Clubfoot
Clubfoot is a term used to describe a foot deformity in newborns. The name is derived from the appearance of an untreated adult foot, which resembles a club. Typically, the foot is turned inward and downward.
It affects both feet in half of all patients.
Several types of clubfeet exist. A positional clubfoot is one where the foot has the characteristic appearance but is quite flexible, secondary to in-utero crowding and not abnormal development. This is the mildest and most easily treated form. The most common form of a clubfoot is the idiopathic variety. “Idiopathic” means that we do not know the cause. A teratologic clubfoot is a more severe form and is associated with a known neuromuscular abnormality like spina bifida.
Although a clubfoot gene has not been identified, there is increased risk with a positive family history. Twenty four percent of individuals with a clubfoot have a positive family history. If there is a first degree relative in the family with a clubfoot, then the odds are 17 times higher than normal that another member of the family has a clubfoot. If a second degree relative has a clubfoot, then the odds are 6 times higher than normal. If a parent has a clubfoot, the chances are 1 in 4 that their children will have a clubfoot.
The true cause of an idiopathic clubfoot is unknown. There are, however, associations that have been made. Mechanical factors and “packing problems” are associated with positional clubfeet but there is considerable debate regarding the importance of crowding in idiopathic clubfeet. Since a clubfoot develops during the first trimester of the pregnancy and there are reports of clubfoot deformity in very young fetuses, it seems clear that there is more involved than simple crowding. Current theories regarding the cause of a clubfoot include arrest of normal development, vascular, muscular and histologic anomalies.
A clubfoot is diagnosed by its appearance. Radiographs may be necessary to evaluate for other foot and leg conditions that can be confused or accompany a clubfoot, but are generally not necessary to make the diagnosis. Radiographs can be used to help guide treatment and the need for surgery. A clubfoot is typically curved along the outside border of the foot and may have deep creases along the middle and back of the foot. The foot and calf are smaller than the other side and the difference in foot length and calf size will continue throughout life and generally causes no functional deficit. There are numerous classifications schemes for clubfeet, but they are unreliable and not very useful as a guide to treatment.
Treatment of a clubfoot begins as soon as the condition is diagnosed. Positional clubfeet may be observed or a stretching program can be used. The initial treatment for the vast majority of clubfeet is serial casting. The foot is stretched for a short period of time in the office and then the foot is held in an improved position with a cast. Fiberglass and plaster casts can be used. The casts include the entire foot and go up to the thigh with the knee bent. The cast is changed frequently, generally once a week, in order to take advantage of a young tissue’s ability to stretch quickly. Fiberglass casts can easily be removed without tools in the office, while plaster cast can be soaked off at home in water or removed with a cast saw. The process is then repeated until the foot is corrected or can no longer be improved with casting alone.
There are several methods of stretching and casting. Our preferred method is the Ponseti method developed by Dr. I. Ponseti at the University of Iowa. Using this method, a typical clubfoot requires 5 or 6 casts to correct. Roughly 15% of clubfeet can be fully corrected with casting alone. The remainder of the feet are often tight in the back of the ankle restricting full motion and are treated with an Achilles tenotomy. The tenotomy can be done in the office with local anesthesia or in the operating room under general anesthesia. It involves a very small incision just above the heel which completely cuts the tight Achilles tendon. The foot is then stretched and another cast is applied. This final cast is worn for 3 weeks allowing the tendon to heal in an elongated position.
Once the foot is fully corrected, it is maintained in an abduction orthosis, or Dennis-Browne Bar. The shoes and bar are worn for 3 months full time, then part time for another 3 months and then at nighttime until the children are 3 years of age. The purpose of the bar is to prevent a recurrence of the deformity and its use is critical to a success. Children generally tolerate the bars and shoes well. Initially they need to be shown how to kick both feet at the same time and most adapt very well to them after 1 or 2 days. Since the bar is only used at nighttime after around 9 months of age, there is no delay in crawling, walking or development. Around 5% of clubfeet recur during or after the bracing period. Occasionally a previously treated clubfoot will tighten up and require a brief period of additional casting.
Some clubfeet will not fully correct with stretching, casting, manipulations or other non-operative methods. For these resistant feet, surgery is recommended, typically around 6 months of age. A variety of “releases” are used to loosen up tight tendons, ligaments and joint capsules which then allows the bones to move into proper alignment. Pins are generally used to help hold the bones in proper alignment as the soft tissues heal in the cast. A cast above the knee is used for 6 weeks at which point the pins can be removed and another cast below the knee is used for another 6 weeks. After surgery, most feet do not need braces.
If a clubfoot has been well corrected either with casting or with surgery, then the child should be able to lead a healthy, active life without the need for special shoes, inserts or braces. The affected foot will be a little shorter in length, generally ½ shoe size, than the other foot and the calf will be slightly smaller in circumference. Long term studies have shown around 85% good results well into adult life with casting and with surgery.
As more and more long term studies are completed, there seems to be a slightly better outcome in feet treated with casting, minor surgery and bracing than with feet treated with formal “releases”. The stretched feet are less painful, more mobile and less disabling than surgically treated feet. This difference between the two techniques is not apparent until 30-40 years after treatment and has lead to a recent change among many pediatric orthopaedists favoring the Ponseti method. It is important to remember, however, that some feet cannot be fully corrected with this method and may require a formal “release”.
Here are just a couple of individuals who have had success with a history of clubfoot. Kristi Yamaguchi, 1992 Olympic Figure Skating Gold Medalist was born with bilateral clubfeet. Troy Aikman, former Dallas Cowboys Quarterback and two-time Super Bowl champion also had bilateral clubfeet. Mia Hamm, US Women’s Soccer Female Athlete of the Year from 1994-96, and actors Damon Wayans and Dudley Moore all had a clubfoot.