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'{{short description|Bone development disease}} {{Other uses}} {{Use mdy dates|date=September 2021}} {{Infobox medical condition (new) | name = Clubfoot | synonyms = Clubfeet, congenital talipes equinovarus (CTEV)<ref name=Gib2013/> | image = Pied bot, varus équin (bilateral).jpg | caption = Bilateral clubfeet | pronounce = | field = [[Orthopedics]], [[podiatry]] | symptoms = Foot that is rotated inwards and downwards<ref name=NIH2017/> | complications = | onset = During early pregnancy<ref name=Gib2013/> | duration = | types = | causes = Unknown<ref name=Gib2013/> | risks = [[Genetics]], [[Smoking and pregnancy|mother who smokes cigarettes]], males,<ref name=Gib2013/> ethnicity | diagnosis = [[Physical examination]], [[prenatal ultrasound|ultrasound during pregnancy]]<ref name=Gib2013/><ref name=Dob2009/> | differential = [[Metatarsus adductus]]<ref>{{cite web| vauthors = Moses S |title= Clubfoot |url= http://www.fpnotebook.com/Ortho/Peds/Clbft.htm|website=www.fpnotebook.com|access-date=15 October 2017|language=en|url-status=live|archive-url=https://web.archive.org/web/20171015150501/http://www.fpnotebook.com/Ortho/Peds/Clbft.htm|archive-date=15 October 2017}}</ref> | prevention = | treatment = [[Ponseti method]] (manipulation, casting, cutting the [[Achilles tendon]], braces), French method, surgery<ref name=Gib2013/><ref name=Dob2009/> | medication = | prognosis = Good with proper treatment<ref name=Dob2009/> | frequency = 1 in 1,000 <ref name=Dob2009/> | deaths = | alt = }} <!-- Definition and symptoms --> '''Clubfoot''' is a [[congenital]] or acquired defect where one or both feet are [[supinated|rotated inward]] and [[plantar flexion|downward]].<ref name=Gib2013>{{cite journal | vauthors = Gibbons PJ, Gray K | title = Update on clubfoot | journal = Journal of Paediatrics and Child Health | volume = 49 | issue = 9 | pages = E434–E437 | date = September 2013 | pmid = 23586398 | doi = 10.1111/jpc.12167 | s2cid = 6185031 }}</ref><ref name=NIH2017>{{cite web |title=Talipes equinovarus |url=https://rarediseases.info.nih.gov/diseases/5112/talipes-equinovarus |website=Genetic and Rare Diseases Information Center (GARD) |access-date=15 October 2017 |language=en |date=2017 |url-status=live |archive-url=https://web.archive.org/web/20171015145904/https://rarediseases.info.nih.gov/diseases/5112/talipes-equinovarus |archive-date=15 October 2017}}</ref> Congenital clubfoot is the most common congenital malformation of the foot with an incidence of 1 per 1000 births.<ref name="Dibello 78">{{cite journal | vauthors = Dibello D, Di Carlo V, Colin G, Barbi E, Galimberti AM | title = What a paediatrician should know about congenital clubfoot | journal = Italian Journal of Pediatrics | volume = 46 | issue = 1 | pages = 78 | date = June 2020 | pmid = 32498693 | pmc = 7271518 | doi = 10.1186/s13052-020-00842-3 }}</ref> In approximately 50% of cases, clubfoot affects both feet, but it can present unilaterally causing one leg or foot to be shorter than the other.<ref name=Gib2013/><ref name="Sm2017">{{cite journal | vauthors = Smythe T, Kuper H, Macleod D, Foster A, Lavy C | title = Birth prevalence of congenital talipes equinovarus in low- and middle-income countries: a systematic review and meta-analysis | journal = Tropical Medicine & International Health | volume = 22 | issue = 3 | pages = 269–285 | date = March 2017 | pmid = 28000394 | doi = 10.1111/tmi.12833 | doi-access = free }}</ref> Most of the time, it is not associated with other problems.<ref name=Gib2013/> Without appropriate treatment, the foot deformity will persist and lead to pain and impaired ability to walk, which can have a dramatic impact on the quality of life'''.'''<ref name="Dibello 78"/><ref name=Dob2009>{{cite journal | vauthors = Dobbs MB, Gurnett CA | title = Update on clubfoot: etiology and treatment | journal = Clinical Orthopaedics and Related Research | volume = 467 | issue = 5 | pages = 1146–1153 | date = May 2009 | pmid = 19224303 | pmc = 2664438 | doi = 10.1007/s11999-009-0734-9 }}</ref><ref name="O2016">{{cite journal | vauthors = O'Shea RM, Sabatini CS | title = What is new in idiopathic clubfoot? | journal = Current Reviews in Musculoskeletal Medicine | volume = 9 | issue = 4 | pages = 470–477 | date = December 2016 | pmid = 27696325 | pmc = 5127955 | doi = 10.1007/s12178-016-9375-2 }}</ref> <!-- Cause and diagnosis --> The exact cause is usually not identified.<ref name=Gib2013/><ref name=Dob2009/> Both genetic and environmental factors are believed to be involved.<ref name=Gib2013/><ref name=Dob2009/> There are two main types of congenital clubfoot: [[Idiopathic disease|idiopathic]] (80% of cases) and secondary clubfoot (20% of cases). The idiopathic congenital clubfoot is a multifactorial condition that includes environmental, vascular, positional, and genetic factors.<ref name="Basit 107–113">{{cite journal | vauthors = Basit S, Khoshhal KI | title = Genetics of clubfoot; recent progress and future perspectives | journal = European Journal of Medical Genetics | volume = 61 | issue = 2 | pages = 107–113 | date = February 2018 | pmid = 28919208 | doi = 10.1016/j.ejmg.2017.09.006 }}</ref> There appears to be hereditary component for this birth defect given that the risk of developing congenital clubfoot is 25% when a first-degree relative is affected.<ref name="Basit 107–113"/> In addition, if one [[identical twin]] is affected, there is a 33% chance the other one will be as well.<ref name=Gib2013/> The underlying mechanism involves disruption of the [[muscles]] or [[connective tissue]] of the lower leg, leading to joint [[contracture]].<ref name=Gib2013/><ref>{{cite journal | vauthors = Cummings RJ, Davidson RS, Armstrong PF, Lehman WB | title = Congenital clubfoot | language = en-US | journal = The Journal of Bone and Joint Surgery. American Volume | volume = 84 | issue = 2 | pages = 290–308 | date = February 2002 | pmid = 11861737 | doi = 10.2106/00004623-200202000-00018 }}</ref> Other abnormalities are associated 20% of the time, with the most common being [[distal arthrogryposis]] and [[myelomeningocele]].<ref name=Gib2013/><ref name=Dob2009/> The diagnosis may be made at birth by physical examination or before birth during an [[ultrasound]] exam.<ref name=Gib2013/><ref name=Dob2009/> <!-- Treatment --> The most common initial treatment is the [[Ponseti method]], which is divided into two phases: 1) correcting of foot position and 2) [[orthopedic casting|casting]] at repeated weekly intervals.<ref name=Gib2013/> If the clubfoot deformity does not improve by the end of the casting phase, an [[Achilles tendon]] tenotomy can be performed.<ref>{{cite journal | vauthors = Ganesan B, Luximon A, Al-Jumaily A, Balasankar SK, Naik GR | title = Ponseti method in the management of clubfoot under 2 years of age: A systematic review | journal = PLOS ONE | volume = 12 | issue = 6 | pages = e0178299 | date = 2017-06-20 | pmid = 28632733 | pmc = 5478104 | doi = 10.1371/journal.pone.0178299 | bibcode = 2017PLoSO..1278299G | doi-access = free | veditors = Nazarian A }}</ref> The procedure consists of a small posterior skin incision through which the tendon cut is made. In order to maintain the correct position of the foot, it is necessary to wear an orthopedic brace until 5 years of age.<ref>{{cite journal | vauthors = Morcuende JA, Abbasi D, Dolan LA, Ponseti IV | title = Results of an accelerated Ponseti protocol for clubfoot | journal = Journal of Pediatric Orthopedics | volume = 25 | issue = 5 | pages = 623–626 | date = September 2005 | pmid = 16199943 | doi = 10.1097/01.bpo.0000162015.44865.5e | s2cid = 25067281 }}</ref> 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" /> 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" /> <!-- Epidemiology and culture --> Congenital clubfoot occurs in 1 to 4 of every 1,000 live births, making it one of the most common birth defects affecting the legs.<ref name="Sm2017">{{cite journal | vauthors = Smythe T, Kuper H, Macleod D, Foster A, Lavy C | title = Birth prevalence of congenital talipes equinovarus in low- and middle-income countries: a systematic review and meta-analysis | journal = Tropical Medicine & International Health | volume = 22 | issue = 3 | pages = 269–285 | date = March 2017 | pmid = 28000394 | doi = 10.1111/tmi.12833 | doi-access = free }}</ref><ref name=Dob2009/><ref name=O2016>{{cite journal | vauthors = O'Shea RM, Sabatini CS | title = What is new in idiopathic clubfoot? | journal = Current Reviews in Musculoskeletal Medicine | volume = 9 | issue = 4 | pages = 470–477 | date = December 2016 | pmid = 27696325 | pmc = 5127955 | doi = 10.1007/s12178-016-9375-2 }}</ref> About 80% of cases occur in developing countries where there is limited access to care.<ref name=Sm2017/> Clubfoot is more common in firstborn children and males.<ref name=Gib2013/><ref name="Sm2017" /><ref name=O2016/> It is more common among [[Māori people]], and less common among [[Han Chinese|Chinese]] people.<ref name=Dob2009/> ==Epidemiology== Birth prevalence of clubfoot varies between 0.51 and 2.03/1,000 live births in Low to middle income countries.<ref name="Sm2017" /><ref name="O2016" /><ref name="Dob2009" /> Clubfoot disproportionally affects those in [[Developing country|low and middle-income countries]] (LMICs). About 80% of those with clubfoot, or approximately 100,000 children per year as of 2018, are born in LMICs.<ref name="Sm2017" /><ref name="Drew2018">{{cite journal | vauthors = Drew S, Gooberman-Hill R, Lavy C | title = What factors impact on the implementation of clubfoot treatment services in low and middle-income countries?: a narrative synthesis of existing qualitative studies | journal = BMC Musculoskeletal Disorders | volume = 19 | issue = 1 | pages = 72 | date = March 2018 | pmid = 29499667 | pmc = 5834880 | doi = 10.1186/s12891-018-1984-z }}</ref> ==History== Pharaohs [[Siptah]] and [[Tutankhamun]] had clubfeet, and the condition appears in Egyptian paintings.<ref name="pmid22754429">{{cite journal | vauthors = Matuszewski L, Gil L, Karski J | title = Early results of treatment for congenital clubfoot using the Ponseti method | journal = European Journal of Orthopaedic Surgery & Traumatology | volume = 22 | issue = 5 | pages = 403–406 | date = July 2012 | pmid = 22754429 | pmc = 3376778 | doi = 10.1007/s00590-011-0860-4 }}</ref> Indian texts ({{circa|1000 BC}}) and Hippocrates ({{circa|400 BC}}) describe treatment.<ref>{{cite journal | vauthors = Dobbs MB, Morcuende JA, Gurnett CA, Ponseti IV | title = Treatment of idiopathic clubfoot: an historical review | journal = The Iowa Orthopaedic Journal | volume = 20 | pages = 59–64 | date = 2000 | pmid = 10934626 | pmc = 1888755 | author3-link = Christina Gurnett }}</ref> In 1823, Delpech presented a new procedure to treat the condition. The new method, known as tenotomy, involved the cutting of the Achilles tendon. The surgical procedure had complications such as infections.<ref>{{cite journal | vauthors = Ezra E, Cohen N, Segev E, Hayek S, Lokiec F, Keret D, Wientroub S | title = Primary subacute epiphyseal osteomyelitis: role of conservative treatment | journal = Journal of Pediatric Orthopedics | volume = 22 | issue = 3 | pages = 333–337 | date = 2002-05-01 | pmid = 11961449 | doi = 10.1097/00004694-200205000-00012 }}</ref> ==Signs and symptoms== In clubfoot, feet are [[supinated|rotated inward]] and [[plantar flexion|downward]].<ref name=Gib2013/><ref name="NIH2017" /> The affected foot and leg may be smaller than the other, while in about half of cases, clubfoot affects both feet.<ref name="Gib2013" /><ref name="Sm2017" /><ref name=O2016/> Most of the time clubfoot is not associated with other problems.<ref name="Gib2013" /> Clubfoot can be diagnosed by ultrasound of the fetus in more than 60% of cases. The earliest week of gestation in which the condition is diagnosed with a high degree of confidence was the 12th and the latest was the 32nd. Not all patients were diagnosed at an early stage. In 29% of fetuses the first ultrasound examination failed to detect the deformity which subsequently became obvious at a later examination. Clubfoot was diagnosed between 12 and 23 weeks of gestation in 86% of children and between 24 and 32 weeks of gestation in the remaining 14%.<ref>{{Cite journal | vauthors = Keret D, Ezra E, Lokiec F, Hayek S, Segev E, Wientroub S |date=September 2002 |title=Efficacy of prenatal ultrasonography in confirmed club foot |url=https://online.boneandjoint.org.uk/doi/10.1302/0301-620X.84B7.0841015 |journal=The Journal of Bone and Joint Surgery. British Volume |language=en |volume=84-B |issue=7 |pages=1015–1019 |doi=10.1302/0301-620X.84B7.0841015 |issn=0301-620X}}</ref> Without treatment the foot remains deformed and people walk on the sides or tops of their feet, which can cause calluses, foot infections, trouble fitting into shoes, pain, difficulty walking, and disability.<ref name=O2016/><ref name="Dob2009" /> ==Causes== Hypotheses about the precise cause of clubfoot vary. However, research has found that genetics, environmental factors or a combination of both are associated with this condition. Evidence suggests that the etiology of clubfoot is most likely multifactorial. A meta-analysis and systematic review found that the most clinically relevant risk factors for clubfoot were family history, paternal and maternal smoking, maternal obesity, gestational diabetes, amniocentesis, and the use of selective serotonin re-uptake inhibitors (SSRIs).<ref>{{cite journal | vauthors = Chen C, Kaushal N, Scher DM, Doyle SM, Blanco JS, Dodwell ER | title = Clubfoot Etiology: A Meta-Analysis and Systematic Review of Observational and Randomized Trials | journal = Journal of Pediatric Orthopedics | volume = 38 | issue = 8 | pages = e462–e469 | date = September 2018 | pmid = 29917009 | doi = 10.1097/BPO.0000000000001191 | s2cid = 49297540 }}</ref> Many 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 | vauthors = Miedzybrodzka Z | title = Congenital talipes equinovarus (clubfoot): a disorder of the foot but not the hand | journal = Journal of Anatomy | volume = 202 | issue = 1 | pages = 37–42 | date = January 2003 | pmid = 12587918 | pmc = 1571059 | doi = 10.1046/j.1469-7580.2003.00147.x }}</ref> The most commonly associated conditions are [[distal arthrogryposis]] or [[myelomeningocele]].<ref name="Dob2009" /> The factors contributing to the development of clubfoot can be categorized as extrinsic and intrinsic factors.<ref name=":02">{{cite journal | vauthors = McKinney J, Rac MW, Gandhi M | title = Congenital talipes equinovarus (clubfoot) | journal = American Journal of Obstetrics and Gynecology | volume = 221 | issue = 6 | pages = B10–B12 | date = December 2019 | pmid = 31787157 | doi = 10.1016/j.ajog.2019.09.022 | s2cid = 208538201 | doi-access = free }}</ref> '''Extrinsic Factors''' Factors that can influence the positioning of the fetal foot in utero include oligohydramnios, breech presentation, Müllerian anomalies, multiple gestation, amniotic band sequence, or amniocentesis at <15 weeks of gestation.<ref name=":02"/> In cases that impede normal growth and position for longstanding period of times, clubfoot can be accompanied with other deformations and may be associated with developmental hip dysplasia.<ref>{{cite journal | vauthors = Perry DC, Tawfiq SM, Roche A, Shariff R, Garg NK, James LA, Sampath J, Bruce CE | display-authors = 6 | title = The association between clubfoot and developmental dysplasia of the hip | journal = The Journal of Bone and Joint Surgery. British Volume | volume = 92 | issue = 11 | pages = 1586–1588 | date = November 2010 | pmid = 21037357 | doi = 10.1302/0301-620X.92B11.24719 }}</ref> The theory of fetal growth arrest was proposed by Von Volkmann in 1863, and has been verified by other authors since. According to this theory, intrinsic errors or environmental insults during gestation prevents the correction of an equinovarus to pronated foot.<ref>{{cite journal | vauthors = Anand A, Sala DA | title = Clubfoot: etiology and treatment | journal = Indian Journal of Orthopaedics | volume = 42 | issue = 1 | pages = 22–28 | date = January 2008 | pmid = 19823650 | pmc = 2759597 | doi = 10.4103/0019-5413.38576 }}</ref> Other researchers hypothesize that clubfoot may derive from external insults during gestation. For example, a research study found an alarming high incidence of club foot and limb contractures associated with iatrogenic amniotic leakage caused by early [[amniocentesis]] between the 11th and 12th week of gestation.<ref>{{cite journal | vauthors = Tredwell SJ, Wilson D, Wilmink MA | title = Review of the effect of early amniocentesis on foot deformity in the neonate | journal = Journal of Pediatric Orthopedics | volume = 21 | issue = 5 | pages = 636–641 | date = September 2001 | pmid = 11521033 | doi = 10.1097/01241398-200109000-00016 | s2cid = 43401909 }}</ref> '''Intrinsic Factors''' * ''Chromosomal abnormalities'' found in 30% and 2% of complex clubfoot and isolated clubfoot respectively.<ref name="Viaris de le Segno 100–105">{{cite journal | vauthors = Viaris de le Segno B, Gruchy N, Bronfen C, Dolley P, Leporrier N, Creveuil C, Benoist G | title = Prenatal diagnosis of clubfoot: Chromosomal abnormalities associated with fetal defects and outcome in a tertiary center | journal = Journal of Clinical Ultrasound | volume = 44 | issue = 2 | pages = 100–105 | date = February 2016 | pmid = 26179848 | doi = 10.1002/jcu.22275 | s2cid = 25799281 }}</ref> These include trisomy 18, 13, 21, sex chromosome abnormalities, micro-deletions and duplications.<ref name=":02"/> * ''Genetic Syndromes:'' Larsen, Gordon, Pierre-Robin, Meckel-Gruber, Roberts, Smith-Lemli-Opitz, TARP (Talipes equinovarus, Atrial septal defect, Robin sequence, Persistence of left superior vena cava).<ref name=":02"/> * ''Skeletal Dysplasias:'' Ellis van Creveld syndrome, diastrophic dysplasia, chondrodysplasia punctata, camptomelic dysplasia, atelosteogenesis, and mesomelic dysplasia.<ref name=":02"/> * ''Neuromuscular and Neurologic abnormalities:'' arthrogryposis multiplex congenita, myotonic dystrophy, spinal muscular atrophy, neural tube defects, holoprosencephaly, and hydranencephaly.<ref name=":02"/> ==Genetics== Clubfoot can be diagnosed prenatally as early as 13 weeks of gestation via ultrasound.<ref>{{cite journal | vauthors = Bronshtein M, Zimmer EZ | title = Transvaginal ultrasound diagnosis of fetal clubfeet at 13 weeks, menstrual age | journal = Journal of Clinical Ultrasound | volume = 17 | issue = 7 | pages = 518–520 | date = September 1989 | pmid = 2506248 | doi = 10.1002/jcu.1870170711 | s2cid = 20911471 }}</ref> According to the Society of Maternal-Fetal Medicine, a diagnostic testing for genetic causes is recommended when clubfoot is diagnosed prenatally.<ref name=":02"/> If prenatal screening is suspicious for aneuploidy, karyotype analysis or chromosomal microarray (CMA) may be performed. However, if patients decline diagnostic testing, Cell-Free DNA is another screening option to identify high-risk pregnancies for aneuploidy and it is not diagnostic.<ref name=":02" /> The incidence of chromosomal abnormalities in fetuses with prenatal diagnosis of clubfoot is relatively low.<ref>{{cite journal | vauthors = Singer A, Maya I, Banne E, Baris Feldman H, Vinkler C, Ben Shachar S, Sagi-Dain L | title = Prenatal clubfoot increases the risk for clinically significant chromosomal microarray results - Analysis of 269 singleton pregnancies | journal = Early Human Development | volume = 145 | pages = 105047 | date = June 2020 | pmid = 32339917 | doi = 10.1016/j.earlhumdev.2020.105047 | s2cid = 216594501 }}</ref> Overall, fetal ultrasound should be performed with a prenatal diagnosis of clubfoot in order to classify the condition as either complex or isolated because of the significant differences in rates of chromosomal abnormalities and outcomes between these two groups.<ref name="Viaris de le Segno 100–105"/> If one [[identical twin]] is affected, there is a 33% chance the other one will be as well.<ref name="Gib2013" /> 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 | vauthors = Weymouth KS, Blanton SH, Bamshad MJ, Beck AE, Alvarez C, Richards S, Gurnett CA, Dobbs MB, Barnes D, Mitchell LE, Hecht JT | display-authors = 6 | title = Variants in genes that encode muscle contractile proteins influence risk for isolated clubfoot | journal = American Journal of Medical Genetics. Part A | volume = 155A | issue = 9 | pages = 2170–2179 | date = September 2011 | pmid = 21834041 | pmc = 3158831 | doi = 10.1002/ajmg.a.34167 }}</ref> Clubfoot can also be present in people with genetic conditions such as [[Loeys–Dietz syndrome]] and [[Ehlers-Danlos syndrome]].<ref>{{cite book | vauthors = Byers PH | chapter = Vascular Ehlers-Danlos Syndrome | veditors = Adam MP, Everman DB, Mirzaa GM, Pagon RA, Wallace SE, Bean LJ, Gripp KW, Amemiya A | display-editors = 6 | title = GeneReviews |date=2019 |publisher=University of Washington, Seattle |pmid=20301667 | chapter-url= https://www.ncbi.nlm.nih.gov/sites/books/NBK1494/ |language=en}}</ref> 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 of clubfoot. PITX1 and TBX4 are uniquely expressed in the hind limb.<ref name="Dobbs2012">{{cite journal | vauthors = Dobbs MB, Gurnett CA | title = Genetics of clubfoot | journal = Journal of Pediatric Orthopedics. Part B | volume = 21 | issue = 1 | pages = 7–9 | date = January 2012 | pmid = 21817922 | pmc = 3229717 | doi = 10.1097/BPB.0b013e328349927c }}</ref> ==Diagnosis== Clubfoot is diagnosed through physical examination. Typically, babies are examined from head-to-toe shortly after they are born. There are '''four''' components of the clubfoot deformity: {| class="wikitable" |+ |1 |[[File:Cavus Illustration.png|frameless]] |[[cavus deformity|Cavus]]: the foot has a high arch, or a caved appearance. |- |2 |[[File:Adductus Illustration.png|frameless]] |[[metatarsus adductus|Adductus]]: the forefoot curves inwards toward the big toe. |- |3 |[[File:Varus Illustration.png|frameless]] |[[varus deformity|Varus]]: the heel is inverted, or turned in, forcing one to walk on the outside of the foot. This is a natural motion but in clubfoot the foot is fixed in this position. |- |4 |[[File:Equinus Illustration.png|frameless]] |[[equinus deformity|Equinus]]: the foot is pointed downward, forcing one to walk on tiptoe. This motion occurs naturally, but in clubfoot the foot is fixed in this position. This is because the [[Achilles tendon]] is tight and pulls the foot downwards. |} Factors used to assess severity include the stiffness of the deformity (how much it can be corrected by manually manipulating the foot), the presence of skin creases at the arch and heel, and poor muscle consistency. Sometimes, it is possible to detect clubfoot before birth using [[Obstetric ultrasonography|ultrasound]]. Prenatal diagnosis by ultrasound can allow parents to learn more about this condition and plan ahead for treatment after their 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=Clubfoot - Symptoms and causes |website=[[Mayo Clinic]] |access-date=2014-08-13 |url-status=live |archive-url=https://web.archive.org/web/20140708173258/http://www.mayoclinic.org/diseases-conditions/clubfoot/basics/definition/con-20027211 |archive-date=2014-07-08 }}</ref> More testing and imaging is typically not needed, unless there is concern for other associated conditions. == Treatment == [[File:Pieds bot varus équin, en cours de correction.jpg|thumb|right|Clubfeet in the course of correction]] Treatment is usually with some combination of the [[Ponseti method]] and French method.<ref name=Dob2009/><ref>{{cite journal | vauthors = Meyer Z, Zide JR, Cherkashin A, Samchukov M, Bohl DD, Riccio AI | title = Narrative review of ring fixator management of recurrent club foot deformity | journal = Annals of Translational Medicine | volume = 9 | issue = 13 | pages = 1104 | date = July 2021 | pmid = 34423016 | pmc = 8339855 | doi = 10.21037/atm-20-7621 }}</ref> The Ponseti method involves a combination of [[orthopedic casting|casting]], [[Achilles tendon]] release, and bracing. It is widely used and highly effective under the age of two.<ref>{{cite journal | vauthors = Ganesan B, Luximon A, Al-Jumaily A, Balasankar SK, Naik GR | title = Ponseti method in the management of clubfoot under 2 years of age: A systematic review | journal = PLOS ONE | volume = 12 | issue = 6 | pages = e0178299 | date = 2017 | pmid = 28632733 | pmc = 5478104 | doi = 10.1371/journal.pone.0178299 | bibcode = 2017PLoSO..1278299G | doi-access = free }}</ref> The French method involves realignment, taping, and long-term home exercises and night splinting.<ref name=Dob2009/> It is also effective but outcomes vary and rely on heavy involvement of caregivers.<ref name=Dob2009/> Generally, the Ponseti method is preferred.<ref name="Dob2009" /><ref name=":2">{{cite journal | vauthors = Bina S, Pacey V, Barnes EH, Burns J, Gray K | title = Interventions for congenital talipes equinovarus (clubfoot) | journal = The Cochrane Database of Systematic Reviews | volume = 2020 | issue = 5 | pages = CD008602 | date = May 2020 | pmid = 32412098 | pmc = 7265154 | doi = 10.1002/14651858.CD008602.pub4 }}</ref> Another technique, the Kite method, does not appear to be as effective.<ref name=":2" /> In about 20% of cases, additional surgery is required after initial treatment.<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}} The Ponseti method corrects clubfoot over the course of several stages. * '''''Serial casting''''': First, the foot is manually manipulated into an improved position and held in place with a long leg cast which extends from the toes up to the thigh. After a week this cast is removed, the foot is re-manipulated, and placed into a new cast. This process repeats and the foot is gradually reshaped over the course of 4-6 serial casts, although some feet may require additional casts. ** The goal of the initial cast is to align the forefoot with the hindfoot. Ponseti describes the forefoot as [[pronation|pronated]] in relation to the hindfoot, so [[supination|supinating]] the forefoot and elevating the first [[Metatarsal bones|metatarsal]] improves this alignment. ** Subsequent casts are applied after stretching the foot with a focus on [[abduction (anatomy)|abducting]] the forefoot with lateral pressure at the [[Talus bone|talus]], to bring the [[navicular bone|navicular]] laterally and improve the alignment of the [[Talocalcaneonavicular joint|talonavicular joint]]. In contrast to the Kite method of casting, it is important to avoid constraining the [[calcaneocuboid joint]]. With each additional cast, the abduction is increased and this moves the hindfoot from [[Varus deformity|varus]] into [[Valgus deformity|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]]. The foot must have the ability to dorsiflex to at least 10 degrees past 0 (neutral, or L position), although 15 degrees or more is better and preferred. If the foot can not dorsiflex enough, the brace will not work/be tolerated. If it is determined the foot can not dorsiflex at least 10 degrees, the Achilles Tenotomy surgical procedure is performed. * '''''Achilles tendon release''''': At the end of the serial casting, most children have corrected cavus, adductus and varus deformities, but continue to have equinus deformity. To correct this, a procedure called an [[Achilles tendon]] release (commonly called Achilles [[tenotomy]]) is performed. Before the procedure, many centers place the child under sedation or monitored anesthesia care, although Ponseti recommended using local anesthetic alone. Next, the area around the heel is cleansed and numbed, and a small scalpel is used to cut the Achilles tendon. The incision is small so there is minimal bleeding and no need for stitches. The skin is covered with a small dressing, and the foot is placed into a final long leg cast in a fully corrected position. This cast is typically left in place for three weeks. During this time, the Achilles tendon will regrow in a lengthened position. * '''''Bracing''''': After successful correction is achieved through serial casting and Achilles tenotomy, the foot must be kept in a brace to prevent it from returning to the deformed position over the first few years of a child's life. The brace is made up of two shoes or boots that are connected to each other by a bar that is bent under the shoes at 10-15 degrees, or curved to create 10-15 degrees dorsiflexion. This device is also called a foot abduction brace (FAB) or more generally boots and bar (BnB). At first, the brace is worn full-time (23 hours per day) on both feet, regardless of whether the clubfoot affects one or two feet. After 3 months of 23/7 wear, the brace is worn less frequently by gradually reducing hours a couple at a time, every couple months so that hours are down to 12-14 per day at or around a year old. From this point on until at least 4–5 years, or even longer (6–9 years if needed), the brace is worn mostly while sleeping at night and during naps (12–14 hours per day). Bracing is essential in preventing recurrence of the deformity and is a major determinant of a child's long-term outcome.<ref name=":0">{{cite journal | vauthors = Radler C | title = The Ponseti method for the treatment of congenital club foot: review of the current literature and treatment recommendations | journal = International Orthopaedics | volume = 37 | issue = 9 | pages = 1747–1753 | date = September 2013 | pmid = 23928728 | pmc = 3764299 | doi = 10.1007/s00264-013-2031-1 }}</ref> The Ponseti method is highly effective with short-term success rates of 90%.<ref name=":0" /> However, anywhere from 14% to 41% of children experience a recurrence of the deformity, with as many as 56% requiring an additional surgery beyond the 10 year mark.<ref name=":1">{{cite journal | vauthors = Zionts LE, Dietz FR | title = Bracing following correction of idiopathic clubfoot using the Ponseti method | journal = The Journal of the American Academy of Orthopaedic Surgeons | volume = 18 | issue = 8 | pages = 486–493 | date = August 2010 | pmid = 20675641 | doi = 10.5435/00124635-201008000-00005 | s2cid = 7317959 }}</ref><ref>{{cite journal | vauthors = El-Hawary R, Karol LA, Jeans KA, Richards BS | title = Gait analysis of children treated for clubfoot with physical therapy or the Ponseti cast technique | language = en-US | journal = The Journal of Bone and Joint Surgery. American Volume | volume = 90 | issue = 7 | pages = 1508–1516 | date = July 2008 | pmid = 18594100 | doi = 10.2106/JBJS.G.00201 }}</ref><ref>{{cite journal | vauthors = McCahill JL, Stebbins J, Harlaar J, Prescott R, Theologis T, Lavy C | title = Foot function during gait and parental perceived outcome in older children with symptomatic club foot deformity | journal = Bone & Joint Open | volume = 1 | issue = 7 | pages = 384–391 | date = July 2020 | pmid = 33215128 | pmc = 7659680 | doi = 10.1302/2633-1462.17.BJO-2020-0046.R1 }}</ref> The most common reason for this is inadequate adherence to bracing, such as not wearing the brace properly, not keeping it on for the recommended length of time, or not using it every day. Children who do not follow proper bracing protocol have up to seven times higher recurrence rates than those who follow bracing protocol, as the muscles around the foot can pull it back into the abnormal position.<ref name=":1" /> Low parental education level and failure to understand the importance of bracing is a major contributor to non-adherence.<ref name=":0" /> Relapses are managed by repeating the casting process. Relapsed feet may also require additional, more extensive surgeries and have a reduced chance of achieving subsequent correction.<ref name=":0" /> Furthermore, research has revealed the possibility of overcorrection after use of the Ponseti method.<ref>{{cite journal | vauthors = Hayes CB, Murr KA, Muchow RD, Iwinski HJ, Talwalkar VR, Walker JL, Milbrandt TA, Hosseinzadeh P | display-authors = 6 | title = Pain and overcorrection in clubfeet treated by Ponseti method | language = en-US | journal = Journal of Pediatric Orthopedics. Part B | volume = 27 | issue = 1 | pages = 52–55 | date = January 2018 | pmid = 28240717 | doi = 10.1097/BPB.0000000000000442 | s2cid = 2527438 }}</ref><ref>{{cite journal | vauthors = McCahill JL, Stebbins J, Harlaar J, Prescott R, Theologis T, Lavy C | title = Foot function during gait and parental perceived outcome in older children with symptomatic club foot deformity | journal = Bone & Joint Open | volume = 1 | issue = 7 | pages = 384–391 | date = July 2020 | pmid = 33215128 | pmc = 7659680 | doi = 10.1302/2633-1462.17.BJO-2020-0046.R1 }}</ref> Another reason for recurrence is a congenital muscle imbalance between the muscles that invert the ankle ([[Tibialis posterior muscle|tibialis posterior]] and [[Tibialis anterior muscle|tibialis anterior]] muscles) and the muscles that [[evert]] the ankle ([[Peroneus muscles|peroneal muscles]]). This imbalance is present in approximately 20% of infants successfully treated with the Ponseti casting method, and makes them more prone to recurrence. This relapse is usually treated with Ponseti casting and can be done multiple times before resorting to surgery. If after all non-surgical casting and bracing options have been exhausted, and when the child is over four years of age (many doctors prefer to wait until after seven years old), this can be addressed with a surgery to transfer the tibialis anterior tendon from its medial attachment (on the [[Navicular bone|navicula]]) to a more lateral position (on the [[Cuneiform bones|lateral cuneiform]]). The surgery requires general anesthesia and subsequent casting while the tendon heals, but it is a relatively minor surgery that re-balances the muscles of the foot without disturbing any joints. ===French method=== The French method is a conservative, non-operative method of clubfoot treatment that involves daily physical therapy for the first two months followed by thrice-weekly physical therapy for the next four months and continued home exercises following the conclusion of formal physical therapy. During each physical therapy session the feet are manipulated, stretched, then taped to maintain any gains made to the feet's range of motion. Exercises may focus on strengthening the [[Peroneus muscles|peroneal muscles]], which is thought to contribute to long-term correction. After the two month mark, the frequency of physical therapy sessions can be weaned down to three times a week instead of daily, until the child reaches six months. After the conclusion of the physical therapy program, caregivers must continue performing exercises at home and splinting at night in order to maintain long-term correction. Compared to the Ponseti method which uses rigid casts and braces, the French method uses tape which allows for some motion in the feet. Despite its goal to avoid surgery, the success rate varies and surgery may still be necessary. The Ponseti method is generally preferred over the French method.<ref name=Dob2009/> === Surgery === {{More citations needed section|date=December 2009}} If non-operative treatments are unsuccessful or achieve incomplete correction of the deformity, surgery is sometimes needed.<ref>{{cite journal | vauthors = Gaber K, Mir B, Shehab M, Kishta W | title = Updates in the Surgical Management of Recurrent Clubfoot Deformity: a Scoping Review | journal = Current Reviews in Musculoskeletal Medicine | volume = 15 | issue = 2 | pages = 75–81 | date = April 2022 | pmid = 35118632 | pmc = 9076776 | doi = 10.1007/s12178-022-09739-6 }}</ref> 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.<ref>{{cite journal | vauthors = Dobbs MB, Nunley R, Schoenecker PL | title = Long-term follow-up of patients with clubfeet treated with extensive soft-tissue release | journal = The Journal of Bone and Joint Surgery. American Volume | volume = 88 | issue = 5 | pages = 986–996 | date = May 2006 | pmid = 16651573 | doi = 10.2106/JBJS.E.00114 | url = https://digitalcommons.wustl.edu/open_access_pubs/1042 }}</ref> Some people 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. ===Developing world=== Despite effective treatments, children in [[Developing country|LMICs]] face many barriers such as limited access to equipment (specifically casting materials and abduction braces), shortages of [[Health professional|healthcare professionals]], and low education levels and socioeconomic status amongst caregivers and families.<ref>{{cite journal | vauthors = Owen RM, Capper B, Lavy C | title = Clubfoot treatment in 2015: a global perspective | journal = BMJ Global Health | volume = 3 | issue = 4 | pages = e000852 | date = 2018 | pmid = 30233830 | pmc = 6135438 | doi = 10.1136/bmjgh-2018-000852 }}</ref> These factors make it difficult to detect and diagnose children with clubfoot, connect them to care, and train their caregivers to follow the proper treatment and return for follow-up visits. It is estimated that only 15% of those diagnosed with clubfoot receive treatment.<ref name="Drew2018" /> In an effort to reduce the burden of clubfoot in LMICs, there have been initiatives to improve early diagnosis, organize high-volume Ponseti casting centers, utilize [[mid-level practitioner]]s and non-physician health workers, engage families in care, and provide local follow-up in the person's community.<ref>{{cite journal | vauthors = Harmer L, Rhatigan J | title = Clubfoot care in low-income and middle-income countries: from clinical innovation to a public health program | journal = World Journal of Surgery | volume = 38 | issue = 4 | pages = 839–848 | date = April 2014 | pmid = 24213946 | doi = 10.1007/s00268-013-2318-9 | s2cid = 2577109 }}</ref> ==Cultural references== [[File:Nätti-Jussi.jpg|thumbnail|A well-known storyteller from [[Lapland (Finland)|Lapland]], Juho "[[Nätti-Jussi]]" Nätti (surname can be translated as 'pretty') (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 footprints of snow.]] * Hippolyte Tautain, the stableman at the Lion D'Or public house in the 1856 novel ''[[Madame Bovary]]'' by [[Gustave Flaubert]], has clubfoot. Charles Bovary tries to correct it, but the procedure is unsuccessful, and Tautain must have an amputation. * Philip Carey, the main character of the 1915 novel ''[[Of Human Bondage]]'' by [[W. Somerset Maugham]], has clubfoot. It is a central theme of the work. * Velma, a character in the 1941 film ''[[High Sierra (film)|High Sierra]]'', has clubfoot. It is successfully treated with surgery. * Gimpy, a coworker of the main character in the 1959 science fiction short story "[[Flowers for Algernon]]" by [[Daniel Keyes]], has clubfoot. * Kashiwagi, a character in the 1956 novel ''[[The Temple of the Golden Pavilion]]'' by [[Yukio Mishima]], has clubfoot. It parallels the main character, Mizoguchi, who has a stutter. * Johnson, a character in the 1965 short story "[[The Lame Shall Enter First]]" by [[Flannery O'Connor]], has clubfoot. It is a major symbol in the story. * The main character of the 1974 science fiction novel ''[[The Bladerunner]]'' by [[Alan E. Nourse]] has clubfoot. * The main character of the 1985 novel ''[[Perfume: The Story of a Murderer]]'' by [[Patrick Süskind]], has clubfoot. It causes a limp. * Senji, a character in the 1987 to 1991 fantasy book series ''[[The Mallorean]]'' by [[David Eddings]], has clubfoot. * Kwai Geuk-Chat, a character in the 1993 film ''[[Once Upon a Time in China III]]'', which is part of the 1991 to 1997 ''[[Once Upon a Time in China]]'' series, has clubfoot. He is nicknamed "Clubfoot Seven Chiu-Tsat" – "Clubfoot" because of his foot, and "Seven Chiu-Tsat" because he is the seventh member of the character Chiu Tin-bak's apprentices, disciples, and henchmen. * Mordred, King of Dumonia, a character in the 1995 to 1997 historical fantasy book series ''[[The Warlord Chronicles]]'' by [[Bernard Cornwell]], has clubfoot. It is often used as a symbol for his weakness as a ruler. * Charlie Wilcox, the main character of the 2000 children's book [[Charlie Wilcox|of the same name]] by Sharon McKay, has clubfoot. * Vulcan the blacksmith, a character in the 2001 novel ''The Secrets of Vesuvius'', which is part of the 2001 to 2009 historical fiction series ''[[The Roman Mysteries]]'' by [[Caroline Lawrence]], has clubfoot. * Princess Matilda, the main character of ''Handbook for Dragon Slayers'' by Merrie Haskell, a 2013 novel published by [[HarperCollins]], has a clubfoot. * Ada, the main character of the 2016 children's book ''[[The War That Saved My Life]]'' by [[Kimberly Brubaker Bradley]], has clubfoot. Her mother emotionally and physically abuses her because of it. * Larys Strong, called "the Clubfoot", first appears in [[George R. R. Martin]]'s 2013 fantasy novella ''[[The Princess and the Queen]]'', part of ''[[A Song of Ice and Fire]]''. He is the secretive and sly master of whisperers for King Viserys I Targaryen and his successor Aegon II Targaryen. Larys's character was later expanded on in the novel ''[[Fire & Blood (novel)|Fire & Blood]]'' (2018) and its television adaptation ''[[House of the Dragon]]'' (2022). {{-}} == 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:Wikipedia medicine articles ready to translate]]'