Clubfoot

What is Clubfoot?

Clubfoot, also known as talipes equinovarus, is a birth defect that affects the foot. It’s one of the most frequently seen birth deformities, showing up in different degrees of severity. The condition presents four main abnormalities:

• The middle of the foot is too high (midfoot cavus)
• The front of the foot turns inward (forefoot adductus)
• The heel turns inward (heel/hindfoot varus)
• The foot points downward (hindfoot equinus)

If clubfoot is identified and treated early in a baby’s life, the results can be very successful, leading to better overall outcomes for the child in the long run.

What Causes Clubfoot?

There is ongoing debate about what exactly causes clubfoot, but most agree that it’s likely a combination of factors related to genes and the environment.

Certain conditions that a mother might have during pregnancy, like smoking or diabetes, seem to have the strongest links to the development of clubfoot. Drinking alcohol while pregnant might also increase the risk. There are studies showing that more clubfoot cases occur during certain seasons, suggesting the environment, and potentially a mother’s body temperature while pregnant, could play a part. Moreover, the position of the baby in the womb might also contribute to clubfoot.

The role of genetics is also likely significant, yet the exact gene modification that might cause clubfoot is still unclear. However, research shows that about a quarter of clubfoot cases have a family history of the disorder, but no definite pattern of inheritance has been identified. In twins who are genetically identical, or ‘monozygotic’, there’s a 33% chance for both to be affected compared to only a 3% chance in ‘dizygotic’, or fraternal, twins.

In one out of five cases, clubfoot appears alongside at least one of the following conditions:

– Distal arthrogryposis
– Congenital myotonic dystrophy
– Myelomeningocele
– Amniotic band sequence
– Other genetic syndromes like Trisomy 18 and Chromosome 22q11 deletion syndrome

It’s also important to note that around 7% of babies with clubfoot are born with another abnormality, and about 7.6% have some form of neurodevelopmental condition.

Risk Factors and Frequency for Clubfoot

Clubfoot is a condition that occurs between 0.5 and 2 times per 1000 births. However, certain groups, like Hawaiians and Maori, have a higher number of cases up to 6.8 per 1000 births. Males are more likely to be born with Clubfoot than females, and it usually affects both feet in about 50% of cases. If it only affects one foot, it is typically the right one.

• Clubfoot occurs in between 0.5 and 2 out of 1000 births.
• Higher rates are seen in Hawaiians and Maori, with up to 6.8 cases per 1000 births.
• Males have double the risk compared to females.
• About half of the cases impact both feet.
• When only one foot is affected, it’s usually the right foot.

Signs and Symptoms of Clubfoot

Clubfoot is a condition that can be detected during prenatal ultrasounds. However, in places where such ultrasound screenings aren’t common, Clubfoot might first be noticed at birth or during newborn check-ups. During a foot examination, clubfoot will show particular deformities like a high arch (midfoot cavus), an inward-twisting foot (forefoot adductus), an inward-facing heel (hindfoot varus), and a downward-pointing foot (hindfoot equinus). The severity of these deformities can vary from baby to baby.

Doctors often use a system developed by Dr. Pirani to measure the severity of clubfoot. This system involves scoring six different aspects of the foot, each rated with a score of 0, 0.5, or 1, depending on severity. With this system, a foot’s total score can range from 0 to 6. Three of the aspects relate to the heel, and three relate to the midfoot.

The following are details of this system:

Hindfoot

• Posterior crease: Doctors will assess the crease over the back section of the Achilles tendon. A score of 0 is given for multiple fine creases, 0.5 for two or three moderate creases and 1 for a single deep crease.
• Equinus: The foot’s ability to flex beyond the plantigrade position is corrected as much as possible. A score of 0 means that dorsiflexion beyond plantigrade is possible, 0.5 means that the foot can reach plantigrade, and 1 means the foot cannot reach plantigrade.
• Empty heel: The physician will feel the calcaneus. A score of 0 indicates that the calcaneus is easily felt beneath the skin, 0.5 means that a layer of tissue can be felt between the finger and calcaneus but the calcaneus is palpable, and 1 means the calcaneus is not palpable.

Midfoot

• Medial crease: The doctor will correct any high arch and assess the medial plantar crease. A score of 0 is given if there are many fine creases, 0.5 if there are two or three moderate creases, and 1 if there is a single deep crease.
• Curved lateral border of the foot: A pen or similar object is used to check the alignment of the foot’s lateral border. If the lateral border is straight in line with the pen, it gets a score of 0. If it deviates at the metatarsals, it gets a 0.5, and if it deviates at the calcaneocuboid joint, it gets a 1.
• Lateral head of the talus: The physician will palpate the talus’s head and passively correct the clubfoot deformity to see if the lateral head of the talus remains covered or uncovered by the navicular. A score of 0 means the talus’ lateral head is covered on correction, 0.5 means that it’s partially covered, and 1 means it remains uncovered.

A higher score at the start of treatment usually means more casts will be needed and a higher likelihood of requiring Achilles tenotomy, a surgical procedure to lengthen the Achilles tendon. Therefore, the scoring system can help doctors advise the family about what to expect for treatment, and it provides a way to track the progress of the condition getting better.

It’s important to note that if a baby has clubfoot, it doesn’t always mean that there are other medical issues. In about 80% of cases, clubfoot occurs by itself. However, in the other 20% of cases, clubfoot might be seen in combination with conditions like arthrogryposis or diastrophic dysplasia. Therefore, doctors will examine other areas such as the baby’s back for evidence of spina bifida or myelomeningocele, and the hips for signs of developmental dysplasia, a condition that can affect normal hip development. Research has shown that babies with clubfoot are approximately 25 times more likely to have developmental dysplasia of the hip than those without clubfoot.

Testing for Clubfoot

Clubfoot, a deformity in which the foot is twisted out of shape, is usually identified during pregnancy through an ultrasound or evaluated immediately after a child’s birth. Foot x-rays aren’t often useful right after birth because many of the foot bones won’t have hardened yet.

In older children coming in late or showing signs of incomplete correction, x-rays taken while the child is standing may help gauge the seriousness of the remaining deformity. The x-rays may display a parallel alignment of specific foot bones (talus and calcaneus) with an angle of less than 20 degrees. They might also display a negative angle between the talus and the first metatarsal bone, indicating an unusual outward positioning.

If doctors suspect the clubfoot is part of a wider syndrome, they might conduct a genetic investigation to confirm this.

Treatment Options for Clubfoot

The Ponseti method, developed in the 1940s, is a two-step technique that remains a trusted way to correct clubfoot, a common foot deformity in children. This method involves applying a series of casts to the foot, ideally from the first week of a child’s life and up to the age of two. These casts are changed weekly and, depending on the condition of the foot, between five and nine plasters may be necessary for optimum results.

To make the cast, a substance called Plaster of Paris is often used due to its affordability and flexibility compared to materials like fiberglass. The cast reaches above the knee and bends at about 110 degrees to help it stay in place.

When correcting the deformity, impacts need to be taken step by step for the best outcome. The journey starts by easing the foot’s arch, then the front of the foot is gradually moved outwards from the ankle, which will also correct any awkward positioning of the heel. During this process, it is important to avoid applying direct pressure on the heel and causing the foot to roll inwards; these could potentially recreate the foot deformity we’re trying to fix.

Once the foot has been successfully repositioned, it is then flexed upwards. If the foot can’t flex more than 10 degrees, a minor procedure called percutaneous Achilles tenotomy, which loosens the tight Achilles tendon, is recommended – and about 80% of patients need this. This procedure is performed under local anesthesia in a clinic, after ensuring that the family understands what it involves. After the procedure, a final cast is applied, putting the foot at a 60-degree outward angle and a 20-degree upward flex for three weeks.

The second part of the treatment involves wearing a brace that holds the correction in place. This brace, typically worn continuously for the first three months, then scaled back to 12 hours a day for up to four years, keeps the foot in a precise position. The brace fits the foot at about hip-width and turns the affected foot around 70 degrees outward.

The brace treatment is extremely important, and it is vital that it is worn as directed. Studies show that up to 80% of those who do not wear the brace as recommended experience recurrence of the clubfoot, compared to just 6% of those who follow the guidance. If reappearance of the condition is noticed early enough, a new series of casting can be started.

In some cases, surgery may be needed for leftover deformities or recurring ones. For instance, if a child above 30 months shows signs of certain foot conditions, a procedure to reposition a certain tendon might be necessary. In some instances, further processes like an open Achilles lengthening could also be required.

What else can Clubfoot be?

There are different types of inborn foot deformities, including calcaneovalgus foot and what is known as a ‘vertical talus’ foot. In both of these conditions, the foot seems to be bent upwards at the ankle, instead of being pointed downwards with a high arch, as is typical in other deformities.

A foot condition called ‘equinovarus’, could look just like a clubfoot that has not been treated. But it is different because it is not present at birth. Rather, it often occurs as a result of a nerve disorder like cerebral palsy or spina bifida.

What to expect with Clubfoot

The Ponseti method, a treatment for idiopathic clubfoot, boasts a successful initial correction rate of 98%. Almost four out of five patients would need a procedure called ‘percutaneous Achilles tenotomy’ towards the end of their casting. About one fifth of the patients might require a surgery known as ‘anterior tibialis transfer’.

In the long term, studies have shown that approximately 78% of patients treated for idiopathic clubfoot using the Ponseti method have experienced excellent or good outcomes. In situations where only one foot is affected, patients may find that foot to be 1 to 2 sizes smaller than the unaffected one.

Possible Complications When Diagnosed with Clubfoot

The main risk factor associated with treating clubfoot is that the condition can reappear. This is often due to not properly following the maintenance schedule using special boots and bars. If the maintenance regime is not followed correctly, there’s up to an 80% chance the condition will come back. It’s important that families receive proper advice and education from the beginning and have the support they need.

If surgery becomes necessary, there are additional risks. These can include infection and harm to surrounding body parts. Health professionals should avoid intensive surgical procedures, like extensive soft tissue release, whenever possible. This is because it can lead to other problems down the line like arthritis, overcorrection (fixing the issue too much), mechanical weakness, and even a condition where bone tissue dies due to lack of blood (avascular necrosis).

Preventing Clubfoot

As previously pointed out, it’s essential for families to be properly informed and guided to ensure that the treatment is successful and yields positive long-term results. Families must know that the Ponseti method, a technique for treating clubfoot, usually involves a commitment of 4 to 5 years. However, if followed correctly, this method can yield excellent long-term results. Not adhering to the treatment plan may result in extended periods of having to wear a cast and potentially needing surgery.