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Clubfoot

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Clubfoot
SpecialtyMedical genetics Edit this on Wikidata
For other uses, see Clubfoot (disambiguation).

A clubfoot, or congenital talipes equinovarus (CTEV),[1] is a congenital deformity involving one foot or both.[2] The affected foot appears rotated internally at the ankle. TEV is classified into 2 groups: Postural TEV or Structural TEV. Without treatment, persons afflicted often appear to walk on their ankles, or on the sides of their feet. It is a common birth defect, occurring in about one in every 1,000 live births. Approximately 50% of cases of clubfoot are bilateral. In most cases it is an isolated dysmelia. This occurs in males more often than in females by a ratio of 2:1.

Deformities

The deformities affect joints of the foot occur at three joints of foot to varying degrees. They are [2]

The deformities can be remembered using the mnemonic, "InAdEquate" for Inversion, Adduction and Equinus.[2]

Causes

There are different causes for clubfoot depending on what classification it is given. Structural TEV is caused by genetic factors such as Edwards syndrome, a genetic defect with three copies of chromosome 18. Growth arrests at roughly 9 weeks and compartment syndrome of the affected limb are also causes of Structural TEV. Genetic influences increase dramatically with family history. It was previously assumed that postural TEV could be caused by external influences in the final trimester such as intrauterine compression from oligohydramnios or from amniotic band syndrome. However, this is countered by findings that TEV does not occur more frequently than usual when the intrauterine space is restricted.[3] Breech presentation is also another known cause.[citation needed] TEV may be associated with other birth defects such as spina bifida cystica. Use of MDMA (Ecstasy) and smoking [4] while pregnant has been linked with this congenital abnormality.[5]

Treatment

Clubfoot is treated with manipulation by podiatrists, physiotherapists, orthopedic surgeons, specialist Ponseti nurses, or orthotists by providing braces to hold the feet in orthodox positions, serial casting, or splints called knee ankle foot orthoses (KAFO). Other orthotic options include Dennis-Brown bars with straight last boots, ankle foot orthoses and/or custom foot orthoses (CFO). 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.

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.

Of course, 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

Main article: Ponseti Method

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 [7] also helped the Ponseti gain wider attention. The Ponseti method, if correctly done, is successful in >95% of cases [8] 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 or 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.

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

Dr. Ignacio Ponseti passed away at the age of 95 on Sunday, October 18, 2009 in Iowa City, Iowa.

Watch a Video on the Ponseti Method

Surgical treatment

On occasion, stretching, casting and bracing are not enough to correct a baby'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 1 1/2 sizes smaller and somewhat less mobile than a normal foot. The calf muscles in a leg with a clubfoot will also stay smaller.

Famous people

The club-foot, by José de Ribera.

Many notable people have been born with clubfoot, including the Roman emperor Claudius, statesman Prince Talleyrand, Civil War politician Thaddeus Stevens, the comedian Damon Wayans, actors Gary Burghoff, Dudley Moore and Eric The Midget from The Howard Stern Show, footballer Steven Gerrard, mathematician Ben Greenberg, and filmmaker Jennifer Lynch (daughter of David Lynch).

British Romantic poet Lord Byron had a clubfoot, which caused him much humiliation.

Actor/musician/comedian 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

Kristi Yamaguchi was born with a clubfoot, and went on to win figure skating gold in 1992. Soccer star Mia Hamm was born with the condition. Baseball pitcher Larry Sherry was born with club feet, 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. San Francisco Giants (the team with the all-time most clubbed feet players) infielder Freddy Sanchez cites his ability to overcome the defect as a reason for his success.[10]

Nazi Propaganda Minister Joseph Goebbels had a right clubfoot (possibly incurred after birth as a complication of osteomyelitis),[11] a fact hidden from the German public by censorship. Because of this malformation, Goebbels needed to wear a leg brace. That, plus his short stature, led to his rejection for military service in World War I.

DeWitt Clinton was born with a clubfoot. De Witt Clinton Fort was known during the American Civil War as Captain "Clubfoot" Fort, C.S.A..

In literature

  • The main character, Philip Carey, in W. Somerset Maugham's novel Of Human Bondage, has a club foot, a central theme in the work.
  • Hippolyte Tautain, the stable man at the Lion D'Or public house in Gustave Flaubert's novel Madame Bovary is unsuccessfully treated for clubfoot by Charles Bovary, leading to the eventual amputation of his leg.
  • Charlie Wilcox, the main character in Sharon McKay's novel Charlie Wilcox had a club foot.
  • In Yukio Mishima's seminal novel The Temple of the Golden Pavilion the character Kashiwagi has club feet which parallels the stutter of the main character, Mizoguchi.
  • In David Eddings' Malloreon series, Senji the sorcerer has a club foot.
  • In Caroline Lawrence's Roman Mysteries series, a character called Vulcan the blacksmith appears in the book "The Secrets of Vesuvius". He reveals that he gained the nickname because of his club foot.
  • In Bernard Cornwell's "Warlord Chronicles," Mordred, King of Dumnonia, has a club foot that is often used as a symbol for his ugliness and weakness as a ruler.
  • In Daniel Keyes' Flowers for Algernon Gimpy, one of Charlie's co-workers at the bakery, has a club foot.
  • In Heinrich von Kleist's play The Broken Jug, the main character Judge Adam has a club foot, betraying him as the culprit who broke the jug.

References

  1. ^ The term talipes is from Latin talus, ankle + pes, foot. Equino-, of or resembling a horse and -varus, turned inward.
  2. ^ a b c "CTEV: Deformities & Correction". LifeHugger. Retrieved 2009-12-26. Cite error: The named reference "LHC" was defined multiple times with different content (see the help page).
  3. ^ Wynne-Davies R (1972) Genetic and environmental factors in the etiology of talipes equinovarus. Clin Orthop 84: 9–13
  4. ^ Honein M, Paulozzi L, Moore C (2000) Family history, maternal smoking, and clubfoot: an indication of a gene-environment interaction. Am J Epidemiol 152: 658–65
  5. ^ McElhatton PR, Bateman DN, Evans C, Pughe KR, Thomas SH (1999). "Congenital anomalies after prenatal ecstasy exposure". Lancet. 354 (9188): 1441–2. doi:10.1016/S0140-6736(99)02423-X. PMID 10543673.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  6. ^ To Parents of Children Born with Clubfeet: Orthopaedics: UI Health Topics
  7. ^ nosurgery4clubfoot : nosurgery4clubfoot
  8. ^ 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.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  9. ^ [1]
  10. ^ Freddy or not, here comes last leg of batting race
  11. ^ Goebbels is commonly said to have had club foot (talipes equinovarus), a congenital condition. But William L. Shirer, who spent the 1930s in Berlin as a journalist and was acquainted with Goebbels, wrote in The Rise and Fall of the Third Reich (Simon and Schuster 1960) that the 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.
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