Clubfoot, also known as congenital talipes equinovarus (CTEV), or talipes equinovarus (TEV), is a congenital deformity of the foot that occurs in about 150,000-200,000 babies each year worldwide. It is about twice as common in boys and occurs in both feet about 50% of the time. Clubfoot results from the abnormal development of the muscles, tendons, and bones in the foot while the fetus is forming during pregnancy. While researchers have been unable to pinpoint the exact cause of clubfoot, both genetic and environmental factors are thought to play a role. Not only is the foot "clubbed", but if only one foot is involved, the clubfoot will be shorter, the leg will be shorter, and the calf muscle itself will be thinner.
The clubfoot consists of 4 major features that are pictured below:
- Cavus of the midfoot - high arch to the foot
- Adductus of the forefoot - front part of foot turned in
- Varus of the hindfoot - heel is turned in
- Equinus of the hindfoot - entire foot is pointing down
A clubfoot is often an isolated finding, meaning, that your child will otherwise be healthy. There are many famous athletes that were born with clubfeet including Troy Aikman (NFL football) and Kristi Yamaguchi (Professional and Olympic Figure Skater). There are other times; however, when clubfeet can be associated with other medical conditions, such as arthrogryposis or spina bifida. These types of medical conditions are often diagnosed pre-natally as well (before your child is born).
Without treatment, a child will likely have pain, difficulty with walking and difficulty with wearing shoes. Clubfoot is most often recognized at the time of birth, and often times is detected on a prenatal ultrasound. The cause of clubfoot is not exactly known.
Treatment should ideally be started soon after birth, but treatment can be affective in older children as well. The gold standard for treatment is the Ponseti Method
Ponseti Method (Preference of COA)
- Corrective Phase: The major principle behind the Ponseti Method is the idea that the tissues of a newborn's foot, including tendons, ligaments, joint capsules, and bones, will respond to gentle manipulation followed by casting of the feet at weekly intervals. By applying this Ponseti Method to the clubfoot within the first few weeks of life, most can be successfully corrected without the need for major reconstructive surgery. The feet undergo weekly gentle stretching followed by long leg casting with the knee at 90 degrees. The child's normal movements while in the cast allow for further stretching in subsequent visits. Up to 15% of clubfeet will be fully corrected using this method alone with the rest requiring an Achilles tendon release (to correct the hindfoot equinus) for final full correction. The Achilles tendon release is performed under general anesthesia . Following the Achilles tendon surgery, your child will be placed back in a cast for three weeks to allow the tendon to heal.
- Maintenance Phase: Following full correction your child will be required to wear a foot abduction bar and shoes brace to maintain the correction and prevent recurrence. The most commonly prescribed brace at COA are Mitchell shoes. Initially, most children will wear this brace nearly full time (23 hours per day) for the first three months. Following this period, then your child will wear the brace during naptime and at nights until the age of 4. Without wearing these corrective shoes, the risk for recurrence is extremely high, especially in the first two years.
For a small percentage of patients, casting may not be effective, and surgery is therefore recommended to acheive correction. Surgical treatment may be extensive and require release of soft tissues and joint contractures as well as tendon lengthening and temporary pin fixation of joints in the foot. Prognosis varies based on type and extent of surgery. Your COA surgeon will be able to discuss the details of these surgeries with you if such treatment is recommended.
With early treatment, most children, even with severe clubfeet can grow up to wear regular shoes, take part in sports and lead full, active lives. However, in those cases where only one foot is involved, the affected foot is generally 1 to 1 1/2 shoe sizes smaller than the unaffected one, the leg is shorter, and the calf appears slightly thinner. The differences do no impact on function.