A clubfoot, or congenital talipes equinovarus (CTEV),[1] is a congenital deformity involving one

foot or both.[2] The affected foot appears rotated internally at the ankle. TEV is classified into 2
groups: Postural TEV or Structural TEV. Without treatment, persons afflicted often appear to
walk on their ankles, or on the sides of their feet. It is a common birth defect, occurring in about
one in every 1,000 live births. Approximately 50% of cases of clubfoot are bilateral. In most
cases it is an isolated dysmelia. This occurs in males more often than in females by a ratio of 2:1.

Contents
[hide]

• 1 Deformities
• 2 Causes
• 3 Treatment
o 3.1 Non-surgical treatment and the Ponseti Method
o 3.2 Surgical treatment
• 4 Famous people
• 5 In literature
• 6 References

• 7 External links

[edit] Deformities
The deformities affecting joints of the foot occur at three joints of the foot to varying degrees.
They are [2]

• Inversion at subtalar joint

• Adduction at talonavicular joint and
• Equinus at ankle joint

The deformities can be remembered using the mnemonic, "InAdEquate" for Inversion,
Adduction and Equinus.[2]

[edit] Causes
There are different causes for clubfoot depending on what classification it is given. Structural
TEV is caused by genetic factors such as Edwards syndrome, a genetic defect with three copies
of chromosome 18. Growth arrests at roughly 9 weeks and compartment syndrome of the
affected limb are also causes of Structural TEV. Genetic influences increase dramatically with
family history. It was previously assumed that postural TEV could be caused by external
influences in the final trimester such as intrauterine compression from oligohydramnios or from
amniotic band syndrome. However, this is countered by findings that TEV does not occur more
frequently than usual when the intrauterine space is restricted.[3] Breech presentation is also
another known cause.[citation needed] TEV occurs with some frequency in Ehlers Danlos Syndrome
and some other connective tissue disorders. TEV may be associated with other birth defects such
as spina bifida cystica.

[edit] Treatment
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Please help improve this article by adding reliable references. Unsourced material may be challenged
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Clubfoot is treated with manipulation by podiatrists, physiotherapists, orthopedic surgeons,

specialist Ponseti nurses, or orthotists by providing braces to hold the feet in orthodox positions,
serial casting, or splints called knee ankle foot orthoses (KAFO). Other orthotic options include
Dennis-Brown bars with straight last boots, ankle foot orthoses and/or custom foot orthoses
(CFO). In North America, manipulation is followed by serial casting, most often by the Ponseti
Method. Foot manipulations usually begin within two weeks of birth. Even with successful
treatment, when only one side is affected, that foot may be smaller than the other, and often that
calf, as well.

Extensive surgery of the soft tissue or bone is not usually necessary to treat clubfoot; however,
there are two minimal surgeries that may be required:

1. Tenotomy (needed in 80% of cases) is a release (clipping) of the Achilles tendon - minor
surgery- local anesthesia
2. Anterior Tibial Tendon Transfer (needed in 20% of cases) - where the tendon is moved
from the first ray (toe) to the third ray in order to release the inward traction on the foot.

Of course, each case is different, but in most cases extensive surgery is not needed to treat
clubfoot. Extensive surgery may lead to scar tissue developing inside the child's foot. The
scarring may result in functional, growth and aesthetic problems in the foot because the scarred
tissue will interfere with the normal development of the appendage. A child who has extensive
surgery may require on average two additional surgeries to correct the issues presented above.

In stretching and casting therapy the doctor changes the cast multiple times over a few weeks,
gradually stretching tendons until the foot is in the correct position of external rotation. The heel
cord is released (percutaneous tenotomy) and another cast is put on, which is removed after three
weeks. To avoid relapse a corrective brace is worn for a gradually reducing time until it is only at
night up to four years of age.

[edit] Non-surgical treatment and the Ponseti Method

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sources remain unclear because it lacks inline citations. Please improve this article
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Main article: Ponseti Method
Treatment for clubfoot should begin almost immediately to have the best chance for a successful
outcome without the need for surgery. Over the past 10 to 15 years, more and more success has
been achieved in correcting clubfeet without the need for surgery. The clubfoot treatment method
that is becoming the standard in the U.S. and worldwide is known as the Ponseti Method [4]. Foot
manipulations differ subtly from the Kite casting method which prevailed during the late 20th
century. Although described by Dr. Ignacio Ponseti in the 1950s, it did not reach a wider
audience until it was re-popularized around 2000 by Dr. John Herzenberg in the USA and in
Europe and Africa by NHS surgeon Steve Mannion while working in Africa. Parents of children
with clubfeet using the Internet [5] also helped the Ponseti gain wider attention. The Ponseti
method, if correctly done, is successful in >95% of cases [6] in correcting clubfeet using non- or
minimal-surgical techniques. Typical clubfoot cases usually require 5 casts over 4 weeks.
Atypical clubfeet and complex clubfeet may require a larger number of casts. Approximately
80% of infants require an Achilles tenotomy (microscopic incision in the tendon requiring only
local anesthetic and no stitches) performed in a clinic toward the end of the serial casting.

After correction has been achieved, maintenance of correction may require the full-time (23
hours per day) use of a splint—also known as a foot abduction brace (FAB)—on both feet,
regardless or whether the TEV is on one side or both, for several weeks after treatment. Part-time
use of a brace (generally at night, usually 12 hours per day) is frequently prescribed for up to 4
years. Without the parents' participation, the clubfoot will almost certainly recur, 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 may require a surgical tendon
transfer after two years of age. While this requires a general anesthetic, it is a relatively minor
surgery that corrects a persistent muscle imbalance while avoiding disturbance to the joints of the
foot.

The developer of the Ponseti Method, Dr Ignacio Ponseti, was still treating children with clubfeet
(including complex/atypical clubfeet and failed treatment clubfeet) at the University of Iowa
Hospitals and Clinics well into his 90s. He was assisted by Dr Jose Morcuende, president of the
Ponseti International Association.

The long-term outlook [7] for children who experienced the Ponseti Method treatment is
comparable to that of non-affected children.

Watch a Video on the Ponseti Method

Botox is also being used as an alternative to surgery. Botox is the trade name for Botulinum
Toxin type A. a chemical that acts on the nerves that control the muscle. It causes some
paralysis(weakening) of the muscle by preventing muscle contractions (tightening). As part of
the treatment for clubfoot, Botox is injected into the child’s calf muscle. In about 1 week the
Botox weakens the Achilles tendon. This allows the foot to be turned into a normal position, over
a period of 4–6 weeks, without surgery.

The weakness from a Botox injection usually lasts from 3–6 months. (Unlike surgery it has no
lasting effect). Most club feet can be corrected with just one Botox injection. It is possible to do
another if it is needed. There is no scar or lasting damage. BC Women and Childrens Hospital
[edit] Surgical treatment

This section needs additional citations for verification.

Please help improve this article by adding reliable references. Unsourced material may be challenged
and removed. (December 2009)

On occasion, stretching, casting and bracing are not enough to correct a baby's clubfoot. Surgery
may be needed to adjust the tendons, ligaments and joints in the foot/ankle. Usually done at 9 to
12 months of age, surgery usually corrects all clubfoot deformities at the same time. After
surgery, a cast holds the clubfoot still while it heals. It is still possible for the muscles in the
child's foot to try to return to the clubfoot position, and special shoes or braces will likely be used
for up to a year or more after surgery. Surgery will likely result in a stiffer foot than nonsurgical
treatment, particularly over time.

Without any treatment, a child's clubfoot will result in severe functional disability, however with
treatment, the child should have a nearly normal foot. He or she can run and play without pain
and wear normal shoes. The corrected clubfoot will still not be perfect, however; a clubfoot
usually stays 1 to 1 1/2 sizes smaller and somewhat less mobile than a normal foot. The calf
muscles in a leg with a clubfoot will also stay smaller.

[edit] Famous people

The club-foot, by José de Ribera.

Many notable people have been born with clubfoot, including the Roman emperor Claudius,
Egyptian pharaoh Tutankhamun, statesman Prince Talleyrand, Civil War politician Thaddeus
Stevens, the comedian Damon Wayans, actors Gary Burghoff, Dudley Moore and Eric The
Midget from The Howard Stern Show, footballer Steven Gerrard, sledge hockey player Matt
Lloyd (Paralympian),mathematician Ben Greenberg, and filmmaker Jennifer Lynch (daughter of
David Lynch).

British Romantic poet Lord Byron had a clubfoot, which caused him much humiliation.

Actor/musician/comedian Dudley Moore was born with a club foot. This was mostly unknown to
the public as he wore one shoe with a slightly bigger sole to compensate when walking.

Kristi Yamaguchi was born with a clubfoot, and went on to win figure skating gold in 1992.
Soccer star Mia Hamm was born with the condition. Baseball pitcher Larry Sherry was born with
club feet, as was pitcher Jim Mecir, and both enjoyed long and successful careers. In fact, it was
suggested in the book Moneyball that Mecir's club foot contributed to his success on the mound
—it caused him to adopt a strange delivery that "put an especially violent spin" on his screwball,
his specialty pitch. San Francisco Giants (the team with the all-time most clubbed feet players)
infielder Freddy Sanchez cites his ability to overcome the defect as a reason for his success.[8]
Tom Dempsey of the New Orleans Saints, born with a right club foot and no toes (this was his
kicking foot), kicked an NFL record 63 yard field goal. This kick is famous as the longest
regular-season NFL kick in history(until 2009).

Nazi Propaganda Minister Joseph Goebbels had a right clubfoot (possibly incurred after birth as
a complication of osteomyelitis),[9] a fact hidden from the German public by censorship. Because
of this malformation, Goebbels needed to wear a leg brace. That, plus his short stature, led to his
rejection for military service in World War I.

De Witt Clinton Fort was born with a clubfoot. De Witt Clinton Fort was known during the
American Civil War as Captain "Clubfoot" Fort, C.S.A..

Tutankhamun suffered from a club foot and a cleft palate and it is likely that he needed a cane to
walk

Definition
Club foot repair, also known as foot tendon release or club foot release, is the surgical repair of a
birth defect of the foot and ankle called club foot.

Purpose

Club foot or talipes equinovarus is the most common birth defect of the lower extremity,
characterized by the foot turning both downward and inward. The defect can range from mild to
severe and the purpose of club foot repair is to provide the child with a functional foot that looks
as normal as possible and that is painless, plantigrade, and flexible. Plantigrade means that the
child is able to stand with the sole of the foot on the ground, and not on his heels or the outside
of his foot.

Demographics

In the United States, club foot is a common birth defect, and occurs at a rate of one to four cases
per 1,000 live births among whites. Severe forms of clubfoot affect some 5,000 babies (about
one in 735) born in the United States each year. Boys are affected with severe forms of clubfoot
twice as often as girls. The risk increases 30-fold in individuals who have a relative of the first-
degree affected by the defects.

Description

A newborn baby's club foot is first treated with applying a cast because the tendons, ligaments,
and bones are quite flexible and easy to reposition. The procedure involves stretching the foot
into a more normal position and using a cast to maintain the corrected position. The cast is
removed every week or two, so as to stretch the foot gradually into a correct position. Serial
casting goes on for approximately three months.

In 30% of cases, manipulation and casting is successful, and the foot can be placed in a brace to
maintain the correction. In about 70% of cases, manipulation and castings alone do not correct
the deformity completely and a decision will be made concerning surgery.

The type of surgery depends on how severe the club foot is. The deformity features tight and
short tendons around the foot and ankle. Surgery consists of releasing all the tight tendons and
ligaments in the posterior (back) and medial (inside) aspects of the foot and repairing them in a
lengthened position. Metal pins may also be used to maintain the bones in place for some six
weeks. Surgery usually involves an overnight stay in hospital. After surgery, the foot is casted
for some three months, followed by the use of a brace to hold the correction. The brace is worn
for approximately six to 12 months after surgery.

Diagnosis/Preparation

Presurgical diagnosis requires radiography. The evaluation usually includes only the acquisition
of weight-bearing images because the stress involved is reproducible. In babies, weight-bearing
is simulated by the application of dorsal flexion stress.
Some surgeons prefer to wait until the child is about one year old before performing surgery, so
that the foot may grow a little larger to facilitate surgery. Other surgeons operate as early as three
months of age when it becomes clear that further castings will not achieve any more correction.

Aftercare

The patient usually stays in the hospital for two days after club foot repair. The foot is casted and
kept elevated, with application of ice packs to reduce swelling and pain. Painkillers may also be
prescribed to relieve pain. During the 48 hours following surgery, the skin near the cast and the
toes are examined carefully to ensure that blood circulation, movement, and feeling are
maintained. After leaving the hospital, the cast is usually left on for about three months. Skin
irritations due to the cast or infections may occur. A course of physical therapy may be indicated
after removal of the cast to help keep the foot in good position and improve its flexibility and to
strengthen the muscles in the repaired foot. The well-treated clubfoot is no handicap and is fully
compatible with a normal, active life. Most children who have undergone club foot repair
develop normally and participate fully in any athletic or recreational activity that they choose.

Risks

The risks involved in club foot repair are the general risks associated with anesthesia and
surgery.

Risks Associated With Anesthesia

• adverse reactions to medications

• breathing problems

Risks Associated With Surgery

• excessive bleeding
• infections

Normal Results

If club foot repair is required, the foot usually becomes quite functional after surgery. In some
cases, the foot and calf may remain smaller throughout the patient's life.

Morbidity and Mortality Rates

If left untreated, club foot will result in an abnormal gait, and further deformity may occur on
side of the foot due to preferential weight bearing.

Alternatives

The Ponseti Non-Surgical Treatment

Dr. Ignacio Ponseti developed this method which consists of a weekly series of gentle
manipulations followed by the application of casts which are placed from the toes to the upper
thigh. Five to seven casts are applied every week. Before applying the last cast, which is worn
for three weeks, the heel-cord is cut to finalize the correction of the foot. By the time the cast is
removed the heel-cord has healed. After this two-month period of casting, a splint is worn full-
time by the patient for a few months and is then worn only at night for two to four years. Special
shoes also maintain the foot in the corrected position.

The French Treatment

This method consists of daily physical therapy, featuring gentle and painless stretching of the
foot. The foot is then taped to maintain the corrected position until just the next day's visit. At
night, the taped foot is inserted into a continuous passive motion machine at home to maximize
the amount of stretching. The tape is removed for a few hours each day to wash the foot, air the
skin, and to perform exercises. Removable splints are also used to support the taped foot. The
one-hour physical therapy sessions are conducted five days each week for approximately three
months. Taping is stopped when the child starts walking.

Resources

Books

Lehman, W. B. The Clubfoot. Philadelphia: Lippincott, Williams and Wilikins, 1980.

Ponseti, I. V. Congenital Clubfoot. Fundamentals of Treatment. Oxford: Oxford University

Press, 1996.

Simons, G. W. The Clubfoot: The Present and a View of the Future New York: Springer Verlag,
1994.

Deformations:
In utero, the feet can be pressed into odd postures. The key thing
about such deformation by outer pressure is that the feet
themselves are passive in the process.

They would not be that way of their own growth programming.

Once straightened out by their own resilience or with a helping
nudge
or two (exercises, casts, or shaped shoes etc.), such feet will do
fine. They maintain correction naturally, as correct form is already
inherent in the tissue blue print.
 There are a variety of conservative "corrections". They
share a common property, they are gentle forces
applied to the foot in the direction of return of shape. A
hands-on manipulation is an externally applied force. A
corrective shoe is an externally applied force. A cast is
an externally applied force. The big difference is how
long applied and how meticulously shaped. Frankly,
many orthopedists cringe at the "exercises" that parents
do to their own children in the quest to avoid "braces"
(the little white shoe with the thingy on the bottom). "Exercise" sounds like a nice upbeat
word, but it is not rare to see feet literally dislocated by inexpert hands.

Club Foot:
Club foot is not just a bent foot. If you straighten a club foot and
then let it alone it goes back to being clubbed. That is the one
single most important fact about club foot from which nearly every
decision can be properly deduced. Club feet work from a bent blue
print. They seek club-ness with growth.
Correction of shape must not be merely
attained. It must be actively maintained.
To not maintain a corrected club foot is to play Russian Roulette
with half the chambers loaded.

Attaining correction of club foot deformity was anything but

easy even as recently as the 1930's. In fact adults with
uncorrected club feet sought treatment by prosthetics.

This man had the typical club foot deformity that we see in the
new born, except that as an adult he has to walk on it - as there
was no effective treatment for him as a child nor did a late
reconstructive procedure exist for him as an adult.

Note the left (club foot) heel at the red arrow and the right normal heel at the yellow
arrow. The orthotist created a raised right shoe with a laced sock to allow needed space to
place a false foot below the left club foot, assisted by a bit of left hip hiking. This was life
in the 20's and 30's. Even in the 50's, we saw such folks who had adjusted to this state of
affairs.
But not everybody could deal with the intact look. How far will people go to look better? Far. The
woman above could not bear these feet even though she walked on them well into her middle years.

How far will people go? In the old days, the options
were stark, sobering. It isn't vanity that leads to a
woman seeking amputation and prosthetic substitution.
That was the best way to get the best prosthesis for
function and least notice from others. It wasn't about
getting noticed but rather about not getting noticed. That
is the essential difference between "cosmetic" and
reconstructive surgery.

The single greatest problem and the fear of parents was

and still is ostracism. Back then, women were apt to
select ablative surgery to permit better prosthetics with less risk of ostracism. Such prosthetics were
capable of near normal levels of function (see SACH).

What else do we learn from the past? Children and adults with club feet who do not have
additional impairments can walk. However, unprotected, the feet take a beating, they
become sore, and the gait is unsteady.

But this was palliation, not correction. Orthopedics attacked from two directions: 1) Early
manipulative techniques combined with casts and 2) More aggressive surgeries, many of
which were made more effective by cast pretreatment. Various surgical strategies all had
shortcommings, but the justification was better feet than doing nothing.

There were stunning successes with casts + manipulation methods but

it was a percentage thing. Some were great. Some were, after
concerted effort, left as if untreated. Between these extremes was the
range of most outcomes.

It was clear enough, very aggressive and early (immediate)

manipulation of club feet on day one of life and thereafter did best.
But, still, many very stiff feet did not yield. One noted practitioner urged frequent
manipulations and very skilled cast applications - each time performed under anesthesia.
Multiple aggressive manipulations and anesthesia sessions, led to many better feet, yet
many failures persisted.

In recent years, this concept has been revisited with continuous passive motion machines
and splinting with some success. Limited lengthening of a posterior tendon may be used
to boost the process. The formula is still essentially the more movement and holding in
the direction of correction the better - for some feet, more feet, but still, not all of them.
Botulinum toxin has been used for paralytic versions of clubbed feet with some success.
Recently a similar usage was reported from Texas Scottish Rite Childrens Hospital. It is
yet another way to create suppleness in the shortened tissues.

Even in the most aggressively conservative hands, the surgical rate was about 40%.
Critics also argued that even in the 60% of successes, were many "questionable" feet. It
depends on the criteria. If patient satisfaction was "glad not to need amputations" then the
60% rating was solid. But if the criteria included willingness to show bare feet on a public
beech, or engage in sports, then another lesser statistic emerges. It comes down to "pursuit
of happiness". What does that take? Avoiding surgery? Surgery? Or just plain outcome?
Throw in risk. It is fear of the latter that has parents looking for conservative choices,
even if monumental in scope and unequal to surgery in outcomes. Pursuit of happiness...
but whose?

For feet that resist manipulative correction the surgical question was "Just what needs to
be released to get a real, not just a partial or semicosmetic correction?"

The answer turned out to be

"Everything". Club foot surgery
essentially divides all the ligaments
connecting the foot bones and
lengthens all the tendons to allow total
mobility.

With that strategy, as was championed

by Dr. Turco, real corrections are now
possible. With that insight an array of
me-too variations touting one skin
incision over another flooded the
reporting. Despite the rhetoric, the modern operations stress completeness. Some
surgeons remind us of rotational needs, other stress bone column geometry, but to get
there you have to disconnect a lot of stiff stuff.

"Corrections", of bone position and foot shape. But growth? It is still a club foot, no? Of
the feet that come to surgery (60% of them) 40% of those come to surgery again. A
"corrected" club foot that is just let loose to go its own way will do exactly that. Its own
way is clubbed. Some sort of maintenance foot wear is recommended in the very early
years after correction. The kids are too young to mind and the potential for recurrence too
great to ignore.
Nowadays we expect all club feet to look good and be
functional. The one unsolved issue is the smaller size
of both foot and calf. When both feet are club feet, size
is not a problem. But one sided club foot may result in
½ to 2 sizes difference. There are shoe and insert tricks
to deal with this. But size equalization is not yet
solved.

However, it is a big
world. Strange things can walk in... such as these feet:
This 12 year old boy was walking on these club feet.
Note the knobs on what is anatomically the foot top but
which is his weight bearing area. He trips and hurts
himself, he said.

Attempts to straighten these feet included pins through

the feet and through the shins to large metal rings with
turn buckle parts which were dialed out progressively, until...

until his shin bone broke, actually both tibias broke! Of course they had to be allowed to
heal. He has scars (you can see one on the right ankle area) from earlier failed releases
done several times. Releases & Ilazarov frames did not even slightly correct these feet.
There is nothing that ALWAYS works. In this case neither side budged.
 Back to prosthetics?

No.

Surgery for correction isn't all that's new.

There is also "salvage" surgery.

Rather than remove the foot, we can

remove internal substance to generate
space and mobility to help the nastiest
looking feet. These are the same feet as
above. The youngster is getting about fine.
The lump of thickened skin, that served as
his heel, is shrinking by the week. We can
still see some of that thickened skin on the
outer side of the ankle above. This was
done in a short single step operation. No
external metal. By hollowing out the talus the heel can be counter shaped and placed
inside - easily (talo-calcaneal intussuseption). X-rays look weird but the feet look fine and
work.

Valgus Foot:

These methods are not only for club foot deformity but any similar foot deformation
including the opposite type called "Valgus" foot. The severe paralytic valgus foot twists
out rather than in. This forefoot is twisted 90 degrees off alignment with the heel which is
90 degrees off relationship with the leg. On the right we see the correction (the white is
powder after taking plaster castings).
So, what did we learn? Beware of slogans. There is easy stuff and there is difficult stuff.
No one method, so & so's exercise, the wachamacallit brace, the whoozie's operation,
whatever - no one method is appropriate for the full range of problems that we see.

Macrodactyly is a focal gigantism present at birth but progressive. Sometimes a

single digit will grow to enormous size. One of our children had a toe as long and as wide
as the rest of the foot. It is variable in
the extent and degree of soft tissue
enlargement. The latter can wedge the
foot apart and thus deform the
uninvolved bones.

The x-ray to the right shows a

toddler's foot. The great toe is longer
than the foot. The toe bones and the
metatarsal (between red arrows) are
very wide. Normal width is seen
between the green arrows. The yellow
arrow points out normal skin
thickness. The blue arrows point out
the excessive tissue that triples the
thickness of the foot and which wedges the second toe off in the wrong direction.

As with severe club foot, many places used to and still do

amputate the abnormal parts of the foot. In that case the great
toe and its metatarsal would go. We prefer staged growth
arrests (to stop linear growth with segment removal to aim at
mature length (to grow into) with mass reduction. That
includes narrowing oversized bones by longitudinal section.
The lengthy process of staging an ultimate foot match makes
some folks prefer amputation. It depends quite a bit on how
much of the mid foot is involved.

This same condition may involve fingers and hands.

Ectromelia is a failure to form the central portion

of the terminal limbs (hands &/or feet). It may be a
first case by spontaneous gene mutation, however,
most have an involved parent as it is a genetic
disorder.

Many have no difficulty with walking at all but

significant problems with shoe wear. Treatment
problems are those of timing. These feet can be
closed up to look fairly reasonable. However,
avoiding growth arrest in the process is important. Many wait until maturity for definitive
reconstruction. Interestingly, many of those who do wait find that they really are OK with
it and elect to let the feet be.

Our advise is to base decision making on function. If function is a problem, examine to

see what specifically is interfering with the needed processes of walking. Address those
items. That may well be something other than a cosmetic attack. For example, an orthotic-
prosthetic hybrid may be fabricated which extends the foot rolling point forward to where
a foot should have a rolling line (metatarsal heads). Depending on how much tissue exists,
the reconstructive approach might not match the prosthetic extension in ability to further
walking mechanics. Each case needs individual consideration of all the issues.

There are other methods for the intermediate problems. There are other ways to deal with the
relapsed club feet that are not discussed here. The particulars get too particular for those. Just know
that there are many tools in the tool chest.