Clubfoot

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.

Description

True clubfoot is characterized by abnormal bone formation in the foot. There are four variations of clubfoot: 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 (when looking at the left foot head-on). 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.

The four varieties of clubfoot. Talipes varus is by far the most common type.

(Illustration by GGS Information Services.)

Clubfoot can affect one foot or both feet. Sometimes the feet of an infant appear abnormal at birth because of the intrauterine position of the fetus prior to 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.

True clubfoot is usually obvious at birth because 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.

Demographics

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 one in every 1,000 live births. A 1980 Danish study reported an overall incidence of 1.2 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.

A family history of clubfoot has been reported in 24.4 percent of families in a single study. These findings suggest the potential role of one or more genes being responsible for clubfoot.

Causes and symptoms

Experts do not agree on the precise cause of clubfoot. Some experts feel that clubfoot may begin early in pregnancy, probably in the 10th to 12th weeks of gestation. The exact genetic mechanism of inheritance has been extensively investigated using family studies and other epidemiological methods. As of 2004, no definitive conclusions had been reached, 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. But, as of 2004, these findings had not been replicated in humans.

Several environmental causes have been proposed for clubfoot. Many 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. 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.

The physical appearance of a clubfoot may vary. However, at birth, an affected foot usually turns inward and points downward. It resists realignment. The calf muscle may be smaller and less well developed than normal. One or both feet may be affected.

When to call the doctor

An pediatrician should be consulted at birth, the usual time clubfoot is initially diagnosed. While there is no immediate urgency, the condition should be evaluated by a pediatrician or an orthopedic surgeon in the first weeks of life so that treatment can be started.

Diagnosis

Clubfoot is diagnosed by physician inspection. This is most often completed immediately after birth. Clubfoot may be suspected during the latter stages of pregnancy, especially in a mother of shorter or smaller than normal stature, a large fetus, or multiple infants.

Treatment

Clubfoot is corrected by casting or surgery. To have the best chances for successful resolution without resorting to surgery, treatment as soon after birth as possible. The Ponseti method of stretching and casting has been used with increasing success since the 1990s. The Ponseti method requires that a doctor stretch the child's affected foot toward its anatomically correct position and hold it in place with a cast. The foot is realigned and a new cast applied weekly for several weeks. Once the correct position has been achieved, a brace must be worn during periods of sleep to maintain the correction. To be successful, the method requires active parental involvement.

When casting and bracing are not successful, surgery may be required to realign the tendons, ligaments, and joints in the foot and ankle. Such a procedure is usually completed between nine and 12 months of age. After surgery, a cast holds the foot in the desired position.

Prognosis

The prognosis for successfully treating clubfoot is good at this time. Persons with clubfoot that is corrected by surgery may notice some increased stiffness in their affected feet as they age. A corrected clubfoot is often a shoe size smaller than normal and may be somewhat less flexible. The calf muscles in an affected clubfoot leg may be slightly smaller than an unaffected leg. However, without treatment, clubfoot will result in a functional disability.

Prevention

At the present time, there is no way to prevent clubfoot. Pregnant women can reduce the risk of clubfoot by refraining from smoking .

Parental concerns

Parents of an infant with clubfoot should be prepared to participate in treatment for two or more years. They should seek prompt treatment from a qualified health care provider.

Resources

BOOKS

Hall, Judith G. "Single Gene and Chromosomal Disorders." In Cecil Textbook of Medicine , 22nd ed. Edited by Lee Goldman, et al. Philadelphia: Saunders, 2003, pp. 191–7.

Hassold, Terry, and Stuart Schwartz. "Chromosome Disorders." In Harrison's Principles of Internal Medicine , 15th ed. Edited by Eugene Braunwald, et al., New York: McGraw Hill, 2001, pp. 396–403.

Thompson, George H. "Talipes Equinovarus (Clubfoot)." In Nelson Textbook of Pediatrics , 17th ed. Edited by Richard E. Behrman, et al. Philadelphia: Saunders, 2003, pp. 2256–7.

PERIODICALS

Gigante, C., et al. "Sonographic assessment of clubfoot." Journal of Clinical Ultrasound 32, no. 5 (2004): 235–42.

Ippolito, E., et al. "The influence of treatment on the pathology of club foot. CT study at maturity." Journal of Bone and Joint Surgery of Britain 86, no. 4 (2004): 574–89.

Mammen, L., and C. B. Benson. "Outcome of fetuses with clubfeet diagnosed by prenatal sonography." Journal of Ultrasound Medicine 23, no. 4 (2004): 497–500.

Noonan, K. J., et al. "Leg length discrepancy in unilateral congenital clubfoot following surgical treatment." Iowa Orthopedic Journal 24, no. 1 (2004): 60–64.

Papavasiliou, V. A., and A. V. Papavasiliou. "A novel surgical option for the operative treatment of clubfoot." Acta Orthopedica Belgium 70, no. 2 (2004): 155–61.

ORGANIZATIONS

American Academy of Orthopedic Surgeons. 6300 North River Road, Rosemont, Illinois 60018–4262. Web site: http://www.aaos.org/.

American Academy of Pediatrics. 141 Northwest Point Boulevard, Elk Grove Village, IL 60007–1098. Web site: http://www.aap.org/default.htm.

March of Dimes. 1275 Mamaroneck Avenue, White Plains, NY 10605. Web site: http://www.modimes.org/.

National Easter Seal Society. 230 W. Monroe St., Suite 1800, Chicago, IL 60606–4802. Web site: http://www.easterseals.org/.

National Organization for Rare Disorders (NORD). PO Box 8923, New Fairfield, CT 06812–8923. Web site: http://www.rarediseases.org/.

WEB SITES

"Clubfoot and Other Deformities." March of Dimes. Available online at http://www.marchofdimes.com/professionals/681_1211.asp (accessed November 16, 2004).

Patel, Minoo, and John Herzenberg. "Clubfoot." eMedicine. Available online at http://www.emedicine.com/orthoped/topic598.htm (accessed November 16, 2004).

Ponseti, Ignacia. "Treatment of Congenital Clubfoot." Virtual Children's Hospital, University of Iowa. Available online at http://www.vh.org/pediatric/provider/orthopaedics/Clubfoot/Clubfoot.html (accessed November 16, 2004).

Schopler, Steven A. "Clubfoot." Southern California Orthopedic Institute , 2004. Available online at http://www.scoi.com/clubfoot.htm (accessed November 16, 2004).

Shriners Hospitals for Children. "Help for Patients with Clubfoot." Houston Shriners Hospital. Available online at http://www.shrinershq.org/patientedu/clubfoot2.html (accessed November 16, 2004).

L. Fleming Fallon Jr., MD, DrPH