Club foot

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For other uses, see Club foot (disambiguation).
Club foot
Classification and external resources
Pied bot, varus équin (bilateral).jpg
bilateral club foot
ICD-10 M21.5, Q66.8
ICD-9 736.71, 754.5-754.7
OMIM 119800
DiseasesDB 29395
MedlinePlus 001228
eMedicine radio/177 orthoped/598
MeSH D003025

A club foot or clubfoot, also called congenital talipes equinovarus (CTEV), is a congenital deformity involving one foot or both.[1] The affected foot appears to have been rotated internally at the ankle. Without treatment, people with club feet often appear to walk on their ankles or on the sides of their feet. However with treatment, the vast majority of patients recover completely during early childhood and are able to walk and participate in athletics as well as patients born without CTEV.

Congenital talipes equinovarus (CTEV) or clubfoot is a common foot abnormality present at birth. In babies with clubfoot the tissues connecting the muscles to the bones are shorter than usual causing their feet to be twisted. The ankle can be twisted at a sharp angle making the foot resemble a golf club, hence the name. The severity of clubfoot can range from mild to severe with half of affected babies having both feet affected. [2]

It is a relatively common birth defect, occurring in about one in every 1,000 live births. Approximately half of people with clubfoot have it affect both feet, which is called bilateral club foot. In most cases it is an isolated dysmelia (disorder of the limbs). It occurs in males twice as frequently as in females.

A condition of the same name appears in some animals, particularly horses.

Genetics[edit]

Hippocrates was the first to make a hypothesis about the cause around 400 B.C. and still to this day there are many other hypotheses for clubfoot pathogenesis. Most of the studies have concluded that clubfoot may be caused by environmental factors, genetics, or a combination of both. There was not one study that was able to pinpoint an exact root for clubfoot, but most of findings agreed on one thing, “It is likely there is more than one different cause and at least in some cases the phenotype may occur as a result of a threshold effect of different factors acting together” (Miedzybrodzka, Z., 2003).

Taking a look in the early development stages of humans, some researchers hypothesized that clubfoot is formed by a malfunction that occurred while gestating in the womb. Amniocentesis is believed to increase the rates of this deformity because there is an increase in possible amniotic leakage during the procedure. Underdevelopment of the bones and muscles in the embryonic foot may be another underlying cause to clubfoot. This underdevelopment of the foot does not allow the fetus’ foot to rotate medially leaving it in the club formation after birth. A widely accepted hypothesis in the early 1900s that further supports the foot not being able to rotate medially is one where the fetal foot development is constricted due to the uterus.

Underdevelopment of the bones also affects the muscles and tissues of the foot. Abnormality in the connective tissue causes, “The presence of increased fibrous tissue in muscles, fascia, ligaments and tendon sheaths,” (Miedzybrodzka, Z., 2003). Affected individuals have smaller than normal legs even after corrected. This brought up another hypothesis where it suggests that there are variations in genes that influence muscle development are risk factors for clubfoot. Further evidence showed that mutations in genes components encoding the muscle contractile complex (MYH3, TPM2, TNNT3, TNNI2, and MYH8) cause congenital contractures, including clubfoot, in distal arthrogryposis (DA) syndromes (Weymouth, KS., et al., 2011).

Modern technology advances in genetic mapping techniques, development of mouse models, improved understanding of the control of developmental processes and genetic epidemiology studies have led to a more recent hypothesis that is said to be the closest in finding the etiology of clubfoot. Its inheritance pattern is explained with a polygenic threshold model as a heterogenous disorder. The PITX1-TBX4 transcriptional pathway has become key to the study. PITX1 and TBX4 are uniquely expressed in the hind limb (Dobbs, MB, 2012). Further studies duplicating this pathway in models need to be conducted to hopefully find what genetic abnormalities cause clubfoot.

Ultrasound

Diagnosis[edit]

Clubfoot is usually diagnosed immediately after birth simply by looking at the foot. It is then up to the doctor whether or not to x-ray the foot or feet to examine how the internal structures are positioned. In some cases, it may be possible to detect the disease prior to birth during the ultrasound. It may be more prominent if both feet are affected. The ability to possibly identify clubfoot before live birth can prove beneficial to the child as different treatments can be explored. [3]

Treatment[edit]

A Denis Browne brace. Various types of foot-abduction braces are used to hold the child's feet in the desired position.
Correcting clubfeet

Once your child has been diagnosed with clubfoot treatment can be approached at many different angles. Treatment should start at an early age usually within a week or two after diagnosis to take full advantage of the flexibility in the baby’s bones and joints. This will allow easy manipulation to try to achieve a normal foot.

As medicine evolved, club feet were treated with a complex surgical release, which had many complications. Then a novel idea of serial casting, different from that introduced in the past (such as the Kite method) was introduced by Dr. Ignacio Ponseti of the University of Iowa Hospitals and Clinics in the 1950s, with dramatic results. His results were from recognizing how the forefoot and hindfoot interact and lock into position relative to each other. This type of treatment is generally used today for idiopathic cases of clubfoot, while treatment of neuromuscular causes (such as cerebral palsy) differ.

Clubfoot is treated with manipulation by podiatrists, physiotherapists, orthopedic surgeons, specialist Ponseti nurses, or orthotists by serial casting and then providing braces to hold the feet in a plantigrade position. After serial casting, a brace such as a Denis Browne bar with straight lace boots, ankle foot orthoses and/or custom foot orthoses (CFO) may be used. In North America, manipulation is followed by serial casting, most often by the Ponseti Method. Foot manipulations usually begin within two weeks of birth. Even with successful treatment, when only one side is affected, that foot may be smaller than the other, and often that calf, as well.

French Method[edit]

The French method, also known as the "functional method" or "physiotherapy method", is easiest to do with young bones. A physical therapist will direct parents to stretch and tape their child's foot. Little by little move the child’s foot to achieve the right position then hold it in place with tape. Then in the evenings the child’s foot is hooked up to a machine where it continuously moves the foot while the child sleeps. Treatment can be lessened to three times a week after two months of continuous use. Once the foot has a regular shape to it, daily exercises should be performed and splints should be worn to bed until the baby is ready to walk. This method is not considered the most common because it is so time consuming. [4]

Extensive surgery of the soft tissue or bone is not usually necessary to treat clubfoot; however, there are two minimal surgeries that may be required:

  1. Tenotomy (needed in 80% of cases) is a release (clipping) of the Achilles tendon – minor surgery – local anesthesia
  2. Anterior Tibial Tendon Transfer (needed in 20% of cases) – where the tendon is moved from the first ray (toe) to the third ray in order to release the inward traction on the foot.

Each case is different, but in most cases extensive surgery is not needed to treat clubfoot. Extensive surgery may lead to scar tissue developing inside the child's foot. The scarring may result in functional, growth and aesthetic problems in the foot because the scarred tissue will interfere with the normal development of the appendage. A child who has extensive surgery may require on average two additional surgeries to correct the issues presented above.

In stretching and casting therapy the doctor changes the cast multiple times over a few weeks, gradually stretching tendons until the foot is in the correct position of external rotation. The heel cord is released (percutaneous tenotomy) and another cast is put on, which is removed after three weeks. To avoid relapse a corrective brace is worn for a gradually reducing time until it is only at night up to four years of age.

Non-surgical treatment and the Ponseti Method[edit]

Main article: Ponseti Method

The most common treatment is done by the doctor. This treatment requires stretching and casting, but is better known as the Ponseti method. The foot is repositioned to the normal position then a cast is placed on top of it. The baby’s foot is then continually repositioned and placed back into a cast once or twice a week for several months. Towards the end of the process after being in a cast, the doctor will then go in and surgically lengthen the Achilles tendon. After the foot has been realigned, maintenance is kept by doing routine stretching. The child also has to wear special shoes or braces full-time for three months then just nightly for three years after. This method can be compared to wearing braces on your teeth. Parents’ have to follow the doctor’s orders for when to wear and not wear the brace to keep the foot corrected. Failure will occur if parents don’t follow directions and the foot will return to its odd shape. [5]

Treatment for clubfoot should begin almost immediately to have the best chance for a successful outcome without the need for surgery. Over the past 10 to 15 years, more and more success has been achieved in correcting clubfeet without the need for surgery. The clubfoot treatment method that is becoming the standard in the U.S. and worldwide is known as the Ponseti Method.[6] Foot manipulations differ subtly from the Kite casting method which prevailed during the late 20th century. Although described by Dr. Ignacio Ponseti in the 1950s, it did not reach a wider audience until it was re-popularized around 2000 by Dr. John Herzenberg in the USA and in Europe and Africa by NHS surgeon Steve Mannion while working in Africa. Parents of children with clubfeet using the Internet also helped the Ponseti gain wider attention. The Ponseti method, if correctly done, is successful in >95% of cases[7] in correcting clubfeet using non- or minimal-surgical techniques. Typical clubfoot cases usually require 5 casts over 4 weeks. Atypical clubfeet and complex clubfeet may require a larger number of casts. Approximately 80% of infants require an Achilles tenotomy (microscopic incision in the tendon requiring only local anesthetic and no stitches) performed in a clinic toward the end of the serial casting.

After correction has been achieved, maintenance of correction may require the full-time (23 hours per day) use of a splint—also known as a foot abduction brace (FAB)—on both feet, regardless of whether the TEV is on one side or both, for several weeks after treatment. Part-time use of a brace (generally at night, usually 12 hours per day) is frequently prescribed for up to 4 years. Without the parents' participation, the clubfoot will almost certainly recur, because the muscles around the foot can pull it back into the abnormal position. Approximately 20% of infants successfully treated with the Ponseti casting method may require a surgical tendon transfer after two years of age. While this requires a general anesthetic, it is a relatively minor surgery that corrects a persistent muscle imbalance while avoiding disturbance to the joints of the foot.

The developer of the Ponseti Method, Dr Ignacio Ponseti, was still treating children with clubfeet (including complex/atypical clubfeet and failed treatment clubfeet) at the University of Iowa Hospitals and Clinics well into his 90s. He was assisted by Dr Jose Morcuende, president of the Ponseti International Association.

File:Clubfoot Casting.jpg
Casting for clubfoot

The long-term outlook[8] for children who experienced the Ponseti Method treatment is comparable to that of non-affected children.[9]

Botox is also being used as an alternative to surgery. Botox is the trade name for Botulinum Toxin type A. a chemical that acts on the nerves that control the muscle. It causes some paralysis(weakening) of the muscle by preventing muscle contractions (tightening). As part of the treatment for clubfoot, Botox is injected into the child’s calf muscle. In about 1 week the Botox weakens the Achilles tendon. This allows the foot to be turned into a normal position, over a period of 4–6 weeks, without surgery.

The weakness from a Botox injection usually lasts from 3–6 months. (Unlike surgery it has no lasting effect). Most club feet can be corrected with just one Botox injection. It is possible to do another if it is needed. There is no scar or lasting damage.[10]

Surgical treatment[edit]

In severe cases, surgery may be the only option to correct the foot after trying all other non-invasive methods for treatment. Surgery does not ensure full recovery, but most babies who underwent the surgery have maintained their normal feet. A surgeon will go in and lengthen the muscles and tendons to ease the foot into position. After surgery when the cast is removed, a brace is to be worn to prevent the foot from returning to the old position. [11]

On occasion, stretching, casting and bracing are not enough to correct a child's clubfoot. Surgery may be needed to adjust the tendons, ligaments and joints in the foot/ankle. Usually done at 9 to 12 months of age; surgery usually corrects all clubfoot deformities at the same time. After surgery, a cast holds the clubfoot still while it heals. It is still possible for the muscles in the child's foot to try to return to the clubfoot position, and special shoes or braces will likely be used for up to a year or more after surgery. Surgery will likely result in a stiffer foot than nonsurgical treatment, particularly over time.

Without any treatment, a child's clubfoot will result in severe functional disability, however with treatment, the child should have a nearly normal foot. He or she can run and play without pain and wear normal shoes. The corrected clubfoot will still not be perfect, however; a clubfoot usually stays 1 to 1½ sizes smaller and somewhat less mobile than a normal foot. The calf muscles in a leg with a clubfoot will also stay smaller.

Long-term studies of adults with post-club feet, especially those with substantial numbers of surgeries, may not fare as well in the long term, according to Dobbs, et al.,[12] A percentage of adults may require additional surgeries as they age, though there is some dispute as to the effectiveness of such surgeries, in light of the prevalence of scar tissue present from earlier surgeries.

In some cases the leg stops developing earlier than the healthy leg and a substantial length difference may occur. In some cases a leg lengthening will be necessary, most commonly by use of the Ilizarov method.

History[edit]

Treatment of clubfoot is evident as early as Egyptian paintings. In early days,[when?] the foot was manipulated with a Thomas wrench and casting which caused fracture of several bones in the foot.

Famous people[edit]

The club-foot, by José de Ribera, in fact, a hemiplegia[13]
Famous storyteller from Lapland. Juho "Nätti-Jussi" Nätti (surname can be translated as "pretty") who lived 1890-1964, was known for his stories but also his untreated left club foot. A story tells that "not even the devil himself could tell which way Nätti has gone" from the footprints on snow.

Many notable people have been born with one or both feet in "clubbed" condition, including Roman emperor Claudius, statesman Prince Talleyrand, 19th-century American politician Thaddeus Stevens, comedian Damon Wayans, actor Gary Burghoff, and Eric The Midget from The Howard Stern Show, football players Steven Gerrard and Miguel Riffo, sledge hockey player Matt Lloyd, a Paralympian, mathematician Ben Greenberg, and filmmaker Jennifer Lynch.

While the British Romantic poet George Gordon, Lord Byron was wrongly said to suffer from clubfoot, he did suffer from a similar condition, tendon achillies, which caused him much humiliation.

Comedian, musician, and actor Dudley Moore was born with a club foot. This was mostly unknown to the public as he wore one shoe with a slightly bigger sole to compensate when walking.

NFL Cornerback Charles Woodson was born with severely clubbed feet and went on to win the Heisman Award at the University of Michigan, played in Super Bowl XXXVII with the Oakland Raiders and won Super Bowl XLV with the Green Bay Packers.

The figure-skater Kristi Yamaguchi was born with a clubfoot, and went on to win gold medals at both the 1992 Winter Olympics and World Championships. The soccer star Mia Hamm was born with the condition and won Gold twice with Team USA in the 1996 Olympics and in the 2004 Olympics. Baseball pitcher Larry Sherry, the 1959 World Series MVP, was born with club feet,[14] as was pitcher Jim Mecir, and both enjoyed long and successful careers. In fact, it was suggested in the book Moneyball that Mecir's club foot contributed to his success on the mound; it caused him to adopt a strange delivery that "put an especially violent spin" on his screwball, his specialty pitch. The San Francisco Giants held the record as the team with the all-time highest number of players with clubbed feet as of July 2010,[citation needed] and Freddy Sanchez, one of its infielders, cites his ability to overcome the defect as a reason for his success.[15] Tom Dempsey of the New Orleans Saints, born with a right club foot and no toes (this was his kicking foot), kicked an NFL record 63-yard (58 m) field goal. This kick became famous as the longest NFL field goal in history. Former NFL quarterback Troy Aikman beat being born with a clubfoot to enjoy a productive Hall of Fame career with 3 Super Bowl Rings in Super Bowl XXVII, Super Bowl XXVIII, and Super Bowl XXX.[16] Despite a club foot, Michael Houser, goaltender for the London Knights of the Ontario Hockey League, won the Red Tilson Trophy as the most outstanding player in the OHL in 2011-2012. He was signed by the National Hockey League's Florida Panthers in July, 2012.[17]

Nazi National Socialist and government official in Poland, Austria and Netherlands, Arthur Seyss-Inquart, lived his life walking with a clubfoot, and was still limping on it when he arrived at the gallows and was hanged as the last condemned prisoner at The Nuremberg Trials on October 16, 1946.[18] Nazi Propaganda Minister Joseph Goebbels had a deformity caused by a botched operation for the bacterial infection osteomyelitis, which some mistook for clubfoot.[19]

De Witt Clinton Fort, who served in the Confederate Army as a captain, was born with a clubfoot, and he was known during the American Civil War as Captain "Clubfoot" Fort, C.S.A.

Egyptian pharaoh Tutankhamun had a club foot and a cleft palate, and it is likely that he needed a cane to walk.[20]

In literature[edit]

In animals[edit]

Severe club foot in a pony, probably congenital in origin
Apparent club foot, thought to be from post-natal environmental conditions, not congenital
Left hoof normal, right hoof possible grade one club foot

Club feet occur in other animals, notably equines. The condition is characterized by a strongly upright pastern and a corresponding rotation of the coffin bone in the hoof. The condition often affects only one foot. Severity varies, with some animals usable for work or riding, and others unsound for life. Careful farrier work on the hooves can lessen the severity of many cases, and in certain circumstances surgery may be beneficial. The visible outward appearance of a club foot has different possible origins that include a genetic predisposition to the condition, a congenital defect formed while the animal is in the womb, or problems with diet and bone development during the early post-natal period. Certain horse breeds appear to be more predisposed to the condition than others, but research has yet to identify the genes involved.

A grading scale exists to assess the severity of club feet, which are caused by a deep digital flexor contraction syndrome. When the muscle fibers of the upper leg's deep digital flexor muscle contract excessively, this affects the tendon of the same name that inserts into this muscle group and attaches at the bottom of the coffin bone. A constant upward pull by the tendon on the coffin bone and other structure of the horse's hoof creates the condition. While many young foals are born with somewhat upright pasterns, the condition may resolve naturally or with minimal intervention if begun early. However, some cases are so severe that more drastic treatment may be required.[21]

References[edit]

  1. ^ "CTEV: Deformities & Correction". LifeHugger. Retrieved 2009-12-26. 
  2. ^ AskMayoExpert & et al. Can clubfoot be diagnosed in utero? Rochester, Minn.: Mayo Foundation for Medical Education and Research; 2012. http://www.mayoclinic.org/diseases-conditions/clubfoot/basics/definition/con-20027211
  3. ^ AskMayoExpert & et al. Can clubfoot be diagnosed in utero? Rochester, Minn.: Mayo Foundation for Medical Education and Research; 2012. http://www.mayoclinic.org/diseases-conditions/clubfoot/basics/definition/con-20027211
  4. ^ AskMayoExpert & et al. Can clubfoot be diagnosed in utero? Rochester, Minn.: Mayo Foundation for Medical Education and Research; 2012. http://www.mayoclinic.org/diseases-conditions/clubfoot/basics/definition/con-20027211
  5. ^ AskMayoExpert & et al. Can clubfoot be diagnosed in utero? Rochester, Minn.: Mayo Foundation for Medical Education and Research; 2012. http://www.mayoclinic.org/diseases-conditions/clubfoot/basics/definition/con-20027211
  6. ^ To Parents of Children Born with Clubfeet: Orthopaedics: UI Health Topics
  7. ^ Morcuende JA, Dolan LA, Dietz FR, Ponseti IV (2004). "Radical reduction in the rate of extensive corrective surgery for clubfoot using the Ponseti method". Pediatrics 113 (2): 376–80. doi:10.1542/peds.113.2.376. PMID 14754952. 
  8. ^ Clubfoot Clinic, accessed September 21, 2011
  9. ^ Watch a Video on the Ponseti Method
  10. ^ BC Women and Childrens Hospital
  11. ^ AskMayoExpert & et al. Can clubfoot be diagnosed in utero? Rochester, Minn.: Mayo Foundation for Medical Education and Research; 2012. http://www.mayoclinic.org/diseases-conditions/clubfoot/basics/definition/con-20027211
  12. ^ Dobbs, Matthew B.; Nunley, R; Schoenecker, PL (May 2006). "Long-Term Follow-up of Patients with Clubfeet Treated with Extensive Soft-Tissue Release". The Journal of Bone & Joint Surgery (American) 88 (5): 986. doi:10.2106/JBJS.E.00114. PMID 16651573. 
  13. ^ Franck Fitoussi et Olivier Meslay, Un regard médicla sur le Piedbot, en collaboration avec l'hôpital Robert Debré sur le site cartelfr.louvre.fr
  14. ^ The Big Book of Jewish Baseball: An ... - Google Books
  15. ^ Kovacevic, Dejan (2006-08-18). "Freddy or not, here comes last leg of batting race". Pittsburgh Post-Gazette. 
  16. ^ Clubfoot doesn't stop rookie O.L. Simmons - New England Patriots Blog - ESPN Boston
  17. ^ "Report: Top OHL goalie Houser headed to Florida - NHL.com - News". NHL.com. Retrieved 2013-07-05. 
  18. ^ http://digicoll.library.wisc.edu/cgi-bin/History/History-idx?type=turn&entity=History.Twilight.p0202&id=History.Twilight&isize=text&pview=hide
  19. ^ Goebbels is commonly said to have had club foot (talipes equinovarus), a congenital condition. Historical writer and correspondent William L. Shirer spent the 1930s in Berlin as a journalist and was acquainted with Goebbels, wrote in his The Rise and Fall of the Third Reich (Simon and Schuster 1960) the Goebbels deformity arose from a childhood attack of osteomyelitis and a botched operation to correct it. Osteomyelitis, an infection within the bone marrow, can cause the destruction of one or more of the growing points in the long bones of the leg, a condition known as septic osteoblastic dysgenesis. This will result in a shortened leg.
  20. ^ King Tut died from malaria, broken leg
  21. ^ Redden, R.F. "Inside the Club Foot" The Horse, online edition, May 1, 2008. Accessed February 4, 2011