Club foot

Definition

Clubfoot is a condition in which one or both feet are twisted into an abnormal position at birth. The condition is also known as talipes or talipes equinovarus.
Description
True clubfoot is characterized by abnormal bone formation in the foot. There are four variations of clubfoot, including 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. 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.
Clubfoot can affect one foot or both. Sometimes an infant's feet appear abnormal at birth because of the intrauterine position of the fetus birth. If there is no anatomic abnormality of the bone, this is not true clubfoot, and the problem can usually be corrected by applying special braces or casts to straighten the foot.
The ratio of males to females with clubfoot is 2.5 to 1. The incidence of clubfoot varies only slightly. In the United States, the incidence is approximately 1 in every 1,000 live births. A 1980 Danish study reported an overall incidence of 1.20 in every 1,000 children; by 1994, that number had doubled to 2.41 in every 1,000 live births. No reason was offered for the increase.

Causes and symptoms

Experts do not agree on the precise cause of clubfoot. The exact genetic mechanism of inheritance has been extensively investigated using family studies and other epidemiological methods. No definitive conclusions have been reached as of the early 2000s, although a Mendelian pattern of inheritance is suspected. This may be due to the interaction of several different inheritance patterns, different patterns of development appearing as the same condition, or a complex interaction between genetic and environmental factors. The MSX1 gene has been associated with clubfoot in animal studies. As of the early 2000s, however, these findings have not been replicated in humans.
A family history of clubfoot has been reported in 24.4% of families in a single study. These findings suggest the potential role of one or more genes being responsible for clubfoot.
Several environmental causes have been proposed for clubfoot. Obstetricians feel that intrauterine crowding causes clubfoot. This theory is supported by a significantly higher incidence of clubfoot among twins compared to singleton births. Intrauterine exposure to the drug misoprostol has been linked with clubfoot. Misoprostol is commonly used when trying, usually unsuccessfully, to induce abortion in Brazil and in other countries in South and Central America. Researchers in Norway have reported that males who are in the printing trades have significantly more offspring with clubfoot than men in other occupations. For unknown reasons, amniocentesis, a prenatal test, has also been associated with clubfoot. One international study published in 2004 reported that amniocentesis done at 13 weeks of gestation was associated with a fourfold increase in the risk of clubfoot. The infants of mothers who smoke during pregnancy have a greater chance of being born with clubfoot than are offspring of women who do not smoke.
True clubfoot is usually obvious at birth. The four most common varieties have been described. A clubfoot has a typical appearance of pointing downward and being twisted inwards. Since the condition starts in the first trimester of pregnancy, the abnormality is quite well established at birth, and the foot is often very rigid. Uncorrected clubfoot in an adult causes only part of the foot, usually the outer edge, or the heel or the toes, to touch the ground. For a person with clubfoot, walking becomes difficult or impossible.

Diagnosis

True clubfoot is usually recognizable and obvious on physical examination. A routine x ray of the foot that shows the bones to be malformed or misaligned supplies a confirmed diagnosis of clubfoot. Ultrasonography is not always useful in diagnosing the presence of clubfoot prior to the birth of a child; however, ultrasound is increasingly used in the early 2000s to evaluate the severity of clubfoot after birth and monitor its response to treatment.
Treatment
Most orthopedic surgeons agree that the initial treatment of congenital (present at birth) clubfoot should be nonoperative. Nonsurgical treatment should begin in the first days of life to take advantage of the favorable fibroelastic properties of the foot's connective tissues, those forming the ligaments, joint capsules, and tendons. In a common treatment, a series of casts is applied over a period of months to reposition the foot into normal alignment. In mild cases, splinting and wearing braces at night may correct the abnormality.
Another treatment for clubfoot is the Ilizarov frame, named for the Russian physician who developed it in 1951. The Ilizarov frame has been used in the United States and Canada since 1981. It consists of two metal rings that encircle the leg to be corrected, wires that attach the rings to the bone, and metal rods between the rings that can be extended like a telescope. The frame must be applied by an orthopedic surgeon. After a week, the surgeon begins to lengthen the rods, usually at the rate of 1 mm per day. The frame must be kept in place for several months. Although the Ilizarov frame is somewhat cumbersome, it has been reported as giving satisfactory results in straightening clubfeet, particularly those untreated in infancy.
When clubfoot is severe enough to require surgery, the condition is usually not completely correctable, although significant improvement is possible. In the most severe cases, surgery may be required, especially when the Achilles tendon, which joins the muscles in the calf to the bone of the heel, needs to be lengthened. Because an early operation induces fibrosis, a scarring and stiffness of the tissue, surgery should be delayed until an affected child is at least three months old.
Much of a clubfoot abnormality can be corrected by the use of manipulation and casting during the first three months of life. Proper manipulative techniques must be followed by applications of appropriately molded plaster casts to provide effective and safe correction of most varieties of clubfoot. Long-term care by an orthopedist is required after initial treatment to ensure that the correction of the abnormality is maintained. Exercises, corrective shoes, or nighttime splints may be needed until the child stops growing.

Prognosis

With prompt, expert treatment, clubfoot is usually correctable. One group of French researchers found that 77% of the children they followed over a period of 11 to 18 years had good results from nonsurgical methods of treatment combined with physical therapy. Most individuals are able to wear regular shoes and lead active lives. If clubfoot is not appropriately treated, however, the abnormality may become fixed. This fixation affects the growth of the child's leg and foot, and some degree of permanent disability usually results.
Key terms
Enterovirus — Any of a group of viruses that primarily affect the gastrointestinal tract.
Ilizarov frame — A device invented by a Russian physician for correcting deformities of the legs and feet, consisting of rings to be attached to the bone and rods extending between the rings that stretch the affected limb.
Intrauterine — Situated or occuring in the uterus.
Orthopedist — A doctor specializing in treatment of the skeletal system and its associated muscles and joints.

Resources

Books

Beers, Mark H., MD, and Robert Berkow, MD, editors. "Musculoskeletal Abnormalities." Section 19, Chapter 261 In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2002.
Hall, Judith G. "Chromosomal Clinical Abnormalilties." In Nelson Textbook of Pediatrics, edited by Richard E. Behrman, et al., 16th ed. Philadelphia: Saunders, 2000, 325-34.
Van Allen, Margot I., and Judith G. Hall. "Congenital Anomalies." In Cecil Textbook of Medicine, edited by Lee Goldman, et al., 21st ed. Philadelphia: Saunders, 2000, 150-52.
Periodicals
El Barbary H., H. Abdel Ghani, and M. Hegazy. "Correction of Relapsed or Neglected Clubfoot Using a Simple Ilizarov Frame." International Orthopedics 28 (June 2004): 183-186.
Gigante, C., E. Talente, and S. Turra. "Sonographic Assessment of Clubfoot." Journal of Clinical Ultrasound 32 (June 2004): 235-242.
Philip, J., R. K. Silver, R. D. Wilson, et al. "Late First-Trimester Invasive Prenatal Diagnosis: Results of an International Randomized Trial." Obstetrics and Gynecology 103 (June 2004): 1164-1173.
Souchet, P., H. Bensahel, C. Themar-Noel, et al. "Functional Treatment of Clubfoot: A New Series of 350 Idiopathic Clubfeet with Long-Term Follow-Up." Journal of Pediatric Orthopaedics, Part B 13 (May 2004): 189-196.
Organizations
March of Dimes/Birth Defects Foundation. 1275 Mamaroneck Ave., White Plains, NY 10605. (888) 663-4637. resourcecenter@modimes.org. http://www.modimes.org.
National Easter Seal Society. 230 W. Monroe St., Suite 1800, Chicago, IL 60606-4802. (312) 726-6200 or (800) 221-6827. http://www.easter-seals.org.
National Organization for Rare Disorders (NORD). 55 Kenosia Avenue, P. O. Box 1968, Danbury, CT 06813-1968. (203) 744-0100 or (800) 999-6673. Fax: (203) 798-2291. http://www.rarediseases.org.
Other
Children's and Women's Health Centre of British Columbia. The Ilizarov Apparatus. http://www.cw.bc.ca/orthopaedics/Ilizarov.asp.
"Clubfoot." National Library of Medicine. http://www.nlm.nih.gov/medlineplus/ency/article/001228.htm.
Clubfoot.net. http://www.clubfoot.net/treatment.php3.