CLUB FOOT (CONGENITAL TALIPES EQUINOVARUS)

INTRODUCTION

Clubfoot is a congenital foot condition, which affects approximately 1

out of every 1000 births in the United Kingdom. However, prevalence of this
condition is twice as common in males as females. The deformity can be mild
or severe and it can affect one foot or both feet. As many as 50% of cases
are bilateral (both feet are affected). Club Foot is sometimes confused with
other congenital foot defects, such as Calcaneovalgus and Metatarsus
adductus. These deformities are caused by the position of the foot in the
womb and are usually corrected with minimal intervention. True clubfoot
affects all the joints, tendons and ligaments in the foot and is often referred
to as Congenital Talipes EquinoVarus. Another form of clubfoot is
Congenital Vertical Talus, this is not as common as true clubfoot, the foot
appears more rigid then a true club foot deformity. In most cases, clubfoot is
idiopathic, which means that the cause is unknown and there is no genetic
tendency. However it is associated with Spina Bifida and Hip Dysplasia.

Causes

The cause of clubfoot isn't known (idiopathic). But scientists do know that
clubfoot isn't caused by the position of the fetus in the uterus. In some
cases, clubfoot can be associated with other congenital abnormalities of the
skeleton, such as spina bifida, a serious birth defect that occurs when the
tissue surrounding the developing spinal cord of a fetus doesn't close
properly.

Stages

True clubfoot is characterized by abnormal bone formation in the foot. There

are four variations of clubfoot: talipes varus, talipes valgus, talipes equines,
and talipes calcaneus. In talipes varus, the most common form of clubfoot,
the foot generally turns inward so that the leg and foot look somewhat like
the letter J (when looking at the left foot head-on). In talipes valgus, the foot
rotates outward like the letter L. In talipes equinus, the foot points
downward, similar to that of a toe dancer. In talipes calcaneus, the foot
points upward, with the heel pointing down.
Risk factors

• Sex- Clubfoot is more common in males.

• Family history- If you, your spouse or your other children have had
clubfoot, your baby is more likely to have it as well.

SYMPTOMS

• If left untreated the child will walk on the outer top surface of the foot.
• The patient may also experience corns, hard skin and in growing
toenails.
• Clubfoot in adulthood can lead to difficulty in purchasing shoes and a
gait abnormality (walking pattern).

Etiology

The true etiology of congenital clubfoot is unknown. Most infants who have
clubfoot have no identifiable genetic, syndromal, or extrinsic cause.7 Extrinsic
associations include teratogenic agents (eg, sodium aminopterin),
oligohydramnios, and congenital constriction rings. Genetic associations
include mendelian inheritance (eg, diastrophic dwarfism; autosomal
recessive pattern of clubfoot inheritance).Cytogenetic abnormalities (eg,
congenital talipes equinovarus [CTEV]) can be seen in syndromes involving
chromosomal deletion. It has been proposed that idiopathic CTEV in
otherwise healthy infants is the result of a multifactorial system of
inheritance. Evidence for this is as follows:

• Incidence in the general population is 1 per 1000 live births.

• Incidence in first-degree relations is approximately 2%.
• Incidence in second-degree relations is approximately 0.6%.
 • If one monozygotic twin has a CTEV, the second twin has only a 32%
chance of having a CTEV.

TREATMENTS

There are many treatments available for clubfoot and many different
opinions exist concerning treatment regimes.

The aim of the treatment regime should be: -

1. Correct the deformity early.

2. Correct the deformity fully
3. Hold the correction until growth stops.

Below is the summary of some of the main conditions.

Casting

A series of plaster or fiberglass casts are applied to the foot and lower limb –
these are replaced every few weeks, which each cast progressively moving
the foot towards a more corrected position. The number of times the cast
needs to be replaced will be determined by the severity of theclubfoot (but
several months is not unusual). Most activities are not hampered by wearing
a cast.

• This may be begin from the 1st day of life to several weeks after birth.
• The foot is pushed and twisted into an over corrected position by the
Orthopedist. The cast is then applied in order to hold the foot into that
position. This may be uncomfortable for the child.
• Casts are usually changed every two weeks.
• Splints or braces may be used after a few years of casting the feet.

This above photo of an infant in a Denis Browne bracing bar after undergoing
months of casting using the Ponseti method as treatment for his bilateral
 clubfeet.
He will have to wear the bracing bar for 23 hours a day for about 3 months
and then only at night for two to four years.

• The Ponseti method of casting and manipulation can also be effective.

This method was pioneered in the 1940's by Dr Ignocio Ponseti and can
be successful in certain cases. Please refer to your consultant for
further information.

The above photograph is of a Clubfoot casting.

Surgery

There are many surgical procedures available for clubfoot. Surgery is usually
recommended to a child of six months old. Below are the list of commonly
used surgical procedures. For further information concerning these surgical
procedures, please consult an Orthopedist.

• Perctuneous tenotomy. The Achilles tendon is cut to allow the foot to

drop.
• Posterior release.
• Medial release.
• Subtarsal release.
• Complete tendon transfer.
If cast treatment fails or the clubfoot is rigid, surgery may be needed.
This is not usually done until the child is between four and eight
months of age. There are a variety of surgical procedures which may
be done in isolation or in combination:
• Soft tissue surgery that releases the tight tissues around the joints and
results in lengthening of tendons so the foot can assume a more
corrected position
• Bony procedures such as “breaking bone” and resetting the bone to
correct deformities, or fusing joints together to stabilize joints to
enable the bones to grow solidly together.
• Tendon transfers to move the tendons to a different position, so they
can move the foot into a corrected position.
Indications

Traditionally, surgery is indicated when a plateau has been reached in

nonoperative treatment. Surgery is usually performed when the child is of
sufficient size to enable anatomy to be recognized.

Contraindications

No specific contraindications to surgery exist, although the child's size

dictates that surgery is best performed at approximately age 6 months. With
greater acceptance of the Ponseti conservative technique, surgery is seen to
be a contentious issue. Surgery for clubfeet is no longer the only standard of
care.