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Clubfoot

Clubfoot - also known as talipes - is the most common congenital disorder of the lower extremities. The affected patient has a deformed talus and shortened Achilles tendon, which give the foot a characteristic clublike appearance.

Clubfoot is classified according to the orientation of the deformed foot. In talipes equinovarus, the foot points downward (equinus) and inward (varus) and the front of the foot curls toward the heel (forefoot adduction).

The deformity usually is obvious at birth, allowing an early diagnosis, but clubfoot that causes only subtle deformity must be distinguished from apparent clubfoot such as metatarsus varus (pigeon toe). Such apparent clubfoot results when a fetus maintains a position in utero that gives his feet the appearance of clubfoot; unlike true clubfoot, it can usually be corrected without surgery. Inversion of the feet, another type of apparent clubfoot, may result from the peroneal type of progressive muscular atrophy or dystrophy.

Clubfoot typically affects both feet. It may be associated with other birth defects, such as myelomeningocele, spina bifida, or arthrogryposis. The deformity occurs in about 1 in every 1,000 live births and is twice as common in boys as in girls. Treated promptly. it can be corrected.

Causes

Clubfoot appears to result from a combination of genetic factors and environmental conditions that arise in utero. The mechanism of genetic transmission is unknown, but researchers are convinced that such a mechanism exists. The sibling of a child born with clubfoot has a 1 in 35 chance of being affected. The child of a parent with clubfoot has a 1 in 10 chance of inheriting the disorder.

Among children who have no family history of clubfoot, the anomaly may be linked to arrested development during the 10th to 12th week of gestation, when the feet form. Researchers also suspect muscle abnormalities, which lead to variations in tendon length and insertion points, as possible causes.

Clubfoot may arise in older children secondary to paralysis, poliomyelitis, or cerebral palsy. In these instances, treatment for clubfoot must be accompanied by treatment of the underlying disorder.

Signs and Symptoms

  • Noticeable deformity in foot
  • Stiffness in ankle or in foot tendons
  • Calf appears shorter than the other leg
  • Foot or feet turned or twisted awkwardly
  • Affected foot lacks the normal range of motion

Diagnostic tests

X-rays show the talus superimposed on the calcaneus. The metatarsals have a ladderlike appearance.

Treatment

Correction of clubfoot requires three stages: correcting the deformity, maintaining the correction until the foot regains normal muscle balance, and observing the foot closely for several years to prevent the deformity from recurring.

In neonates, corrective treatment begins immediately. An infant's foot contains large amounts of cartilage, and the muscles, ligaments, and tendons are supple. The ideal time to begin treatment is in the first Jew weeks after birth when the foot is most malleable. Deformities are usually corrected sequentially: first forefoot adduction, then varus (or inversion), then equinus (or plantar flexion). Trying to correct all three deformities at the same time creates a misshapen, rocker-bottomed foot.

Correction begins with manipulating the foot appropriately and casting the foot in that position. The procedure is repeated several times until the foot assumes a normal or nearly normal shape (usually in about 3 months).

The Denis Browne splint, a device that consists of two padded, metal footplates connected by a flat, horizontal bar, is sometimes used as a follow-up measure (when the foot is large enough) to help promote bilateral correction and strengthen the foot muscles. In addition, night splints and orthopedic shoes are used in correcting clubfoot.

More than half of all patients who have clubfoot­even those who receive conservative treatment - also need surgical correction. Typically, the doctor orders surgery if 3 months of casting hasn't corrected the condition or if the forefoot dorsiflexes and the hindroot remains in equinus. Surgical correction may involve tenotomy, tendon transfer, stripping of the plantar fascia, and capsulotomy. If the patient has a severe deformity that persists into later life, surgery may involve wedge resection, osteotomy, or talectomy. The patient must wear a cast to preserve the correction. Clubfoot that is severe enough to require surgical correction usually can't be corrected completely.

After corrective treatment, proper alignment must be maintained actively through exercise, splints, and orthopedic shoes. The patient may need to wear a device such as a polypropylene above-the-knee splint at night and during naps, and a prewalker clubfoot shoe during the day.

Prevention

Although the disabling effects of clubfoot often may be prevented through early treatment, there is no method of preventing the defect at this time. However, women should refrain from smoking, which may reduce their risk of having an affected baby, especially if they have a family history of clubfoot. (Smoking also increases the risk of having a low-birthweight or premature baby, as well as other pregnancy complications.) Genetic counseling can help parents understand the odds with each pregnancy for having a child with clubfoot. Generally, if a child has an isolated clubfoot (no other birth defects present), the recurrence risks in another pregnancy are low (about 3 percent).



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