Clubfoot, also known as talipes
equinovarus, is a relatively common congenital malformation occurring in
approximately one in one thousand births. Clubfeet are seen 2:1, males to
females. If a sibling has a clubfoot (or clubfeet), the incidence rises to
1:35 births for all other siblings. Genetic factors that contribute to
clubfeet have not been determined.
The reason some children are born
with clubfeet is not clearly understood. Several authors have speculated
that the deformity stems from an under developed bone in the foot called the talus. As the talus grows in the
young fetus, the bone 'unfolds' from an inverted (varus) position. This
unfolding process seems to occurs by the neck of the talus straightening over
the first several months of fetal growth. Any disruption of the
straightening process may contribute to a delay or arrest of the straightening
resulting in a residual inverted (varus) position of the foot. Some
authors have speculated that this delay or arrest may be due to a decrease or
interruption in the blood flow to the neck of the talus.
X-rays taken of the infant clubfoot
will show inversion of the talus in relationship to the calcaneus. This
classic x-ray view used to evaluate clubfeet is referred to as Kite's
Angle. X-ray evaluation of clubfeet includes a comparison of the deformity
in relationship to the bones of the lower leg (ankle), the bones of the rearfoot
(talus and calcaneus) and the relationship of the rearfoot bones to the
forefoot.
Most individuals in western countries who are born with clubfeet
will mature to have
full and productive lives. And adult who was treated as a child for clubfeet
will show characteristic findings of the lower extremity. Some of these characteristic findings includes a thin calf, called a stork
deformity. A characteristic 'C' shaped
foot is also common as a result of under treated metatarsus
adductus.
Unfortunately, many cases of
untreated clubfeet in adults may be seen in under developed countries
through-out the world. These patients walk on the side of their foot and
may be extremely limited in the amount of time that they can stand.
Treatment of clubfoot
The foot of a newborn is merely the size of an
adult thumb. As the foot matures, the development of the bones and joints
become rigid and less flexible. Therefore, the earlier
treatment is initiated, the better the potential for a good outcome. Treatment may be
conservative, surgical or a combination of both. The decision as to which
method of treatment depends in a great majority of cases on the degree of
deformity at the talar neck (see the anatomy tab for further information
regarding the talus).
Manipulation and casting are commonly used as
conservative measures in treating neonatal clubfoot. Parents are
instructed by their physician in techniques that will help to correct the
contraction of the posterior and medial ankle and foot. Manipulation may
be reinforced by the use of casts or braces. Several new removable braces
have been developed in the past decade that have virtually eliminated the need
for plaster or fiberglass casting (for additional information see The
Wheaton Brace Company). It is not unusual for the clubfoot
deformity to be corrected within the first 2-3 months of life. Most
importantly, the correction must be maintained with splints, braces and
corrective shoes.
Should three or four months of stretching,
manipulation and casting not reduce the deformities of a clubfoot, surgical
correction may be indicated. The most frequent deformity left following a
period of conservative care is the rearfoot deformity of inversion (varus) and
plantarflexion (equinus). Metatarsus adductus, on the other hand, seems to
be much more easily reduced by conservative care. Surgical release
of the posterior and medial compartments will usually correct the residual
rearfoot deformities.
After the age of two, the deformities of a
clubfoot become much more difficult to manage due to thickening and fibrosis of
the soft tissue structures of the posterior and medial ankle and foot.
Most of the procedures used to treat clubfoot in the child older than 4 years
include some modification of the bony structures of the foot.
Although
most clubfeet in developed countries are addressed and treated when the patient
is an infant, many residual deformities of clubfeet carry over into the adult
foot. Residual metatarsus adductus, calcaneal varus and inversion of the
foot are common. Clubfoot deformity also leads to early degenerative
arthritis of the foot.
