Clinical Orthopaedics and Related Research®

, Volume 469, Issue 5, pp 1442–1449

Vascular Abnormalities Correlate with Decreased Soft Tissue Volumes in Idiopathic Clubfoot

  • Laura J. Merrill
  • Christina A. Gurnett
  • Marilyn Siegel
  • Sushil Sonavane
  • Matthew B. Dobbs
Clinical Research



Lower extremity vascular anomalies have been described for patients with clubfoot but few imaging studies have investigated effects on soft tissues such as fat and muscle. To make these assessments we need noninvasive, noncontrast agents to more safely image children.


We describe a novel noninvasive imaging protocol to identify vascular and soft tissue abnormalities in the lower limbs of patients with clubfoot and determine whether these abnormalities are present in patients who had recurrent clubfoot.

Patients and Methods

Three-dimensional noncontrast-enhanced MR angiography was used to identify vascular, bone, and soft tissue abnormalities in patients with clubfoot. We determined whether these abnormalities were more common in patients who had experienced recurrent clubfoot.


Four patients with isolated unilateral clubfoot had arterial anomalies in the clubfoot limb. All patients had less muscle volume in the affected limb, and nine of 11 patients (82%) had less subcutaneous fat, with a mean difference of 0.56 cm3 ± 0.36 cm3 (range, 0.08–1.12 cm3). Vascular anomalies and decreased fat and muscle volumes were present in all three patients with recurrent clubfoot.


We found a high frequency of vascular and soft tissue anomalies in the affected limbs of patients with unilateral clubfoot that may correlate with response to treatment.

Clinical Relevance

This approach has the potential to enhance our understanding of the anatomy of clubfoot and lead to a larger MRI study that may allow more accurate prediction of the risk of recurrent clubfoot.


  1. 1.
    Ben-Menachem Y, Butler JE. Arteriography of the foot in congenital deformities. J Bone Joint Surg Am. 1974;56:1625–1630.PubMedGoogle Scholar
  2. 2.
    Colletti PM. Nephrogenic systemic fibrosis and gadolinium: a perfect storm. AJR Am J Roentgenol. 2008;191:1150–1153.PubMedCrossRefGoogle Scholar
  3. 3.
    Dimeglio A, Bensahel H, Souchet P, Mazeau P, Bonnet F. Classification of clubfoot. J Pediatr Orthop B. 1995;4:129–136.PubMedCrossRefGoogle Scholar
  4. 4.
    Dobbs MB, Gordon JE, Schoenecker PL. Absent posterior tibial artery associated with idiopathic clubfoot: a report of two cases. J Bone Joint Surg Am. 2004;86:599–602.PubMedGoogle Scholar
  5. 5.
    Dobbs MB, Rudzki JR, Purcell DB, Walton T, Porter KR, Gurnett CA. Factors predictive of outcome after use of the Ponseti method for the treatment of idiopathic clubfeet. J Bone Joint Surg Am. 2004;86:22–27.PubMedGoogle Scholar
  6. 6.
    Dobson MJ, Hartley RW, Ashleigh R, Watson Y, Hawnaur JM. MR angiography and MR imaging of symptomatic vascular malformations. Clin Radiol. 1997;52:595–602.PubMedCrossRefGoogle Scholar
  7. 7.
    Edelson JG, Husseini N. The pulseless club foot. J Bone Joint Surg Br. 1984;66:700–702.PubMedGoogle Scholar
  8. 8.
    Ersoy H, Rybicki FJ. MR angiography of the lower extremities. AJR Am J Roentgenol. 2008;190:1675–1684.PubMedCrossRefGoogle Scholar
  9. 9.
    Ester AR, Weymouth KS, Burt A, Wise CA, Scott A, Gurnett CA, Dobbs MB, Blanton SH, Hecht JT. Altered transmission of HOX and apoptotic SNPs identify a potential common pathway for clubfoot. Am J Med Genet A. 2009;149A:2745–2752.PubMedCrossRefGoogle Scholar
  10. 10.
    Flynn JM, Donohoe M, Mackenzie WG. An independent assessment of two clubfoot-classification systems. J Pediatr Orthop. 1998;18:323–327.PubMedCrossRefGoogle Scholar
  11. 11.
    Greider TD, Siff SJ, Gerson P, Donovan MM. Arteriography in club foot. J Bone Joint Surg Am. 1982;64:837–840.PubMedGoogle Scholar
  12. 12.
    Gurnett CA, Alaee F, Kruse LM, Desruisseau DM, Hecht JT, Wise CA, Bowcock AM, Dobbs MB. Asymmetric lower-limb malformations in individuals with homeobox PITX1 gene mutation. Am J Hum Genet. 2008;83:616–622.PubMedCrossRefGoogle Scholar
  13. 13.
    Hester TW, Parkinson LC, Robson J, Misra S, Sangha H, Martin JE. A hypothesis and model of reduced fetal movement as a common pathogenetic mechanism in clubfoot. Med Hypotheses. 2009;73:986–988.PubMedCrossRefGoogle Scholar
  14. 14.
    Hootnick DR, Levinsohn EM, Crider RJ, Packard DS Jr. Congenital arterial malformations associated with clubfoot: a report of two cases. Clin Orthop Relat Res. 1982:160–163.Google Scholar
  15. 15.
    Hootnick DR, Levinsohn EM, Randall PA, Packard DS Jr. Vascular dysgenesis associated with skeletal dysplasia of the lower limb. J Bone Joint Surg Am. 1980;62:1123–1129.PubMedGoogle Scholar
  16. 16.
    Ippolito E, De Maio F, Mancini F, Bellini D, Orefice A. Leg muscle atrophy in idiopathic congenital clubfoot: is it primitive or acquired? J Child Orthop. 2009;3:171–178.PubMedCrossRefGoogle Scholar
  17. 17.
    Ippolito E, Ponseti IV. Congenital club foot in the human fetus: a histological study. J Bone Joint Surg Am. 1980;62:8–22.PubMedGoogle Scholar
  18. 18.
    Kitziger K, Wilkins K. Absent posterior tibial artery in an infant with talipes equinovarus. J Pediatr Orthop. 1991;11:777–778.PubMedCrossRefGoogle Scholar
  19. 19.
    Kruse L, Gurnett CA, Hootnick D, Dobbs MB. Magnetic resonance angiography in clubfoot and vertical talus: a feasibility study. Clin Orthop Relat Res. 2009;467:1250–1255.PubMedCrossRefGoogle Scholar
  20. 20.
    Levinsohn EM, Hootnick DR, Packard DS Jr. Consistent arterial abnormalities associated with a variety of congenital malformations of the human lower limb. Invest Radiol. 1991;26:364–373.PubMedCrossRefGoogle Scholar
  21. 21.
    Little DG, Aiona MD. Limb length discrepancy in congenital talipes equinovarus. Aust N Z J Surg. 1995;65:409–411.PubMedCrossRefGoogle Scholar
  22. 22.
    Loewe C, Schoder M, Rand T, Hoffmann U, Sailer J, Kos T, Lammer J, Thurnher S. Peripheral vascular occlusive disease: evaluation with contrast-enhanced moving-bed MR angiography versus digital subtraction angiography in 106 patients. AJR Am J Roentgenol. 2002;179:1013–1021.PubMedGoogle Scholar
  23. 23.
    Marckmann P, Skov L, Rossen K, Dupont A, Damholt MB, Heaf JG, Thomsen HS. Nephrogenic systemic fibrosis: suspected causative role of gadodiamide used for contrast-enhanced magnetic resonance imaging. J Am Soc Nephrol. 2006;17:2359–2362.PubMedCrossRefGoogle Scholar
  24. 24.
    Mercuri E, Cini C, Pichiecchio A, Allsop J, Counsell S, Zolkipli Z, Messina S, Kinali M, Brown SC, Jimenez C, Brockington M, Yuva Y, Sewry CA, Muntoni F. Muscle magnetic resonance imaging in patients with congenital muscular dystrophy and Ullrich phenotype. Neuromuscul Disord. 2003;13:554–558.PubMedCrossRefGoogle Scholar
  25. 25.
    Mercuri E, Pichiecchio A, Allsop J, Messina S, Pane M, Muntoni F. Muscle MRI in inherited neuromuscular disorders: past, present, and future. J Magn Reson Imaging. 2007;25:433–440.PubMedCrossRefGoogle Scholar
  26. 26.
    Miyazaki M, Sugiura S, Tateishi F, Wada H, Kassai Y, Abe H. Non-contrast-enhanced MR angiography using 3D ECG-synchronized half-Fourier fast spin echo. J Magn Reson Imaging. 2000;12:776–783.PubMedCrossRefGoogle Scholar
  27. 27.
    Miyazaki M, Takai H, Sugiura S, Wada H, Kuwahara R, Urata J. Peripheral MR angiography: separation of arteries from veins with flow-spoiled gradient pulses in electrocardiography-triggered three-dimensional half-Fourier fast spin-echo imaging. Radiology. 2003;227:890–896.PubMedCrossRefGoogle Scholar
  28. 28.
    Mohrs OK, Petersen SE, Heidt MC, Schulze T, Schmitt P, Bergemann S, Kauczor HU. High-resolution 3D non-contrast-enhanced, ECG-gated, multi-step MR angiography of the lower extremities: Comparison with contrast-enhanced MR angiography. Eur Radiol. 2010 Aug 13. [Epub ahead of print].Google Scholar
  29. 29.
    Morcuende JA, Dolan LA, Dietz FR, Ponseti IV. Radical reduction in the rate of extensive corrective surgery for clubfoot using the Ponseti method. Pediatrics. 2004;113:376–380.PubMedCrossRefGoogle Scholar
  30. 30.
    Nagao H, Morimoto T, Sano N, Takahashi M, Nagai H, Tawa R, Yoshimatsu M, Woo YJ, Matsuda H. [Magnetic resonance imaging of skeletal muscle in patients with Duchenne muscular dystrophy: serial axial and sagittal section studies]. No To Hattatsu. 1991;23:39–43.PubMedGoogle Scholar
  31. 31.
    Ponseti IV. Treatment of congenital club foot. J Bone Joint Surg Am. 1992;74:448–454.PubMedGoogle Scholar
  32. 32.
    Ponseti IV. Congenital Clubfoot: Fundamentals of Treatment. Ed 1. New York, NY: Oxford University Press; 1996.Google Scholar
  33. 33.
    Quillin SP, Hicks ME. Absent posterior tibial artery associated with clubfoot deformity: an unusual variant. J Vasc Interv Radiol. 1994;5:497–499.PubMedCrossRefGoogle Scholar
  34. 34.
    Richards BS, Faulks S, Rathjen KE, Karol LA, Johnston CE, Jones SA. A comparison of two nonoperative methods of idiopathic clubfoot correction: the Ponseti method and the French functional (physiotherapy) method. J Bone Joint Surg Am. 2008;90:2313–2321.PubMedCrossRefGoogle Scholar
  35. 35.
    Ruehm SG, Hany TF, Pfammatter T, Schneider E, Ladd M, Debatin JF. Pelvic and lower extremity arterial imaging: diagnostic performance of three-dimensional contrast-enhanced MR angiography. AJR Am J Roentgenol. 2000;174:1127–1135.PubMedGoogle Scholar
  36. 36.
    Sarrafian S, ed. Anatomy of the Foot and Ankle: Descriptive Topographic Functional. Ed 2. Philadelphia, PA: JB Lippincott Co; 1993.Google Scholar
  37. 37.
    Sodre H, Bruschini S, Mestriner LA, Miranda F Jr, Levinsohn EM, Packard DS Jr, Crider RJ Jr, Schwartz R, Hootnick DR. Arterial abnormalities in talipes equinovarus as assessed by angiography and the Doppler technique. J Pediatr Orthop. 1990;10:101–104.PubMedGoogle Scholar
  38. 38.
    Thomsen HS. Nephrogenic systemic fibrosis: a serious late adverse reaction to gadodiamide. Eur Radiol. 2006;16:2619–2621.PubMedCrossRefGoogle Scholar
  39. 39.
    Urata J, Miyazaki M, Wada H, Nakaura T, Yamashita Y, Takahashi M. Clinical evaluation of aortic diseases using nonenhanced MRA with ECG-triggered 3D half-Fourier FSE. J Magn Reson Imaging. 2001;14:113–119.PubMedCrossRefGoogle Scholar
  40. 40.
    Wynne-Davies R. Family studies and the cause of congenital club foot: talipes equinovarus, talipes calcaneo-valgus and metatarsus varus. J Bone Joint Surg Br. 1964;46:445–463.PubMedGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2010

Authors and Affiliations

  • Laura J. Merrill
    • 1
  • Christina A. Gurnett
    • 1
    • 2
    • 3
  • Marilyn Siegel
    • 4
  • Sushil Sonavane
    • 4
  • Matthew B. Dobbs
    • 1
    • 5
  1. 1.Department of Orthopedic SurgeryWashington University School of MedicineSt LouisUSA
  2. 2.Department of NeurologyWashington University School of MedicineSt LouisUSA
  3. 3.Department of PediatricsWashington University School of MedicineSt LouisUSA
  4. 4.Mallinckrodt Institute of RadiologyWashington University School of MedicineSt LouisUSA
  5. 5.St Louis Shriners Hospital for ChildrenSt LouisUSA

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