Introduction to Clubfoot: Difference between revisions
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== Definition/Description == | == Definition/Description == | ||
[[File:Talipes-equinovarus-Picture.jpg|thumb]] | [[File:Talipes-equinovarus-Picture.jpg|thumb]] | ||
Clubfoot, also known as Congenital Talipes Equinovarus, is a congenital deformity of the foot, that left untreated can limit a person’s mobility by making it difficult and painful to walk. <ref>Amanda Marie De Hoedt, Clubfoot Image Classification, University of Iowa, Iowa Research Online, 2013 [Available from Iowa Research Online /ir.uiowa.edu/etd/4836 http://ir.uiowa.edu/etd/4836]</ref> It is defined as a deformity characterized by complex, | Clubfoot, also known as Congenital Talipes Equinovarus, is a congenital deformity of the foot, not an embryonic malformation, that left untreated can limit a person’s mobility by making it difficult and painful to walk. <ref>Amanda Marie De Hoedt, Clubfoot Image Classification, University of Iowa, Iowa Research Online, 2013 [Available from Iowa Research Online /ir.uiowa.edu/etd/4836 http://ir.uiowa.edu/etd/4836]</ref> It is defined as a deformity characterized by complex, malalignment of the foot involving soft and bony structures in the hindfoot, midfoot and forefoot <ref name=":2">Daniel Augusto Carvalho Maranho, Jose Batista Volpon, Congenital Clubfoot , 2011;19(3):163-9.</ref> It is one of the most common serious congenital abnormalities to affect the foot. Most often it is an isolated abnormality, but occasionally it is associated with other congenital malformations or syndromes. | ||
== Epidemiology | |||
Clubfoot is more common in males with a 2.5 to 2.8:1 Male:Female ratio.<ref name="Boden" /> Various incidences have been noted between countries and regions ranging from 1-1.50 per 1000 live births, rising up to 3 per 1000 live births.<ref name="Boden">Boden, R.A., Nuttall, G.H., & Paton, R.W. (2011). A 14-year longitudinal comparison study of two treatment methods in clubfoot: Ponseti versus traditional. Acta Orhopaedica Belgica, 77(4), pp. 522-528.</ref><ref name="Harnett">Harnett, P., Freeman, R., Harrison, W.J., Brown, L.C., ; Beckles, V. (2011). An accelerated Ponseti versus the standard Ponseti method. The Journal of Bone ; Joint Surgery, 93, pp. 404-408.</ref><ref name="Jowe">Jowett, C.R., Morcuende, J.A., ; Ramachandran, M. (2011). Management of congenital talipes equinovarus using the Ponseti method. The Journal of Bone & Joint Surgery, 93, pp. 1160-1164.</ref> | == Epidemiology == | ||
Clubfoot is more common in males with a 2.5 to 2.8:1 Male:Female ratio.<ref name="Boden" /> Various incidences have been noted between countries and regions ranging from 1-1.50 per 1000 live births, rising up to 3 per 1000 live births.<ref name="Boden">Boden, R.A., Nuttall, G.H., & Paton, R.W. (2011). A 14-year longitudinal comparison study of two treatment methods in clubfoot: Ponseti versus traditional. Acta Orhopaedica Belgica, 77(4), pp. 522-528.</ref><ref name="Harnett">Harnett, P., Freeman, R., Harrison, W.J., Brown, L.C., ; Beckles, V. (2011). An accelerated Ponseti versus the standard Ponseti method. The Journal of Bone ; Joint Surgery, 93, pp. 404-408.</ref><ref name="Jowe">Jowett, C.R., Morcuende, J.A., ; Ramachandran, M. (2011). Management of congenital talipes equinovarus using the Ponseti method. The Journal of Bone & Joint Surgery, 93, pp. 1160-1164.</ref> Similarly, ethnic differences in occurrence have been reported with the lowest incidence (0.6%) among the Chinese Population, while the highest incidence (6.8%) in the Polynesian Region. The accumulative incidence is approximately 1 per 1000 live births among Caucasians.<ref>Henrik M. Wallander, Congenital Clubfoot (Aspects on Epidemiology, Residual Deformity and Patient Reported Outcome), ACTA University, 2009.</ref> | |||
==Global Burden of Disease== | ==Global Burden of Disease== | ||
If Clubfoot is not treated or managed successfully, it can progress to a severe deformity causing lifelong impairment affecting participation in activities of daily living. As the child grows and puts weight on their feet they will bear weight through the sides, or even the tops of their feet. A large callus of thickened skin forms on the weight-bearing surface and the deformed position causes pain and leaves the feet open to injury and infection. | If Clubfoot is not treated or managed successfully, it can progress to a severe deformity causing lifelong impairment affecting participation in activities of daily living. As the child grows and puts weight on their feet they will bear weight through the sides, or even the tops of their feet. A large callus of thickened skin forms on the weight-bearing surface and the deformed position causes pain and leaves the feet open to injury and infection. | ||
In an adult this often means the individual is unable be able to wear normal footwear with most cases experiencing severe restriction in walking by the time they are in their | In an adult, this often means the individual is unable be able to wear normal footwear with most cases experiencing severe restriction in walking by the time they are in their 20's or 30's with visible deformity of the foot. This, in turn, often leads to discrimination and the inability to access education and employment, which further impacts the individual's capacity to contribute economically which may affect both the individual and their family members. | ||
== Epidemiology/Etiology == | == Epidemiology/Etiology == | ||
The causes of Clubfoot are not clearly understood. Several theories have been proposed to explain the origin of Clubfoot, considering both intrinsic and extrinsic causes, including: intrauterine position of the fetus, mechanical compression or increased hydraulic pressure, interruption in fetal development, viral infections, vascular deficiencies, muscular alterations, neurological alterations, defect in the development of the bones structures and genetic defects.<ref name=":2" /><ref name="Pan">Pandey, S., & Pandey, A.K. (2003). The classification of clubfoot a practical approach. The Foot, 13, pp. 61-65.</ref> [[File:Club foot causes.JPG|thumb]] | The causes of Clubfoot are not clearly understood. Several theories have been proposed to explain the origin of Clubfoot, considering both intrinsic and extrinsic causes, including: intrauterine position of the fetus, mechanical compression or increased hydraulic pressure, interruption in fetal development, viral infections, vascular deficiencies, muscular alterations, neurological alterations, defect in the development of the bones structures and genetic defects.<ref name=":2" /><ref name="Pan">Pandey, S., & Pandey, A.K. (2003). The classification of clubfoot a practical approach. The Foot, 13, pp. 61-65.</ref> [[File:Club foot causes.JPG|thumb]] | ||
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=== Summary === | === Summary === | ||
Researchers who have looked into the causes believe there | Researchers who have looked into the causes believe there are both genetic and environmental influences,whereas in some countries and cultures there are different beliefs about what causes a child to be born with Clubfoot. These include include spiritual influences, spells, or curses often leading to mothers being blamed for the deformity. These ideas can cause the child with Clubfoot to be excluded from society, so therefore it is important to explain to families that children with Clubfoot are a valuable part of the community. | ||
== Clinically Relevant Anatomy == | == Clinically Relevant Anatomy == | ||
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=== Idiopathic Clubfoot === | === Idiopathic Clubfoot === | ||
Most commonly Clubfoot is classified as “Idiopathic Clubfoot” | Most commonly, Clubfoot is classified as “Idiopathic Clubfoot” meaning there is no known cause for the deformity. In Idiopathic Clubfoot, there can also be a definite hereditary influence, in that if a person has a relative, parent, or sibling has Clubfoot, then they are more likely to have Clubfoot or have a child with it (3-10% chance). Within the group of Idiopathic Clubfeet there is a wide spectrum of impairment depending on severity, as well as whether the Clubfoot has been untreated, partially treated, poorly treated, or successfully treated.<ref name=":0">Africa Clubfoot Training Project. Chapter 2 Africa Clubfoot Training Basic & Advanced Clubfoot Treatment Provider Courses - Participant Manual. University of Oxford: Africa Clubfoot Training Project, 2017.</ref> | ||
====Untreated Clubfoot==== | ====Untreated Clubfoot==== | ||
All clubfeet from birth up to 2 years of age that have had very little or no treatment can be considered as untreated clubfeet.<ref name=":0" /> | All clubfeet from birth up to 2 years of age that have had very little or no treatment can be considered as untreated clubfeet.<ref name=":0" /> | ||
====Treated Clubfoot==== | ====Treated Clubfoot==== | ||
Untreated clubfeet that have been corrected with Ponseti treatment are termed “treated clubfeet”. Treated clubfeet are usually braced full-time for 3 months and at night up to age 4 or 5 years.<ref name=":0" /> | Untreated clubfeet that have been corrected with Ponseti treatment are termed “treated clubfeet”. Treated clubfeet are usually braced full-time for 3 months and at night up to age 4 or 5 years.<ref name=":0" /> | ||
====Recurrent Clubfoot==== | ====Recurrent Clubfoot==== | ||
This is a Clubfoot which has achieved a good result with Ponseti treatment, but the deformity has recurred. The | This is a Clubfoot which has achieved a good result with Ponseti treatment, but the deformity has recurred. The most common reason is due to abandoning the braces early.<ref name=":0" /> | ||
====Neglected Clubfoot==== | ====Neglected Clubfoot==== | ||
The Neglected Clubfoot is | The Neglected Clubfoot is in a child older than 2 years, where little or no treatment has been performed. The Neglected Clubfoot may respond to Ponseti Treatment, but also may have bony deformity that requires surgical correction.<ref name=":0" /> | ||
====Complex Clubfoot==== | ====Complex Clubfoot==== | ||
Any foot with deformity that has received any type of treatment other than the Ponseti method may have added complexity because of additional pathology or scarring from surgery.<ref name=":0" /> | Any foot with deformity that has received any type of treatment other than the Ponseti method may have added complexity because of additional pathology or scarring from surgery.<ref name=":0" /> | ||
====Resistant Clubfoot==== | ====Resistant Clubfoot==== | ||
This is a Clubfoot where Ponseti Treatment has been correctly performed but there has been no significant improvement. It is often found that this type of Clubfoot is not in fact idiopathic after all and is | This is a Clubfoot where Ponseti Treatment has been correctly performed but there has been no significant improvement. It is often found that this type of Clubfoot is not in fact idiopathic after all and is secondary or syndromic.<ref name=":0" /> | ||
====Atypical Clubfoot==== | ====Atypical Clubfoot==== | ||
This is a | This is a Clubfoot which involves a foot that is often swollen, has a plantar flexed first metatarsal and an extended big toe. It can occur spontaneously but most often occurs after slippage of a cast.<ref name=":0" /> | ||
===Secondary or Syndromic Clubfoot=== | ===Secondary or Syndromic Clubfoot=== | ||
Secondary Clubfoot, on the other hand, occurs when there is another disease or condition that is causing or linked to the development of Clubfoot | Secondary Clubfoot, on the other hand, occurs when there is another disease or condition that is causing or linked to the development of Clubfoot. Such conditions are usually Neurological or Syndromic Disorders such as Arthrogyposis or Spina Bifida. | ||
====Spina Bifida==== | ====Spina Bifida==== | ||
A congenital, neurological condition where there is failure of the formation of the bone or skin or both to cover the lower end of the spinal cord and nerves. It is often associated with neurological problems in the legs, and clubfoot. If cases present to the clubfoot clinic it is important to find out what the long-term prognosis is, and whether the child is likely to walk. If the child is likely to survive and walk then it is worth trying Ponseti Clubfoot Treatment. The success rate with simple manipulation is not high and surgery may be considered. Even if the child has a low likelihood of walking the parents might still like to try to get the feet corrected so that shoes can be worn.<ref name=":1">Africa Clubfoot Training Project. Chapter 15 Africa Clubfoot Training Basic & Advanced Clubfoot Treatment Provider Courses - Participant Manual. University of Oxford: Africa Clubfoot Training Project, 2017.</ref> | |||
====Arthrogryposis==== | ====Arthrogryposis==== | ||
A congenital condition where the child is born with a number of deformities of the joints. A severe case can have stiffness of the elbows, wrists, hips, knees, and feet. People with severe cases are often unable to walk. Clubfoot is a relatively common association. Ponseti treatment can be tried and is often partially successful.<ref name=":1" /> | |||
====Amniotic Band Syndrome==== | ====Amniotic Band Syndrome==== | ||
The cause of amniotic band syndrome is not fully clear, but children with this condition are born with tight skin and soft tissue bands around their limbs, constricting blood and lymph flow and causing swelling. Some cases are associated with clubfoot although in the one illustrated here it is only mild. Treatment of the tight band often involves surgery. If there is a clubfoot associated then Ponseti treatment should only be done with extreme care as blood supply to the foot can be affected and there is a risk of gangrene. These cases are best referred to a centre with surgical experience.<ref name=":1" /> | The cause of amniotic band syndrome is not fully clear, but children with this condition are born with tight skin and soft tissue bands around their limbs, constricting blood and lymph flow and causing swelling. Some cases are associated with clubfoot although in the one illustrated here it is only mild. Treatment of the tight band often involves surgery. If there is a clubfoot associated, then Ponseti treatment should only be done with extreme care as blood supply to the foot can be affected and there is a risk of gangrene. These cases are best referred to a centre with surgical experience.<ref name=":1" /> | ||
====Tibial Agenesis==== | ====Tibial Agenesis==== | ||
Failure in the formation of the tibia. There is a spectrum of presentations from complete absence to a slightly short tibia. In this case there is only a very short tibia and the foot therefore adopts a varus deformity pointing to the midline. This is not a clubfoot deformity even though there is a similarity in the appearance. If there is doubt about the diagnosis, an X-ray should be taken. Treatment is very complicated and many surgeons recommend an amputation with below-knee prosthesis. There is little benefit in starting clubfoot treatment.<ref name=":1" /> | Failure in the formation of the tibia. There is a spectrum of presentations from complete absence to a slightly short tibia. In this case there is only a very short tibia and the foot therefore adopts a varus deformity pointing to the midline. This is not a clubfoot deformity even though there is a similarity in the appearance. If there is doubt about the diagnosis, an X-ray should be taken. Treatment is very complicated and many surgeons recommend an amputation with below-knee prosthesis. There is little benefit in starting clubfoot treatment.<ref name=":1" /> | ||
=== Positional Clubfoot === | === Positional Clubfoot === | ||
Positional related. A foot that at the time of birth has some of the deformity of a clubfoot but which is correctable through simple, pain-free manipulation. In some cases post manipulation the foot can benefit from 1 or 2 Casts to ensure they are maintained in a corrected position although in the majority of cases these feet usually correct well and do not lead to any long lasting, significant impairment.<ref name=":0" /> <ref>Africa Clubfoot Training Project. Chapter 1 Africa Clubfoot Training Basic & Advanced Clubfoot Treatment Provider Courses - Participant Manual. University of Oxford: Africa Clubfoot Training Project, 2017.</ref> | Positional related. A foot that at the time of birth has some of the deformity of a clubfoot but which is correctable through simple, pain-free manipulation. In some cases post manipulation the foot can benefit from 1 or 2 Casts to ensure they are maintained in a corrected position although in the majority of cases these feet usually correct well and do not lead to any long lasting, significant impairment.<ref name=":0" /> <ref>Africa Clubfoot Training Project. Chapter 1 Africa Clubfoot Training Basic & Advanced Clubfoot Treatment Provider Courses - Participant Manual. University of Oxford: Africa Clubfoot Training Project, 2017.</ref> | ||
== Characteristics/Clinical Presentation == | == Characteristics/Clinical Presentation == | ||
The deformity consists of equinus/plantarflexion at the ankle combined with adduction and inversion at the subtalar, midtarsal and anterior tarsal joints<ref name="Ada">Adams, J.C., & Hablen, D.L. (2001). Outline of Orthopaedics. London: Churchill Livingstone.</ref>. Clubfoot can be described as “congenital dislocation of the Talo-Calcaneal-Navicular (TCN) Joint” <ref name="An">Anand, A., & Sala, D.A. (2008). Clubfoot: Etiology and treatment. Indian Journal of Orthopaedics, 42(1), pp. 22-28.</ref>. Further there is an imbalance between the inverter-plantarflexor muscles and the everter-dorsiflexor muscles. The calf and peroneal muscles are usually poorly developed.<ref name="Ada" /> | The deformity consists of equinus/plantarflexion at the ankle combined with adduction and inversion at the subtalar, midtarsal and anterior tarsal joints<ref name="Ada">Adams, J.C., & Hablen, D.L. (2001). Outline of Orthopaedics. London: Churchill Livingstone.</ref>. Clubfoot can be described as “congenital dislocation of the Talo-Calcaneal-Navicular (TCN) Joint” <ref name="An">Anand, A., & Sala, D.A. (2008). Clubfoot: Etiology and treatment. Indian Journal of Orthopaedics, 42(1), pp. 22-28.</ref>. Further there is an imbalance between the inverter-plantarflexor muscles and the everter-dorsiflexor muscles. The calf and peroneal muscles are usually poorly developed.<ref name="Ada" /> | ||
== Diagnosis == | == Diagnosis == | ||
Talipes Equinovarus is usually detected at birth. The examination after birth consists of taking the foot and manipulate it gently to see if it can be brought into normal position. If this examination is positive the condition is considered to be correctable<ref name="Gol">Goldie, B.S. (1992). Orthopaedic Diagnosis and Management. A guide to the care of orthopaedic patients. Oxford: Blackwell Scientific Publications.</ref> | Talipes Equinovarus is usually detected at birth. The examination after birth consists of taking the foot and manipulate it gently to see if it can be brought into normal position. If this examination is positive the condition is considered to be correctable<ref name="Gol">Goldie, B.S. (1992). Orthopaedic Diagnosis and Management. A guide to the care of orthopaedic patients. Oxford: Blackwell Scientific Publications.</ref> | ||
== Prognosis == | == Prognosis == | ||
The prognosis depends mostly on the time the treatment started. When treatment is started within the first week after birth, the chances of healing without relapse in further life are high. Persistence in wearing the abduction bar also contributes to a good prognosis .<ref name="Ada" /> | The prognosis depends mostly on the time the treatment started. When treatment is started within the first week after birth, the chances of healing without relapse in further life are high. Persistence in wearing the abduction bar also contributes to a good prognosis .<ref name="Ada" /> | ||
== Outcome Measures == | == Outcome Measures == | ||
The most common used outcome measure is the scoring system of Pirani. This scoring system assesses the severity of clubfoot deformity and response to treatment<ref name="Doc" />. It has a predictive value concerning the number of casts needed to correct the foot. A high score, 4 or more, predicts the use of at least 4 casts. A score less than 4 predicts the need of 3 or fewer casts. Each component is scored as 0 (normal), 0.5 (mildly abnormal) or 1 (severely abnormal) <ref name="Sta" /> | The most common used outcome measure is the scoring system of Pirani. This scoring system assesses the severity of clubfoot deformity and response to treatment<ref name="Doc" />. It has a predictive value concerning the number of casts needed to correct the foot. A high score, 4 or more, predicts the use of at least 4 casts. A score less than 4 predicts the need of 3 or fewer casts. Each component is scored as 0 (normal), 0.5 (mildly abnormal) or 1 (severely abnormal) <ref name="Sta" /> | ||
== Therapy == | == Therapy == | ||
The Ponseti method is the most common used and known treatment of talipes equinovarus<ref name="Boden" /><ref name="Harnett" /><ref name="Jowe" /><ref name="Doc">Docker, C.E.J., Lewthwaite, S., & Kiely, N.T. (2007). Ponseti treatment in the management of clubfoot deformity – a continuing role for paediatric orthopaedic services in secondary care centres. The Royal College of Surgeons of England, 89, pp. 510-512.</ref><ref name="Suz">Suzann, K.C., Vander Linden, D.W., & Plisano, R.J. (2005). Physical Therapy for Children. Missouri: Elsevier.</ref><ref name="Sta" /> . It consists of a series of manipulations/manual stretchings and immobilisation by plaster casts and abduction bar. The treatment usually starts within one week after birth. The therapist manipulates the foot (or both feet) gently by stretching the tight anatomical structures, i.e. the ligaments of the posterior and medial aspect of the ankle, triceps surae, tibialis posterior, flexor digitorum longus and flexor hallucis longus. When the foot position has obtained a degree of correction that shows progress to the initial situation, a plaster cast is applied and held on for one week. After one week the cast is taken off, the foot is manipulated again and a new cast is applied to correct the position further. This procedure is repeated until the foot position is normal. | The Ponseti method is the most common used and known treatment of talipes equinovarus<ref name="Boden" /><ref name="Harnett" /><ref name="Jowe" /><ref name="Doc">Docker, C.E.J., Lewthwaite, S., & Kiely, N.T. (2007). Ponseti treatment in the management of clubfoot deformity – a continuing role for paediatric orthopaedic services in secondary care centres. The Royal College of Surgeons of England, 89, pp. 510-512.</ref><ref name="Suz">Suzann, K.C., Vander Linden, D.W., & Plisano, R.J. (2005). Physical Therapy for Children. Missouri: Elsevier.</ref><ref name="Sta" /> . It consists of a series of manipulations/manual stretchings and immobilisation by plaster casts and abduction bar. The treatment usually starts within one week after birth. The therapist manipulates the foot (or both feet) gently by stretching the tight anatomical structures, i.e. the ligaments of the posterior and medial aspect of the ankle, triceps surae, tibialis posterior, flexor digitorum longus and flexor hallucis longus. When the foot position has obtained a degree of correction that shows progress to the initial situation, a plaster cast is applied and held on for one week. After one week the cast is taken off, the foot is manipulated again and a new cast is applied to correct the position further. This procedure is repeated until the foot position is normal. | ||
[[File:Ponseti-cast-card1.jpg|thumb]] | [[File:Ponseti-cast-card1.jpg|thumb]] | ||
Revision as of 01:39, 4 August 2017
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Definition/Description[edit | edit source]
Clubfoot, also known as Congenital Talipes Equinovarus, is a congenital deformity of the foot, not an embryonic malformation, that left untreated can limit a person’s mobility by making it difficult and painful to walk. [1] It is defined as a deformity characterized by complex, malalignment of the foot involving soft and bony structures in the hindfoot, midfoot and forefoot [2] It is one of the most common serious congenital abnormalities to affect the foot. Most often it is an isolated abnormality, but occasionally it is associated with other congenital malformations or syndromes.
Epidemiology[edit | edit source]
Clubfoot is more common in males with a 2.5 to 2.8:1 Male:Female ratio.[3] Various incidences have been noted between countries and regions ranging from 1-1.50 per 1000 live births, rising up to 3 per 1000 live births.[3][4][5] Similarly, ethnic differences in occurrence have been reported with the lowest incidence (0.6%) among the Chinese Population, while the highest incidence (6.8%) in the Polynesian Region. The accumulative incidence is approximately 1 per 1000 live births among Caucasians.[6]
Global Burden of Disease[edit | edit source]
If Clubfoot is not treated or managed successfully, it can progress to a severe deformity causing lifelong impairment affecting participation in activities of daily living. As the child grows and puts weight on their feet they will bear weight through the sides, or even the tops of their feet. A large callus of thickened skin forms on the weight-bearing surface and the deformed position causes pain and leaves the feet open to injury and infection.
In an adult, this often means the individual is unable be able to wear normal footwear with most cases experiencing severe restriction in walking by the time they are in their 20's or 30's with visible deformity of the foot. This, in turn, often leads to discrimination and the inability to access education and employment, which further impacts the individual's capacity to contribute economically which may affect both the individual and their family members.
Epidemiology/Etiology[edit | edit source]
The causes of Clubfoot are not clearly understood. Several theories have been proposed to explain the origin of Clubfoot, considering both intrinsic and extrinsic causes, including: intrauterine position of the fetus, mechanical compression or increased hydraulic pressure, interruption in fetal development, viral infections, vascular deficiencies, muscular alterations, neurological alterations, defect in the development of the bones structures and genetic defects.[2][7]
Neurogenic Theory[edit | edit source]
Reduced motor unit, which counts in the distribution of the common peroneal nerve, may be responsible for clinically demonstrable muscle weakness.
Myogenic Theory[edit | edit source]
Suggested by the presence of anomalous muscles, e.g. accessory soleus muscle and flexor digitorum accessorious longus muscles, which can produce equinovarus deformity.
Vascular Theory[edit | edit source]
Diminution of blood flow in the anterior tibial artery and its derivatives.
Embyonic Theory[edit | edit source]
Developmental defect occurring up to 12 weeks of intrauterine life.
Chromosonal Theory[edit | edit source]
Presence of some chromosonal defects in unfertilized germ cells.
Osteogenic Theory[edit | edit source]
Due to some unknown cause, temporary arrest of development occurs in the 7- to 8- week-old embryo, which can lead to clubfoot or other deformities.
Mechanical Block Theory[edit | edit source]
Due to some mechanical obstruction during the intrauterine development period, e.g. intrauterine fibrotic bands, less amniotic fluid, disproportionate uterine cavity, etc, talipes equinovarus can occur.[7]
Summary[edit | edit source]
Researchers who have looked into the causes believe there are both genetic and environmental influences,whereas in some countries and cultures there are different beliefs about what causes a child to be born with Clubfoot. These include include spiritual influences, spells, or curses often leading to mothers being blamed for the deformity. These ideas can cause the child with Clubfoot to be excluded from society, so therefore it is important to explain to families that children with Clubfoot are a valuable part of the community.
Clinically Relevant Anatomy[edit | edit source]
The foot consists of 26 bones. Most relevant for this congenital deformity are the Talus, Calcaneus and Navicular. The Calcaneus and Navicular are medially rotated in relation to the Talus. The foot is held in adduction and inversion by ligaments and muscles. Muscles that are contracted are triceps surae, tibialis posterior, flexor digitorum longus and flexor hallucis longus. Weak peroneal muscles allow the foot to be inverted. The ligaments of the posterior and medial aspect of the ankle are thick and taut.[8].
Type/Classification[edit | edit source]
Not all Clubfeet are the same and it is important that all people treating Clubfoot use the same terms to describe the different types. Each type of clubfoot has unique characteristics and may need specific treatment. Early recognition of the type of clubfoot one is dealing with can help guide appropriate treatment. Although there is no classification system for clubfoot is universally used, clubfoot can be classified according to the nature of the deformity: [9]
Idiopathic Clubfoot[edit | edit source]
Most commonly, Clubfoot is classified as “Idiopathic Clubfoot” meaning there is no known cause for the deformity. In Idiopathic Clubfoot, there can also be a definite hereditary influence, in that if a person has a relative, parent, or sibling has Clubfoot, then they are more likely to have Clubfoot or have a child with it (3-10% chance). Within the group of Idiopathic Clubfeet there is a wide spectrum of impairment depending on severity, as well as whether the Clubfoot has been untreated, partially treated, poorly treated, or successfully treated.[10]
Untreated Clubfoot[edit | edit source]
All clubfeet from birth up to 2 years of age that have had very little or no treatment can be considered as untreated clubfeet.[10]
Treated Clubfoot[edit | edit source]
Untreated clubfeet that have been corrected with Ponseti treatment are termed “treated clubfeet”. Treated clubfeet are usually braced full-time for 3 months and at night up to age 4 or 5 years.[10]
Recurrent Clubfoot[edit | edit source]
This is a Clubfoot which has achieved a good result with Ponseti treatment, but the deformity has recurred. The most common reason is due to abandoning the braces early.[10]
Neglected Clubfoot[edit | edit source]
The Neglected Clubfoot is in a child older than 2 years, where little or no treatment has been performed. The Neglected Clubfoot may respond to Ponseti Treatment, but also may have bony deformity that requires surgical correction.[10]
Complex Clubfoot[edit | edit source]
Any foot with deformity that has received any type of treatment other than the Ponseti method may have added complexity because of additional pathology or scarring from surgery.[10]
Resistant Clubfoot[edit | edit source]
This is a Clubfoot where Ponseti Treatment has been correctly performed but there has been no significant improvement. It is often found that this type of Clubfoot is not in fact idiopathic after all and is secondary or syndromic.[10]
Atypical Clubfoot[edit | edit source]
This is a Clubfoot which involves a foot that is often swollen, has a plantar flexed first metatarsal and an extended big toe. It can occur spontaneously but most often occurs after slippage of a cast.[10]
Secondary or Syndromic Clubfoot[edit | edit source]
Secondary Clubfoot, on the other hand, occurs when there is another disease or condition that is causing or linked to the development of Clubfoot. Such conditions are usually Neurological or Syndromic Disorders such as Arthrogyposis or Spina Bifida.
Spina Bifida[edit | edit source]
A congenital, neurological condition where there is failure of the formation of the bone or skin or both to cover the lower end of the spinal cord and nerves. It is often associated with neurological problems in the legs, and clubfoot. If cases present to the clubfoot clinic it is important to find out what the long-term prognosis is, and whether the child is likely to walk. If the child is likely to survive and walk then it is worth trying Ponseti Clubfoot Treatment. The success rate with simple manipulation is not high and surgery may be considered. Even if the child has a low likelihood of walking the parents might still like to try to get the feet corrected so that shoes can be worn.[11]
Arthrogryposis[edit | edit source]
A congenital condition where the child is born with a number of deformities of the joints. A severe case can have stiffness of the elbows, wrists, hips, knees, and feet. People with severe cases are often unable to walk. Clubfoot is a relatively common association. Ponseti treatment can be tried and is often partially successful.[11]
Amniotic Band Syndrome[edit | edit source]
The cause of amniotic band syndrome is not fully clear, but children with this condition are born with tight skin and soft tissue bands around their limbs, constricting blood and lymph flow and causing swelling. Some cases are associated with clubfoot although in the one illustrated here it is only mild. Treatment of the tight band often involves surgery. If there is a clubfoot associated, then Ponseti treatment should only be done with extreme care as blood supply to the foot can be affected and there is a risk of gangrene. These cases are best referred to a centre with surgical experience.[11]
Tibial Agenesis[edit | edit source]
Failure in the formation of the tibia. There is a spectrum of presentations from complete absence to a slightly short tibia. In this case there is only a very short tibia and the foot therefore adopts a varus deformity pointing to the midline. This is not a clubfoot deformity even though there is a similarity in the appearance. If there is doubt about the diagnosis, an X-ray should be taken. Treatment is very complicated and many surgeons recommend an amputation with below-knee prosthesis. There is little benefit in starting clubfoot treatment.[11]
Positional Clubfoot[edit | edit source]
Positional related. A foot that at the time of birth has some of the deformity of a clubfoot but which is correctable through simple, pain-free manipulation. In some cases post manipulation the foot can benefit from 1 or 2 Casts to ensure they are maintained in a corrected position although in the majority of cases these feet usually correct well and do not lead to any long lasting, significant impairment.[10] [12]
Characteristics/Clinical Presentation[edit | edit source]
The deformity consists of equinus/plantarflexion at the ankle combined with adduction and inversion at the subtalar, midtarsal and anterior tarsal joints[13]. Clubfoot can be described as “congenital dislocation of the Talo-Calcaneal-Navicular (TCN) Joint” [14]. Further there is an imbalance between the inverter-plantarflexor muscles and the everter-dorsiflexor muscles. The calf and peroneal muscles are usually poorly developed.[13]
Diagnosis[edit | edit source]
Talipes Equinovarus is usually detected at birth. The examination after birth consists of taking the foot and manipulate it gently to see if it can be brought into normal position. If this examination is positive the condition is considered to be correctable[15]
Prognosis[edit | edit source]
The prognosis depends mostly on the time the treatment started. When treatment is started within the first week after birth, the chances of healing without relapse in further life are high. Persistence in wearing the abduction bar also contributes to a good prognosis .[13]
Outcome Measures[edit | edit source]
The most common used outcome measure is the scoring system of Pirani. This scoring system assesses the severity of clubfoot deformity and response to treatment[16]. It has a predictive value concerning the number of casts needed to correct the foot. A high score, 4 or more, predicts the use of at least 4 casts. A score less than 4 predicts the need of 3 or fewer casts. Each component is scored as 0 (normal), 0.5 (mildly abnormal) or 1 (severely abnormal) [8]
Therapy[edit | edit source]
The Ponseti method is the most common used and known treatment of talipes equinovarus[3][4][5][16][17][8] . It consists of a series of manipulations/manual stretchings and immobilisation by plaster casts and abduction bar. The treatment usually starts within one week after birth. The therapist manipulates the foot (or both feet) gently by stretching the tight anatomical structures, i.e. the ligaments of the posterior and medial aspect of the ankle, triceps surae, tibialis posterior, flexor digitorum longus and flexor hallucis longus. When the foot position has obtained a degree of correction that shows progress to the initial situation, a plaster cast is applied and held on for one week. After one week the cast is taken off, the foot is manipulated again and a new cast is applied to correct the position further. This procedure is repeated until the foot position is normal.
The manipulations correct first the cavus stance of the foot, then adduction, valgus and at last the equines stance[16] . All components are corrected simultaneously except for the ankle equinus [8]. In severe cases, when plaster casts and manipulation do not obtain the right correction, tenotomy of the achilles tendon is applied to correct the equines stance or other surgical interventions are needed.
After removing the final cast, both feet are held in hyperabduction by a foot abduction brace. The Ponseti bar is to be held on 23 hours a day for three months and afterwards during night till the age of four. The purpose of this final part is to avoid relapse in later life. Although the Ponseti method has good results[3][5][18] , it is a long and intensive treatment. In some developing countries people often have to travel far and long to have a treatment. Most people can’t afford or don’t have time to travel such a distance several times. Therefor an accelerated Ponseti method is applied, where patients are treated within 3 weeks [4].
The French technique involves daily manipulation of the foot for 30 minutes followed by stimulation of the muscles of the foot and lower leg, with the emphasis on the peroneal muscles. The purpose of muscle stimulation is to maintain the correction obtained by manipulation. After manipulation and muscle stimulation taping is applied. The treatment has to be applied daily for two months, followed by three treatments a week for 6 months.
This method gets good results but has decisive disadvantages. The therapy involves too many hospital visits, depends on the manipulation skills of the physical therapist and is costly.[14]
Recent Related Research (from Pubmed)[edit | edit source]
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References[edit | edit source]
- ↑ Amanda Marie De Hoedt, Clubfoot Image Classification, University of Iowa, Iowa Research Online, 2013 [Available from Iowa Research Online /ir.uiowa.edu/etd/4836 http://ir.uiowa.edu/etd/4836]
- ↑ 2.0 2.1 Daniel Augusto Carvalho Maranho, Jose Batista Volpon, Congenital Clubfoot , 2011;19(3):163-9.
- ↑ 3.0 3.1 3.2 3.3 Boden, R.A., Nuttall, G.H., & Paton, R.W. (2011). A 14-year longitudinal comparison study of two treatment methods in clubfoot: Ponseti versus traditional. Acta Orhopaedica Belgica, 77(4), pp. 522-528.
- ↑ 4.0 4.1 4.2 Harnett, P., Freeman, R., Harrison, W.J., Brown, L.C., ; Beckles, V. (2011). An accelerated Ponseti versus the standard Ponseti method. The Journal of Bone ; Joint Surgery, 93, pp. 404-408.
- ↑ 5.0 5.1 5.2 Jowett, C.R., Morcuende, J.A., ; Ramachandran, M. (2011). Management of congenital talipes equinovarus using the Ponseti method. The Journal of Bone & Joint Surgery, 93, pp. 1160-1164.
- ↑ Henrik M. Wallander, Congenital Clubfoot (Aspects on Epidemiology, Residual Deformity and Patient Reported Outcome), ACTA University, 2009.
- ↑ 7.0 7.1 Pandey, S., & Pandey, A.K. (2003). The classification of clubfoot a practical approach. The Foot, 13, pp. 61-65.
- ↑ 8.0 8.1 8.2 8.3 Staheli, L. (2009). Clubfoot: Ponseti Management Third Editon. Seattle: Global Help.
- ↑ Clubfoot,http://emedicine.medscape.com/article/1237077-overview#a4 (accessed 28 June 2017)
- ↑ 10.0 10.1 10.2 10.3 10.4 10.5 10.6 10.7 10.8 Africa Clubfoot Training Project. Chapter 2 Africa Clubfoot Training Basic & Advanced Clubfoot Treatment Provider Courses - Participant Manual. University of Oxford: Africa Clubfoot Training Project, 2017.
- ↑ 11.0 11.1 11.2 11.3 Africa Clubfoot Training Project. Chapter 15 Africa Clubfoot Training Basic & Advanced Clubfoot Treatment Provider Courses - Participant Manual. University of Oxford: Africa Clubfoot Training Project, 2017.
- ↑ Africa Clubfoot Training Project. Chapter 1 Africa Clubfoot Training Basic & Advanced Clubfoot Treatment Provider Courses - Participant Manual. University of Oxford: Africa Clubfoot Training Project, 2017.
- ↑ 13.0 13.1 13.2 Adams, J.C., & Hablen, D.L. (2001). Outline of Orthopaedics. London: Churchill Livingstone.
- ↑ 14.0 14.1 Anand, A., & Sala, D.A. (2008). Clubfoot: Etiology and treatment. Indian Journal of Orthopaedics, 42(1), pp. 22-28.
- ↑ Goldie, B.S. (1992). Orthopaedic Diagnosis and Management. A guide to the care of orthopaedic patients. Oxford: Blackwell Scientific Publications.
- ↑ 16.0 16.1 16.2 Docker, C.E.J., Lewthwaite, S., & Kiely, N.T. (2007). Ponseti treatment in the management of clubfoot deformity – a continuing role for paediatric orthopaedic services in secondary care centres. The Royal College of Surgeons of England, 89, pp. 510-512.
- ↑ Suzann, K.C., Vander Linden, D.W., & Plisano, R.J. (2005). Physical Therapy for Children. Missouri: Elsevier.
- ↑ Gurnett, C.A., Boehm, S., Connolly, A., Reimschisel, T., & Dobbs, M.B. (2008). Impact of congenital talipes equinovarus etiology on treatment outcomes. Developmental Medicine & Child Neurology, 50, pp. 498-502.
