

• Syndromic or neurogenic clubfoot
• Delayed treatment
• Poor brace compliance
• Severe rigid deformity (high Pirani score)

Key Guidelines

1. Ponseti International Association — Provides training and standards for Ponseti method worldwide.

2. POSNA (Pediatric Orthopaedic Society of North America) — Endorses Ponseti method as gold standard.

Landmark Studies

Ponseti (1963-1996) — Original technique description

• Iowa long-term outcomes
• Key finding: Non-surgical correction possible in majority
• Clinical Impact: Revolutionised clubfoot treatment worldwide

Morcuende et al. (2004) — Compliance study

• Key finding: Relapse directly related to brace non-compliance
• Clinical Impact: Emphasised critical importance of parent education

Dobbs et al. (2004) — Long-term outcomes

• 30-year follow-up of Ponseti patients
• Key finding: Excellent functional outcomes maintained
• Clinical Impact: Confirmed durability of Ponseti correction

Evidence Strength

What is Clubfoot?

Clubfoot is a condition where a baby is born with one or both feet turned inward and downward. The medical name is "talipes equinovarus" or "CTEV." It's one of the most common birth defects affecting bones and muscles, occurring in about 1 in every 1,000 babies.

Why does it matter?

Without treatment, clubfoot would make it very difficult to walk normally. Children would have to walk on the outside of their feet, causing pain and disability. The good news is that with proper treatment, children with clubfoot can have completely normal feet that work just like everyone else's.

How is it treated?

Treatment uses a method called the Ponseti method, which is very effective:

1. Casting (4-6 weeks): The foot is gently stretched into a better position, and a plaster cast is applied. This is done weekly, with each cast getting closer to the correct position.

2. Achilles tenotomy (9 out of 10 babies): A small cut is made to lengthen the tight tendon at the back of the ankle. This is done in clinic and isn't as scary as it sounds. A final cast is worn for 3 weeks after.

3. Boots-and-bar bracing (4 years): This is the most important part. Special boots attached to a bar are worn to keep the feet in the corrected position:

   • Full-time for the first 3 months
   • Then during sleep and naps until age 4

What to expect

• Treatment starts soon after birth
• Weekly clinic visits for 4-6 weeks
• Your child will have a small scar on the back of the ankle
• The affected foot and calf will always be slightly smaller — this is normal
• With proper brace wearing, your child should have a completely normal, functional foot

When to seek help

Contact your clinic if:

• The cast becomes loose or slips
• You see any skin marks or sores
• Your child seems in pain with the cast
• You're having trouble with the braces
• The foot seems to be turning back inward (relapse)