Congenital clubfoot (Talipes)
Congenital clubfoot is a complex deformity of the ankle and foot that includes forefoot adduction, midfoot supination, hindfoot varus, and ankle equines. Clubfoot must be treated, it doesn’t correct itself.
Deformities of the foot and ankle are described according to the position of the ankle and foot. The more common positions involve the following variations.
- Talipes varus: an inversion, or bending inward
- Talipes valgus: an eversion, or bending outward
- Talipes equines: plantar flexion, in which the toes are lower than the heel
- Talipes calcaneus: dorsiflexion, in which the toes are higher than the heel
The most frequently occurring type of clubfoot (approximately 95% of the cases) is the composite deformity Talipes equinovarus (TEV), in which the foot is pointed downward and inward in varying degrees of severity. Unilateral clubfoot may occur as an isolated defect or in association with other disorders or syndromes, such as chromosomal aberrations, arthrogryposis (fixation of a joint in a flexed or contracted position, may be due to adhesions in or around the joint), cerebral palsy, or spinal Bifida.
- Clubfoot occurs in about 1 to 3 in 1000 live births
- Boys affected twice as often as girls
- Bilateral clubfoot occurs in 50% of the cases
- Although there Is no known cause for congenital clubfoot
- Some believe that the use of drugs or alcohol during pregnancy or the presence of other diseases can cause it
- There is a genetic predisposition for clubfoot as seen in the increased incidence in first degree relatives.
In pinpointing the specific cause of the clubfoot, the condition is classified into four types,
- Syndrome complex
- Congenital clubfoot: It is the by far the most common form of clubfoot and is also referred to as “idiopathic” clubfoot. A child with congenital clubfoot has no other abnormalities, and the clubfoot is an isolated incident. The condition occurs more frequently within families, prompting scientists to believe that genetics play an important role in causing congenital clubfoot.
- Teratologic clubfoot: it occurs as a part of an underlying neuromuscular disorder, such as spinal Bifida or arthrogryposis multiplex congenital. Clubfoot may or may not be present in children with these disorders. Teratologic clubfoot often is severe and nearly always requires surgery to achieve correction.
- Syndrome Complex: It occurs when a child is born with one of a number of genetic disorders, and clubfoot is part of the bigger disorder. Children with chromosomal abnormalities such as Down Syndrome Complex clubfoot.
- Positional Clubfoot: it occurs when an otherwise normal foot is held in a deformed position in utero, the presence of twins and abnormal fetal position have all been associated with positional clubfoot, although many such pregnancies resulting in babies without clubfoot. Positional clubfoot responds readily to non-surgical treatments, such as splinting and casting. Because positional clubfoot is not an inherent defect, but instead a “packaging” problem, some physicians consider it a true clubfoot.
The exact cause of clubfoot remains unknown. Other possible theories to the cause of clubfoot include:
Arrested fetal development of skeletal and soft tissue during gestational weeks 9 to 10, when foot development occurs; abnormal neuromuscular dysfunction or muscle abnormalities; and possibly a defect in the primary germ plasma(the reproductive tissue), resulting in ankle dysplasia (abnormal development of tissue). Cases of clubfoot have been observed as a possible result of distal limb amniotic banding, a condition in which the amnion forms constructive bands around a limb in utero, cutting off the circulation to the limb and resulting in further abnormal or arrested development.
- Clubfoot is readily apparent at birth if it has not been previously detected antenatally
- Once it is detected, a careful yet comprehensive physical assessment decisions to be made regarding treatment and discussion of possible treatment plans and prognosis with the parents.
- The affected foot (or feet) is usually smaller and shorter, with an empty pad and a transverse plantar crease.
- When the defect is unilateral, the affected limb is usually shorter and some calf atrophy may be present.
- A through hip examination should be done on all infants with a club foot. An increased risk of hip dysplasia is associated with clubfoot deformities.
- Anteroposterior and lateral radiographs are useful in determining the type and severity of clubfoot.
- Ultrasonography may also be used
The goal of treatment for clubfoot is to achieve a painless, plantigrade (the entire sole of the foot is placed on the ground), and stable foot. Once the diagnosis is established, treatment is ideally initiated in the newborn period and involves three stages:
- Correction of the deformity
- Maintenance of the correction until normal muscle balance is regained
- Follow-up observation to avert possible reoccurrence of the deformity
- Serial casting is begun immediately or shortly after birth. Successive castle allows for gradual stretching of skin and tight structure on the medial side of the foot.
- Manipulation and casting are repeated frequently (every few days for 1 to 2 weeks, then at 1 to 2-week intervals) to accommodate the rapid growth of early infancy
- The affected extremity or extremities are cast until maximum correction is achieved, usually until 8 to 12 weeks
- A Denis Browne splint may be used to manage feet that correct with casting and manipulation
- A radiograph or ultrasound is then evaluated to see the relationship of bones to each other
- Failure to achieve normal alignment by 3 months indicates the need for surgical intervention, which may take place between 6 and 12 months of age.
- Surgical intervention for clubfoot involves pin fixation and the release of tight joints and tendons.
- With severe deformities, repeated surgical tendon or joint release may be necessary
- Some feet respond to treatment
- Some respond only to prolonged, vigorous and suspended effort; and
- The improvement in others remains disappointing even with maximum effort.
Parents should realize that outcomes are not always predictable and depend on the severity of the deformity; age of the child at initial intervention; compliance (agreement) with treatment protocols; and development of bones, muscles and nerves.
- Surgical intervention may not restore the ankle to an entirely normal state, with the affected foot and leg remaining smaller and thinner than the unaffected side.
- Many children with surgically corrected clubfoot, however, are able to walk without a limp and run and play.