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CLUBFOOT

Definition

CLUBFOOT

Information for the Podiatric Assistant

Vito J. Rizzo, DPM, DABPS, FAPWCA January 2009

A clubfoot, or talipes equinovarus[1] (TEV), is a birth defect. 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. The ratio is 2:1.

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

CLUBFOOT

CLUBFOOT

Definition

Clubfoot is a condition in which one or both feet are twisted into an abnormal position at birth. The condition is also known as talipes.

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Appearance in Newborn

clubfoot_baby.jpg

clubfoot_baby.jpg

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Appearance at 6 months

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Description True clubfoot is characterized by abnormal bone formation in the foot. Four variations of clubfoot, including talipes varus, talipes valgus, talipes equines, and talipes calcaneus. Talipes varus, most common form, foot generally turns inward so that the leg and foot look somewhat like the letter J. Talipes valgus, foot rotates outward like the letter L. Talipes equinus, foot points downward, similar to that of a toe dancer. Talipes calcaneus, the foot points upward, with the heel pointing down.

club-foot.jpg club-foot.jpg

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Causes Structural TEV is caused by: genetic factors, such as Edwards syndrome, a genetic defect with three copies of chromosome 18.Growth arrest 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 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. [2] Breach Birth presentation is also another known cause. TEV may be associated with other birth defects such as spina bifida cystica. Use of MDMA (Ecstasy) and smoking [3] while pregnant has been linked with this congenital abnormality.[4

Wynne-Davies R (1972) Genetic and environmental factors in the etiology of talipes equinovarus. Clin Orthop 84: 9­13 ^ Honein M, Paulozzi L, Moore C (2000) Family history, maternal smoking, and clubfoot: an indication of a gene-environment interaction. Am J Epidemiol 152: 658­65 ^ {{McElhatton PR, Bateman DN, Evans C, Pughe KR, Thomas SH (1999). "Congenital anomalies after prenatal ecstasy exposure". Lancet 354 (9188): 1441­2.

CLUBFOOT

Treatment

Clubfoot is treated with: Manipulation Braces Serial casting Splints- knee ankle foot orthoses (KAFO) Surgery

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Treatment

CLUBFOOT

Treatment

In North America, manipulation followed by serial casting, most often by the Ponseti Method. Foot manipulations usually begin within two weeks of birth

Ponseti Method

The standard in the U.S. and worldwide Dr. Ignacio Ponseti described 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.Parents of children with clubfeet using the Internet [6] also helped the Ponseti gain wider attention. 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 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)--.

^ nosurgery4clubfoot : nosurg 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): 376­80. PMID 14754952 ery4clubfoot

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Treatment

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Casting

Ponseti Method

The developer of the Ponseti Method, Dr Ignacio Ponseti, at 93 years of age is still treating children with clubfeet (including complex/atypical clubfeet and failed treatment clubfeet) at the University of Iowa Hospitals and Clinics. He is assisted by Dr Jose Morcuende, president of the Ponseti International Association. The long-term outlook [8] for children who experienced the Ponseti Method treatment is comparable to that of non-affected children.

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Casting

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Bracing

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Treatment

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Treatment

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

2.

Surgery

Of course, each case is different but the main idea is that 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 child's foot because the scarred tissue will interfere with the normal development of the foot. A child who has extensive surgery may require on average 2 additional surgeries to correct the issues presented above.

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.

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Famous people

Many notable people have been born with club foot, including the Roman emperor Claudius, the poet Lord Byron, statesman Prince Talleyrand, Civil War politician Thaddeus Stevens, the comedian Damon Wayans, actors Gary Burghoff and Dudley Moore, footballer Steven Gerrard, mathematician , film director David Lynch, and the first American president George Washington.[9] Kristi Yamaguchi was born with a club foot, 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. Pittsburgh Pirates infielder Freddy Sanchez cites his ability to overcome the defect as a reason for his success [10]. Josef Goebbels, the notorious Nazi propaganda minister, had a right club foot (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. Notable Sarah Lawrence College alum Katherine Bodreau was born with severe club foot.

CLUBFOOT

The club-foot, by José de Ribera.

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