Talipes Equinovarus

talipes equinovarus

Talipes equinovarus, also known as club foot, is a deformity of the foot and ankle that a baby can be born with. It is not clear exactly what causes talipes equinovarus. In most cases, it is diagnosed by the typical appearance of a baby's foot after they are born. The Ponseti method is now a widely used treatment for talipes equinovarus. This treatment gives good results for most children and so major surgery is not usually needed to correct the foot deformity.

What do you understand by talipes equinovarus?

Talipes equinovarus is also known as club foot. It is a deformity of the foot and ankle that a baby can be born with. In about half of babies that are born with talipes equinovarus, both feet are affected. Talipes means the ankle and foot and equinovarus refers to the position that the foot is in.

If a baby has talipes equinovarus, their foot looks a typical way. Their foot points downwards at their ankle (doctors call this position equinus) and the heel of their foot is turned inwards (doctors call this position varus). The middle section of their foot is also twisted inwards and their foot appears quite short and wide. It stays (is fixed) in this position and cannot be moved into a normal foot position.

The baby's foot is held in this position because the Achilles tendon at the back of the baby's heel is very tight and the tendons on the inside of their leg have also shortened.

If nothing is done to correct the problem, as the baby develops and learns to stand, they will not be able to stand with the sole of their foot flat on the ground.

In some babies, the position that they hold their foot in may look as if they have talipes equinovarus but, in fact, their foot can be moved easily into a normal position. These babies do not have true talipes equinovarus.

How is talipes equinovarus caused?

It is not clear exactly why talipes equinovarus develops. It is thought that there may possibly be some genetic factors involved. If you have had a baby born with talipes equinovarus, there is about a 3-4 in 100 chance that a brother or sister born after them will also have talipes equinovarus. Babies born to a parent who has talipes equinovarus also have an increased risk of being born with the problem themselves. If both parents have talipes equinovarus, this risk is higher. Talipes equinovarus may also have something to do with the position of the baby's foot when the baby is in the womb.

In most cases (around 4 out of 5), the baby has no other problems apart from the talipes equinovarus. However, in around 1 in 5 babies born with talipes equinovarus, the baby also has another problem. Most commonly, such problems include:

Spina bifida - a condition where the bones of the spine don't form properly, causing the nerves of the spine to lose protection and become damaged.
Cerebral palsy - a general term that describes a group of conditions that cause movement problems.
Arthrogryposis - a condition where a child has curved and stiff joints and abnormal muscle development.

How often talipes equinovarus is present and who are prone to get it?

Talipes equinovarus is a fairly common problem. It is one of the most common deformities that a baby can be born with. About 1 in 1,000 babies born in the India has talipes equinovarus.

About twice as many boys are born with talipes equinovarus than girls.

How do you diagnose talipes equinovarus and what investigations are needed?

Talipes equinovarus is usually diagnosed after a baby is born. However, as the technology of ultrasound scanning during pregnancy improves, increasingly, talipes equinovarus is being detected during scanning before a baby is born.

All babies in the India are routinely examined and checked over by a doctor shortly after they are born. This is to look for talipes equinovarus but also other problems that the baby may be born with. Most commonly, talipes equinovarus is noticed and diagnosed during this check because of the typical appearance of the foot as described above. Investigations such as X-rays are not usually needed to confirm the diagnosis.

There can be different degrees of foot deformity with talipes equinovarus. Some babies have more mild foot deformity than others. If a baby is diagnosed with talipes equinovarus, a specialist (usually an orthopaedic surgeon) will often use a grading system to grade the severity of the foot deformity. A common grading system that is used is the Pirani score. With this grading system, a grade from 0 to 6 is given. The higher the grade, the greater the degree of foot deformity.

How is talipes equinovarus treated?

There have been some changes to the treatment for talipes equinovarus over recent years. Major surgery was often a common treatment used. However, over time, the results of medical research studies have shown that other treatments that don't involve major surgery, particularly a treatment known as the Ponseti method, seem to give good results in the long-term for most children. The Ponseti method is now the preferred treatment by most orthopaedic surgeons throughout the world.

It is important that a baby who has talipes equinovarus be referred to see a doctor specialised in treating this problem as soon as possible after birth. The sooner Ponseti method treatment is started, in general, the easier the correction of the foot deformity should be.

The Ponseti method

First, the specialist gently manipulates (holds, stretches and moves) the child's foot with their hands into a position in which the foot deformity is corrected (put right) as much as possible. This is not painful or uncomfortable for the child. Once in this position, a plaster cast is put on to hold the child's foot in position. This plaster cast usually goes from the child's toes to their groin area.

After one week, the plaster cast is removed, the child's foot is manipulated again and a plaster cast is put back on with the child's foot in the new position. After another week, this procedure is repeated. As each week goes by, usually the child's foot is able to be moved into a position that becomes closer and closer to a normal foot position.

After around six weeks of repeated manipulation and plaster casting of the foot, there is usually good progress and the foot position has improved. At this stage, a small operation is suggested for most children, called an Achilles tenotomy. (The tight Achilles tendon at the back of the foot is released. A small cut is made and the tendon is lengthened so that the heel can drop down.) This is a minor operation and it can usually be done with just a local anaesthetic.

After this, their foot is put in a final plaster cast, usually for three weeks. The child will then need to wear some special boots that are connected together with a bar. They will need to wear these for 23 hours a day for three months but, usually after this, they just need to wear the 'boots and bar' at night time or during sleep periods until they are 4 years old.
It is really important that the child continues to wear their 'boots and bar' as the specialist advises. If the boots and bar are not worn as advised, there is a chance that talipes equinovarus can recur (their foot position can become abnormal again).

What is the outlook (prognosis) for talipes equinovarus?

The Ponseti method works well to correct the foot deformity for most children with talipes equinovarus. For between 8 and 9 out of 10 children, the deformity will be corrected. However, in a small number of children, it does not correct the deformity and more major surgery may be needed. Children who have other problems as well as talipes equinovarus, such as those discussed above, are more likely to need surgery.

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