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What is a Clubfoot?
Clubfoot (medically termed "congenital talipes equinovarus") is a foot deformity that can occur in newborn children. Its actually the most common of all deformities in newborns and occurs in 1 in 250 to 1 in 1000 births, depending on the country. About half of the affected children have the deformity in both feet.
A clubfoot occurs when muscles become contracted (overly tightened) and pull the foot into an abnormal position. The foot is over-arched (called "cavus"), turned inward (called "adducted" and "varus"), and pointed downward ("equinus"). The deformity is appears pretty much the same every time (some variation in severity) due to the same usual suspects. These tight foot muscles include: the toe flexors (called the FHL and FDL), the tibialis posterior, and the Achilles tendon.
Diagnosing a Clubfoot:
This deformity is recognized soon after birth because its pretty apparent. The classic appearance described above will tip-off doctors, and they will order x-rays of the feet to look at the alignment of the foot bones. These x-rays, in combination with examining the foot, will tell doctors about the severity of the child's deformity.
Treating a Clubfoot:
The good news is that the majority of cases will resolve without needed surgery. The history of treating clubfoot is a great story because only a few decades ago, the vast majority of cases were treated with a big surgery, that cut and tightened different tendons to try and reshape the foot. Although the procedure often successfully realigned the bones, many kids were left with lasting stiffness.
This was the standard of treatment until a very smart, and forward-thinking doctor, Dr. Ponseti, came to the United States from Italy in the mid-20th century and began to popularize his own method of treating this deformity through "serial casting". Serial casting refers to a technique where the infant's foot is twisted into certain positions and then placed into a cast to hold the foot in that position for one week, at which time the foot is re-casted, into a slightly different position. This process continues for weeks until these repeat casts mold the foot into a normal position. The central foot bone (called the "talus") is the center around which the rest of the foot bones are re-aligned. The Achilles tendon contracture is the only tight muscle that isnt improved with the casting, and 90% of the time requires a small procedure either in the office or in the operating room to loosen the tendon (called a "heel cord lengthening") so it can be re-shaped, and then casted.
This casting treatment, called the Ponseti Method, would never work in adults because our bones are stiff and rigid. But the body of a newborn is incredibly pliable and soft and the foot can be gradually molded into a normal position. The results of casting have been excellent and have largely replaced surgical treatments.
Once the alignment of the foot has been corrected with casting, the infant isnt finished with treatment. They still need to wear a small boot (called a Foot-Ankle Orthosis) for 23 hours a day (basically all times except for bathing) for 3 months. And then only at nighttime (or nap time) until they are 4 years old.
Despite the success of the Ponseti Method, there are cases when surgery is still required. About 10% of children dont respond to the casting and some infants are not taken to a doctor until 1 or 2 years of age, at which time, their bones and joints are already too hard to be molded. Surgery involves adjusting the tendons of these muscles, and then putting the foot into a cast after surgery (so casting is still part of treatment).
What is the long term outcome?
The Ponseti method of serial casting has a 90% success rate. Its generally very successful as long as the parents.
1) Morcuende JA et al. Radical reduction in the rate of extensive corrective surgery for clubfoot using the Ponseti method. Pediatrics 2004; 113: 376-80. full article. efficacy of casting.
2) Kuo KN, Smith PA. Correcting residual deformity following clubfoot releases. CORR 2009; 467: 1326-33. full article. results surgery, additional procedure ta split transfer.
3) Dobbs MB et al. Long-term follow-up of patients with clubfeet treated with extensive soft-tissue release. JBJS 2006; 88: 986-96. full article. surgery often causes stiff, painful arthritic foot in long term.
4) Ponseti IV. Clubfoot management. JPO 2000; 20: 699-700. full article.
5) Ponseti IV. The Ponseti Technique for correction of congenital clubfoot. JBJS 2002; 84: 1889-90. full article.
6) Noonan KJ, Richards BS. Nonsurgical management of idiopathic clubfoot. JAAOS 2003; 11:392-402. full article.
7) Roye DP Jr, Roye BD. Idiopathic congenital talipes equinovarus. J AAOS 2002;10:239-48. full article.