Club foot

Club foot
Classification and external resources
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.^[2] 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.

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.

Classification

Clubfoot is typically identified as "isolated" if it is the only birth defect present, or "complex," if there are additional conditions diagnosed.^[3]

Clubfoot is classified into two groups, postural TEV and structural TEV.

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

• inversion at subtalar joint, total hindfoot inversion
• adduction at talonavicular joint, and
• equinus and varus at ankle joint, that is, a plantar flexed position, making the foot tend towards toe walking.^[4]

Causes

There is no single known cause for clubfoot. And while clubfoot is often found as an isolated birth defect, many syndromes are frequently found in combination. There are different causes for clubfoot depending on what classification it is given.

Structural cTEV 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 cTEV. Genetic influences increase dramatically with family history. cTEV occurs with some frequency in Ehlers–Danlos syndrome and some other connective tissue disorders, such as Loeys-Dietz syndrome.

It was previously assumed that postural cTEV 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 cTEV does not occur more frequently than usual when the intrauterine space is restricted.^[5]

It may be associated with other birth defects, such as spina bifida cystica.

Etymology

The term talipes is from Latin talus, ankle + pes, foot. Equino-, of or resembling a horse and -varus, turned inward.

A horse's hoof is a large toenail, and the horse's joint that points backwards resembles a human heel. Varus means that the part distal segment of a bone or joint slants toward the body mid-line.^[6]

Prenatal screening

Screening for club foot prenatally is a debatable topic. However, this is commonly done as it is easily identified using an ultrasound scan. Most fetuses undergo a 20 weeks gestation fetal abnormality scan^[7] in which club foot is one of the abnormalities that can be picked up. Some doctors have argued that club foot may occasionally be associated with a syndromic disease and should therefore be screened. If no syndromic association is found prenatally, most fetuses with club foot are born and can live a normal life with medical treatment.

Treatment

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

Correcting clubfeet

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 Ponseti 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 last 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.

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

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.^[8] 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^[9] 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.

The long-term outlook^[10] for children who experienced the Ponseti Method treatment is comparable to that of non-affected children.^[11]

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.^[12]

Surgical treatment

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.,^[13] 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

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

Famous people

The club-foot, by José de Ribera, in fact, a hemiplegia^[1]

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 feet. 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.

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

• 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 The 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's Flowers for Algernon Gimpy, one of Charlie's co-workers at the bakery, has a club foot.
• In Perfume: The Story of a Murderer, the main character is born with a club foot and is described as having a limp throughout the novel.
• In Flannery O'Connor's short story The Lame Shall Enter First, the character Johnson has a club foot, a major symbol within the story.

In animals

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

External links

• Loeys-Dietz Syndrome Canada
• South African website with information about clubfoot for parents
• Australian website with information about clubfoot for parents plus support