Clubfoot

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, mature to have full productive lives. Some of the characteristic findings of an adult clubfoot that was treated as a child 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. In the case of clubfeet, the earlier treatment is initiated, the better the potential 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. 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.


Donald Willemsen