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'{{Other uses}} {{Infobox medical condition (new) | name = Clubfoot | synonyms = Clubfoot, congenital talipes equinovarus (CTEV)<ref name=Gib2013/> | image = Pied bot, varus équin (bilateral).jpg | caption = Bilateral clubfoot | pronounce = | field = [[Orthopedics]] | symptoms = Foot that is rotated inwards<ref name=Gib2013/> | complications = | onset = During early pregnancy<ref name=Gib2013/> | duration = | types = | causes = Unknown<ref name=Gib2013/> | risks = [[Genetics]], mother who smokes<ref name=Gib2013/> | diagnosis = Examination, [[ultrasound]]<ref name=Gib2013/><ref name=Dob2009/> | differential = [[Metatarsus adductus]]<ref>{{cite web|last1=Moses|first1=Scott|title=Clubfoot|url=http://www.fpnotebook.com/Ortho/Peds/Clbft.htm|website=www.fpnotebook.com|accessdate=15 October 2017|language=en|deadurl=no|archiveurl=https://web.archive.org/web/20171015150501/http://www.fpnotebook.com/Ortho/Peds/Clbft.htm|archivedate=15 October 2017|df=}}</ref> | prevention = | treatment = [[Ponseti method]] (manipulation, casting, cutting the [[Achilles tendon]], braces), surgery<ref name=Gib2013/> | medication = | prognosis = Good with treatment<ref name=Dob2009/> | frequency = 1 in 1,000<ref name=Dob2009>{{cite journal|last1=Dobbs|first1=Matthew B.|last2=Gurnett|first2=Christina A.|title=Update on clubfoot: etiology and treatment|journal=Clinical Orthopaedics and Related Research|date=18 February 2009|volume=467|issue=5|pages=1146–1153|doi=10.1007/s11999-009-0734-9|pmid=19224303|issn=1528-1132}}</ref> | deaths = }} <!-- Definition and symptoms --> '''Clubfoot''' is a [[birth defect]] where one or both feet are [[supinated|rotated inwards]] and [[plantar flexion|downwards]].<ref name=Gib2013/><ref>{{cite web|title=Talipes equinovarus|url=https://rarediseases.info.nih.gov/diseases/5112/talipes-equinovarus|website=Genetic and Rare Diseases Information Center (GARD)|accessdate=15 October 2017|language=en|date=2017|deadurl=no|archiveurl=https://web.archive.org/web/20171015145904/https://rarediseases.info.nih.gov/diseases/5112/talipes-equinovarus|archivedate=15 October 2017|df=}}</ref> The affected foot, calf, and leg may be smaller than the other.<ref name=Gib2013/> In about half of those affected, both feet are involved.<ref name=Gib2013/> Most cases are not associated with other problems.<ref name=Gib2013/> Without treatment, people walk on the sides of their feet which causes issues with walking.<ref name=Dob2009/> <!-- Cause and diagnosis --> The exact cause is usually unclear.<ref name=Gib2013/> A few cases are associated with [[distal arthrogryposis]] or [[myelomeningocele]].<ref name=Dob2009/> If one [[identical twin]] is affected there is a 33% chance the other one will be as well.<ref name=Gib2013/> Diagnosis may occur at birth or before birth during an [[ultrasound]] exam.<ref name=Gib2013/><ref name=Dob2009/> <!-- Treatment --> Initial treatment is most often with the [[Ponseti method]].<ref name=Gib2013/> This involves moving the foot into an improved position followed by [[orthopedic casting|casting]], which is repeated at weekly intervals.<ref name=Gib2013>{{cite journal|last1=Gibbons|first1=PJ|last2=Gray|first2=K|title=Update on clubfoot.|journal=Journal of paediatrics and child health|date=September 2013|volume=49|issue=9|pages=E434-7|doi=10.1111/jpc.12167|pmid=23586398}}</ref> Once the inward bending is improved, the [[Achilles tendon]] is often cut and [[orthotics|braces]] are worn until the age of four.<ref name=Gib2013/> Initially the brace is worn nearly continuously and then just at night.<ref name=Gib2013/> In about 20% of cases further surgery is required.<ref name=Gib2013/> <!-- Epidemiology and culture --> It occurs in about one in 1,000 newborns.<ref name=Dob2009/> The condition is less common among Chinese and more common among [[Māori people|Maori]].<ref name=Dob2009/> Males are affected about twice as often as females.<ref name=Gib2013/> Treatment can be carried out by a range of healthcare providers and can generally be achieved in the [[developing world]] with few resources.<ref name=Gib2013/> ==Cause== There are many hypotheses about how clubfoot develops, involving environmental factors, genetics, or a combination of both. No study has pinpointed the root cause, but most findings agree that "it is likely there is more than one different cause and at least in some cases the phenotype may occur as a result of a threshold effect of different factors acting together."<ref name=Miedzybrodzka2003>{{cite journal|last1=Miedzybrodzka|first1=Z|title=Congenital talipes equinovarus (clubfoot): a disorder of the foot but not the hand.| journal=Journal of Anatomy| date=January 2003| volume=202| issue=1| pages=37–42| pmid=12587918| doi=10.1046/j.1469-7580.2003.00147.x| pmc=1571059}}</ref> Some researchers hypothesize, from the early development stages of humans, that clubfoot is formed by a malfunction during gestation. Early amniocentesis (11–13 wks) is believed to increase the rates of this deformity because there is an increase in possible amniotic leakage from the procedure.{{citation needed|date=August 2015}} Underdevelopment of the bones and muscles in the embryonic foot may be another underlying cause. Underdevelopment prevents the fetus's foot from rotating medially, leaving it in the club formation after birth. It was widely believed in the early 1900s that constriction of the foot by the uterus contributed to clubfoot.{{citation needed|date=August 2015}} Underdevelopment of the bones also affects the muscles and tissues of the foot. Abnormality in the connective tissue causes "the presence of increased fibrous tissue in muscles, fascia, ligaments and tendon sheaths".<ref name=Miedzybrodzka2003/> Affected individuals have smaller than normal legs even after corrected. ===Genetics=== Mutations in genes involved in muscle development are risk factors for clubfoot, specifically those encoding the muscle contractile complex (MYH3, TPM2, TNNT3, TNNI2, and MYH8). These can cause congenital contractures, including clubfoot, in distal [[arthrogryposis]] (DA) syndromes.<ref name=Weymouth2011>{{cite journal|last1=Weymouth|first1=KS|last2=Blanton|first2=SH|last3=Bamshad|first3=MJ|last4=Beck|first4=AE|last5=Alvarez|first5=C|last6=Richards|first6=S|last7=Gurnett|first7=CA|last8=Dobbs|first8=MB|last9=Barnes|first9=D|last10=Mitchell|first10=LE|last11=Hecht|first11=JT|title=Variants in genes that encode muscle contractile proteins influence risk for isolated clubfoot.|journal=American Journal of Medical Genetics Part A|date=September 2011|volume=155A|issue=9|pages=2170–9|pmid=21834041|doi=10.1002/ajmg.a.34167|pmc=3158831}}</ref> Clubfoot can also be present in people with genetic conditions such as [[Loeys-Dietz syndrome]]. Genetic mapping and the development of models of the disease have improved understanding of developmental processes. Its inheritance pattern is explained as a heterogenous disorder using a polygenic threshold model. The PITX1-TBX4 transcriptional pathway has become key to the study. PITX1 and TBX4 are uniquely expressed in the hind limb.<ref name=Dobbs2012>{{cite journal|last1=Dobbs|first1=MB|last2=Gurnett|first2=CA|title=Genetics of clubfoot.|journal=Journal of pediatric orthopedics. Part B|date=January 2012|volume=21|issue=1|pages=7–9|pmid=21817922|doi=10.1097/BPB.0b013e328349927c|pmc=3229717}}</ref> ==Diagnosis== Diagnosis of clubfoot deformity is by physical examination. Typically, a baby is examined shortly after delivery with a head to toe assessment. Examination of the foot reveals the deformity, which may affect one foot or both. Examination of the foot shows four components of deformity. * First, there is an increased arch on the inside of the foot. This component of the deformity can occur without the other aspects of clubfoot deformity. In isolation, this aspect of the deformity is called cavus deformity. * Second, the forefoot is curved medially (toward the big toe). This component of the deformity can occur without the other aspects of clubfoot deformity. In isolation, this aspect of the deformity is called metatarsus adductus. * Third, the heel is turned inward. This is a natural motion of the heel and subtalar joint, typically referred to as inversion. In clubfoot deformity, the turning in (inversion) of the heel is fixed (not passively correctable) and considered a varus deformity. * Fourth, and finally, the ankle is pointed downward. This is a natural motion of the ankle referred to as plantar flexion. In clubfoot deformity, this position is fixed (not correctable) and is referred to as equinus deformity. A foot that shows all four components are diagnosed as having clubfoot deformity. These four components of a clubfoot deformity can be remembered with the acronym CAVE (cavus, forefoot adductus, varus, and equinus). The severity of the deformity can also be assessed on physical exam, but is subjective to quantify. One way to assess severity is based on the stiffness of the deformity or how much it can be corrected with manual manipulation of the foot to bring it into a corrected position. Other factors used to assess severity include the presence of skin creases in the arch and at the heel and poor muscle consistency. In some cases, it may be possible to detect the disease prior to birth during a prenatal [[Obstetric ultrasonography|ultrasound]]. Prenatal diagnosis by ultrasound can allow parents the opportunity to get information about this condition and make plans for treatment after the baby is born.<ref name="mayoclinic.org">AskMayoExpert & et al. Can clubfoot be diagnosed in utero? Rochester, Minn.: Mayo Foundation for Medical Education and Research; 2012. {{cite web |url=http://www.mayoclinic.org/diseases-conditions/clubfoot/basics/definition/con-20027211 |title=Archived copy |accessdate=2014-08-13 |deadurl=no |archiveurl=https://web.archive.org/web/20140708173258/http://www.mayoclinic.org/diseases-conditions/clubfoot/basics/definition/con-20027211 |archivedate=2014-07-08 |df= }}</ref> Other testing and imaging is usually not needed. Testing may be needed if there are concerns for other associated conditions. == Treatment == [[File:Pieds bot varus équin, en cours de correction.jpg|thumb|right|Clubfeet in the course of correcting]] Treatment is usually with some combination of the [[Ponseti method|Ponseti]] or French methods.<ref name=Dob2009/> The Ponseti method includes the following: [[orthopedic casting|casting]] together with manipulation, cutting the [[Achilles tendon]], and bracing. The Ponseti method has been found to be effective in correcting the problem in those under the age of two.<ref>{{cite journal|last1=Ganesan|first1=B|last2=Luximon|first2=A|last3=Al-Jumaily|first3=A|last4=Balasankar|first4=SK|last5=Naik|first5=GR|title=Ponseti method in the management of clubfoot under 2 years of age: A systematic review.|journal=PLoS ONE|date=2017|volume=12|issue=6|pages=e0178299|doi=10.1371/journal.pone.0178299|pmid=28632733}}</ref> The French method involves realignment and tapping of the foot is often effective but requires a lot of effort by caregivers.<ref name=Dob2009/> Another technique known as Kite does not appear as good.<ref>{{cite journal|last1=Gray|first1=K|last2=Pacey|first2=V|last3=Gibbons|first3=P|last4=Little|first4=D|last5=Burns|first5=J|date=Aug 12, 2014|title=Interventions for congenital talipes equinovarus (clubfoot).|journal=The Cochrane database of systematic reviews|volume=8|pages=CD008602|doi=10.1002/14651858.CD008602.pub3|pmid=25117413}}</ref> In about 20% of cases further surgery is required.<ref name=Gib2013/> === Ponseti method === [[File:Botas.JPG|thumb|A foot abduction brace type Denis Browne bar. Various types of foot-abduction braces are used to hold the child's feet in the desired position.]] {{Main|Ponseti method}} With the Ponseti method the foot deformity is corrected in stages, by manipulating the foot to an improved position and then holding it with a long leg cast. The cast is removed after a week, and the foot is manipulated again. The foot position usually improves over a course of 4-6 casts. * The initial cast focuses on aligning the forefoot with the hindfoot as Ponseti describes the forefoot as relatively pronated in comparison to the hindfoot. Supinating the forefoot and elevating the first metatarsal improves this alignment. * Subsequent casts are applied after stretching the foot with a focus on abducting the forefoot with lateral pressure at the talus, to bring the navicula laterally and improve the alignment of the talonavicular joint. In contrast to the Kite Method of casting, it is important to avoid constraining the calcanocuboid joint. With each additional cast, the abduction is increased and this moves the hindfoot from varus into valgus. It is important to leave the ankle in equinus until the forefoot and hindfoot are corrected. * The final stage of casting, is to correct the equinus. After fully abducting the forefoot with spontaneous correction of the hindfoot, an attempt is made to bring the ankle up and into dorsiflexion. For the majority of children, the equinus will not fully correct with casting and a procedure is done to facilitate this final aspect of the deformity correction. The procedure is a percutaneous heel cord release or [[Tenotomy]]. Ponseti advocated for doing this in the clinic with a local anesthetic. For safety reasons, many centers perform this procedure with sedation or monitored anesthesia care. In this procedure, numbing medicine is applied, the skin is cleansed, and a small scalpel is used to divide the Achilles tendon. With a small scalpel there is minimal bleeding and no need for stitches. A small dressing is applied and a final clubfoot cast is applied with the foot in a fully corrected position. This cast is typically left in place for 3 weeks. After correction has been achieved with casting, maintenance of correction starts with full-time (23 hours per day) use of a brace —also known as a foot abduction brace (FAB)—on both feet, regardless of whether the TEV is on one side or both, typically full-time for 3 months. After 3 months, brace wear is decreased and used mostly when sleeping for naps and at night-time. This part-time bracing is recommended until the child is 4 years of age. Roughly 30% of children will have recurrence. A recurrence can usually be managed with repeating the casting process. Recurrence is more common when there is poor compliance with the bracing, because the muscles around the foot can pull it back into the abnormal position. Approximately 20% of infants successfully treated with the Ponseti casting method will have an imbalance between the muscles that invert the ankle (posterior tibialis and anterior tibialis muscles) and the muscles that evert the ankle (peroneal muscles). Patients with this imbalance are more prone to recurrence. After 18 months of age, this can be addressed with surgery to transfer the anterior tibialis tendon from it medial attachment (the navicula) to a more lateral position (the lateral cuneiform) to rebalance these muscle forces. While this requires a general anesthetic and subsequent casting while the tendon heals, it is a relatively minor surgery that corrects a persistent muscle imbalance while avoiding disturbance to the joints of the foot. === French Method === The French Method can also be called the French Functional Method or the French Physiotherapy Method. The French Method often is another non-surgical option to treat clubfoot. The French Method first came to the United States in 1996 <ref>Faulks, S., Richards, B. S (2009). Clubfoot treatment: Ponseti and French Functional Methods are equally effective. ''Clin Orthop Relat Res, 467''(5), doi: 10.1007/s11999-009-0754-5''''</ref>. Physical Therapists perform this method by using stretching of the tightened muscles and tissues, using functional electrical stimulation and other exercises to strengthen muscles, combined with taping and splinting of muscles to help realign the clubfoot. A lot of children who have clubfoot have been treated with the combined use of the Ponseti and French methods with relatively high success. Combining these two methods together can delay or eliminate the need or surgical interventions. Physical Therapists can perform both of the above listed methods. Success using these methods is typically seen in Physical Therapists who perform either one or both of the methods. === Surgery === {{Refimprove section|date=December 2009}} If non-operative treatments are unsuccessful or achieve incomplete correction of the deformity, surgery is sometimes needed. Surgery was more common prior to the widespread acceptance of the Ponseti Method. The extent of surgery depends on the severity of the deformity. Usually, surgery is done at 9 to 12 months of age and the goal is to correct all the components of the clubfoot deformity at the time of surgery. For feet with the typical components of deformity (cavus, forefoot adductus, hindfoot varus, and ankle equinus), the typical procedure is a Posteromedial Release (PMR) surgery. This is done through an incision across the medial side of the foot and ankle, that extends posteriorly, and sometimes around to the lateral side of the foot. In this procedure, it is typically necessary to release (cut) or lengthen the plantar fascia, several tendons, and joint capsules/ligaments. Typically, the important structures are exposed and then sequentially released until the foot can be brought to an appropriate plantigrade position. Specifically, it is important to bring the ankle to neutral, the heel into neutral, the midfoot aligned with the hindfoot (navicula aligned with the talus, and the cuboid aligned with the calcaneus). Once these joints can be aligned, thin wires are usually placed across these joints to hold them in the corrected position. These wires are temporary and left out through the skin for removal after 3–4 weeks. Once the joints are aligned, tendons (typically the Achilles, posterior tibialis, and flexor halluces longus) are repaired at an appropriate length. The incision (or incisions) are closed with dissolvable sutures. The foot is then casted in the corrected position for 6–8 weeks. It is common to do a cast change with anesthesia after 3–4 weeks, so that pins can be removed and a mold can be made to fabricate a custom AFO brace. The new cast is left in place until the AFO is available. When the cast is removed, the AFO is worn to prevent the foot from returning to the old position.<ref name="mayoclinic.org" /> For feet with partial correction of deformity with non-operative treatment, surgery may be less extensive and may involve only the posterior part of the foot and ankle. This might be called a posterior release. This is done through a smaller incision and may involve releasing only the posterior capsule of the ankle and subtalar joints, along with lengthening the Achilles tendon. Surgery leaves residual scar tissue and typically there is more stiffness and weakness than with nonsurgical treatment. As the foot grows, there is potential for asymmetric growth that can result in recurrence of foot deformity that can affect the forefoot, midfoot, or hindfoot. Many patients do fine, but some require orthotics or additional surgeries. Long-term studies of adults with post-surgical clubfeet, especially those needing multiple surgeries, show that they may not fare as well in the long term, according to Dobbs, et al.<ref>{{cite journal|last=Dobbs|first=Matthew B.|author2=Nunley, R |author3=Schoenecker, PL |title=Long-Term Follow-up of Patients with Clubfeet Treated with Extensive Soft-Tissue Release|journal=The Journal of Bone & Joint Surgery (American)|date=May 2006|volume=88|issue=5|pages=986–96|doi=10.2106/JBJS.E.00114|pmid=16651573}}</ref> Some patients may require additional surgeries as they age, though there is some dispute as to the effectiveness of such surgeries, in light of the prevalence of scar tissue present from earlier surgeries. ==History== Treatment of clubfoot is evident as early as Egyptian paintings. In early days,{{when|date=May 2014}} the foot was manipulated with a [[Thomas wrench]] and casting which caused fracture of several bones in the foot. Hippocrates around 400 B.C. was the first to offer a medical explanation. ==Society and culture== [[File:José de Ribera 017.jpg|thumb|The club-foot, by [[José de Ribera]], in fact, a [[hemiplegia]]<ref>Franck Fitoussi et Olivier Meslay, [http://cartelfr.louvre.fr/pub/fr/pdf/31924_mois120.pdf Un regard médicla sur le Piedbot, en collaboration avec l'hôpital Robert Debré] {{webarchive|url=https://web.archive.org/web/20160303185716/http://cartelfr.louvre.fr/pub/fr/pdf/31924_mois120.pdf |date=2016-03-03 }} sur le site [http://cartelfr.louvre.fr cartelfr.louvre.fr] {{webarchive|url=https://web.archive.org/web/20121105200054/http://cartelfr.louvre.fr/ |date=2012-11-05 }}</ref>]] [[File:Nätti-Jussi.jpg|thumbnail|Famous storyteller from [[Lapland (Finland)|Lapland]]. Juho "[[Nätti-Jussi]]" Nätti (surname can be translated as "pretty") who lived 1890-1964, was known for his stories but also his untreated left clubfoot. A story tells that "not even the devil himself could tell which way Nätti has gone" from the footprints on snow.]] ===Literature=== *The main character, Philip Carey, in [[W. Somerset Maugham]]'s novel ''[[Of Human Bondage]]'', has a clubfoot, a central theme in the work. *Hippolyte Tautain, the stable man at the Lion D'Or public house in [[Gustave Flaubert]]'s novel ''[[Madame Bovary]]'' is unsuccessfully treated for clubfoot by Charles Bovary, leading to the eventual amputation of his leg. *Charlie Wilcox, the main character in Sharon McKay's novel ''[[Charlie Wilcox]]'' had a clubfoot. *In [[Yukio Mishima]]'s seminal novel ''[[The Temple of the Golden Pavilion]]'' the character Kashiwagi has clubfoot which parallels the stutter of the main character, Mizoguchi. *In [[David Eddings]]' ''[[Malloreon]]'' series, Senji the sorcerer has a clubfoot. *In [[Caroline Lawrence]]'s ''Roman Mysteries'' series, a character called Vulcan the blacksmith appears in the book "The Secrets of Vesuvius". He reveals that he gained the nickname because of his clubfoot. *In [[Bernard Cornwell]]'s ''[[The Warlord Chronicles]]'' Mordred, King of Dumnonia, has a clubfoot that is often used as a symbol for his ugliness and weakness as a ruler. *In [[Daniel Keyes]]'s ''[[Flowers for Algernon]]'' Gimpy, one of Charlie's co-workers at the bakery, has a clubfoot. * In ''[[Perfume: The Story of a Murderer]]'', the main character is born with a clubfoot and is described as having a limp throughout the novel. *In [[Flannery O'Connor]]'s short story "[[The Lame Shall Enter First]]", the character Johnson has a clubfoot, a major symbol within the story. {{-}} ==References== {{reflist}} == External links == {{Medical resources | DiseasesDB = 29395 | ICD10 = {{ICD10|M|21|5|m|20}}, {{ICD10|Q|66|8|q|65}} | ICD9 = {{ICD9|736.71}}, {{ICD9|754.5}}-{{ICD9|754.7}} | ICDO = | OMIM = 119800 | MedlinePlus = 001228 | eMedicineSubj = radio | eMedicineTopic = 177 | eMedicine_mult = {{eMedicine2|orthoped|598}} | MeshID = D003025 }} {{Acquired deformities}} {{Congenital malformations and deformations of musculoskeletal system}} {{DEFAULTSORT:ClubFoot}} [[Category:Congenital disorders of musculoskeletal system]] [[Category:Arthropathies]] [[Category:RTT]]'