Pediatrics

Clubfoot

Overview: What every practitioner needs to know

Are you sure your patient has clubfoot? What are the typical findings for this disease?

Clubfoot (congenital talipes equinovarus) is a congenital foot deformity that is present at birth. It is a clinical diagnosis based on the following:

Equinus (fixed plantar flexion) of the hindfoot

Varus (inward angle) of the hindfoot

Cavus (abnormally high arch) of the forefoot

Adductus (turning inward) of the forefoot

These deformities are not passively correctable. There is usually a deep transverse plantar crease distal to the calcaneus and a convex deformity of the lateral border of the foot (seen in metatarsus adductus as well). If clubfoot is unilateral, the involved side will have a smaller foot and calf muscle and possibly a shorter leg. Please see Figure 1 for a picture of an idiopathic clubfoot before treatment.

Figure 1.

Posterior view of idiopathic clubfoot.

No definitive, repeatable classification system to assess severity and rigidity is universally accepted, although many exist. The DiMeglio scale provides a classification of severity based on four essential parameters, including equinus in the sagittal plane, varus in the frontal plane, derotation around the talus of the calcaneo-forefoot block, and adduction of the forefoot on the hindfoot in the horizontal plane. This has been used to predict non-operative versus operative treatment results.

Types of clubfoot

Idiopathic

Positional

Neurogenic

Syndromic

Incidence

The incidence of clubfoot is 0.39-6.8/1000 live births, with the lowest occurrence in Chinese individuals (0.39 per 1000 live births) and the highest in Polynesians (6.5 to 7/1000 live births).

What other disease/condition shares some of these symptoms?

Metatarsus adductus has the same appearance, but it is only adductus of the forefoot on the midfoot and usually does not need any treatment. Casting, bracing, or shoe modifications are occasionally required.

What caused this disease to develop at this time?

This disorder has a multifactorial etiology. Genetics play a role; the incidence is increased in siblings of children with clubfoot. Environmental factors, such as positioning in utero, are important. Other causes include muscle and nerve pathologic conditions, fetal developmental issues, vascular anomalies, bone deformity, developmental arrest, and infection.

What laboratory studies should you request to help confirm the diagnosis? How should you interpret the results?

If diagnostic findings suggest the type of clubfoot or the cause is neurogenic or syndromic, the appropriate workup should be done based on history and physical examination.

Would imaging studies be helpful? If so, which ones?

Prenatal ultrasonography can identify clubfoot before birth. This enables the clinician to counsel the family and start early treatment. Radiographs are not recommended in the initial evaluation. Most bones in the midfoot do not have ossification centers at birth, and alignment can be evaluated clinically. Radiographs are beneficial in surgical planning or treatment monitoring as the patient matures. Weight-bearing radiographs can help evaluate deformity as the patient matures to 2-3 years of age.

Confirming the diagnosis

There are no algorithms for confirming diagnosis, as diagnosis is purely clinical based on physical examination. If the cause is felt to be neurogenic or syndromic, history and physical examination should lead the appropriate workup for the overall diagnosis; clubfoot treatment decisions can be made taking into account this diagnostic information.

If you are able to confirm that the patient has clubfoot, what treatment should be initiated?

For idiopathic clubfoot, non-operative treatment should be started as soon after birth as possible. This consists of the following:

Ponseti casting: This consists of a series of weekly castings to correct the deformity. Percutaneous Achilles tenotomy is needed in 95%-97% of cases to correct the equinus deformity. Abduction bracing is used full time for 2-3 months and during the night and naps until 2-5 years of age, which has been shown to reduce the incidence of recurrence.

French physical therapy method: The foot is manipulated by a trained physical therapist daily with corrective taping or casting. A continuous passive motion machine is used. This is time intensive and requires visits to the physical therapist several times weekly during initial correction. Availability is limited with few trained therapists in the United States. It is more commonly used in Europe.

Clinical results of these two treatments are equal in studies, with good initial results, but there are still often long-term pain and deformity issues. Recent research has shown that strict adherence to the Ponseti method significantly reduces the need for subsequent unplanned surgical treatment. There are currently many protocols published and techniques to help families adhere to the postoperative bracing recommendations.

Surgical treatment is needed for rigid, uncorrectable clubfeet when non-operative treatment has failed or often for syndromic or neurogenic clubfeet, as they do not respond well to non-operative treatment, although these results are changing at this time. Surgical treatment is a la carte, with release of soft tissue and lengthening of tendons as needed to achieve a plantigrade foot.

Surgical procedures can include capsulotomy of the subtalar, tibiotalar, and talonavicular joints, lengthening of the posterior tibialis, flexor hallucis longus, flexor digitorum longus, and Achilles tendons, and correction of rotational bony deformity with fixation for 4-8 weeks. Long-term bracing may be required after surgery, especially in syndromic or neurogenic cases. In these cases the results are marginal, with high rates of residual pain, stiffness, and disability.

Recurrent deformity can be treated with repeated non-operative measures or can be corrected surgically.

Surgical treatment for recurrent deformity includes possible release of capsule and tendon structures, anterior tibialis tendon transfer for dynamic inversion deformity, or reconstructive and/or rotational osteotomies.

What are the adverse effects associated with each treatment option?

Non-operative treatment has good results achieving a pain-free, plantigrade foot that fits well in shoes. Long-term results are excellent. Results approximate age-matched controls in terms of pain and function. Many studies have shown that there are significant long-term problems with stiffness and disability in patients who have had aggressive surgical treatment when compared with results using non-operative treatment.

What are the possible outcomes of clubfoot?

Prognosis for idiopathic clubfoot is good. Successful non-operative management can produce a functional foot for ambulation. If non-operative treatment cannot be done or does not correct the deformity, surgical treatment carries the usual risks, as well as possible long-term issues with pain, stiffness, and deformity, but the foot can usually still be corrected to a functional position for shoe wear and activities of daily living.

A patient with a non-treated clubfoot will still be able to ambulate, but depending on severity of deformity they will potentially have pain, shoe wear issues, and decreased functional walking capabilities.

What causes this disease and how frequent is it?

Clubfoot occurs in 0.39-6.8/1000 live births, with about 1 in 1000 in the United States.

How do these pathogens/genes/exposures cause the disease?

Idiopathic clubfoot is due to muscle and bony imbalance and intrauterine positioning. Genetic factors contribute, but no definitive gene involvement has been identified. The family history is positive in 25% of all patients. If a sibling has clubfoot, there is a 5% chance that the second child will also have it. Studies are under way to identify a gene or genes involved. No formal genetic counseling for clubfoot is advised at this time, but the families should be informed of the possibility of recurrence despite successful initial treatment.

What complications might you expect from the disease or treatment of the disease?

Long-term foot pain and deformity with possible recurrence of deformity or overcorrection with planovalgus deformity that is difficult to treat can occur.

Surgical treatment of clubfeet that have needed aggressive release will often cause long-term pain, stiffness, and disabling deformity affecting a patient's functional gait and causing shoe wear issues.

How can clubfoot be prevented?

There are no modifications of behavioral factors that will prevent clubfoot. There are also no maternal nutritional factors that are found to cause clubfoot.

What is the evidence?

There is a large amount of evidence supporting non-operative management of idiopathic clubfoot. There is also good evidence documenting that there are minimal differences in outcomes through the two more commonly accepted techniques of non-operative treatment. The articles below are a selection of the best current evidence.

Steinman, S, Richard, BS, Faulk, S. "A comparison of two non-operative methods of idiopathic clubfoot correction the Ponseti method and the French functional (physiotherapy) method. Surgical technique". J Bone Joint Surg Am. vol. 9. 2009. pp. 299-312.

(This study allowed families to choose between the two most common non-operative treatments for clubfoot, the Ponseti and the French method, and found that there was not a significant difference at a minimum of 2 years of follow-up.

Dobbs, MB, Gurnett, CA. "Update on clubfoot: etiology and treatment". Clin Orthop Relat Res. vol. 467. 2009. pp. 1146-53.

(This review gives an update on the description of the clubfoot deformity and etiology and discusses current treatment standards.)

Ponseti, IV, Zhivkov, M, Davis, N. "Treatment of the complex idiopathic clubfoot". Clin Orthop Relat Res. vol. 451. 2006. pp. 171-6.

(This article is a description of the treatment method for severe clubfeet that do not respond to standard treatment protocols and discusses the results that include successful treatment with modified treatment that still avoided extensive corrective surgery.)

Ziont, LE, Zhao, G, Hitchcock, K. "Has the rate of extensive surgery to treat idiopathic clubfoot declined in the United States?". J Bone Joint Surg Am. vol. 92. 2010. pp. 882-9.

(This review showed a significant decrease in the rate of extensive surgical treatment of clubfoot and presented that this was likely due to the increased use of the Ponseti method.)

Halanski, MA, Davison, JE, Huang, JC. "Ponseti method compared with surgical treatment of clubfoot: a prospective comparison". J Bone Joint Surg Am. vol. 9. 2010. pp. 270-83.

(A prospective study comparing Ponseti treatment versus surgical release found that both cohorts had high recurrence rates, but the Ponseti method required less revisional surgical treatment.)

Laaveq, SJ, Ponseti, IV. "Long-term results of treatment of congenital club foot". J Bone Joint Surg Am. vol. 62. 1980. pp. 23-31.

(This is an original study describing the long-term results of clubfoot after treatment. There were still range of motion issues, but the patients and families were happy with the results.)

Dobbs, MB, Nunley, R, Schoenecker, PL. "Long term follow-up of patients with clubfeet treated with extensive soft-tissue release". J Bone Joint Surg Am. vol. 88. 2006. pp. 986-96.

(This study was a retrospective review that showed that patients with extensive soft tissue surgical release for treatment of clubfoot had poor long-term foot function and issues with stiffness, pain, and arthritic changes that impaired their quality of life.)

Dobbs, MB, Rudzki, JR, Purcell, DB. "Factors predictive of outcome after use of the Ponseti method for the treatment of idiopathic clubfeet". J Bone Joint Surg Am. vol. 86-A. 2004. pp. 22-7.

(This was a retrospective study that looked at patient and patient's family characteristics and outcomes after non-operative treatment of clubfoot. It was found that noncompliance and the educational level of the parents (high school education or less) were significant risk factors for recurrence of the deformity after treatment with the Ponseti method.)

DiMeglio, A, Bensahel, H, Souchet, P. "Classification of clubfoot". J Pediatr Orthop B. vol. 4. 1995. pp. 129-36.

(This article describes the Dimeglio classification system based on severity of deformity and is used to help predict results of operative versus non-operative treatment.)

Janicki, JA, Narayanan, UG, Harvery, BJ, Roy, A. "Comparison of surgeon and physiotherapist-directed Ponseti treatment of idiopathic clubfoot". J Bone Joint Surg Am. vol. 91. 2009 May. pp. 1101-8.

(This is an article comparing the results of Ponseti treatment of clubfoot being managed by a physiotherapist versus a surgeon and shows the results are equal.)

Avilucea, FR, Szalay, EA, Bosch, PP, Sweet, KR, Schwend, RM. "Effect of cultural factors on outcome of Ponseti treatment of clubfeet in rural America". J Bone Joint Surg Am. vol. 91. 2009 Mar 1. pp. 530-40.

(This article reviews distance from treatment center for Ponseti treatment of clubfoot and shows that compliance with brace wear and communication are key components of successful treatment with patients living in a rural areas having more incidence of recurrence of clubfoot needing further treatment.)

Zhao, D, Li, H, Zhao, L, Liu, J. "Results of clubfoot management using the Ponseti method: do the details matter? A systematic review". Clin Orthop Relat Res. vol. 472. 2014 Apr. pp. 1329-36.

(This article is a literature review that looks at the variation on treatment principles, protocols, and techniques and how closely the published Ponseti technique is followed. It showed that the more stringent the protocol is followed, the less likely it was to have recurrent deformity after non-operative treatment of clubfoot deformity.)

Miller, NH, Carry, PM, Mark, BJ, Engelman, GH, Georgopoulos, G, Graham, S, Dobbs, MB. "Does Strict Adherence to the Ponseti Method Improve Isolated Clubfoot Treatment Outcomes? A Two-institution Review". Clin Orthop Relat Res. vol. 474. 2016 Jan. pp. 237-43.

(This article compares two institutions' use of a rigid Ponseti method. One institution required a rigid protocol to be followed with only one provider doing the casting and following the method. The other institution had 16 providers treating clubfeet with the Ponseti method but they all adapted the method at their discretion. There was an increased number of revision casts and surgery at the institution that did not follow the rigid method and therefore this shows that adherence to the protocol reduces the need for other procedures and treatment in the future.)

Ongoing controversies regarding etiology, diagnosis, treatment

There are ongoing studies looking at and comparing non-operative treatment options to improve long-term results and decrease the incidence of recurrence.

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