What is Talipes Equinovarus?
Talipes equinovarus (TEV) is a condition that a baby is born with, that affects quite a number of people worldwide. This condition can negatively impact an individual’s quality of life, ability to move around, and can even result in disabilities. TEV can be recognized by abnormal shapes of the foot including a high, bent arch, the front of the foot turning inwards, the heel of the foot bent inwards, and the foot pointing downwards.
About 1 to 2 in every 1000 babies born will have this condition. If it isn’t treated, TEV will continue into adulthood, leading to movement difficulties and a poorer quality of life. Currently, we don’t know what causes TEV, although it has been linked to several genetic factors. There seems to be a higher risk for developing TEV if there’s a family history of the condition or the mother smoked during pregnancy. However, no links have been found between TEV and low amniotic fluid during pregnancy, the season the baby is born, the age of the parents, or the number of children the parents have.
Typically, TEV is managed through non-surgical methods. This involves hands-on adjustment of the foot over time, casts, and special braces to help the foot hold its correct position. This approach is known as the Ponseti method. If these methods are not effective, a variety of surgical procedures may be used to correct the position of the foot.
What Causes Talipes Equinovarus?
TEV, or talipes equinovarus, is a condition that’s usually caused by a mixture of factors – these can both be physical issues with your body or it could be due to certain genes you have. In the past, research has found things like a parent smoking, having low amounts of amniotic fluid during pregnancy, or a family history of TEV could make this condition more likely.
Multiple studies have pointed out that if your mom smoked during her pregnancy, it might increase the likelihood of you getting TEV. Moreover, a research study in Norway discovered that, alongside a family history of TEV, being exposed to cleaning chemicals could also make TEV more likely. Additionally, a recent review of multiple studies found that factors like both of your parents smoking, your mom having a higher body mass index (BMI – a measure of body fat), having a particular type of test during pregnancy called an amniocentesis, a family history of TEV, taking certain types of antidepressants (SSRI), having diabetes during pregnancy, never having given birth, or belonging to the aboriginal Australian race could also play a part in developing TEV.
However, it’s also important to note that several studies did not find an increased risk of TEV when considering factors like the age or education of your parents, having a low amount of amniotic fluid during pregnancy, how many times your mother has given birth, the season you were born in, whether your parents drink alcohol, or if your mom suffers from anxiety or depression.
Researchers have also tried to find genetic reasons for getting TEV. Whilst they’ve not yet discovered one single gene that causes it, they have found multiple genes which could make developing TEV more likely. They’ve suggested that genes called HOXA and HOXD might add to the genetic risk of TEV – these genes play a part in controlling how and when cells die, and how muscle cells contract. Furthermore, another recent study suggested that a process known as the PITX1-TBX4 pathway (which plays a role in how limbs are formed) might be linked with developing TEV.
Risk Factors and Frequency for Talipes Equinovarus
TEV, or Triphalangeal thumb-polysyndactyly syndrome, is a condition that varies in how often it occurs within different populations around the world. In the Chinese population, it only affects about 0.39 out of every 1000 babies born, which is on the lower end of the scale. On the other hand, in communities such as the native Hawaiian and Maori groups, the condition is quite prevalent with about 7 in every 1000 babies affected. For people of European descent and those in the United States, the chances of having a baby with TEV is between 1 and 2 in 1000 births.
- TEV occurs in different frequencies globally.
- In Chinese populations, about 0.39 out of 1000 babies are affected.
- In native Hawaiian and Maori populations, about 7 out of 1000 babies are affected.
- In European and US populations, the incidence is between 1 and 2 per 1000 live births.
- TEV tends to be more common in males, with a ratio of approximately 2:1.
- However, the condition does not differ significantly across different ethnicities.
Signs and Symptoms of Talipes Equinovarus
When diagnosing Talipes Equinovarus (TEV), or clubfoot, a complete background is needed. This includes information before, during, and after the baby’s birth, any medicines the mother might have taken, and any risks like smoking, alcohol, or drug use. There’s a higher chance of a baby having clubfoot if the mother smokes during her pregnancy. However, drinking alcohol doesn’t show any connection. If any family member had clubfoot, that also increases a baby’s chance of having the condition. There is a potential risk related to exposure to solvents (chemical substances), so it’s important to know if the mother was exposed to any solvents during her pregnancy.
During the physical check-up of the newborn, the doctor will look at the position of the foot, which is usually bent inward and downward. Sometimes, a prenatal ultrasound can give a hint of clubfoot even before the baby’s born. To remember the position of the foot, doctors use the acronym CAVE, which stands for cavus (high arch), adduction (turning inwards), varus (angling inward at the heel), and equinus (tilted downwards).
Other physical signs include a small foot and calf, a shortened shin bone (tibia), and creases on the back and side of the foot. The doctor must perform a full-body exam as a baby with clubfoot can often have other related conditions. Details like the length of the legs, skin folds, and calf size are important to note. The baby’s nerve function should also be tested. Lastly, the doctor will check how flexible the clubfoot is, as this helps understand how the condition can be treated and whether surgery may be avoided.
Testing for Talipes Equinovarus
Talipes equinovarus (TEV), also known as clubfoot, is usually diagnosed based on a doctor’s clinical examination. However, to understand the condition better, certain imaging studies might be required. In newborns, whose bones haven’t fully formed, regular x-rays might not always offer the best information.
Instead, the doctor might use specific types and views of x-rays. They might capture views from the front (anterior-posterior, or AP) and the side (lateral) of the foot and lower leg bones (tibia and fibula). From these x-rays, the doctor will then measure the angle between the heel bone (talus) and ankle bone (calcaneus), which is typically parallel in patients with clubfoot.
Interestingly, prenatal ultrasound (an ultrasound carried out during pregnancy) might sometimes pick up signs of clubfoot. However, these scans are not always 100% accurate, which is why a thorough medical examination after birth is the key to diagnosing clubfoot.
There has been some suggestion in the past that clubfoot might be associated with another birth defect – developmental dysplasia of the hip, which affects the hip joint. However, recent research has shown that routine imaging to screen for hip problems in a patient with clubfoot is not typically needed.
Treatment Options for Talipes Equinovarus
Before the 1990s, most doctors handling a patient with TEV – a foot and ankle condition where the foot points down and turns inwards – used a method introduced by Hiram Kite. However, in the 1990s, a physician named Ignacio Ponseti developed a new non-surgical method of managing the condition, which became widely accepted due to its success rate in over 90% of cases.
This method, known as the Ponseti method, involves a series of manipulations and castings. The process isn’t forceful or painful, and includes the doctor spending about a minute repositioning the foot before securing it in a cast. The affected limb gets this treatment weekly. The goal is to gradually align the forefoot and hindfoot by adjusting the cast each week. After about 3 or 4 casts, the only remaining deformity will be in the heel, which the doctor then addresses using a similar process. In many cases, a minor procedure may be necessary to correct this deformity.
Once the foot has been reshaped properly using casting, the child then wears a special brace, known as a foot abduction orthosis. The brace positions the feet at a certain angle to ensure correct alignment. Initially, this brace should be worn almost all day for several months, and then only during naps and at night until the child is around 3 to 5 years old.
Surgery is usually considered when non-surgical methods have not worked or if the condition returns. The surgical procedures can include moving tendons, reshaping foot bones, slowing the growth of leg bone to correct the abnormal foot angle, and releasing tense areas in the ankle and heel. Remember, these surgeries are generally used when other methods don’t work, or after relapse.
Before performing a tendon transfer, the foot should have fully recovered from the initial correction, and should be freely movable. Reshaping foot bones with the use of a method known as osteotomies is reserved for children aged 4-9 years old with persistent or recurrent conditions.
It’s important to remember that every patient is unique, and the treatments may vary depending on the patient’s specific needs, so the doctors will always consider all options and discuss the best approach for each individual case.
What else can Talipes Equinovarus be?
TEV, or talipes equinovarus, often appears in a particular way that makes it hard to mix up with other conditions. However, it’s vital to rule out any deformities that can be corrected. Some deformities that look like TEV could be temporary or ‘postural,’ and these often get better by themselves as time goes on. So, when figuring out a treatment plan, it’s critical to know the difference between TEV that can be fixed and TEV that can’t be corrected.
What to expect with Talipes Equinovarus
The outlook for TEV, also known as Clubfoot, is very positive. In most cases, Clubfoot can be fixed using the Ponseti method. This approach involves manipulating the foot and then putting it in a series of casts, followed by a foot brace that helps maintain the correct position.
If the foot doesn’t fully correct or if the condition comes back, there are various surgical techniques that can help correct the shape of the foot. Numerous studies have reported that more than 90% of Clubfoot cases are successfully treated using the Ponseti method.
Possible Complications When Diagnosed with Talipes Equinovarus
After a treatment for twisted foot (known as TEV), you may experience less mobility, potential disability and reduced quality of life. Some people get complications from their cast, such as skin problems or damage to surface-level nerves due to pressure on them. Regular changes of the cast, as done with the Ponseti treatment method, can minimize these issues. After the non-surgical treatment, some people might have weak foot movement, particularly when trying to flex their foot upwards while it is turned inwards. This weakness is usually managed by transferring a tendon from the front of your shin.
Another potential adverse effect is a change in the shape of the under part of your foot (rocker-bottom foot deformity), which usually happens when your doctor tries to correct the position of your foot before treating its outward angle and tendency to turn inwards.
Surgery carries its own risks, including the typical complications associated with anesthetics, as well as the usual risks with surgery such as pain, infection, issues with the surgical wound, and blood loss. Generally, the rate of complication or unsuccessful treatment following surgical care is between 13% and 50%.
One specific study showed that 2% of the treated patients experienced serious bleeding complications after a small cut was made in their Achilles tendon (a procedure known as percutaneous Achilles tenotomy), mainly from accidental damage to the nearby peroneal artery. But the most significant risk is that the twisted foot could come back – this typically happens when the person doesn’t consistently use their brace at home.
Risks and Complications:
- Loss of mobility and a decrease in quality of life
- Cast complications such as skin damage or nerve injury
- Weakness in foot movement
- Rocker-bottom foot deformity
- Complications related to anesthesia and the usual surgical risks
- Serious bleeding after Achilles tenotomy
- The return of the twisted foot, usually from not using the brace regularly at home
Preventing Talipes Equinovarus
It’s very important that parents fully understand the treatment plan and what’s expected of them at home when their child is being treated for an orthopedic condition called Talipes Equinovarus (TEV), commonly known as clubfoot. Both surgical and non-surgical treatments have their own benefits and potential risks, and parents should be fully informed about these.
If the child is undergoing a non-surgical treatment known as the Ponseti method, they will need to wear a special shoe or brace (called an orthosis) on their foot after a series of casts. Parents should feel confident in how to use and look after this orthosis. Moreover, they need to understand that the success of the treatment could be compromised if the orthosis is not used as advised; there’s a risk that the clubfoot could come back (also referred to as a relapse).
