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Clubfoot

The most common congenital disorder of the lower extremities, clubfoot, or talipes, is marked primarily by a deformed talus and shortened Achilles tendon, which give the foot a characteristic club like appearance. In talipes quinovarus, the foot points downward (equinus) and turns inward (varus), while the front of the foot curls toward the heel (forefoot adduction).

Clubfoot, which has an incidence of approximately 1 per 1,000 live births, usually occurs bilaterally and is twice as common in boys as in girls. It may be associated with other birth defects, such as myelomeningocele, spina bifida, and arthrogryposis. Clubfoot is correctable with prompt treatment.

Causes

In children without a family history of clubfoot, this anomaly seems linked to arrested development during the 9th and 10th weeks of embryonic life, when the feet are formed. Researchers also suspect muscle abnormalities, leading to variations in length and tendon insertions, as possible causes of clubfoot.

Signs and symptoms

Talipes equinovarus varies in severity. Deformity may be so extreme that the toes touch the inside of the ankle, or it may be only vaguely apparent.

• If left untreated the child will walk on the outside 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).

Diagnosis

An early diagnosis of clubfoot is usually no problem because the deformity is obvious. In subtle deformity, however, true clubfoot must be distinguished from apparent clubfoot (metatarsus varus or pigeon toe).

Apparent clubfoot results when a fetus maintains a position in utero that gives his feet a clubfoot appearance at birth. This can usually be corrected manually.

Another form of apparent clubfoot is inversion of the feet, resulting from the personal type of progressive muscular atrophy and progressive muscular dystrophy. In true clubfoot, X-rays show superimposition of the talus and the calcaneus and a ladder like appearance of the metatarsals.

Treatment

Appropriate treatment for clubfoot is administered in three stages:

• correcting the deformity.
• maintaining the correction until the foot regains normal muscle balance.
• observing the foot closely for several years to prevent the deformity from recurring.

In newborns, corrective treatment for true clubfoot should begin at once. An infant's foot contains large amounts of cartilage; the muscles, ligaments, and tendons are supple. The ideal time to begin treatment is during the first few days and weeks of life-when the foot is most malleable.

Sequential correction

Clubfoot deformities are usually corrected in sequential order: forefoot adduction first, then varus (or inversion), then equinus (or plantar flexion). Trying to correct all three deformities at once only results in a misshapen,rocker-bottomed foot.

Forefoot adduction is corrected by uncurling the front of the foot away from the heel (forefoot abduction); the varus deformity is corrected by turning the foot so the sole faces outward (eversion); and finally, equinus is corrected by casting the foot with the toes pointing up (dorsiflexion). This last correction may have to be supplemented with a subcutaneous tenotomy of the Achilles tendon and posterior capsulotomy of the ankle joint.

Treatment methods

Several therapeutic methods have been tested and found effective in correcting clubfoot. The first is simple manipulation and casting, whereby the foot is gently manipulated into a partially corrected position, then held there in a cast for several days or weeks. (The skin should be painted with a nonirritating adhesive liquid beforehand to prevent the cast from slipping.)

After the cast is removed, the foot is manipulated into an even better position and casted again. This procedure is repeated as many times as necessary In some cases, the shape of the cast can be transformed through a series of wedging maneuvers, instead of changing the cast each time.

After correction of clubfoot, proper foot alignment should be maintained through exercise, night splints, and orthopedic shoes. With manipulating and casting, correction usually takes 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 to help promote bilateral correction and strengthen the foot muscles.

Resistant clubfoot may require surgery. Older children, for example, with recurrent or neglected clubfoot usually need surgery.

Tenotomy, tendon transfer, stripping of the plantar fascia, and capsulotomy are some of the surgical procedures that may be used. In severe cases, bone surgery (wedge resections, osteotomy, or astragalectomy) may be appropriate. After surgery, a cast is applied to preserve the correction.

Whenever clubfoot is severe enough to require surgery, it's rarely totally correctable. However, surgery can usually ameliorate the deformity.