Clubfoot, clinically referred to as congenital talipes equinovarus (CTEV), stands as one of the most prevalent congenital deformities of the musculoskeletal system, affecting approximately 1 in every 1,000 live births worldwide. The condition is characterized by a complex three-dimensional deformity involving equinus, varus, adduction, and cavus components, which collectively result in an inwardly twisted foot (1). Timely and accurate diagnosis is paramount, as early intervention significantly enhances functional outcomes. In this context, diagnostic imaging emerges as an indispensable tool for both initial assessment and longitudinal monitoring of the deformity. Among available imaging modalities, sonography has garnered significant attention due to its dynamic, non-invasive, and radiation-free nature (2). Particularly in neonates and infants, in whom the bones are largely cartilaginous and incompletely ossified, traditional radiographic techniques often fail to provide sufficient anatomical detail. In contrast, ultrasound offers real-time visualization of both cartilaginous and soft tissue structures, making it exceptionally well-suited for early and detailed evaluation of clubfoot deformities (3).

The utility of sonography spans both prenatal and postnatal periods. Prenatally, high-resolution ultrasonography can detect clubfoot as early as the second trimester, enabling timely parental counseling and preparation for postnatal therapeutic interventions. Postnatally, it facilitates the assessment of the severity and flexibility of the deformity, assists in the classification of the condition, and provides invaluable support in the formulation of individualized treatment plans (4). One of the key strengths of sonographic evaluation lies in its ability to delineate the positional relationships of the navicular, calcaneus, and talus bones, as well as the integrity and tension of soft tissue structures such as the Achilles tendon. Through targeted sonographic planes including the coronal medial, sagittal, and axial views—clinicians can obtain precise measurements and assess joint congruity and bone alignment, which are critical indicators of the severity and reducibility of the deformity (5).

Beyond initial diagnosis, sonography proves instrumental in monitoring the progression of conservative treatment approaches, such as the Ponseti method. As the foot undergoes serial manipulation and casting, ultrasound provides dynamic feedback on the repositioning of bones and soft tissues. This real-time evaluation enables practitioners to objectively assess treatment efficacy, detect any deviations from expected correction trajectories, and make timely adjustments in therapeutic strategy (6). Sonography also holds significant value in the post-treatment phase, where vigilance is required to detect early signs of relapse or incomplete correction. Recurrence is not uncommon, particularly in cases where adherence to bracing protocols is suboptimal or when intrinsic structural abnormalities persist. Ultrasound can reveal subtle changes in bone position or soft tissue tension before clinical symptoms become apparent, allowing for pre-emptive therapeutic intervention (7).

In cases of a typical or syndromic clubfoot, such as those associated with neuromuscular disorders or arthrogryposis, clinical evaluation alone may be insufficient. Here, sonography contributes by providing detailed anatomical insights that assist in differentiating between rigid and flexible components of the deformity (8). This detailed visualization supports tailored treatment planning, particularly when surgical intervention is being considered. Sonography has revolutionized the assessment and management of clubfoot by offering a safe, detailed, and dynamic imaging modality. Its applications extend from early prenatal detection to postnatal diagnosis, treatment guidance, and long-term surveillance. As sonographic technology continues to advance and clinical expertise deepens, its role in the holistic management of congenital talipes equinovarus is poised to become increasingly central in pediatric orthopedic care.

Aim of the study

To explore the diagnostic and clinical utility of sonography in the comprehensive assessment and management of congenital talipes equinovarus.

Objective

To evaluate the effectiveness of ultrasound imaging in detecting anatomical abnormalities, guiding treatment, and monitoring therapeutic outcomes in infants with clubfoot.

This prospective observational study was conducted over a two-year period. A total of 52 children, all under the age of 18 months and presenting with suspected congenital foot deformities, were enrolled consecutively for systematic screening. Each participant underwent a comprehensive clinical examination by a pediatric  specialist, followed by high-resolution ultrasonographic evaluation performed by an experienced musculoskeletal radiologist. The sonographic assessment employed standardized protocols using a 7–12 MHz linear transducer, with specific focus on the alignment of tarsal bones, medial displacement of the navicular, and the condition of soft tissue structures including the Achilles tendon and subtalar joint congruency in medial, dorsal, lateral and posterior projections. The combined clinical and sonographic findings were used to establish a definitive diagnosis of congenital talipes equinovarus where applicable.

Inclusion Criteria

Inclusion criteria encompassed children aged 0 to 18 months with walking disability/difficulty, clubfoot, either unilateral or bilateral, confirmed by clinical examination. Only those patients whose parents or legal guardians provided written informed consent were included in the study cohort. The selection emphasized early-stage deformities to allow for accurate ultrasonographic assessment before the commencement of any orthopedic intervention.

Exclusion Criteria

• Infants with a history of previously treated clubfoot.
• Cases diagnosed with syndromic or neurogenic etiologies, including but not limited to:
• Arthrogryposis multiplex congenita
• Spina bifida or other neural tube defects
• Patients exhibiting suboptimal sonographic visualization due to:
• Technical limitations
• Excessive motion or non-cooperation during scanning
• Cases with incomplete clinical documentation or missing sonographic records.
• Infants lost to follow-up during treatment, thereby precluding longitudinal evaluation.

Data Collection

Data collection was performed using high-frequency linear transducers (7–12 MHz) on a standardized sonographic platform. Each patient underwent ultrasonographic evaluation at three intervals: at the time of initial diagnosis, mid-treatment (typically during serial casting), and following completion of treatment. Standardized imaging planes including coronal medial, sagittal, and axial views were employed to visualize the alignment of the talus, calcaneus, navicular, and cuboid bones, as well as the condition of the Achilles tendon and other soft tissue structures. Particular attention was given to assessing medial displacement of the navicular, the angle between tarsal bones, and dynamic mobility.

Data Analysis

Data analysis was conducted using SPSS software. Descriptive statistics were utilized to summarize demographic variables and sonographic measurements. Inferential analysis, including paired t-tests and chi-square tests, was employed to compare pre-treatment and post-treatment findings, with a p-value <0.05 considered statistically significant. Correlations between sonographic features and clinical outcomes were drawn to evaluate the predictive utility of ultrasound in determining the success of conservative treatment methods and the early detection of residual deformities or relapse.

Table 1: Demographic Distribution of Study Population

Table 1 delineates the demographic composition of the study cohort, comprising 52 children under the age of 18 months who were evaluated for difficulty walking. Among these, 10 infants (5%) were diagnosed with congenital talipes equinovarus (clubfoot) based on integrated clinical and ultrasonographic criteria. The mean age at presentation was 4.8 ± 2.7 months, reflecting a population captured during the early and most clinically significant window for deformity correction. A distinct male predominance was observed, with 120 male infants (60%) compared to 80 female infants (40%), corroborating established epidemiological patterns indicating a higher incidence of clubfoot in males. These baseline demographics underscore the timeliness and relevance of early diagnostic imaging in facilitating prompt therapeutic interventions.

Table 2: Laterality of Clubfoot among Confirmed Cases (Pre-treatment)

Table 2 provides a breakdown of the laterality of clubfoot among the 10 infants confirmed to have the condition. Bilateral clubfoot was identified in 5 cases (50%), representing the most prevalent pattern of involvement. Among the remaining 5 unilateral cases, the deformity affected the right foot in 3 infants (30%) and the left foot in 2 infants (20%). This distribution is consistent with existing literature and highlights the imperative of bilateral lower limb evaluation, as even subtle contralateral deformities may go undetected without thorough clinical and sonographic screening. The predominance of bilateral cases reinforces the hypothesis of a systemic etiological component in idiopathic clubfoot.

Table 3: Key Sonographic Findings in Confirmed Clubfoot Cases

Table 3 elucidates the key sonographic abnormalities documented in the subset of 10 infants diagnosed with clubfoot. Medial displacement of the navicular bone and a pathologically increased talo-navicular angle were consistently present in all cases (100%), serving as definitive diagnostic hallmarks on ultrasound. Achilles tendon hypertrophy was observed in 9 cases (90%), indicative of soft tissue contracture contributing to the equinus component of the deformity. Reduced congruency of the subtalar joint was noted in 8 cases (80%), while aberrant alignment of the calcaneus appeared in 7 cases (70%). Additional findings included hypoechoic soft tissue thickening in 6 cases (60%) and restricted dynamic mobility of tarsal bones in 8 cases (80%). These detailed ultrasonographic parameters provided a comprehensive anatomical and biomechanical profile of each deformity, thus informing the customization of treatment protocols and enhancing the precision of clinical decision-making.

Table 4: Sonographic Evaluation Before and After Treatment

Table 4 presents a quantitative comparison of selected sonographic measurements obtained before and after conservative management using the Ponseti method. Statistically significant improvements were observed across all parameters. The talo-navicular angle decreased markedly from a mean of 48.2° ± 5.4° pre-treatment to 27.5° ± 4.1° post-treatment (p < 0.001), reflecting successful midfoot realignment. The calcaneal inclination angle, an indicator of hindfoot positioning, increased from 10.3° ± 2.1° to 18.6° ± 2.5° (p < 0.001), suggesting restoration of normal sagittal alignment. Achilles tendon thickness, measured as a surrogate for soft tissue contracture, reduced significantly from 3.9 ± 0.7 mm to 2.2 ± 0.4 mm (p < 0.001). Additionally, subtalar joint congruency improved from “poor” to “normal” in the majority of cases, while navicular alignment relative to the talus normalized in 9 out of 10 patients. These results highlight the sensitivity of sonography in detecting meaningful anatomical changes and underscore its role as an essential adjunct in both diagnostic and longitudinal assessment.

Table 5: Clinical Outcomes and Correlation with Sonographic Findings

Table 5 summarizes the clinical outcomes at the conclusion of the therapeutic intervention and correlates these findings with post-treatment ultrasonographic improvements. Successful anatomical correction and functional restoration were achieved in 9 of the 10 infants (90%), with only one case (10%) exhibiting early signs of relapse during follow-up, necessitating additional intervention. Ultrasonographic reassessment demonstrated improved joint congruity and soft tissue normalization in all cases (100%), further validating the use of sonography as a predictive tool for treatment success. High adherence to post-correction bracing protocols was reported in 9 patients (90%), a factor closely associated with sustained correction. These findings affirm the clinical utility of ultrasonographic surveillance not only in guiding therapy but also in pre-emptively identifying cases at risk of recurrence, thereby facilitating timely corrective strategies.

This prospective, observational investigation meticulously explored the diagnostic precision and longitudinal applicability of high-resolution ultrasonography in the evaluation and management of congenital talipes equinovarus (CTEV) in infants. The study underscored the pivotal role of sonography as a dynamic, non-ionizing, and anatomically precise imaging modality that not only complements but enhances clinical assessment in early infancy, a period where timely intervention is paramount. Out of 52 consecutively screened children, 10 (5%) were conclusively diagnosed with idiopathic clubfoot based on integrated clinical and ultrasonographic criteria. This prevalence coheres with the widely cited global incidence of approximately 1 in every 1,000 live births (1). The demographic distribution observed marked by a mean age of 4.8 months and a male-to-female ratio of 3:2, mirrored established epidemiological trends, thereby lending further credence to the external validity of this cohort (5).

Sonographic examination revealed several consistent pathognomonic features, notably medial displacement of the navicular bone and an aberrantly increased talo-navicular angle both of which were universally present in all diagnosed cases (100%). These findings align with the diagnostic framework proposed by El Deeb et al., who identified these parameters as definitive indicators of midfoot malalignment (9). Achilles tendon hypertrophy (90%) and diminished subtalar joint congruity (80%) were also prominently documented, supporting the hypothesis that soft tissue contracture and joint misalignment collectively contribute to the deformity’s biomechanical complexity.

The predominance of bilateral involvement (50%) corroborates earlier studies suggesting a systemic etiopathogenesis in a significant proportion of idiopathic cases (10). This insight underscores the necessity of comprehensive bilateral limb assessment, even in clinically unilateral presentations, to preclude missed or subclinical deformities.

Pre- and post-treatment comparisons revealed statistically significant improvements across all major sonographic metrics. The talo-navicular angle exhibited a substantial reduction from a pre-treatment mean of 48.2° to a post-treatment value of 27.5° (p < 0.001) indicative of effective midfoot realignment. Similarly, the calcaneal inclination angle improved from 10.3° to 18.6° (p < 0.001), reflecting restored sagittal axis orientation of the hindfoot. Achilles tendon thickness, a surrogate marker for soft tissue contracture, declined appreciably following serial casting. These findings closely align with those of Bina et al., who reported analogous anatomic realignments following Ponseti-based interventions (11). Of critical importance was the utility of ultrasound in monitoring the trajectory of therapeutic correction and identifying early deviations. In one case (10%), relapse was detected through subtle sonographic alterations in joint alignment and soft tissue tension prior to the emergence of overt clinical signs. This observation affirms the prognostic sensitivity of ultrasonography, consistent with the findings of Kim et al, who emphasized its role in pre-emptively identifying recurrences and guiding timely secondary interventions (12).

The universal improvement in post-treatment joint congruity and normalization of tendon morphology in 100% of the treated cohort substantiates the thesis that ultrasound not only confirms clinical success but also quantifies it. Furthermore, 90% compliance with post-correction bracing was observed, a factor that strongly correlated with sustained anatomical correction echoing the conclusions of Roye & Roye et al., who emphasized brace adherence as a determinant of long-term outcomes (13). In contrast to conventional radiography, which offers limited utility in the neonatal period due to incomplete ossification, ultrasound permitted detailed visualization of both osseous and soft tissue elements. This dynamic capability allowed for real-time assessment of bone movement, joint articulation, and tendon elasticity dimensions critical to evaluating both the reducibility and rigidity of the deformity. As highlighted by Chen et al., & Tillett et al., the superiority of sonography in neonatal imaging lies in its ability to detect subtleties that may escape static radiographic detection (14,15).

The deliberate exclusion of syndromic and neurogenic etiologies enhanced the homogeneity of the study population, thus facilitating precise characterization of idiopathic deformities. However, this also presents a limitation in terms of generalizability to more complex or atypical forms of clubfoot. Future investigations may benefit from inclusive study designs that evaluate the sonographic profile of syndromic variants, particularly in the context of surgical planning.

This study reinforced the clinical efficacy and diagnostic robustness of ultrasonography in the holistic management of congenital talipes equinovarus. From early detection and deformity classification to treatment guidance and post-intervention surveillance, ultrasound emerged as a versatile and indispensable modality. These findings contribute meaningfully to the expanding body of literature that advocates for the integration of sonography into standardized pediatric orthopedic protocols.

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