Clubfoot

Contents

• What Is Clubfoot?
• How Common Is It?
• What Causes It?
• What Are The Symptoms?
• How Is It Diagnosed?
• How Is It Treated?
• Prognosis
• How Much Does Treatment Cost?

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Birth Defects

What Is Clubfoot?

A clubfoot is a common birth defect where the foot is twisted out of shape. It is a congenital birth defect which means it is present at birth. The most common form is the so-called equinovarus deformity which means the heel and foot bends inwards (image). In more severe cases the shinbone or tibia may also be twisted in and the lower leg muscles can be under developed. Clubfoot is twice as frequent in boys as girls. Treatment is usually started soon after birth and the appearance and function of the foot should soon improve. The medical term for clubfoot is talipes or talipes equinovarus.

How Common Is It?

It is a relatively common defect and occurs in about 1 out of every 1,000 births in Western countries. It can occur in one (unilateral) or both feet (bilateral). The occurrence in both feet is between 30-50 percent.

What Causes It?

One theory suggests that many cases are the result of pressure on the baby's feet from the mother’s uterus while it was developing in later pregnancy. Depending on where the fetus' feet were placed when the pressure was exerted this would determine if one or both feet were affected or if they were varus (turned inward) or valgus (turned outwards). It may also be for some reason that the baby's joints do not develop the sort of strength they should and thus are more vulnerable to any pressure.

A genetic factor is one fairly probable cause - although genetic testing is still not possible as scientists have not isolated the gene which causes the problem. If one child in the family is born with clubfoot, the risk for subsequent children is 20 times higher than average. Identical twins are often more affected than their siblings which certainly suggest a strong genetic link. If you are worried contact a genetic counselor for personal advice.

If the mother smokes during pregnancy she increases the baby's risk of clubfoot by 20 times the average. All expectant mothers should follow a prenatal care guide to ensure maximum health for both herself and her baby. If there is a history of birth defects in the family, this may mean preparing for pregnancy a few months before conception by following a healthy diet and taking a daily dose of multivitamins and folic acid supplement. In fact this is good preparation for all women trying for a baby.

In rare cases clubfoot is associated with neural tube defect such as spina bifida and other neuromuscular diseases such as multiple sclerosis, Huntington's disease and muscular dystrophy. In such cases the foot is usually severely deformed.

What Are The Symptoms?

The signs are usually very clear. Key identifying factors are:

• One or both feet turned inwards.
• Toes are pointing downwards.
• The affected foot is rigid and difficult to move.
• Where only one foot is affected, the clubfoot is likely to be smaller and broader than the normal foot. There may be up to 2 or 3 shoe sizes in the difference, which means the same pair of shoes cannot be worn. Where both feet are affected, one foot is still likely to be slightly smaller than the other. This shoe size difference cannot be 'repaired' and will persist throughout life.
• The calf muscles on an affected foot are usually weaker and thin.
• Occasionally one leg is shorter than the other.

How Is It Diagnosed?

Sometimes the condition is discovered during an anatomy scan, usually by week 20 of pregnancy. After childbirth the condition is straight forward to diagnose with a physical examination. An exam will also be performed to rule out any other spinal or muscular conditions. An X-ray of the foot or feet is also taken to determine the extent of bone abnormalities.

How Is It Treated?

Although clubfoot is painless at birth, it can worsen over time if untreated. Untreated children will develop abnormal walking patterns; gradually their feet become crippled and unsightly to look at.

Non-Surgical Options

Treatment involves repeated manipulation of the foot and ankle and is best started straight after birth when the foot is at its most pliable. The goal is to make the foot functional and stable for walking. Non-surgical intervention involves manipulating the foot into the correct position and then holding it in place with a cast or splint. There are 2 main schools of treatment: the French Functional method and the Ponseti method.

French Function Method

This method involves daily stretching, exercise and massage of the baby's foot and taping it with a molded plastic splint to slowly move the foot into the correct position. Usually carried out by a trained physical therapist, sessions are carried out 3 times a week for 30-60 minutes (image). Parents are trained to continue the mobilization and taping techniques at home until the child is 2 years old.

Ponseti Casting Method

The most popular method in America, ideally the Ponseti method should be started within a few days of birth. This therapy involves some gentle stretching of the foot before placing a cast over it to thigh level (image). The cast remains on and is changed every week until the baby is 3 to 6 months old. Regular X-rays will be taken to assess if the treatment is working or not. It should become apparent by week 6 and in 95 percent of cases all components of the condition are corrected at this point (except for the tightness of the heel cord). The doctor will perform a heel cord release with a small tool which only involves a small pinprick of the skin. A final cast is worn for another 3 weeks to allow the tendon to heal. After this the baby wears a brace with shoes attached to the bar to ensure the foot remains in the correct position. The brace is worn full time for 3 months and then at night until the child is 2 years of age.

Which Method Is Better?

A study by Steinman et al compared the French functional and Ponseti methods. The study showed that there were no significant differences between the success rates of the therapies (both were about 95 percent successful). However twice as many parents opt for the Ponseti method. Relapses occurred in 37 percent of Ponseti patients and in one third of those cases further non-surgical intervention was successful. However surgery was necessary for the other two thirds. Relapse cases were slightly less at 29 percent for the French Function method however surgery was required in all cases. An overall outcome from the study reported that the Ponseti method gave 'good' results in 72 percent of cases, 'fair' in 12 percent and 'poor' in 16 percent. The French functional method gave 'good' results in 67 percent of cases, 'fair' in 17 percent and 'poor' in 16 percent.

Surgical Intervention

As not all clubfeet can be correct by therapy, sometimes surgery is necessary (image). Where a partial recurrence after the Ponseti or French Function method occurs, only limited surgery is necessary. The Limited Posterior Release will release the heel cord and joint capsule at the back of the ankle. Where a tendon, that helps to move the foot, needs repositioning a Tibialis Anterior Tendon Transfer is performed.

In about 15 percent of cases more extensive foot surgery will be required. This is known as a Posteromedial Release procedure and it usually leads to a better positioning of the foot long-term. It is usually only performed after a child is at least 9 months old, although some orthopedic surgeons choose to operate at 6 months.

If bone abnormalities persist an osteotomy can be performed when the child is at least 5 years of age. It involves cutting into the bone. An arthrodesis procedure which involves fusing and stabilizing the bones can be performed when the child is 10 or older.

Prognosis

Most children do well if treatment is started early and are able to participate in most athletic activities without any problems. The gold medallist figure skater Kristi Yamaguchi for example was a former clubfoot infant. If treatment is delayed however then neither non-surgical nor surgical intervention will be as successful and the child may end up with a foot deformity for life.

How Much Does Treatment Cost?

Average Surgery Costs (United States)
• Unilateral surgery after Ponseti: $5,000
• Unilateral surgery with recurrence after Ponseti: $15,000
• Bilateral surgery after Ponseti: $9,700
• Bilateral surgery with recurrence after Ponseti: $33,000

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For more on pregnancy complications, see the following:

• Cleft palate: Signs, causes and treatment.
• Bones of the body: How they work and how many are there?
• How common are twins?: Naturally and with fertility treatment.
• Genetic testing before pregnancy: How it's done.

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