Increased Microvessel and Arteriole Density in the Contracted Side of the Relapsed Clubfoot

J Pediatr Orthop. Nov/Dec 2020;40(10):592-596. doi: 10.1097/BPO.0000000000001563.


Background: Clubfoot deformity (pes equinovarus) is one of the most common birth defects, and its etiology is still unknown. Initial clubfoot treatment is based on the Ponseti method throughout most of the world. Despite the effectiveness of this therapy, clubfoot may relapse. Recent studies confirm the theory of active fibrotic remodeling processes in the extracellular matrix of the affected tissue. The aim of this study was to clarify whether relapses in clubfoot therapy are associated with altered angiogenesis and to suggest possible regulatory pathways of this pathologic process.

Methods: We compared microvessel density, arteriole density, and concentration of angioproliferative-related proteins found between tissues in the contracted, that is, the medial side (M-side), and noncontracted, that is, the lateral side (L-side) of the relapsed clubfeet. Tissue samples from 10 patients were analyzed. Histopathologic analysis consisted of immunohistochemistry and image analysis. Real-time polymerase chain reaction was used to study mRNA expression.

Results: An increase in microvessel and arteriole density was noted in contracted, relapsed clubfoot tissue. This was accompanied by a significant increase in the levels of the vascular endothelial growth factor, vascular endothelial growth factor receptor 2, β catenin and active β catenin. Vascular endothelial growth factor, vascular endothelial growth factor receptor 2, and CD31 overexpression was also seen with mRNA analysis.

Conclusions: Increased microvessel and arteriole density in the contracted side of the relapsed clubfoot was noted. These processes are mediated by specific proangiogenic proteins that are overexpressed in the contracted tissue. These findings contribute to the etiology and the development of relapses in the treatment of clubfoot.

Level of evidence: Level II-analytical and prospective.

MeSH terms

  • Arterioles*
  • Casts, Surgical
  • Child, Preschool
  • Clubfoot / etiology*
  • Clubfoot / metabolism
  • Clubfoot / therapy
  • Female
  • Humans
  • Male
  • Neovascularization, Pathologic*
  • Prospective Studies
  • Recurrence
  • Treatment Outcome
  • Vascular Endothelial Growth Factor A / metabolism
  • Vascular Endothelial Growth Factor Receptor-2 / metabolism
  • beta Catenin / metabolism


  • CTNNB1 protein, human
  • VEGFA protein, human
  • Vascular Endothelial Growth Factor A
  • beta Catenin
  • KDR protein, human
  • Vascular Endothelial Growth Factor Receptor-2