Incidence: 1-2/1000 births (Europe), boys are more often affected than girls. The malformation is bilateral in 50 % of cases. In underdeveloped countries, where there is no neonatal care, children end up walking on the edge of their feet.
The malformation affects 3 joints to varying degrees:
- talo-calcaneal, deformed in inversion (combination of varus and supination): the sole of the foot turns inwards
- talo-navicular, causing the aduction of the forefoot: the front of the foot turns inwards from the back of the foot.
- tibio-astragalian, deformed in equinism: plantar flexion often associated with a short Achilles tendon.
Clubfoot is usually idiopathic (90 %) but can be secondary, associated with another pathology (see these terms):
- posterior dysraphism: myelomeningocele, tethered spinal cord, sacral agenesis, diasteatomyelia
- amniotic band disease
- some myopathies (central core disease)
- X-linked TARP syndrome (clubfoot, congenital heart disease, palatine division and glossoptosis);
- diastrophic dwarfism
- multi-epiphyseal dysplasia;
- Freeman-Sheldon syndrome (or cranio-carpo-tarsal syndrome, Windmill-Vane-Hand syndrome, whistling syndrome, distal arthrogryposis type 2A)
- Gordon syndrome (clubfoot, camptodactyly, palatine division).
The valgus clubfoot is rarer: the sole of the foot turns outwards.
.jpg)
.jpg)
Treatments:
- either rehabilitation by physiotherapy.
- or the so-called Ponseti technique: plaster once a week, for 6 weeks to gradually bring the forefoot back into the overall axis of the foot. Often a tenotomy of the Achilles tendon is necessary around 6 to 10 weeks of life. Then a plaster for 1 month and splints up to about 5 years of age.
Clubfoot surgery (open approach of the foot and dissection of soft tissues) is reserved for cases resisting to above treatment and in case of recurrence.
Anesthetic implications:
Preoperative evaluation: check for the absence of associated, specially lombosacral malformations.
According to the planned intervention:
- lengthening of the Achilles tendon: this is a minimally invasive percutaneous and short lasting surgical procedure most often performed in the supine position. Analgesia is well ensured by local infiltration of local anesthetics supplemented by paracetamol (acetaminophen) postoperatively.
- Clubfoot surgery: generally performed in the ventral position, which requires endotracheal intubation. It is a painful surgery best managed with an uni or bilateral sciatic nerve block, preferably at the popliteal fossa or caudal anesthesia.
References :
- Zanette G, Manani G, Pittori G, Angelini C, Trevisan CP, Turra S.
Prevalence of unsuspected myopathy in infants presenting for clubfoot surgery.
Pediatr Anesth 1995 ; 5 : 165-70.
- Zanette G, Robb N, Zadra N, Zanette L, Manani G.
Undetected centralcore disease in an infant presenting for clubfoot surgery.
Pediatr Anesth 2007 ; 17 : 380-2.
- Cady R, Hennessey TA, Schwend RM;
AAP Section on Orthopedics. Diagnosis and treatment of idiopathic congenital clubfoot.
Pediatrics 2022;149(2):e2021055555
Updated: September 2022