CLUBFOOT

Clubfoot, or congenital talipes equinovarus (CTEV), is a congenital

deformity involving one foot or both. 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 affecting joints of the foot occur at three joints of the foot to
varying degrees. They are [2]

 Inversion at subtalar joint

 Adduction at talonavicular joint and
 Equinus at ankle joint

The deformities can be remembered using the mnemonic, "InAdEquate"

for Inversion, Adduction and Equinus.

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. TEV occurs with some frequency
in Ehlers Danlos Syndrome and some other connective tissue disorders. TEV
may be associated with other birth defects such as spina bifida cystica.
SIGNS AND SYMPTOMS

• The top of the baby's foot twists downwards and inwards.

• The arch is more pronounced and the heel turns inward.
• In severe cases the foot may look as if it is upside-down.
• The calf muscles are generally underdeveloped.
• If only one foot is affected, it is usually slightly shorter than the other
(especially the heel).
• There is usually no discomfort or pain when the patient is not trying to
walk.

When to see a doctor - in virtually all cases health care professionals will
detect the condition when the baby is born; and sometimes before birth.

RISK FACTORS OF CLUB FOOT

• Gender - males are twice as likely as females to be born with club

foot.
• Genetics - if a parent was born with club foot, there is a higher risk of
his/her baby being born with the same condition. The same applies to
siblings. According to the National Health Service (NHS), UK, if one parent
has club foot there is a 3% to 4% chance that the child will have the same
condition; if both parents were born with the condition the risk for their
child is 15%.

DIAGNOSTIC PROCEDURES

The condition is immediately visible at birth. It can also be detected before

birth by ultrasound, especially if both feet are affected. If it is detected
before birth no treatment is possible until after the baby is born.

If the condition is detected during pregnancy or after birth doctors will

recommend more tests to determine whether the baby has any other health
problems, such as spina bifida and muscular dystrophy.

Sometimes the doctor may order X-rays to observe the deformity in more
detail.

PATHOPHYSIOLOGY

Theories of the pathogenesis of clubfeet are as follows:

• Arrest of fetal development in the fibular stage

• Defective cartilaginous anlage of the talus
 • Neurogenic factors: Histochemical abnormalities have been found in
posteromedial and peroneal muscle groups of patients with clubfeet.
This is postulated to be due to innervation changes in intrauterine life
secondary to a neurologic event, such as a stroke leading to mild
hemiparesis or paraparesis. This is further supported by a 35%
incidence of varus and equinovarus deformity in spina bifida.
• Retracting fibrosis (or myofibrosis) secondary to increased fibrous
tissue in muscles and ligaments: In fetal and cadaveric studies,
Ponseti also found the collagen in all of the ligamentous and tendinous
structures (except the Achilles tendon), and it was very loosely
crimped and could be stretched. The Achilles tendon, on the other
hand, was made up of tightly crimped collagen and was resistant to
stretching. Zimny et al found myoblasts in medial fascia on electron
microscopy and postulated that they cause medial contracture.1
• Anomalous tendon insertions: Inclan proposed that anomalous tendon
insertions result in clubfeet.However, other studies have not supported
this. It is more likely that the distorted clubfoot anatomy can make it
appear that tendon insertions are anomalous.
• Seasonal variations: Robertson noted seasonal variations to be a
factor in his epidemiologic studies in developing countries. This
coincided with a similar variation in the incidence of poliomyelitis in the
children in the community. Clubfoot was therefore proposed to be a
sequela of a prenatal poliolike condition. This theory is further
supported by motor neuron changes in the anterior horn in the spinal
cord of these babies.

INTERVENTIONS
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.

MEDICAL
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 ]. 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 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 for children who experienced the Ponseti Method
treatment is comparable to that of non-affected children.

The French functional method - consists of daily stretching, exercise,

massage, and immobilization of the foot with nonelastic tape to slowly move
the foot to the correct position. These therapy sessions are performed
primarily by a physical therapist for the first three months, when most of the
improvement occurs, but parents receive training during this time in order to
perform some of the treatments at home. The taping and splinting continues
until the child is two years old. It is important to note that this method is
currently not available in many parts of the United States

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. BC Women and Childrens Hospital
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.

Tenotomy (needed in 80% of cases) is a release (clipping) of the Achilles

tendon - minor surgery- local anesthesia

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.

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.
NURSING INTERVENTIONS

• Discussthe deformity and expected treatment that the client can

understand
• Encourage parents to hold and play with the child and participate in
care.
• Assess and teach the parent/patient for signs of excessive pressure on
the skin, redness and excoriation
• Elevate the extremity to promote venous return and prevents edema
• Stimulate movement of the toes to promote circulation
• Provide comfort measures such as soft music, pacifier (infant),
teething ring (infant) or rocking
• Discuss importance of physical therapist.
• Educate patient with the following:

After the cast application:

The first 24 hours after the cast is applied, your baby may be restless, but
he/she should be comfortable after a day or two. Please do the following:
1. Check the circulation in the foot every hour for the first 12 hours after the
cast is applied. This is done by gently squeezing the toes and watching for
the
return of blood flow. The toes will turn white when you squeeze and and
then
quickly return to pink if the blood flow to the toes is good. This is called
blanching.
If the toes are dark and cold and do not blanch (white to pink), the cast may
be
too tight. If this occurs, please contact the Clinic at the Orthopaedic Hospital
Outpatient Medical Center. If it’s after hours, take the cast off and
reevaluate the
toes. If normal circulation returns, please call the Clinic to schedule a follow-
up
visit. If after removing the cast, you are not sure about the color of the toes,
please take the child to the Orthopaedic Medical Center Urgent Care, or to a
local
emergency room.
2. The tips of the toes should be exposed. If you cannot see the toes, it may
mean the cast has slipped and correct position of the foot is not being
maintained.
Call the Clinic at the Orthopaedic Hospital Outpatient Medical Center to make
them aware of this.
3. Keep the cast clean and dry. The cast may be wiped clean with a slightly
dampened cloth if it becomes
soiled.
4. Whenever your baby is on his/her back, place a pillow under the cast to
elevate the leg so that the heel
extends just beyond the pillow. This prevents pressure on the heel, which
could cause a sore.
5. Use disposable diapers and change the baby often to prevent cast soiling.
Apply the diaper above the
top of the cast to prevent urine/stool from getting inside the cast.

Notify your doctor or the clinic nurse if you notice any of the
following:
• Any drainage on the cast.
• Any foul smelling odors coming from inside the cast.
• If the skin at the edges of the cast becomes very red, sore, or irritated.
• If your child runs a fever of 38 degrees C/101.3°F or higher without an
explainable reason, such as
a cold or ear infection.
Following the removal of the last cast, and in order to prevent relapse, the
baby will be fit with a brace. The brace will need to be worn 23 hours a
day, for two to three months, and thereafter, at nighttime for two to four
years. The first and second nights of wearing the brace the baby may be
uncomfortable, but it is important that the brace not be removed. After the
second night, the baby will adapt to the brace. Relapses will occur if the
brace is not worn as prescribed.
When the brace is removed, ordinary shoes can be worn. Yearly visits will be
scheduled for the next thre

What are the possible complications of club foot?

If left untreated

An untreated baby will usually feel no pain or discomfort until they have to
stand and walk. The risk of eventually developing arthritis is significant. The
unusual appearance of the foot may cause self-image problems later in life.

The individual will find it hard to walk on the soles of the feet, using instead
the balls of the feet, the outside of the feet, and in very severe cases the top
of the feet.
 Posteromedial release for clubfoot.

Ilizarov distraction for arthrogrypotic clubfoot.

 Schematic representation of posteromedial release.

Traditional manipulation and casting methods fail, as they do not

allow the free rotation of the calcaneum and the talus.
Never forcibly evert or pronate the foot during clubfoot casting.

Spontaneous correction of the hind foot varus by abducting the

forefoot and allowing the calcaneum to freely rotate under the
talus.