Clubfoot is the most common congenital disorder of the lower extremity. One or both feet turn downward and inward. Genetic and environmental factors in the development of the fetus are the apparent causes.
Fetal clubfoot, also known as talipes equinovarus, is a congenital foot deformity in which the foot is curved toward the middle of the body and the toes point downward. It affects the bones, muscles, tendons and blood vessels (of the limb) and can affect one or both feet. The foot is usually short and broad in appearance, and the heel points downward while the front half of the foot, or forefoot, turns inward.
The heel can appear narrow and the muscles in the calf are smaller compared to a normal lower leg. Despite its appearance and its name, the affected foot and leg contain all the same bones, muscles, tendons, and anatomic parts as the unaffected limb — only they are misshapen until corrected.
Clubfoot occurs in approximately one in every 1,000 live births and occurs in males twice as often as females. One in every two cases affects both feet.
Clubfoot is a congenital condition that affects newborn infants. The medical term for clubfoot is Congenital Talipes Equinovarus. This condition has been described in medical literature since the ancient Egyptians. Congenital means that the condition is present at birth and occurred during fetal development.
What part of the foot is affected?
The tarsal bones are the seven bones that make up the heel and the midfoot. The metatarsals and the phalanges are connected to the tarsals and form the forefoot. Clubfoot primarily affects three bones: the calcaneus, talus and navicular. Other bones can be involved as the deformity can affect the growth of the entire foot to some degree.
The clubfoot is unmistakable. The foot is turned under and towards the other foot. The medical terminology for this position is equinus and varus. Equinus means that the toes are pointed down and the ankle flexed forward (sort of like the position of the foot when a ballet dancer is on her toes). Varus means tilted inward. The ankle is in varus when you try to put the soles of your feet together.
How does this problem develop?
During the nine months of pregnancy, the fetus undergoes remarkable changes. In the skeleton, these changes include the separation of each individual bone in the body from one mass of bone material. In some cases, this process is flawed. A clubfoot occurs when this type of failure of separation occurs in the tarsal bones of the foot.
Until recently, most experts believed that the deformity was due to the foot being stuck in the wrong position in the womb. As development progressed, the foot could not grow normally because it was turned under and held in that position. Today, most information suggests that clubfoot is hereditary, meaning that it runs in families. It is not clear what genetic defect causes the problem. It is not known yet whether the defect affects the development of the muscles, blood vessels, or bones of the foot.
What does this problem feel like?
Clubfoot looks like no other condition. At birth, the baby's foot or feet are turned down and in. They can't be straightened just by trying to move the foot.
The primary problem of a clubfoot is that the foot can not be placed flat on the ground so that the child can walk on the sole of the foot. The condition is not painful to the child. In developing countries where there is sometimes no treatment for conditions such as this, adults with clubfoot walk on the side of their foot.
They do not walk normally. The foot is extremely deformed with calluses where the foot contacts the ground. Shoe wear is very difficult to fit and usually must be custom made. Normal shoes will not fit. Eventually the abnormality can lead to wear and tear arthritis in the abnormal joints, pain, and decreased ability to walk.
How do doctors identify the problem?
The history and physical examination make the diagnosis of clubfoot. The appearance alone is usually enough to make the diagnosis. A complete examination of the newborn is critical, since there are other genetic conditions that are associated with clubfeet. Your pediatrician will perform a complete evaluation to make sure there are no other congenital conditions to be concerned with.
A clubfoot can be diagnosed before birth using ultrasound. Many women have routine ultrasound test to assess the status of the pregnancy. When a clubfoot is found, there is no treatment currently available before birth. Because clubfoot is associated with other serious congenital and genetic abnormalities, the obstetrician may recommend amniocentesis to look for genetic problems in the fetus. An amniocentesis is a test where a needle is inserted into the uterus and a small amount of fluid removed. This fluid is sent to the lab for analysis. If evidence for serious genetic or congenital anomalies are found, then the option of terminating the pregnancy exists.
X-rays are helpful in determining the severity of the condition. This information may become important later in trying to decide what treatment is best to recommend. Usually, no other imaging studies are needed.
After a fetus is diagnosed with clubfoot, the surgeons and nurses at Children's Memorial counsel parents about what to expect when their baby is born and reassure them that the condition is correctable after birth. Parents also meet with the physical therapist before their baby is born to discuss how the stretching and casting is done.
Parents are asked to bring their infants for evaluation as early as one week of age. Treatment using the Ponseti method begins immediately; this includes a series of weekly stretching and casting by the physical therapist to gradually correct the forefoot and midfoot. After 6 to 8 weeks of treatment, some infants require a small surgery called a tenotomy to release the tendon in the foot, which is done on an outpatient basis. After surgery, the baby may require a few more weeks of casting until the deformity is completely corrected. To prevent recurrence, the infant wears a night splint for about six months after the last cast is removed and up to more than a year. Once the baby starts walking, his weight completes and maintains the correct position of the foot.
This method of treatment generally results in a 90 to 95 percent success rate. Some babies, however, do not respond to casting or have more severe defects that may require further surgery.
The most commonly used treatment in the newborn and infant is manipulation and casting. This is started as soon as possible. The foot is manipulated to stretch and loosen the tight structures. The foot is then placed in a cast to hold it in a corrected position. This is repeated every one or two weeks until the deformity is corrected or surgery is performed.
When it is clear that manipulation and casting alone will not result in success, surgery will be recommended by your surgeon. The main question is when to perform the surgery. The earlier the surgery is performed, the more growth remains in the foot. The more growth remaining, the more the deformity can be corrected. But, a smaller foot is much harder to operate on effectively. The surgery is much harder and the risk of damage to the nerves, blood vessels, and bones is much higher.
Most surgeons recommend waiting until the foot is about eight cm (three inches) long. This usually occurs when the infant is about nine months old. Most surgeons agree that it is ideal to have the surgery over and healed before the infant starts to try and walk. Surgery performed at nine months usually will accomplish this as well.
After surgery for clubfoot, a large bandage is applied to the foot. Some type of cast or brace may also be used. The child will probably need to wear some type of brace for several months - and maybe even years after the surgery - but ideally, the treatment should not interfere with the normal developmental milestones. Once the surgery is over, mother nature takes over. Weightbearing will help guide the growth in the foot towards a more functional orientation where the sole of the foot can be placed flat on the floor.
What can go wrong?
As with any treatment, complications can result from both conservative and surgical treatment of clubfoot. Failure of manipulation and casting to result in a successful outcome is not a complication. The majority of patients will not be treated successfully with non-surgical treatment alone.
Several complications are possible both during and after surgery. Wound problems may occur after surgery due to abnormal swelling or pressure from the cast. When the foot is markedly deformed, correction of the deformity may stretch the skin so tight that the blood supply is compromised. This may result in a small section of the skin actually dying. This normally heals with time and only rarely does this require a skin graft.
Infection can occur following any type of surgery. A wound infection can occur after clubfoot surgery. This may require additional surgery to drain the infection and antibiotics to treat the infection.
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