The management of club foot: issues for debate.

Congenital talipes equinovarus (CTEV) is a common and challenging musculoskeletal deformity. The prevalence in a recent, prospective national survey is 0.89 per thousand live births1 although rates of 1.242 or greater3 have been reported in the UK. Thus in a district general hospital with a catchment population of 500 000 up to ten babies with CTEV will present annually. Increasingly, the presence of CTEV can be diagnosed prenatally by ultrasound.4 Racial and genetic factors are influential. Maoris and other Pacific islanders present with a rate of prevalence of 6 to 7 per thousand live births, whereas in the Chinese and Japanese the rate is 0.5 per thousand.5 Some of this variation may reflect different attitudes to the inclusion of postural (resolving) deformities and of syndromic (nonidiopathic) club feet (Table I). Idelberger’s twin studies6 identified a monozygote concordance of 32.5%, strongly suggesting a genetic influence since dizygotic twin concordance was only 2.9%. Acquired or modulating factors, leading to a multifactorial inheritance pattern, are reflected in the seasonal variation of the condition1,3,7 and in the neurological deficit which may underly the deformity.8-10 The proportion of muscle fibre types in the calf have been variously described as normal or abnormal by a large number of authors but may be a secondary feature rather than a primary alteration. Vascular anomalies have also been described along with many other intrinsic abnormalities involving the soft tissues of the affected foot.11